Innovation in Global Health Governance

Innovation in Global Health Governance

Global Environmental Governance Series Editors: John J. Kirton, Munk Centre for International Studies, Trinity College, Canada and Miranda Schreurs, Freie Universität Berlin, Germany Global Environmental Governance addresses the new generation of twenty-first century environmental problems and the challenges they pose for management and governance at the local, national, and global levels. Centred on the relationships among environmental change, economic forces, and political governance, the series explores the role of international institutions and instruments, national and sub-federal governments, private sector firms, scientists, and civil society, and provides a comprehensive body of progressive analyses on one of the world’s most contentious international issues. Recent titles in the series (full listing continued at the back of the book) Environmental Skepticism Ecology, Power and Public Life Peter J. Jacques ISBN 978-0-7546-7102-2 Transatlantic Environment and Energy Politics Comparative and International Perspectives Edited by Miranda A. Schreurs, Henrik Selin, and Stacy D. VanDeveer ISBN 978-0-7546-7597-6 The Legitimacy of International Regimes Helmut Breitmeier ISBN 978-0-7546-4411-8 Governing Agrobiodiversity Plant Genetics and Developing Countries Regine Andersen ISBN 978-0-7546-4741-6 The Social Construction of Climate Change Power, Knowledge, Norms, Discourses Edited by Mary E. Pettenger ISBN 978-0-7546-4802-4

Innovation in Global Health Governance Critical Cases

Edited by Andrew F. Cooper The Centre for International Governance Innovation, Canada JOHN J. KIRTON University of Toronto, Canada

© Andrew F. Cooper and John J. Kirton 2009 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise without the prior permission of the publisher. Andrew F. Cooper and John J. Kirton have asserted their right under the Copyright, Designs and Patents Act, 1988, to be identified as the editors of this work. Published by Ashgate Publishing Group Ashgate Publishing Company Wey Court East Suite 420 Union Road 101 Cherry Street Farnham Burlington, VT 05401-4405 Surrey GU9 7PT USA England Ashgate website: http://www.ashgate.com British Library Cataloguing in Publication Data Innovation in global health governance : critical cases. (Global environmental governance series) 1. World health 2. Communicable diseases - Prevention International cooperation I. Cooper, Andrew F. II. Kirton, John J. 362.1 Library of Congress Control Number: Cooper, Andrew Fenton, 1950Innovation in global health governance : critical cases / by Andrew F. Cooper and John J. Kirton. p. cm. Includes bibliographical references and index. ISBN 978-0-7546-4872-7 -- ISBN 978-0-7546-8985-0 (ebook) 1. World health. 2. Public health--International cooperation. I. Kirton, John J. II. Title. RA441.C665 2009 362.1--dc22 09ANSHT  ISBN 978 0 7546 4872 7 eISBN 978 0 7546 8985 0 (ebook)

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Contents List of Tables List of Figures List of Contributors Preface and Acknowledgements List of Abbreviations and Acronyms Part I Introduction 1 Critical Cases in Global Health Innovation Andrew F. Cooper, John J. Kirton, and Michael A. Stevenson

vii viii ix xi xv

3

Part II Responding to Pandemics: Severe Acute Respiratory Syndrome 2 Epidemic of Fear: SARS and the Political Economy of Contagion Andrew T. Price-Smith and Yanzhong Huang

23

3 Lessons from SARS: Past Practice, Future Innovation Carolyn Bennett

49

4 The WHO and SARS:The Challenge of Innovative Responses to Global Health Security Adam Kamradt-Scott

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Part III Preparing for Pandemics: Avian InflUenza 5 SARS and Avian Influenza in China and Canada: The Politics of Controlling Infectious Disease Sonny Shiu-Hing Lo

83

6

7

The Role of Civil Society in Pandemic Preparedness Kathryn White and Maria Banda

105

In-Flew-Enza: Pandemic Influenza and Its Security Implications Yanzhong Huang

129

Part IV Accessing Affordable Medicines 8 Coming to Terms with Southern Africa’s HIV/AIDS Epidemic Hany Besada

155

vi

9

Innovation in Global Health Governance

The Renovation of Institutions to Support Drug Access: Is it Enough? Jillian Clare Cohen-Kohler

10 Global Health Governance from Below: Access to AIDS Medicines, International Human Rights Law, and Social Movements Lisa Forman

179

193

Part V Conducting Campaigns against Chronic Illness: Polio and Tobacco 11 Rotary International and Eradicating Polio Robert Scott, Wilfrid Wilkinson, and John Eberhard 211 12 Globalisation and the Politics of Health Governance: The Framework Convention on Tobacco Control Jeff Collin and Kelley Lee

219

Part VI Defining Future Directions in Global Health Governance 13 Forging the Trade Link in Global Health Governance Benedikte Dal, Laura Sunderland, and Nick Drager

245

14 Explaining Compliance with G8 Health Commitments, 1996–2006 John J. Kirton, Nikolai Roudev, Laura Sunderland, and Catherine Kunz

257

15 Global Health Initiatives: A Healthy Governance Response? Caroline Khoubesserian

285

Part VII Conclusion 16 Innovation in Global Health Governance John J. Kirton and Andrew F. Cooper

309

Bibliography Index

341 381

List of Tables Table 5-1:

SARS and the Impact on Various Countries and Places, 1 November 2002 to 31 July 2003 Table 5-2: Infectious Disease Control, Regime Openness, and Size Table 5-3: Infectious Disease Response, Leadership Decisiveness, and Departmental Coordination Table 7-1: Estimates of the Economic Damage from Pandemic Influenza Table 7-2: Total Exports as Share of Gross Domestic Product and Estimated Economic Shocks Table 7-3: State Capacity, Civil Society Engagement, and Sociopolitical Impacts Table 8-1: Regional Comparison of HIV/AIDS, 2001 and 2007 Table 8-2: HIV/AIDS Indicators for South Africa Table 8-3: The Impact of HIV/AIDS on HIV-Related Health Services in Southern Africa Appendix 13-1: Implementing the Resolution on International Trade and Health Appendix 13-3: Diagnostic Tool for Trade and Health Appendix 14-1: An Overview of G8 Health Performance Appendix 14-2: G8 Health Compliance by Commitment and Country Appendix 14-3: G8 Health Compliance by Issue Area and Country Appendix 14-4: Compliance Catalysts Defined Appendix 14-5: G8 Health Commitments with Compliance Catalysts, 1996–2005 Appendix 14-6: Specific International Organisations and G8 Bodies, by Commitment Table 15-1: Global Health Initiatives with Annual Budgets Appendix 16-1: The Challenge-Response-Innovation Framework Appendix 16-2: Cases Appendix 16-3: International Institutions Involved in Global Health Governance Appendix 16-4: Instrumental Innovations in Global Health Governance Appendix 16-5: Institutional Innovations in Global Health Governance Appendix 16-6: National Innovations in Global Health Governance Appendix 16-7: Ideational Innovations in Global Health Governance

86 88 88 135 138 142 156 162 168 254 256 270 272 274 276 278 282 286 332 333 334 336 337 339 340

List of Figures Appendix 13-2: The House that GATS Built

255

List of Contributors Maria Banda is a JD candidate at Harvard Law School and a DPhil candidate at Oxford University, a Trudeau Scholar, and a Catherwood Scholar. Carolyn Bennett is a physician who served as Canada’s minister of state for public health from 2003 to 2006. Hany Besada is a senior researcher on weak and fragile states and leader of the Health and Social Governance program at The Centre for International Governance Innovation in Waterloo, Canada. Jillian Clare Cohen-Kohler is a professor at the Leslie Dan Faculty of Pharmacy and the lead researcher of the Initiative for Drug Equity and Access. Jeff Collin is a senior lecturer in global health policy at the Centre for International Public Health Policy at the University of Edinburgh. Andrew F. Cooper is the associate director of the Centre for International Governance Innovation and a professor in the Department of Political Science at the University of Waterloo. Benedikte Dal is a technical officer in the Department of Ethics, Equity, Trade, and Human Rights at the World Health Organization. John Eberhard is a past director of Rotary International, executive director of the Canadian Rotary Collaboration for International Development, chair of Disaster Relief—Rotarian Action Group, and past president of the Rotary Club of London, Ontario. Lisa Forman is a postdoctoral fellow with the Canadian Institutes of Health Research and the Comparative Program on Health and Society at the Munk Centre for International Studies at Trinity College in the University of Toronto. Yanzhong Huang is a professor and the director of the Center for Global Studies in the John C. Whitehead School of Diplomacy and International Relations at Seton Hall University. Adam Kamradt-Scott is a research fellow at the London School of Hygiene and Tropical Medicine.



Innovation in Global Health Governance

Caroline Khoubesserian works with the International Red Cross Society in Haiti. John J. Kirton is director of the G8 Research Group, director of the G20 Research Group, and a professor of political science at the Munk Centre for International Studies in Trinity College at the University of Toronto. Catherine Kunz holds a Master of Arts in Economics from McGill University. Kelley Lee is Reader in Global Health at the London School of Hygiene and Tropical Medicine. Sonny Shiu-Hing Lo is a professor of political science at the University of Waterloo. Andrew T. Price-Smith is director of the Project on Energy, Environment, and Security and a professor of political science and adjunct professor of environmental science at The Colorado College. Nikolai Roudev is a PhD candidate in political science at Stanford University. Robert S. Scott is former chair of the International PolioPlus and of the Rotary Foundation, and past vice-chair of Rotary International. Michael A. Stevenson is a PhD candidate at the University of Waterloo and a Balsillie Fellow at the Centre for International Governance Innovation. Laura Sunderland is the branch and membership coordinator at the Canadian International Council. Kathryn White is executive director of the United Nations Association of Canada. Wilfrid Wilkinson is past-president of the Rotary International, chair of Rotary’s ‘Reach Out to Africa’ committee, and the Rotary PolioPlus National Advocacy Advisor for Canada.

Preface and Acknowledgements This volume was inspired by the contemporary health crisis in the world and the manifest failure of the existing galaxy of global governance arrangements to cope. It takes as its central theme the need for innovation in the ideas and institutions of global health governance that have dominated for so long and still stand in centre place, but are now rapidly challenged, contested, and changing in response to new entrants in the field. This book continues the tradition in Ashgate Publishing’s Global Environmental Governance series of exploring the central issues and contemporary challenges of global governance in places where the stable single-issue areas of old are coming together in today’s more intensely integrated, interconnected world. Nowhere is this fusion greater than in the field of health. Here the environmental causes and consequences of health are quickly becoming more understood. The broader socioeconomic determinants and results of health are becoming a dominant paradigm in the health field. And the link between trade and health is moving to centre stage. Such interwoven issues now stand at the core of the global health policy agenda and thus of this book. But they and their components are still largely governed by the single-issue international organisations of old. Only a few integrative bodies—the United Nations, the G8, and new multi-stakeholder forums—are called upon to forge the needed connections and coherence in an effective way. That is why the need for innovation in global governance provides the focus for this work. To address the critical challenges, global governance responses, and patterns of innovation in ideas and institutions in the world of health, this volume brings together the resources of two scholarly research programmes. The first is that of the Centre for International Governance Innovation (CIGI) and the University of Waterloo, under the direction of John English and Andrew F. Cooper. The second is that of the research programmes on ‘Global Governance and the G8’ and ‘Strengthening Canada’s Environmental Community Through International Regime Reform’ (EnviReform), under the direction of John Kirton, and of the Centre for Global Health and International Affairs under the direction of John Kirton and James Orbinski, at the Munk Centre for International Studies at Trinity College in the University of Toronto. It builds on the previous volume Governing Global Health: Challenge, Response, Innovation, edited by Andrew Cooper, John Kirton, and Ted Schrecker, which deals with the contribution of the UN and G8 systems and of civil society organisations in coping with the contemporary health crisis. This current volume explores how these and other actors, with their old and new ideas, confront some of the critical cases of the major diseases and health shocks that afflict people throughout the world today.

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Acknowledgements In producing this volume, we have enjoyed the exceptional support of those who have contributed so much in so many different ways. We are grateful in the first instance to CIGI. It provided funding, organised and hosted the meetings and workshops, and ensured that this effort moved from the initial stage of research projects and papers into this polished, published book. CIGI also took the lead in bringing in the multistakeholder community, led by Rotary International, to enrich the effort. We are also grateful to Ted Schrecker at the Institute of Population Health at the University of Ottawa for his efforts in organising workshops and recruiting scholars and practitioners, including several from the developing world. We also owe much to the G8 Research Group, particularly to Ella Kokotsis, director of research, Jenilee Guebert, senior researcher, Madeline Koch, managing director, and the many hard-working and dedicated researchers who have contributed so much to this volume. We are also grateful to the Social Sciences and Humanities Research Council of Canada, under its strategic grant programme on ‘Social Cohesion in a Globalizing Age’, for its award to the University of Toronto’s EnviReform project and its standard research grant to John Kirton for his project on ‘After Anarchy: G8 Governance in a Globalizing World’. Institutionally, we appreciate the loyal support of our colleagues, administrators, and staff at our home institutions. At CIGI we appreciate very much the support of John English, the executive director, and Daniel Schwanen, acting executive director. Valuable work was also done by Andrew Schrumm, research officer, and Kelly Jackson, former research project manager, as well as Thomas Agar, research assistant. Michael A. Stevenson made a highly constructive contribution in the last stages of the project. As with all projects at CIGI, we are indebted to the strong support and personal interest of Jim Balsillie, chair of CIGI’s operational board of directors and co-CEO of Research in Motion. At the University of Waterloo our thanks go to Ken Coates, dean of arts, Bob Kerton, former dean of arts, and Amit Chakma, vice-president and provost. At the University of Toronto our gratitude goes to the Centre for International Studies at the Munk Centre for International Studies and its director, Louis Pauly. At the Centre for International Studies Tina Lagopoulos and her colleagues worked tirelessly in support of our work. We owe a particular word of thanks to Madeline Koch, for her editing and production skills and for her dedication in producing this book. We are particularly appreciative of the work by Peter I. Hajnal, who supervised the anonymous referee process of this manuscript. We are most grateful for the dedication, thoroughness, and insight of those referees, whose important comments have been taken fully into account. As always we reserve a special word of thanks for Kirstin Howgate and her colleagues at Ashgate for recognising the value of producing this volume and for working so effectively, and with such generous patience and understanding, to ensure the smooth adoption and ultimate publication of this book.

Preface and Acknowledgements

xiii

We thank our students for their endless enthusiasm, constructive criticism, intellectual contributions and challenges, and continuing commitment to the causes and issues dealt with in this book. We acknowledge, as always, the patience and support of our families as we laboured to organise our research, produce our own initial papers, and convert rough drafts into finished chapters. It is to our spouses, Sarah Maddocks and Mary Kirton, that we dedicate this work. Andrew F. Cooper and John J. Kirton January 2009

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List of Abbreviations and Acronyms ADB Asian Development Bank AIC Akaike information criteria AIDS acquired immune deficiency syndrome APEC Asia-Pacific Economic Cooperation ART antiretroviral therapy or treatment ASEAN Association of South East Asian Nations AU African Union AZT zidovudine BAT British American Tobacco BIT bilateral investment treaty BSE bovine spongiform encephalopathy CAC Codex Alimentarius Commission CAMR Canadian Access to Medicines Regime CBACI Chemical and Biological Arms Control Institute CDC U.S. Centers for Disease Control and Prevention CESCR United Nations Committee on Economic, Social, and Cultural Rights CFIA Canadian Food Inspection Agency CFR case fatality rate CIA United States Central Intelligence Agency CIDA Canadian International Development Agency CIGI The Centre for International Governance Innovation CIPIH Commission on Intellectual Property Rights, Innovation, and Public Health CME Canadian Manufacturers and Exporters China CDC China Center for Disease Control and Prevention CSIS Center for Strategic and International Studies CSR corporate social responsibility DALY disability-adjusted life year DFID Department for International Development (United Kingdom) ECOSOC Economic and Social Council (of the United Natios) EPI Expanded Programme on Immunization (of the World Health Organization) FAO Food and Agriculture Organization FCA Framework Convention Alliance FCO United Kingdom Foreign and Commonwealth Office FDI foreign direct investment FCTC Framework Convention on Tobacco Control FTA free trade agreement

xvi

G7

Innovation in Global Health Governance

Group of Seven (Canada, France, Germany, Italy, Japan, the United Kingdom, and the United States) G8 Group of Eight (G7 plus Russia) G20 Group of Twenty finance ministers and central bank governors (G8 plus Argentina, Australia, Brazil, China, India, Indonesia, Mexico, Saudi Arabia, South Korea, and Turkey) GATS General Agreement on Trade in Services GATT General Agreement on Tariffs and Trade GAVI Global Alliance for Vaccines and Immunisation GDP gross domestic product GHSAG Global Health Security Action Group GHSI Global Health Security Initiative GOARN Global Outbreak Alert and Response Network GPEI Global Polio Eradication Initiative GPHIN Global Public Health Intelligence Network HIV human immunodeficiency virus HKSAR Hong Kong Special Administrative Region HPAI highly pathogenic avian influenza IAVI International AIDS Vaccine Initiative ICJ International Court of Justice IDB Inter-American Development Bank IGWG Intergovernmental Working Group on Public Health, Innovation, and Intellectual Property (of the World Health Organization) IHR International Health Regulations (formerly known as the International Sanitary Regulations of 1903) IHR(2005) Revision of the International Health Regulations ILO International Labour Organization IMF International Monetary Fund INB intergovernmental negotiating body IO international organisation IOM Institute of Medicine of the National Academies IPR intellectual property right IPS International Policy Statement (of the Government of Canada) IPV inactivated polio vaccine ITGA International Tobacco Growers Association LDC least developed country LPAI low-pathogenic avian influenza MDG Millennium Development Goal MNC multinational corporation MSF Médecins Sans Frontières NACP National AIDS Coordination Programme (Zimbabwe) NAFTA North American Free Trade Organization NCE new chemical entity NGO nongovernmental organisation

Abbreviations and Acronyms

xvii

NID national immunisation day NPC National People’s Congress (of China) ODA official development assistance OECD Organisation for Economic Co-operation and Development OIC Organisation of the Islamic Conference OIE World Organisation for Animal Health OLS ordinary least squares OPV oral polio vaccine PAG Polio Advocacy Group PAHO Pan American Health Organization PE punctuated equilibrium PEPFAR United States President’s Emergency Plan for AIDS Relief PHAC Public Health Agency of Canada PRC People’s Republic of China PMA Pharmaceutical Manufacturers’ Association of South Africa PMTCT ��������������������������������������� preventing mother-to-child transmission PPP public–private partnership R&D research and development ROC Republic of China SAP structural adjustment programme SARS severe acute respiratory syndrome SPP Security and Prosperity Partnership of North America SPS Agreement Agreement on the Application of Sanitary and Phytosanitary Measures STB Stop TB Partnership TB tuberculosis TBT Agreement Agreement on Technical Barriers to Trade TFI Tobacco Free Initiative TRIPS Trade-Related Aspects of Intellectual Property Rights TSI Therapeutic Solidarity Initiative UNAIDS Joint United Nations Programme on HIV/AIDS UNAC United Nations Association of Canada UNCTAD United Nations Conference on Trade and Development UNDP United Nations Development Programme UNEP United Nations Environment Programme UNHCHR United Nations Office of the High Commission for Human Rights UNICEF United Nations International Children’s Fund UNSC United Nations Security Council USAID United States Agency for International Development USTR United States Trade Representative WFP World Food Programme WHA World Health Assembly WHO World Health Organization WTO World Trade Organization

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Part I Introduction

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Chapter 1

Critical Cases in Global Health Innovation Andrew F. Cooper, John J. Kirton, and Michael A. Stevenson

Global health is in a cascading crisis as the powerful process of globalisation gathers ever more of the world in its grip. Amidst the many material and epistemic advances brought by globalisation, many millions of people still die annually from infectious and chronic disease. These mega deaths are made all the more tragic, threatening, and morally reprehensible precisely because so many are predictable, preventable, and treatable now. For most of the past millennium, many died quickly, painfully, and prematurely from infectious diseases such as smallpox, plague, and cholera. They died in large part due to ignorance, malnutrition, poor water and sanitation, and the failure of the diagnosis and treatment process to protect their health. They were largely left with only divine retribution as the dominant cause of their illness and the provision of spiritual solace and the hope of a better afterlife when death approached. European imperialism carried new diseases and death to much of the world, while the growth of commerce and travel brought illness from ever more distant continents into the European core to exact a similarly fatal toll. Even with the growth of the national quarantine system over the past millennium, and the emergence of intergovernmental health conferences, regulations, and institutions and vast improvements in public hygiene and sanitation in the second half of the 19th century, many still died as the 20th century began. The great influenza pandemic at the end of World War I killed an estimated 50 million around the world, taking more lives than those killed deliberately during the world’s most deadly war to date (Soper 1919; Harrison 2006). The 20th century promised a much brighter and healthier future in so many ways. It brought advances in medicine, hygiene, education, sanitation, and public health. These came with the professionalisation of health practitioners, the creation of pharmaceutical firms of national and then international reach, and the advent of philanthropic nongovernmental organisations (NGOs), such as the Rockefeller Foundation, devoted to research to alleviate humanity’s suffering. At the end of World War II the victorious powers created the World Health Organization (WHO) to produce health for all and assist the new states freed from colonialisation as they constructed their governments to provide their citizens with better health (Goodman 1971). As with earlier imperial ventures and world wars, the Cold War and periodic hot wars that followed also spurred innovation, for the imperial powers acquired



Innovation in Global Health Governance

new national security needs to identify, treat, and prevent the diseases their troops encountered in the many exotic locations where they were now deployed. At the height of the Cold War, the success of the WHO-led smallpox eradication campaign demonstrated that ideological differences could be overcome in the name of global health. With the ensuing collapse of the Soviet Union and the spread of openness to regions of the globe where it had long been denied, there was great anticipation that chief among its fruits would be significant improvements in the health and welfare of citizens everywhere. Post–Cold War globalisation created a new generation of possibilities and resources to save lives, increase life expectancy, and improve the quality of human health and life. It brought and spread new knowledge, diagnostic techniques, therapeutic options, and medicines to treat some of the most important diseases. These were delivered by health professionals with ever more training and specialised knowledge and received by a more informed citizenry taking control of their own health and life. There emerged a greater awareness of the social, economic, environmental, and political determinants of health. The advent of low-cost and rapid communications and transportation promised to spread information, assistance, and wealth to foster health everywhere in the world. But globalisation also spread disease and death (Drager and Beaglehole 2001). The rapid increase in social and economic interconnectedness led to new health threats and the re-emergence of old health threats long thought to be under control. In the span of just over two decades, HIV/AIDS has gone from being unknown to science to being the single most important infectious disease in the world. In some countries it has prevalence rates so high that it has become a significant threat to economic and national security and, potentially, to national survival itself (PriceSmith 1999; Peterson 2002). While many now receive affordable treatment, even more become infected each year. Other diseases such as tuberculosis (TB) and vector-borne diseases such as dengue fever and malaria are re-emerging as major global health threats, with their control complicated by the development of resistance to many of the existing therapeutics agents used in their treatment (Osterholm 2005). Biological and political resistance to many of the proven medicines and treatments long relied on is, in many cases, on the increase. Globalisation increases the rate and means for health threats to be transplanted from one region of the world to another. At the same time, globalisation has enabled healthcare professionals badly needed in their own poor countries to migrate to better jobs and opportunities in the already abundantly endowed North. It has further facilitated the export and marketing of behaviour and lifestyle choices associated with adverse health effects. This has given rise to new epidemics of conditions and chronic diseases associated with alcohol, smoking, and consumption of processed foods, such as diabetes, obesity, and various cancers, as well as a range of diseases associated with exposure to a long list of environments pollutants (Beaglehole and Yach 2003). This comes at a time when governments around the world have been forced by persistent poverty, financial crisis, natural disaster, and war to watch their public health systems decline and the economic and health inequalities among their citizens rise (Garrett 1996).

Critical Cases in Global Health Innovation



The Inadequate Governance Response In the face of such demanding deadly challenges—now reaching crisis proportions in the sheer volume of avoidable deaths—the global community still struggles to devise an appropriate and adequate response. The causes and cures of the compounding global health crisis that come from agriculture, demography, economics, ecology, security, and technology are well known, but seldom related to health and a health governance response in a comprehensive or coherent way. Through its general requirements for reductions in public sector spending, the neo-liberal economic policies espoused by the International Monetary Fund (IMF) and the World Bank have often counterproductively constrained the national governments that borrow from them and thus made them fail to protect global health (Thomas and Weber 2004). Lack of capacity and an abundance of corruption hamper national governments around the world. Within wealthy countries, there still exists an isolationist mentality that views the developing South as a reservoir of human disease that can be guarded against by better medicines, bigger border barriers, and more protective policies at home (Aginam 2004). Yet domestic health policy cannot address the determinants of health that originate beyond national borders. And the dire poverty in much of the developing world is still found in abundance inside the developed North itself (Kickbusch and de Leeuw 1999). Sovereignty, national suspicions, and profit motives compound the challenge. Attempts to harmonise national policies for the purpose of strengthening global health continue to face fierce resistance from states unwilling to give up sovereignty, as shown by the recent process of revising the International Health Regulations (IHR) (Gostin 2004). Hindered by conflict over human rights, bioterrorism, and the political status of Taiwan, the success of those regulations depends ultimately on whether states decide to implement them (Fidler and Gostin 2006). Certainly much of the responsibility can be laid on the doorstep of national governments, as states have yet to internalise the value of public health as a human right (Fidler 2001). But other actors share the blame. Transnational pharmaceutical companies have had little financial incentive to invest in the research and development (R&D) of drugs for neglected diseases such as trypanosomiasis, even though the moral imperative has always been there (Trouiller et al. 2002; t’Hoen 2002). At the centre of the growing array of actors responsible for governing global health stands the WHO. This organisation, charged with improving the health of the world’s population, has been limited by political and financial constraints imposed by its member states. It may indeed need radical reform to do its job in today’s world (Godlee 1994). There is a gap between monies committed and what is actually delivered (Labonté and Schrecker 2004). However, the principal impediment to improving global health is not merely lack of money but the poorly coordinated and bureaucratic nature of the disbursement of funds. It is also the tendency of governments, international organisations, and public-private partnerships (PPPs) to focus on individual diseases instead of vigorously investing in health human resources and public health infrastructure and working to reduce social, economic,



Innovation in Global Health Governance

and environmental determinants of disease in both the developing South and in the developed North (Garrett 2007). The comprehensiveness, coherence, and credibility of global health governance are ultimately at stake.

Recent Innovations In light of these growing health challenges and failures in the governance response, there has been considerable innovation, especially as many new actors have gotten into the global health governance game (Cooper 2007). In the realm of institutions, PPPs have demonstrated their value in areas where the public sector lacks skills and resources, such as product development, manufacturing, and marketing, even if PPPs are not appropriate for policy development or regulation itself (Widdus 2001). In the realm of ideas, the concept of global public goods has arisen as an effective way to raise money for mechanisms to strengthen communicable disease control (Smith et al. 2004). The proposal to develop a global health research fund through direct public investment in vaccine development, as well as an international health treaty to enshrine countries’ commitments for such a fund, has been widely embraced, showing that new international norms are being developed regarding the concept of global health (Archibugi and Bizzarri 2004). Investing in public health is increasingly perceived to be a core criterion of ‘good governance’ (Dodgson, Lee, and Drager 2002; Fidler 2004). Philanthropists led by Bill and Melinda Gates and faith-based communities, private sector corporations, and celebrities from the arts, athletics, and entertainment have come forward to mobilise much more money, awareness, expertise, and political pressure than before. And because of the intersection of domestic and foreign policy, consensus is mounting toward pooling state sovereignty and organising global health governance through a series of intergovernmental networks, with an unencumbered WHO coordinating global health policy (Kickbusch 2000; Taylor 2004). Indeed, there is a cornucopia of innovative individuals, institutions, ideas, and instruments now engaged and available. The central challenge for global public health is not only to add more, but above all to determine in disciplined fashion which ones work under different circumstances to generate the heath all deserve.

The Analytical Framework This book takes up that task. Its first and central purpose is to develop and test in critical cases an analytical framework that explains the process of innovatively delivering global public health in today’s complex, rapidly changing, globalised world. Its second purpose is to assess on this basis the current state of innovation in global health governance. Its third purpose is to evaluate and expand the innovations that could improve the way the governance system works and the health that results. This volume builds directly on a general framework of global health governance first constructed to assess and improve the performance of the major intergovernmental

Critical Cases in Global Health Innovation



institutions of the United Nations and the G8 and the many actors now involved in their governance systems (Cooper, Kirton, and Schrecker 2007). That framework flowed from the literature in the rapidly emerging field of global health governance (Kirton 2009, forthcoming). The framework had three core components: physical challenges to health, governance responses to these challenges, and the innovation called forth and needed in the face of new challenges when the old responses failed. That general framework of challenge-response-innovation conceived of intergovernmental institutions, national governments, civil society organisations, private firms, and individual citizens as complacent reactors, constrained learners, and reluctant innovators. Only seldom were they prescient, creative, proactive, strategic actors who regularly and accurately anticipated future trends and adapted to or prevented the threats to health that physical challenges brought. To be sure, there were some supply-driven successes, such as the eradication of smallpox. But mostly the principal actors’ innovations were reactions to severe crises and shocks. Their next response to such crises typically entailed trying to do more of the same, on the basis of their existing missions, mandates, organisational routines, professional repertoires, and resources, based upon the dominant understanding of cause-andeffect relationships to solve the new problem. The initial instinct was to replicate past successes in new cases. The first defence in the face of failure was to plead for more money and other resources to solve the current challenge. Yet in response to the failure of these old actors and approaches to meet those challenges, there arose competition from the many new actors and new approaches that had entered the global health game. From this challenge and failure of the old responses and new competition came innovation in the dominant institutions and ideas that govern global health. Driving successive stages of this challenge-response-innovation dynamic is the process of globalisation, as it has intensified from the mid-19th century until now. Most broadly, globalisation has increased the scale, speed, scope, simultaneity, and domestic intrusiveness of disease and the other forces that directly or indirectly harm human health. This has placed the demand for global health governance on centre stage in many countries as the 21st century unfolds. Globalisation has also intensified the economic, ecological and social interconnectedness, interdependence, complexity, and uncertainty that add force to contemporary global health challenges. Yet the scientific and information revolutions fuelled by globalisation have also brought new insights and resources through which many more actors can respond to the challenge in innovative and effective ways. The challenge-response-innovation framework developed and tested in this book builds on this basic conception. It proceeds on three levels. The first traces the process and pathways of action in each of the three components of challenge, response, and innovation. The second causally connects these three components by identifying the responsiveness, appropriateness, and effectiveness with which challenges evoke response and innovation. The third charts the overall transformation brought about by new non-state controlled vulnerabilities, by governance innovativeness as a self-



Innovation in Global Health Governance

sustaining, spreading process, and by non-Westphalian forms of sovereignty as the innovative key. The first level of process charts in detail the pathways of challenge, response, and innovation by identifying in each case who does what to whom, to what effect, and why. This charting starts with the problem of the physical health challenges that could catalyse a public governance response from various players and that could lead to innovation on their part. Such physical health challenges, with their ultimate origins in human, animal, and plant biology or material chemistry, can be brought by state, non-state, and non-human actors or a mixture of the above. They can be intentional, targeted, and guided or unintentional, random, and uncontrolled. They can emerge and remain in the developed North or developing South, or move from South to North or North to South. They can arise and spread, through physical and psychological processes, in a slow, incremental, largely invisible fashion, or in a sudden, severe, concentrated, visible, shocking, panic-inducing one. The second component—public governance response—involves a similar tracing. Such responses can come from some or all of concerned and caring individuals, health professionals, private sector, civil society actors, nation-states, and international institutions. They can respond consciously to the physical health problem or unknowingly in ways that affect the challenge for better or worse. They can respond at the source, at the borders the threatening challenge crosses, or at the destinations to which it flows. The third component of innovation follows a similar cadence. It conceives of innovation broadly as changes over time that are novel or a rediscovery of past concepts or practices, rather than a return to what has been regularly relied on before. It asks who innovates, with the spectrum ranging from individuals to international institutions themselves. It traces how deliberately they innovate, from accidental discoveries through trial and error to purposeful big project science. And it identifies where they innovate, with the possibilities ranging from the physical source to the destination to which the disease has spread. The second level of system responsiveness causally connects the three components of challenge, response, and innovation. It does so by identifying the relationships among them according to the three criteria of responsiveness, appropriateness, and effectiveness. Responsiveness refers to the speed with which the first appearance of a physical health challenge affecting a large population evokes a response and then innovation as a result. Here the spectrum extends widely from non-existent or slow, through immediate responses and resulting innovations in the middle, to proactive, preventive action at the other end of the scale. For convenience the framework is arranged with the physical challenge as the independent variable, public governance response as the intervening variable, and governance innovation as the dependent variable. But through feedback loops and autonomously, innovation can start new processes of public governance that prevent physical challenges before they start. The criterion of appropriateness refers to the fit between the physical problem, governance response, and resulting innovation in its diagnosis, resource mobilisation, targeting, instrumentalities, and centre of responsibility. The criterion of effectiveness

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refer to the quality of the response and innovation in terms of the number of lives saved and improved and the broader ecological, social, economic, and politicalsecurity values enhanced. The third level of system transformation assesses the causal connections according to three criteria. The first is the new vulnerability, in which non-state and nonhuman actors create in unconscious, unintended, untargeted, uncontrolled fashion the physical health challenges that rapidly and readily flow across state borders around the world to overwhelm the inherited governance responses and kill or harm many there (Kirton 1993). This ‘neo-vulnerability’ is different from the inherited, largely Westphalian structure in which states and their national governments largely cause or control disease within or at their borders and rely on sovereignty-respecting international diplomacy, agreements, or institutions for whatever international coordination is required to cope. The old vulnerability arose in a still state-centric world of bioweapons and biowarfare: states sent controlled threats against their adversaries in ways that the latter’s unilateral change in national policy could not protect against and where such failure bred new international institutions to cope (Keohane and Nye 1977). Neo-vulnerability, in contrast, arises in an era of intense globalisation where many threats from many unconscious, uncaring sources attack and overwhelm the standard repertoire of national and intergovernmental policy responses and call for multiple sources and forms of innovation within multilevel governance instead. Here the size, speed, and spread of the new vulnerability is hypothesised to catalyse multi-actor innovation when the initial response from Westphalian governance fails. The second criterion is innovativeness. It refers first to the speed with which an innovation effectively solves the challenge when the previous Westphalian governance repertoire has not. It also refers to the spread of the innovation in a broader process of borrowing and adaptation that saves lives in other places, assaulted by other diseases, in coming years. Here the novel, appropriate, and effective innovation created in response to a particular health challenge becomes institutionalised, adopted by other actors for other purposes, and ultimately inspires a culture of innovation overall (Homer-Dixon 2001). The third criterion is the new sovereignty. It arises as actors beyond nation-states and their intergovernmental institutions emerge as appropriate and effective centres of innovation and thus become legitimately embedded as authoritative institutions of global health governance. In the realm of ideas, health governance passes from being a matter of national security for imperialism, war, or counter-terrorism, or a matter of economic advantage in a relative capability competition or a matter of redistribution to develop countries than can help or harm; it becomes a right and a responsibility to protect human lives and the global ecosystem on which all life depends. In the realm of institutions, those actors that can appropriately, effectively, and legitimately work with others to produce such values create the fluid networks that are the health sovereigns of the new age. This new sovereignty transcends the new, ‘open source’ anarchy that the entry of so many more diverse players into global health politics, diplomacy, and governance has brought (Fidler 2007, 2008).

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The Analytical Strategy To develop and test this framework this book looks beyond and below the major intergovernmental institutions long responsible for global health. It starts with specific, current, critical cases of disease that provide the catalyst for the cadence of challenge-response-innovation to start. Five cases provide the focus: severe acute respiratory syndrome (SARS), avian influenza, HIV/AIDS, polio, and tobacco. These cases provide the necessary variation on the independent variable of physical challenge. SARS arose from non-human sources and spread in uncontrolled fashion with great speed from South to North. Avian influenza in its deadly human H5N1 form likewise arose from non-human sources and has spread in uncontrolled fashion, although more slowly and still largely where it started among countries of the developing South. HIV/AIDS emerged from non-human sources in the South but was spread by humans to and in the North and has slowly spread back across the South. Polio came from non-human sources and spread slowly across the North and South but has been driven back over many decades to a few remaining enclaves in the South. And tobacco flowed from intentional and conscious human activity first in the South, then largely in the North, and now increasingly in the South. Across these five cases, the physical character of the challenge alone does not readily account for the deaths these diseases have brought. The death toll from SARS and avian influenza has been modest, while that from the others has been very high. It is thus the quality of the governance response and the innovation that critically determines who lives and dies. To be sure, these five cases are by no means all of the many high-profile and neglected, acute, and attrition cases of communicable and non-communicable diseases that deserve attention by global health scholars and practitioners today. Indeed, in focussing on these big five, this volume deals with a wide number of others that are and should be on the global health agenda today. These five allow for a point of entry to this much broader terrain, and a disciplined, detailed way of identifying lessons that could be used much more broadly to understand and improve global health as a whole. To explore the dynamics of challenge-response-innovation, this book examines in turn these five cases along a spectrum from acute outbreak to diffuse attrition events. The individual sections devoted to the first three contain chapters that generally concentrate in turn on the challenge, response, and innovation. Each section and chapter deliberately contains some overlap in case subject and analytical components in order to facilitate and highlight comparison, convergence, and cumulation in the overall story of innovation in global health governance as a whole. To conduct this analysis, this book adopts a broad but bounded definition of the core, rapidly changing and heavily contested conceptions that comprise the scholarly field of global health. ‘Global’ refers to the geographic reach across many, substantially separated sovereign state boundaries of processes that directly do or could constitute, cause, cure, or otherwise change human health. ‘Health’, consistent with the definition contained in the WHO’s (1986) charter, consists of all physical

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and mental things that directly constitute and improve the longevity and quality of human life. ‘Governance’ is the conscious creating, shaping, steering, strengthening, and using of international and transnational institutions and regimes of principles, norms, rules, and decision-making procedures that influence how autonomous actors behave (Krasner 1983). ‘Diplomacy’, both generically and in the form of global health diplomacy, is the conscious practice of actors operating across international boundaries to get what they want from outsiders without the use of violent physical force. Scholars of international politics of realist, liberal-institutionalist, political economy, and constructivist traditions each have competing conceptions of how governance and diplomacy affect outcomes. But all agree on their importance, with classic realists highlighting diplomacy as the ultimate determinant of what happens in the world (Morgenthau 1948).

The Authors To enrich and apply this framework, this volume assembles the contributions of leading scholars, researchers, and practitioners from a wide array of global regions, scientific disciplines, and professional fields. It includes those from North America, Europe, Africa, and Asia, and those with extensive experience elsewhere in the developing world. The contributors work in major multilateral organisations, national governments, universities, research institutions, and civil society organisations. Their contributions come from the disciplines of political science, economics, law, sociology, medicine, pharmacy, and a wide range of component fields. The contributions draw upon a broad array of the major theories of global governance, including realism, liberal institutionalism, constructivism, epistemic communities, principal-agency theory, and complexity theory. This book’s purpose is not to test these competing theories against the evidence to identify and proclaim a winner, but to mobilise the insights of several traditions in an improved synthetic understanding of how global health governance does, could, and should work in the contemporary world. Thus many of the contributions are explicitly normative in inspiration, flow from positive analysis into policy-oriented judgements, and offer recommendations for further innovation of both practical and more visionary kinds.

The Authors’ Arguments Part II, ‘Responding to Pandemics: Severe Acute Respiratory Syndrome’, begins with the lessons from SARS, as the most dramatic and deadly of the infectious diseases recently assaulting the developed North from the developing South with striking severity, speed, and surprise. In Chapter 2, ‘Epidemic of Fear: SARS and the Political Economy of Contagion’, Andrew Price-Smith and Yanzhong Huang illustrate, through the case of SARS, how in a globalised world no country is immune to the potentially damaging economic

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effects of public health emergencies. They argue that SARS exposed the vulnerability of existing governance structures, and that the great fear generated by the failure of governments to control the disease had significant ramifications for the domestic economies of affected states. These proved to be a catalyst for structural change. The Chinese and Canadian experiences show how fear prompted large-scale population flight, avoidance of public spaces and significant decreases in consumer spending and investor confidence. Combined with an increase in healthcare delivery costs, this took a heavy economic toll on both countries. The significant economic impacts and the intense negative international scrutiny of government failings increased the prominence of public health issues among political elites. They created transparency and incentives for more proactive approaches to dealing with other pressing public health issues. The case shows that states need to be more proactive in preparing for unforeseen public health emergencies. SARS has led to significant macro-level innovations at the domestic level in affected countries, most notably in China, as well as to strengthening regional cooperation on public health in southeast Asia. However, it has not had a significant impact on global health governance. It did highlight the antiquated nature of the IHR reporting model and temporarily increased the power of the WHO. But it has not increased states’ compliance with international health regimes or the WHO’s long-term influence. In Chapter 3, ‘Lessons from SARS: Past Practice, Future Innovation’, Carolyn Bennett emphasises knowledge improvement and dissemination, collaboration, and leadership in improving global health outcomes. While SARS highlighted many areas of structural weakness, most notably how governments communicated with each other and with citizens, some jurisdictions performed admirably. Singapore designated one hospital to treat cases, performed contact tracing within 24 hours of case admission, held regular news briefings to share facts and uncertainties, and provided advice to citizens on how to protect themselves from infection. It thus offers a model for emulation and adaptation elsewhere. In Canada SARS led to learning and innovation through the creation of a fact-finding mission, the results of which generated the political will to create the Public Health Agency of Canada (PHAC) and the position of chief medical officer of health at the federal level. But governments must re-learn what public health means. There is merit in community-based ‘bottomup’ initiatives, such as Thailand’s community health liaisons. NGOs need to be included in public health planning and more emphasis must be placed on addressing the social determinants of health. Finally, there is a need for government candour on public health issues, requiring a shift in culture to be able to admit challenges and ask for help from the international community through the WHO. Effective global health governance requires fostering relationships based on respect and trust and a model of transparency and equity, evidence-based policy, and citizen engagement. In Chapter 4, ‘The WHO and SARS: The Challenge of Innovative Responses to Global Health Security’, Adam Kamradt-Scott examines the role and authority of the WHO during the SARS crises. He responds to positions taken by David Fidler, Andrew Cortell, and Susan Peterson that the WHO was guilty of ‘agency slack’, exceeding its authority and mandate and engaging in unauthorised, unprecedented,

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and undesired actions. Kamradt-Scott argues that the WHO was intended to be an independent entity, performing duties on behalf of member states. Communicable disease control was its primary purpose from its inception. The WHO’s response to SARS stood in stark contrast to its usual state-centric deferential approach to public health emergencies. While SARS was an exceptional epidemiological event, the WHO’s actions were entirely consistent with its mandate and explicitly authorised by the collective WHO membership through its approval of the WHO constitution. It directs the WHO to be the designated leader, coordinator, and policy formulator of global initiatives to control infectious disease. Several provisions within article 2 of the WHO’s (2006) constitution are explicit about this. The organisation’s interventionist approach, most apparent in its public criticism of the Chinese government, was sanctioned by member states through the formation of the Global Outbreak Alert and Response Network (GOARN) in 2000 and the passing of resolution WHA54.14 on Global Health Security: Epidemic Alert and Response in 2001 (WHO 2001). The ongoing revision of the IHR—the only treaty designed to combat the international spread of infectious diseases—gave the WHO discretionary powers regarding infectious disease policy and procedures. The WHO’s actions were thus in keeping with the expectations of the member states—that of an impartial technical organisation charged with a duty of care to safeguard the health of the global population. Part III, ‘Preparing for Pandemics: Avian Influenza’, presents a different set of challenges. In Chapter 5, ‘SARS and Avian Influenza in China and Canada: The Politics of Controlling Infectious Disease’, Sonny Shiu-Hing Lo argues that in today’s globalised world, where highly virulent pathogens can be rapidly transplanted anywhere and lead to unforeseen epidemics, a critical measure of state strength in health governance rests on its ability to cope with rapidly emerging public health crises. Three key performance measures—preparedness, transparency, and responsiveness—should be used to assess state capacity in this regard. In the Asian epidemics of acute, highly virulent respiratory infections such as SARS and H5N1 avian influenza, certain Asian jurisdictions, especially densely populated urban centres, both innovated successfully and failed. Other countries, such as Canada, can learn from these experiences to prepare for future public health emergencies such as a global influenza pandemic. Despite Toronto’s experience with SARS and the government’s development of the Pandemic Influenza Plan for the Health Sector, the Canadian public remains psychologically ill prepared for a large-scale public health emergency. Canada should instil a ‘crisis consciousness’, for example by ensuring Canadians are aware of the need of government to balance civil liberties with the need to maintain public safety, and prepare for a rapid mobilisation of civic resources to what will likely be an overextended healthcare workforce. It remains unclear whether the logistical challenges that plagued municipal, provincial, and federal governmental responses to SARS—specifically regarding roles, responsibilities, and communication—have been resolved. Lo thus proposes a 20-point action plan to bolster Canadian preparedness for dealing with the eventual epidemic attributed to a highly virulent and infectious pathogen.

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In Chapter 6, ‘The Role of Civil Society in Pandemic Preparedness’, Kathryn White and Maria Banda examine the challenge of avian influenza and what response is needed for society to be prepared for a global outbreak. They discuss how the inclusion of multiple levels and areas of society can benefit the planning for and the prevention of a pandemic. Beginning with the evolution of avian influenza, and the possible lessons learned from each of the responses seen thus far, they look at past failures and potential successes of the global health system and the possible role civil society can play. Turning to governance, they suggest that numerous actors are needed from a wide range of areas, including health, agriculture, trade, the environment, development, and civil society. The best approaches to controlling infectious disease are both transnational and multi-actor. Avian influenza requires a four-part response: a genuine commitment to human development, a dependable and all encompassing human rights system, a public security framework to deal with the security threats of ill health, and a new attitude toward environmental responsibilities that takes food security more seriously. Only when an all-encompassing plan is in place will an investment in global health governance be truly entrenched and society adequately prepared for a pandemic, whether it be avian influenza or some other infectious disease. In Chapter 7, ‘In-Flew-Enza: Pandemic Influenza and Its Security Implications’, Yanzhong Huang examines the potential implications of a virulent influenza pandemic on the international economy, on sociopolitical stability within states, and on regional security. He offers recommendations aimed at mitigating the identified risks. The world has changed since the last virulent influenza pandemic in 1918. Improvements have come from the increased prominence of public health within the political arena, the many advances in health sciences and care delivery, the vast improvements in communications technology, the multilayered network of non-state actors involved in health promotion and health care, and the existence of the WHO with a well-defined mandate to provide leadership during public health emergencies. However, 4 billion additional prospective human hosts in a world where access to health resources disproportionately favours populations in wealthy countries, where significantly higher levels of the population live in impoverished settings, where incentives to suppress information in certain jurisdictions remain strong, and where both people and goods cross borders at unprecedented rates may erode any advantage for population health. A future influenza pandemic may well be very damaging to the international economy, especially if its epidemiology resembles the pandemic of 1918. The SARS case suggests that how governments respond to a pandemic can greatly affect social and political stability. International security could be compromised if peacekeeping operations are interrupted or if governments resort to deliberately stoking sectarian tensions to detract from state failures. Governments should thus increase public health expenditures, increase capacity in developing countries through monetary aid as well as knowledge and technology transfer, strengthen national healthcare surge capacity while balancing influenza preparedness investments with other important infectious disease programmes, and improve risk communication skills and ties with civil society groups.

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Part IV, ‘Accessing Affordable Medicines’, takes up the issue of HIV/AIDS and the governance and human rights aspects of accessible medicine. In Chapter 8, ‘Coming to Terms with Southern Africa’s HIV/AIDS Epidemic’, Hany Besada examines the demographic and economic impacts of HIV/AIDS in Swaziland, Botswana, Zambia, Zimbabwe, and South Africa. These countries have some of the highest HIV/AIDS prevalence and associated mortality rates in the world. However, their governments have largely failed to reduce social determinants of disease transmission and increase access to antiretroviral treatment (ART) for those infected. Besada reviews individual governmental policy responses to the HIV/AIDS crisis, with a primary focus on South Africa, where HIV/AIDS-related mortality is likely to continue to increase. South Africa shows how inconsistent political leadership can be a major impediment to disease control. The most prominent indicator of poor domestic health governance is the consistently low percentage of individuals living with HIV receiving ART, despite concessions by large pharmaceutical companies that have allowed the country to manufacture low-cost generics domestically. There is also a government failure to reduce the social stigma associated with HIV infection. Yet there have been positive developments, such as the decisions of large firms to absorb the cost of ART for HIVpositive employees and a national HIV/AIDS policy emphasising prevention. While governments should re-evaluate what strategies have worked in the regional context, the international community must increase its financial aid to southern African states to subsidise the rising cost of treatment resulting from increased access to ART. It must also accept some responsibility for the migration of healthcare workers from southern African states to wealthier countries and offer some solutions. In Chapter 9, ‘The Renovation of Institutions to Support Drug Access’, Jillian Clare Cohen-Kohler asks how governments can maximise conditions for positive health outcomes at the same time as economic growth is supported through trade and incentives for the private sector, such as through the application of rigorous intellectual property law regimes. She argues that the potential tension between these objectives arises in the pharmaceutical sector. In a world that has distorted drug access and where one third of the population lacks regular access to medicines, there is a morally compelling reason to identify potential institutional obstacles to drugs irrespective of the potential commercial or budgetary costs. Governments should not experience any conflicting pressure when they design policies to improve drug access. Access to medicines should be viewed as a fundamental human right as expressed in international human rights law that places attendant obligations on states to ensure drug access. Article 12 of the UN’s International Covenant on Economic, Social, and Cultural Rights outlines the ‘right to the highest attainable standard of health’, which includes the right to the availability of essential medicines as defined by the WHO. In Chapter 10, ‘Global Health Governance from Below: Access to AIDS Medicines, International Human Rights Law and Social Movements’, Lisa Forman explores the actual power of the human right to medicines to enable access to ART for millions of people with HIV and AIDS throughout the world. She argues that the right to health in international law holds a transformative potential to overcome the political and

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economic obstacles to access posed by the Agreement on Trade-Related Aspects of Intellectual Property (TRIPS) set out by the World Trade Organization (WTO), the contestation of price reductions by multinational pharmaceutical companies and their host governments, and governments’ denial of AIDS medicines. In South Africa primary human rights battles over AIDS medicines show the contingent legal, social, and political variables that can determine the efficacy of this right. Using international legal compliance theories that debate whether actors comply with norms because they are coerced or persuaded into doing so, Forman suggests that the persuasive power of this right derives from its normative status in international law, amplified by rights discourse, advocacy, social mobilisation, and the devastating consequences of HIV/AIDS. However, rights-related persuasion is less effective and public coercion is necessary where powerful actors have entrenched economic or political interests. While litigation is a traditionally coercive legal tool, public pressure and moral shaming can be similarly coercive. When actors can maximise both the coercive and persuasive force of the right to medicines, they may be able to overcome legal and political obstacles to access. Part V, ‘Conducting Campaigns against Chronic Illness: Polio and Tobacco’, begins with Chapter 11 on ‘Rotary International and Eradicating Polio’. Robert Scott, Wilfrid Wilkinson, and John Eberhard use Rotary International’s longstanding global polio eradication efforts to illustrate how community service organisations can be major agents of change. The global polio eradication movement began in the 1950s with the development of two safe, effective, inexpensive vaccines. Since then great strides have been made through a collaborative effort involving multiple actors from several disciplines. The global eradication of a dreaded childhood disease now appears within reach. Rotary International, a large network of community service organisations composed of business and professional leaders from various backgrounds, has managed successfully to keep polio eradication on the agenda of governments for more than 20 years. Rotary’s PolioPlus programme, established in 1985, has raised hundreds of millions of dollars to fund immunisation campaigns in 125 countries and mobilised more than 1 million volunteers. Rotary has successfully partnered with governments, UN agencies, and multilateral organisations. Through networking and its capacity to cooperate, it has kept political apathy at bay and kept the issue of polio on the agendas of individuals who have the ability to influence outcomes. In Chapter 12, ‘Globalisation and the Politics of Health Governance: The Framework Convention on Tobacco Control’, Jeff Collin and Kelly Lee focus on the Framework Convention on Tobacco Control (FCTC), the WHO’s first attempt to exercise its authority to negotiate an international public health treaty. While the final text of the convention provides a more impressive policy template than many health advocates had expected, the significance of the FCTC lies primarily in the process of its negotiation. The chapter examines the political dynamics of the FCTC, highlighting the leadership role of developing countries, support among international organisations, a partial opening to civil society, and the efforts of tobacco companies to influence the process. The FCTC constitutes an explicit response to globalisation

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and an implicit attempt to regulate the conduct of transnational corporations. It thus has broader implications for global health governance. Part VI, ‘Defining Future Directions in Global Health Governance,’ turns from case studies to the general issue of governance. In Chapter 13, ‘Forging the Trade Link in Global Health Governance’, Benedikte Dal, Laura Sunderland, and Nick Drager argue that to effectively manage health risks that spill into and out of national borders, domestic health planners must work in tandem with their counterparts in foreign affairs and trade to attain policy convergence. Only through international cooperation and collective action can governments seek to address the multiple and inherently complex public health risks in an increasingly globalised world. As international trade is a major amplifier of public health risks across borders, states must develop robust population health policies prior to their integration into trade organisations and agreements. Responses to global health challenges increasingly require expertise in several disciplines. Multiple actors with often competing interests must be persuaded to reconcile their differences so that effective policies designed to mitigate health risks may be developed. Thus the emerging new discipline of health diplomacy is urgently in need of development. The concept and processes of health diplomacy are illustrated by the Intergovernmental Working Group on Public Health, Innovation, and Intellectual Property (IGWG), a body formed in 2007 to facilitate the work of the WHO’s Commission on Intellectual Property Rights, Innovation, and Public Health (CIPIH). The IGWG is an example of how evidencebased trade and health policy convergence can be attained through an inclusive and cooperative process, based upon the principles of trust and transparency, and the inclusion of performance measures to permit ongoing evaluation. In Chapter 14 ‘Explaining Compliance with G8 Health Commitments, 1996–2006’, John Kirton, Nikolai Roudev, Laura Sunderland, and Catherine Kunz examine why plurilateral and informal soft law bodies such as the G8 increasingly work with traditional international organisations to advance pressing international health issues. Beginning in the 1980s the G8 began to involve itself in health issues because of the growing vulnerability of its members states to emerging and reemerging infectious diseases, and a shared perception that the WHO was an ineffective leader in addressing global health challenges. The authors outline several schools of thought on the role of the G8 in strengthening global health governance, explain why G8 members comply with their respective health commitments, and identify how G8 leaders can craft their commitments in ways that improve compliance, by setting a one-year timetable and involving the WHO. In Chapter 15, ‘Global Health Initiatives: A Healthy Governance Response?’ Caroline Khoubessarian argues that official development assistance shortfalls and an under-funded WHO are the primary drivers of global health initiatives, such as funds set up through international organisations or large private foundations that typically focus on the prevention, control, or eradication of specific diseases. The successes of initiatives such as the International Campaign to Ban Landmines and the Jubilee Debt Campaign demonstrate that broad coalitions working outside of the traditional system can bring about positive change. Khoubessarian identifies

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the strengths and weaknesses of global health initiatives as a means of addressing global health problems. These initiatives have proven to be one way of building and engaging broad multi-layered networks. They may develop into effective global health governance if states are willing to support them through sustained funding. However, global health initiatives place specific single-issue initiatives in competition with one another for funding and attention, and mirror governments’ fixation on crisis management as opposed to developing collaborative, long-term public health strategies. These concerns need to be addressed before such initiatives can be viewed as global health governance structures worthy of emulation. Part VII concludes with Chapter 16, ‘Innovation in Global Health Governance’, by John Kirton and Andrew Cooper. It draws out patterns from the preceding 14 chapters. It begins with the challenges brought by globalised health threats and then examines the responses of the various public actors now involved in global health. It explores the innovations that have arisen in these responses to the new challenges. It concludes by assessing the responsiveness of the current system of global health governance and its possible transformation into a post-Westphalian form.

References Aginam, Obijifor (2004). ‘Salvaging Our Global Neighbourhood: Critical Reflections on the G8 Summit and Global Health Governance in an Interdependent World.’ Law, Social Justice, and Global Development, vol. 1. <www2.warwick.ac.uk/fac/soc/law/elj/lgd/2004_1/ aginam> (September 2008). Archibugi, Daniele and Kim Bizzarri (2004). ‘The Global Governance of Communicable Diseases: The Case for Vaccine R&D.’ Law and Society, vol. 27, no. 1, pp. 33–51. Beaglehole, Robert and Derek Yach (2003). ‘Globalisation and the Prevention and Control of Non-Communicable Disease: The Neglected Chronic Diseases of Adults.’ Lancet, vol. 362, pp. 903–908. Cooper, Andrew F. (2007). Celebrity Diplomacy. (Boulder: Paradigm Publishers). Cooper, Andrew F., John J. Kirton, and Ted Schrecker, eds. (2007). Governing Global Health: Challenge, Response, Innovation. (Aldershot: Ashgate). Dodgson, Richard, Kelley Lee, and Nick Drager (2002). ‘Global Health Governance: A Conceptual Review.’ World Health Organization and London School of Hygiene and Tropical Medicine, Geneva. <whqlibdoc.who.int/publications/2002/a85727_eng.pdf> (September 2008). Drager, Nick and Robert Beaglehole (2001). ‘Globalization: Changing the Public Health Landscape.’ Bulletin of the World Health Organization, vol. 79, no. 9, p. 803. <www.who.int/ bulletin/pdf/2001/issue9/bu1488.pdf> (September 2008). Fidler, David P. (2001). ‘The Globalization of Public Health: The First 100 Years of International Health Diplomacy.’ Bulletin of the World Health Organization, vol. 79, no. 9, pp. 842–849. Fidler, David P. (2004). ‘Germs, Governance, and Global Public Health in the Wake of SARS.’ Journal of Clinical Investigation, vol. 113, no. 6, pp. 799–804.

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Fidler, David P. (2007). ‘Architecture amidst Anarchy: Global Health’s Quest for Governance.’ Global Health Governance, vol. 1, no. 1. (September 2008). Fidler, David P. (2008). ‘A Theory of Open-Source Anarchy.’ Indiana Journal of Global Legal Studies, vol. 15, no. 1, pp. 259–284. Fidler, David P. and Laurence O. Gostin (2006). ‘The New International Health Regulations: An Historic Development for International Law and Public Health.’ Journal of Law, Medicine, and Ethics, vol. 34, no. 1, pp. 85–94. Garrett, Laurie (1996). ‘The Return of Infectious Disease.’ Foreign Affairs, vol. 75, no. 1, pp. 66–79. <www.foreignaffairs.org/19960101faessay4172/laurie-garrett/the-return-ofinfectious-disease.html> (September 2008). Garrett, Laurie (2007). ‘The Challenge of Global Health.’ Foreign Affairs. <www. foreignaffairs.org/20070101faessay86103/laurie-garrett/the-challenge-of-global-health. html> (September 2008). Godlee, Fiona (1994). ‘The World Health Organization: WHO in Crisis.’ British Medical Journal, vol. 309, pp. 1424–1428. Goodman, Neville (1971). International Health Organizations and Their Work. (London: Churchill Livingston). Gostin, Laurence O. (2004). ‘International Infectious Disease Law: Revision of the World Health Organization’s International Health Regulations.’ Journal of the American Medical Association, vol. 291, no. 21, pp. 2623–2627. Harrison, Mark (2006). ‘Disease, Diplomacy, and International Commerce: The Origins of International Sanitary Regulation in the Nineteenth Century.’ Journal of Global History, vol. 1, no. 2, pp. 197–217. Homer-Dixon, Thomas (2001). The Ingenuity Gap: Can We Solve the Problems of the Future? (Toronto: Vintage). Keohane, Robert and Joseph Nye (1977). Power and Interdependence: World Politics in Transition. (Boston: Little, Brown). Kickbusch, Ilona (2000). ‘The Development of International Health Policies—Accountability Intact?’ Social Science and Medicine, vol. 51, no. 6, pp. 979–989. Kickbusch, Ilona and Evelyne de Leeuw (1999). ‘Global Public Health: Revisiting Healthy Public Policy at the Global Level.’ Health Promotion International, vol. 14, no. 4, pp. 285–288. Kirton, John J. (1993). ‘The Seven Power Summits as a New Security Institution.’ In D. Dewitt, D. Haglund, and J.J. Kirton, eds., Building a New Global Order: Emerging Trends in International Security, pp. 335–357. (Toronto: Oxford University Press). Kirton, John J. (2007). Canadian Foreign Policy in a Changing World. (Toronto: Thomson Nelson). Kirton, John J. (forthcoming). Global Health. (Aldershot: Ashgate). Krasner, Stephen D. (1983). International Regimes. (Ithaca, NY: Cornell University Press). Labonté, Ronald and Ted Schrecker (2004). ‘Committed to Health for All? How the G7/8 Rate.’ Social Science and Medicine, vol. 59, no. 8, pp. 1661–1676. Morgenthau, Hans Joachim (1948). Politics among Nations: The Struggle for Power and Peace. (New York: Knopf). Osterholm, Michael T. (2005). ‘Preparing for the Next Pandemic.’ Foreign Affairs, vol. 84, no. 4, pp. 24–37. <www.foreignaffairs.org/20050701faessay84402/michael-t-osterholm/ preparing-for-the-next-pandemic.html> (September 2008).

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Peterson, Susan (2002). ‘Epidemic Disease and National Security.’ Security Studies, vol. 12, no. 2, pp. 42–81. Price-Smith, Andrew (1999). ‘Ghosts of Kigali: Infectious Disease and Global Stability at the Turn of the Century.’ International Journal, vol. 54, no. 3, pp. 426–442. Smith, Richard, David Woodward, Arnab Acharya, et al. (2004). ‘Commmunicable Disease Control: A “Global Public Good”.’ Health Policy and Planning, vol. 19, no. 5, pp. 271–278. Soper, George A. (1919). ‘The Lessons of the Pandemic.’ Science, vol. 49, no. 1274, pp. 501–506. t’Hoen, Ellen (2002). ‘TRIPS, Pharmaceutical Patents, and Access to Essential Medicines: A Long Way from Seattle to Doha.’ Chicago Journal of International Law, vol. 3, no. 1, pp. 27–46. Taylor, Allyn L. (2004). ‘Governing the Globalization of Public Health.’ Journal of Law, Medicine, and Ethics, vol. 32, no. 3, pp. 500–508. Thomas, Caroline and Martin Weber (2004). ‘The Politics of Global Health Governance: Whatever Happened to “Health for All by the Year 2000”?’ Global Governance, vol. 10, pp. 187–205. Trouiller, Patrice, Piero Olliaro, Els Torreele, et al. (2002). ‘Neglected Diseases and Pharmaceuticals: Between Deficient Market and Public Health Failure.’ Lancet, vol. 359, no. 9324, pp. 2188–2194. Widdus, Roy (2001). ‘Public-private partnerships for Health: Their Main Targets, Their Diversity, and Their Future Directions.’ Bulletin of the World Health Organization, vol. 79, no. 8, pp. 713–720. World Health Organization (1986). Ottawa Charter for Health Promotion. (Geneva: World Health Organization). <www.who.int/healthpromotion/conferences/previous/ottawa/en> (September 2008). World Health Organization (2001). ‘Global Health Security: Epidemic Alert and Response.’ WHA54.14, 21 May. Geneva. (September 2008). World Health Organization (2006). ‘Constitution of the World Health Organization.’ 45th ed. Geneva. <www.who.int/entity/governance/eb/who_constitution_en.pdf> (September 2008).

Part II Responding to Pandemics: Severe Acute Respiratory Syndrome

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Chapter 2

Epidemic of Fear: SARS and the Political Economy of Contagion Andrew T. Price-Smith and Yanzhong Huang

Great catastrophes may not necessarily give birth to genuine revolutions, but they infallibly herald them and make it necessary to think, or rather to think afresh, about the universe. —Fernand Braudel Catastrophes act as the principal catalysts of change, in the belief structures of those individuals who weather a given crisis, in the macro-level social structures of affected societies, or indeed in the relations among sovereign states. The emergence and diffusion of infectious disease on a global scale create a process that has been underway since the beginnings of intercontinental trade, as plague bacilli came to Europe via the Silk Road and Europeans bequeathed the terrible gift of smallpox to Amerindian populations with their discovery of the Americas (McNeill 1977; Crosby 1986). Public health victories against microbial adversaries reached a zenith in the mid 1970s; however, the pace and intensity of pathogen emergence have increased with the emergence of HIV, bovine spongiform encephalopathy (BSE), West Nile virus, severe acute respiratory syndrome (SARS), and virulent H5N1 influenza. Modern processes associated with continuing disease emergence include environmental degradation, the increased speed and magnitude of international trade and tourism, conflict, and inequities in the international distribution of resources between developed and developing countries.1 During the era of the Cold War, public health issues were typically consigned to the realm of ‘low politics’, with the exception of biological weaponry. With the end of superpower rivalry in the 1990s, issues of low politics, such as environmental change, terrorism, migration, and public health, began to ascend on the international agenda. The rise of HIV/AIDS as a threat to the economy, governance, and, perhaps, the security of societies in the developing world has galvanised the academic and policy communities, as well as many nongovernmental organisations (NGOs), into action against this emerging foe. The SARS epidemic of 2002–03 provided another example of the importance of public health as an international concern in this increasingly complex and interdependent world.

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During the outbreak, SARS produced significant levels of fear and psychological trauma in affected populations, impeded international trade and migration flows, and resulted in significant economic damage to the economies of many Pacific Rim countries (particularly China and Canada). This chapter argues that SARS generated substantial institutional innovation at the domestic level (particularly in China and Canada), while generating a powerful yet ephemeral change at the level of global governance.

Demographic Impact and Aetiology Despite the fact that the SARS epidemic threatened the economies of seriously affected states and posed a grave threat to the health of populations in the region, it was successfully contained with relatively little mortality. Specifically, the epidemic resulted in 8422 cases of infection (morbidity) and 916 deaths (mortality) between 1 November 2002 and 7 August 2003, exhibiting a mortality rate of approximately 10.88 percent (World Health Organization [WHO] 2003a). The SARS coronavirus is thought to be a novel zoonotic pathogen that recently crossed over from its animal reservoir (in which it had apparently gone from bats to civet cats) into humans (Peiris, Lai, and Poon 2003). It is imperative to note that the damage generated by the epidemic was not so much the result of the morbidity and mortality that SARS induced, but rather the fear and panic that the epidemic generated, both within infected areas and in uninfected populations.2 This fear resulted in sub-optimal economic outcomes for the entire Pacific Rim as tourism ground to halt, international trade flows were slowed, and foreign investors cautiously withdrew from the region during the crisis.

Literature Review For the catastrophe was so overwhelming that men, not knowing what would happen next to them, became indifferent to every rule of religion or of law … Athens owed to the plague the beginnings of a state of unprecedented lawlessness. Seeing how quick and abrupt were the changes of fortune … people now began openly to venture on acts of self-indulgence which before then they used to keep in the dark … As for what is called honour, no one showed himself willing to abide by its laws, so doubtful was it whether one would survive to enjoy the name for it … No fear of god or law of man had a restraining influence. As for offences against human law, no one expected to live long enough to be brought to trial and punished. —Thucydides

The study of the role of public health and international relations theory has its genesis in Thucydides’ account of the plague of Athens, wherein he observed the withering effect of contagion upon the governance of the Athenian city-state.

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Historians, including William McNeill (1977) and Alfred Crosby (1986), continued this discourse, noting the perennial influence of pathogens (and their vectors of transmission) upon the course of history and the fate of states (Diamond 2005). This historical tradition constitutes the theoretical bedrock for the investigations launched by political scientists who began their inquiries in the latter half of the 1990s (Pirages 1996; Price-Smith 1999). The nascent field of health security enjoyed a pronounced increase in salience in 2000, as the U.S. National Intelligence Council (2000) issued its National Intelligence Estimate on the threat that infectious disease posed to U.S. material interests. The inexorable expansion of the HIV/AIDS pandemic throughout the latter half of the 1990s resulted in the epidemic being designated a major threat to global security by the United Nations Security Council (UNSC) in 2000. This dramatic rise in the significance of global public health issues was augmented by the anthrax bioterror attacks of 2001 in the United States, and resulted in efforts by the academic and policy community to link health concerns to foreign policy and national security. In the post–September 11 era there has been a surge of scholarly activity in the field of health and international affairs. Such investigations have identified the emergence and recrudescence of pathogens as a threat to the economies, governance, and security of states and their populations (Price-Smith 1999; Peterson 2002; Singer 2002). Those who advocate a state-centric view see contagion as a significant threat to the material interests of the state such as its population base, economy, trade, foreign investment, the capacity of the military, and the apparatus of governance. This school perceives the state as motivated by self-interest to protect its power base, which by extension entails the protection of the health of its populace from pathogenic depredation. Due to the comparatively recent emergence of the SARS coronavirus, literature on the political dimensions of the epidemic is sparse. Elizabeth Prescott (2003) argues that the SARS epidemic illustrates the increasingly acute nature of complex interdependence among states in the domain of public health, and provides lessons that may help states in their efforts to prevent bioterrorist attacks. She observes that the emergence of the contagion ‘illuminated significant and vital weaknesses in global and local preparedness for surprise outbreaks’ (211). Melissa Curley and Nicholas Thomas (2004) argue that infectious diseases (the SARS outbreak in particular) represent a significant and growing threat to human security in southeast Asia, while David Fidler (2004) conceptualises SARS as a threat to the material interests of the state, which would seem to fit classical realist models. A classical (or republican) realist perspective views epidemic disease as a distinct threat to the material and perhaps ideational interests of the sovereign state, through its destruction and debilitation of the populace, disruption of institutions of governance, and generation of fear that erodes prosperity.3 A caveat, however, is required: even though classical or republican realism supports the notion of disease as a threat to the material interests (i.e., to prosperity and governance) of the state, strategies of self-help in an increasingly globalised world are likely to be less than effective. This is particularly true of countries in the developing world that possess lower

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levels of endogenous capacity to respond to disease outbreaks (Price-Smith 2008). Ethnocentric visions of global health that exclusively advocate self-help, to the exclusion of building capacity in the developing world, are myopic. This suggests that while realism is a useful lens through which to view the challenge posed by contagion, liberal institutional recommendations and the acceleration of international cooperation are the means by which to maintain surveillance and containment of pathogens effectively on a global scale.4 The emergence of the SARS pathogen in China and later in Canada demonstrates that both developing and highly developed G8 countries remain vulnerable to emerging and re-emerging pathogens. The emergence of BSE in the United Kingdom in the mid 1990s, its subsequent spread throughout the European community, and its extension to Japan, Canada, and the U.S. form a vivid illustration that developed countries are not immune to the deleterious effects of novel epidemic disease agents. Due to the processes of microbial evolution, pathogens will continue to evolve rapidly and colonise ecological niches within all human societies. Theoretical Ramifications The central problem is that existing theories of international relations do not deal well with the problem of the global proliferation of pathogens. Ernst Haas (1964) advocated a functionalist paradigm, stipulating that incremental progress in cooperation between states on technical issues would produce radiating effects to generate protoregimes. The economist Joseph Schumpeter (2005) argued that catalytic events and processes could generate ‘creative destruction’ wherein dysfunctional institutions were dissolved and replaced with more effective successors. In a Schumpeterian sense epidemics have generated profound disruptions, but have often acted as catalysts of change as well, generating transformation in the belief structures of policy makers, in the economic and social structures of affected polities, in the relations between society and the state, and, ultimately, among sovereign states. In fact, in light of the historical evolution of public health regimes, it becomes apparent that the process is primarily driven by a dynamic of punctuated equilibrium (PE).5 PE theory essentially holds that the progress of human societies (and institutions) is in fact non-linear, and that the evolution of a given society depends heavily upon its reaction to exogenous shocks that destabilise the pre-existing order, undercutting the legitimacy and cohesion of social hierarchies.6 This PE paradigm is more compelling than functionalist paradigms because it accounts for the reactionary and non-linear spurts of human social ingenuity that modify structures of governance at both the inter-state and intra-state levels.7 The SARS epidemic of 2003 provides additional evidence to support PE theory in the domain of political science. The outbreak of SARS in China in late 2002 and its spread throughout the Pacific Rim in the first half of 2003, is a good example of an exogenous shock. Specifically it destroyed the mythology (prevalent at the time) that infectious disease was primarily a concern for the developing countries of the

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world, which possessed limited levels of endogenous state capacity.8 The infection of populations in Canada, Hong Kong, and Taiwan by the SARS coronavirus illustrated a central component of public health: microbes evolve to colonise all available ecological niches (Morse 2001). Therefore, as a result of the SARS contagion, developed countries realised that they too were vulnerable to the proliferation of debilitating and lethal pathogens. Political theories of PE have been utilised with increasing frequency in the realm of comparative politics (Skocpol 1985) and recently in the realm of international relations theory. Robert Jervis (1997, 39) argues that ‘jumps rather than smooth progressions often characterize operations of systems … [and] when variables interact in a non-linear manner, changes may not be gradual. Instead, for a prolonged period there may be no apparent deterioration, followed by a sudden collapse or transformation’ (see also Blyth 2002; Diehl and Goertz 2000). Stephen Krasner (1984, 240) concurs, stating that ‘studies of political development point to differential rates of change in social and political structures over time’. Such models typically hold that a shock may destabilise the status quo, generating in response a burst of human social and technical ingenuity and significant incentives for international cooperation (Homer-Dixon 2001). However, following this burst of ingenuity, there follows a plateau during which concern over the issue of public health declines, only to awaken during the next crisis situation. Therefore, PE models are optimal for explaining the evolution of public health as an issue in the domain of international relations. To date, theories of international relations have a rather difficult time integrating the growing threat of epidemic disease, which originates at the domestic level but may subsequently manifest as an externality at the global level in the form of pandemic disease. If such a non-linear (PE) perspective is adopted, then the evolution of structures of governance in the face of epidemic disease might best be understood as following the trajectory of a PE model. In this instance, an exogenous shock challenges the capacity and resilience of a state (or system). If the populace is innovative and hardy, and apparatus of governance flexible (i.e., it possesses sufficient endogenous capacity), then the state will survive. In a Darwinian sense the shock generates a spurt of ingenuity that propels a given society to a higher level of social and technical innovation. However, states that possess lower endogenous capacity, and therefore lack resilience, will succumb and falter, periodically disintegrating into a state of chaos, stabilising, and then failing again. As William Zartman (1995) argues, it is a process akin to that of a ball falling down a set of stairs, a descent followed by partial stabilisation, only to be followed by another plunge. A rational critique of such a PE model might argue that the role of epistemic communities would be valuable in explaining the role of cooperation, in that microbiologists effectively communicated their concerns to decision makers who then modified existing regimes to deal with forthcoming epidemics. Unfortunately, such a proactive model is not borne out by historical evidence, as nations typically exhibit reactive and not proactive stances regarding disease surveillance and control. Epistemic communities have been successful in generating change based on two

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principal factors: first, the existence of a real threat to the material interests of a given state as a result of epidemic disease and, second, the interpretation of the scientific communities concerns into the language of materialism and national security by the policy community in order to galvanise political action.

On Materialism and Fear The actions taken by the policy community, such as improved global pathogen surveillance systems and public health regimes, are then the product of two central factors, namely materialism and fear. Epidemics have historically generated extraordinary levels of affect (i.e., emotion) within involved populations, leading to generalised economic and social chaos within the states direclty involved, and to quarantine and trade embargo (i.e., isolation) by other states that fear the spread of contagion. The emergence of a novel pathogen is accompanied by high levels of uncertainty regarding its virulence, transmissibility, and aetiology. This uncertainty generates high levels of negative affect (fear), which in turn generates very real damage to a state’s material interests, over and above the actual morbidity and mortality that result from the epidemic. The SARS epidemic provides a vivid illustration of this paradigm wherein the emergence of the SARS coronavirus, coupled with seemingly high levels of both virulence and transmissibility, combined to generate extreme levels of anxiety throughout the entire Pacific Rim community. Major epidemics have historically produced significant worry, anxiety, fear, panic, and even mass hysteria in an affected society. Depressed and helpless, victims and survivors may heavily discount their future and engage in all kinds of risky behaviour, such as crimes and riots, that put the social fabric to a severe test. Confused and shocked, people may turn to superstitious or bizarre practices during an outbreak. Moreover, fear and panic generated by the disease can also take the form of mass exodus. For example, when plague struck Surat, a city in the western part of India in 1994, the fear of an epidemic was so intense that 500 000 residents fled in less than a week. A series of factors exacerbated SARS-associated fear and panic during the course of the contagion. First, the virus is highly pathogenic and contagious as the main route of transmission was direct contact, via the eyes, nose, and mouth, through infectious respiratory droplets. Unlike the threats of HIV/AIDS, it is difficult to control the behaviour that caused the transmission of the disease. Second, the disease exhibited relatively high levels of mortality in infected hosts. The morbidity rate of 10.88 percent is significantly higher than the 2.5 percent case fatality rate for the 1918 Spanish influenza, which led to the death of approximately 50 million people worldwide (Johnson and Mueller 2002; Taubenberger and Morens 2006). Third, SARS is an indiscriminate killer that affected all classes, genders, and ethnicities. The contagion was reported to have passed through the exclusive Zhongnanhai compound, the headquarters of China’s Communist Party.

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Moreover, the fact that SARS was an entirely novel pathogen meant that public health personnel did not have a clear idea of the symptoms, routes of transmission, and effective prevention of transmission during its outbreak. This uncertainly not only resulted in diagnostic delays or misdiagnosis, but also put healthcare workers at particular risk. Witnessing that nurses and doctors were unable to protect themselves from the infection, the public developed a highly exaggerated estimate of their personal risk of being infected. A nationwide survey of 1026 respondents in China found that manifestations of panic were exhibited by 19 percent of the people in areas with local transmission and 11 percent of the people in areas without local transmission.9 Similarly, an online internet survey of 1070 students of the University of Hong Kong between 16 April and 22 April 2003 found a profound level of stress (49 percent) among the respondents (Chan 2003). Within the People’s Republic of China (PRC), a governmental information clampdown and a fatal period of hesitation further magnified levels of fear and anxiety, leading to widespread speculation and rumour mongering. As early as 8 February, reports about a ‘fatal’ influenza began to be sent via short messages on mobile phones in Guangzhou, capital of Guangdong province (‘Officials Need to Stay on Top of Rumour Mill’ 2003). Soon, residents in Guangzhou and other cities cleared pharmacy shelves of antibiotics and influenza medication. In some cities, even vinegar, believed to be a disinfectant, was sold out. The panic spread quickly to other provinces as well. Farmers in many provinces set off firecrackers in the belief that would frighten off SARS. In the northwestern province of Shaanxi, farmers invited sorcerers and sorceresses into their homes to help them exorcise the flu-like virus. At the height of the epidemic in Beijing, a sea of people in white masks—most of them scared migrant workers and university students—flocked to train and bus stations and airports in the hope of fleeing the city. By late April, an estimated 1 million people, around 10 percent of the population, had fled the city for other parts of China. They would soon find themselves personae non gratae even in their hometowns. In the countryside, worried villagers set up roadblocks to keep away people from Beijing. A series of riots against quarantine centres were also reported in May. This fear resulted in substantial negative economic impacts on affected nations. The rapid spread of the lethal disease and the perceived high risk of social interactions led people in affected regions to alter their daily routines and leisure habits. Restaurants, air-conditioned shopping malls, and public entertainment venues such as theatres and internet cafés were either closed or avoided. Meanwhile, fear of contagion and the implementation of anti-epidemic measures discouraged travel and interrupted transport services. This caused substantial decline in consumer demand in the service sector. The adverse demand shock affected two industries in particular: retail sales and tourism. By mid April 2003 retail sales in Hong Kong had declined by 50 percent relative to mid March indicators (WHO 2003c). Additionally, tourism arrivals from mainland China had fallen by between 75 percent to 80 percent, and the entertainment and restaurant industries had recorded an 80 percent decline in business. In general, the economic shock was far greater for those economies with a prominent service sector and that possessed a larger share of affected industries (i.e.,

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retail sale and tourism) within that sector. This may explain why Hong Kong, with its losses accounting for 2.9 percent of gross domestic product (GDP), suffered the worst given the size of its economy (Asian Development Bank [ADB] 2003). In early April 2003, Morgan Stanley chief economist Stephan Roach estimated the global economic cost of SARS at circa US$30 billion (WHO 2003c). The Far Eastern Economic Review later estimated initial SARS-related damage to regional GDP growth at US$10.6 billion to US$15 billion (Saywell, Fowler, and Crispin 2003). If SARS had continued to spread, quarantines could have affected manufacturing, which accounted for approximately 30 percent of Asia’s GDP (minus Japan), by closing factories and slowing trade (13). If the costs of premature deaths of income earners, lost workdays of sick employees, and health care were factored into the equation, the eventual bill for the region could total almost US$50 billion. China sustained significant losses in its service sector, which makes up 33.6 percent of the country’s GDP (China, National Bureau of Statistics 2002). SARS caused a decline in sectoral productivity of 6.8 percent during the second quarter (‘GDP Growth Revised Up for 1st Half of 2003’ 2004). According to a government economist, the loss borne by the sector was 23.5 billion yuan, including 20 billion yuan in tourism and 3.5 billion yuan in retail sales (Hu Angang and Linlin 2004). Based on the economic indicators of China’s economy affected by SARS, the Asian Development Bank (2003) put the GDP losses in China at US$6.1 billion, or 0.5 percent of total GDP. If calculated by total final expenditure, the total loss was US$17.9 billion, or 1.3 percent of China’s GDP. While the dampening of tourism and consumer confidence is the most important channel through which SARS wreaked havoc, other developments during the outbreak highlighted the fragility of China’s economy. In some regions, people rushed to purchase daily necessities, and this panic buying threatened to trigger a ‘bank run’ that could have further disrupted China’s ailing financial industry, where state-run banks were generally in poor financial shape and were frequently confronted with rumour-driven mass withdrawals. Moreover, China’s export sector—the engine of its economic growth—was threatened by calls for other countries to quarantine China, and thereby suspend all travel links with the country until it implemented a transparent public health campaign. During the crisis, 110 out of the 164 countries with which China had diplomatic relations placed at least some restrictions on travel to China (Embassy of Switzerland 2003). If SARS had persisted and disrupted the production and supply line, the increased risk profile associated with doing business in China would have led to a reduction in foreign investment and exports, which eventually would have hurt China’s manufacturing sector (which accounts for a hefty 36.8 percent of the country’s GDP) (Fei Feng 2006). The end result would be a rapid decline in the economic growth rate, on which the regime’s legitimacy hinges (see below). The emergence of HIV/AIDS was also initially accompanied by high levels of fear, but given that transmissibility is more difficult, it did not significantly compromise international trade. At this point a distinction between two types of epidemics must be made: outbreak events, such as SARS and the plague of Surat in

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1994, generate significant levels of fear, which then damages the material interests of the state (primarily economic interests); and attrition epidemics, which include the HIV/AIDS pandemic, malaria, and tuberculosis (TB), do not generate similar levels of fear as there is relatively high certainty about morbidity, mortality, and pathways of transmission regarding these pathogens. However, attrition epidemics do very much threaten the material interests of the state through the inexorable debilitation and destruction of its populace, weakening of military forces, depletion of human capital, erosion of governance capacity, and general macroeconomic decline. States will then seek to cooperate in order to limit transmission to prevent the erosion of their material interests and this becomes the basis for regime formation. In both cases a PE model remains useful, although it is more applicable to the outbreak cases. However, whereas realism and the state’s concern for its material interests would seem to be the principal motivating force impelling it to act, realism does not provide a theoretical framework that is effective in containing pathogens, particularly in the context of increasing international trade flows and migration. Sovereign states have realised that strategies of self-help are doomed to failure as borders are increasingly porous in this modern era of globalisation. Effective surveillance and containment of pathogenic threats must necessarily include high levels of cooperation with other sovereign states, as moderated by international institutions and assisted by NGOs. It is ironic then that the basis of state concern is the prism of realism, yet realist strategies of self-help will likely result in significant losses for all states, even a hegemon. Liberal strategies of cooperation among sovereign states, increased transparency, and the dissemination of information through international organisations and NGOs permit pareto-optimal outcomes not possible under realist constraints.

History of an Epidemic The epidemic of SARS began in Guangzhou in November 2002. A physician who attended the ill, Dr. Liu Jianlun, inadvertently became the index case for a global chain of transmission when he travelled to Hong Kong and unknowingly infected other travellers, who then spread the disease throughout the Pacific Rim countries (Vietnam, Canada, Singapore, Taiwan, and other regions of China). Despite attempts to suppress dissemination of epidemiological information, in February 2003 the Chinese Ministry of Health notified the World Health Organization (WHO) that 305 cases of acute respiratory syndrome (of unknown cause) had occurred in Guangdong province of southern China since November 2002. In that same month a Chinese traveller to Hanoi infected several healthcare providers there. Later that month a cluster of similar illness among healthcare workers occurred in Hong Kong. On 12 March, the WHO issued a global outbreak alert and began international surveillance efforts to track this syndrome. At that point the contagion had spread throughout the states of the Pacific Rim, with the greatest incidence of cases in China (5327), Hong Kong (1755), Taiwan (665), Canada (251), Singapore (238), Vietnam (63), and the U.S. (33) (WHO 2003d).

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Effective response to the epidemic was initially complicated by fear, confusion, and denial in China, as Beijing engaged in a deliberate attempt to suppress knowledge of the epidemic in both the domestic and international arenas. According to Yanzhong Huang (2003, 65), the first SARS case was ‘thought to have occurred in Foshan, a city southwest of Guangzhou in Guangdong province, in mid November 2002’. Reports on the spreading illness by the health authority in Guangdong province were classified as top secret by Beijing, such that the disclosure or discussion of the outbreak was a direct violation of the State Secrets Law (66). Ultimately, the epidemic generated such levels of panic among the general Chinese populace that warnings of the growing crisis leaked out through individuals on the internet. Yet Beijing persisted in its attempts to mislead the WHO. On 27 February the Chinese Ministry of Health declared the epidemic to be officially over, while the disease was actually spreading rapidly through the populace of Beijing (Fidler 2004, 75). The Chinese began to crack on 4 April, when the head of the China Center for Disease Control and Prevention (China CDC) publicly apologised to the Chinese people and international community for failing to inform the public about a highly contagious and frequently lethal new infection (Pomfret 2003b). The full extent of Beijing’s duplicity became clear when on 9 April a prominent Communist Party member (and physician), Jiang Yanyong, publicly accused the government of covering up the extent of the epidemic in Beijing (Pomfret 2003c). On 16 April the WHO took the unprecedented step of issuing a very public rebuke of China’s actions, chastising Beijing for misleading the global community regarding the true extent of SARS infection throughout that country (Pomfret 2003a). Two days later chastened national leaders announced a national war on the virus, and ordered Communist Party officials to reveal the true extent of the epidemic or be held accountable. On 20 April, the party leadership sacked the minister of health, Zhang Wenkang, and the mayor of Beijing, Meng Xuenong, for their complicity in the cover-up (Fidler 2004, 98). This move was seen as an attempt to deflect blame from senior party officials for their role in the crisis, and was summed up in the Chinese idiom ‘scaring the chickens to catch the monkey’ (Curley and Thomas 2004). Vietnam’s superior response to the outbreak resulted in that country being declared SARS free on 28 April. On 5 July 2003, the WHO announced that the SARS epidemic had been effectively contained. Despite the fact that the international community successfully contained the spread of the virus in a relatively brief span of time, the medical community insisted that it represented a significant global threat. Thomas Tsang, the epidemiologist who oversaw the investigations in Hong Kong, commented that there was a possibility of a global pandemic ‘if the appropriate control measures were not taken’ (Bradscher and Altman 2003).

Costs of the Epidemic in Canada Unfortunately, the economic effects of the SARS epidemic remain largely unknown, particularly on the Canadian economy. At the sectoral level, the SARS epidemic had a pronounced negative impact on the Canadian economy in the second and third

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quarters of 2003. Industries that bore the brunt of the contagion included tourism and hospitality and the film industry. Toronto’s film, television, and commercial business—the largest in Canada—brought in a billion dollars per year, and it was badly damaged by the epidemic of 2003, as foreign production houses withdrew their operations. According to Joe Halstead, commissioner of economic development for the City of Toronto, the SARS epidemic resulted in a decline of production, resulting in a loss of CA$163 million (roughly 18 percent) for the film sector in 2003 (Porter 2004). Commercial production in the city exhibited a similar decline of CA$32.8 million in 2003 (roughly 20 percent) (Porter 2004). These statistics were compiled from permit applications that production houses must file with the City of Toronto. Tourism in Ontario also took a significant hit as a result of the epidemic. The City of Toronto estimated a drop in tourism of 18 percent during 2003, largely as a function of the epidemic and its after effects (Porter 2004). According to Jeff Dover of KPMG, the SARS epidemic resulted in the loss of approximately CA$993 million in the tourism sector of the Canadian economy during the second and third quarters of 2003 (Spears 2003). Macro Level SARS seems to have been largely responsible for a pronounced economic downturn in Ontario, Canada’s largest province, where it resulted in two consecutive quarters of economic decline in 2003. Ontario finance minister Gregory Sorbara noted that the widespread decline was ‘an economic downturn that was driven by SARS’ (Little 2004). According to Ministry of Finance estimates, Ontario’s real GDP fell by 0.7 percent in the second quarter, and by a further 2.5 percent decline in the third quarter of 2003. Fortunately, the economy rebounded in the fourth quarter when growth reportedly increased at a rate of 4.5 percent (Little 2004). The minister of health for Ontario during the epidemic, Tony Clement, revealed that SARS had cost the province’s healthcare system CA$945 million as of 27 June 2003. Cost increases were associated with extra staffing needs, special supplies required to protect healthcare workers, and expenditures to build specialised SARS isolation and treatment facilities (Little 2004). Altogether the best-guess estimate is that the contagion cost Ontario at least CA$1.5 billion in 2003, a significant blow to the Canadian economy.

Effects on Domestic Governance in Canada Given that the SARS epidemic would seem to have ushered in a new era of increased cooperation between states for the purposes of health, it is ironic that the epidemic revealed significant problems in governance within those sovereign states most affected by the epidemic (namely Canada and China). Fidler (2004) and Huang (2003) have published exhaustive works regarding the effects of the SARS contagion on governance within China. The effects of the contagion on governance in Canada,

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and the problematic responses of the government at both the provincial and federal levels, deserve serious investigation. Specifically, in the Canadian case the epidemic revealed that Canadian public health infrastructure was fragile, particularly in the province of Ontario, which saw the most significant outbreak of SARS outside of China. Ontario experienced significant problems in infection control, ranging from the questionable leadership of Colin D’Cunha, the province’s commissioner of public health, to problems in staffing hospitals, to the persistent violation of quarantine and subsequent spread of infection. The Canadian case also illustrates chronic problems in communication between the provincial government in Toronto and the federal government in Ottawa, exacerbated by the perennial conflict over which tier of governance should preside over matters of public health. At present such duties are relegated to the provinces, as is the matter of funding supplemented by transfer payments from Ottawa. Partisan differences may have also led the Liberal federal government of Prime Minister Jean Chrétien to be less than cooperative with Ontario’s Conservative provincial government of Ernie Eaves. The Chrétien government also demonstrated a significant failure of leadership during the crisis, as the federal minister of health, Anne McClellan, often proved less than cooperative in her dealings with the province and the WHO. Moreover, Chrétien displayed a striking lack of leadership when he refused to interrupt his vacation abroad to return to Ottawa and deal with the rapidly expanding epidemic in the Greater Toronto region. As a result of these glaring deficiencies in the Canadian response to the epidemic, the SARS commission (under the stewardship of Justice Archie Campbell) determined precisely how the system failed, and developed recommendations for improving the response capacity of Canadian public health delivery (SARS Commission 2006). Prescott (2003, 218) chides Canadian officials for their limited response to the emergence of contagion in Toronto: Canadian officials appeared to be more concerned with the short-term impact of a [WHO] travel advisory on tourism, retail and other industries, even though the epidemic appeared to have spread through the community and to other countries partially because the Canadian health authorities had ignored a WHO advisory that all departing passengers from Toronto be screened by medical personnel.

Ultimately, the Canadian response to the exogenous shock of the SARS epidemic provides some evidence to confirm the PE model. Specifically, the federal government created a new Cabinet-level Public Health Agency of Canada (PHAC), led by a chief public health officer who (despite a certain degree of autonomy) reports to the minister of health. A central mission of this agency is the facilitation of cooperation between the federal and provincial governments in the domain of public health emergencies. This clearly demonstrates the increasing salience of public health issues in the mind of Canadian political elites. The SARS debacle clearly resulted in the elevation of public health to the level of ‘high politics’ in Ottawa. This is evident in the reference in the report of Canada’s National Advisory Committee on SARS and Public Health (2003, 220) to Benjamin Disraeli’s argument that ‘public health was the foundation

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for “the happiness of the people and the power of the country. The care of the public health is the first duty of the statesman.”’

Effects on Domestic Governance in China While the epidemic inflicted significant short-term economic damage to Pacific Rim economies, it also had important implications for intra-state governance. The SARS epidemic exposed significant problems in China’s governance structure. Initially, the government chose not to publicise the outbreak for fear that this would have a negative impact on economic development. The information clampdown persisted even after the epidemic spread to Beijing, in part because the party-state did not want SARS to ruin the meeting of the National People’s Congress (NPC), a showcase for its highly controlled and carefully staged version of participatory democracy. By early April, it was evident that SARS had already raised the eyebrows of the central leaders. Yet the government’s ability to formulate a sound policy against SARS was impeded by lower-level government officials who intercepted and distorted the information flow up the chain of command. It was alleged that Beijing municipal authorities, for example, deliberately hid the actual SARS situation in the city from the party centre. Initial deception by lower-level officials led the central leaders to misjudge the situation and declare on 2 April that SARS had already been brought under effective control. The cover-up paralleled the absence of effective official response to the original outbreak. As late as 20 January the ministry of health was aware that a dangerous new type of pneumonia existed in Guangdong. However, China CDC did not issue a nationwide bulletin to hospitals on how to prevent the ailment from spreading until 3 April. It was not until mid April that the government formally listed SARS as a disease to be closely monitored and reported on a daily basis under the Law of Prevention and Treatment of Infectious Diseases. The Chinese government thus waited more than three months before taking decisive action. This lack of ‘sensitivity’ was to large extent caused by the problem of ‘connectivity’ (i.e., interdepartmental cooperation). In addition to the tensions among different levels of health authorities, coordination problems existed between functional departments and territorial governments, and between civilian and military institutions. Organisational barriers also delayed the process of correctly identifying the cause of the disease. In fact, China CDC had to negotiate with local disease-control centres to obtain the virus samples. As the number of new cases in Beijing grew rapidly, a significant burden was imposed on the healthcare system, particularly its hospital capacity. Overwhelmed by the extraordinarily high flow of traffic through emergency rooms in mid April, major hospitals in Beijing took few measures to reduce the chances of cross-infection. The crisis raised serious concerns about the capacity of the health systems in resourcepoor regions to cope with a pathogenic challenge on the scale of SARS. Paradoxically, the SARS crisis also granted an opportunity for the Chinese government to address internal governance problems. As Albert O. Hirschman (1991)

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suggests, politicians have strong incentives to exploit crisis and danger and emphasise the risks of inaction in order to mobilise opinion and arouse action. In view of the dying communist ideology and official resistance to democracy, the legitimacy of the current regime in China is performance based, rooted in delivering economic growth. The possibility of an economic recession caused by SARS, therefore, posed a direct threat to the regime’s legitimacy. In the words of Premier Wen Jiabao, ‘the health and security of the people, overall state of reform, development, and stability, and China’s national interest and international image now are at stake’.10 This perceived crisis impelled the central leaders rally the full potential for autonomous action. On 17 April the PRC’s national leaders convened an urgent meeting to kick off a national war on the epidemic. This dramatic policy switch was accompanied by a significant relaxation of media control as government media began to publicise the number of SARS cases in each province, updated daily. The crisis also led to government efforts to increase bureaucratic control and earmark more financial resources for anti-SARS campaign. On 23 April, a task force known as the SARS Control and Prevention Headquarters of the State Council was established to coordinate national efforts to combat the disease, with Vice Premier Wu Yi appointed as commander-in-chief. The same day, a national fund of 2 billion yuan (US$242 million) was created for SARS prevention and control. As part of a nationwide campaign to mobilise the system, the State Council sent out inspection teams to 26 provinces to scour government records for unreported cases and to fire officials for lax prevention efforts. According to the official media, by 8 May China had sacked or penalised more than 120 officials for their ‘slack’ response to the SARS epidemic. These actions shook the complacency of local government officials, who then abandoned their initial hesitation and jumped onto the anti-SARS bandwagon. With the intensive and direct involvement of the party centre, maximum interagency and intergovernmental cooperation were achieved. Indeed, it took only one week for China to construct and put into operation a SARS hospital that had the capacity to accommodate 1200 patients. In addition to this augmentation of state capacity, the crisis apparently forced the government to take steps to establish an image of a more open and transparent government.11 On 2 May the official Xinhua news agency reported a submarine accident in April that had cost 70 lives, which marked a significant departure from the traditionally secretive approach taken to the nation’s military disasters. The SARS transparency campaign also provided incentives to be more open in dealing with other infectious diseases. After July 2003, information on current veterinary epidemics, such as foot and mouth diseases, swine vesicular disease, and avian influenza were no longer classified as state secrets. In retrospect, the SARS crisis challenged the traditional concept of governance in China and helped to elevate the status of public health significantly on the government’s agenda. The government has now realised that economic development does not trickle down, and that public health should be treated as an independent criterion of good governance. Premier Wen said that ‘one important inspirational lesson’ the new Chinese leadership learned from the SARS crisis was that any

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‘imbalance between economic development and social development’ was ‘bound to stumble and fall’.12 The government since then has earmarked billions of dollars for the public health sector. On various occasions since the crisis, central leaders have emphasised the importance of public health, especially public health emergency response. The government capacity to mobilise against a disease outbreak is enhanced by a more institutionalised crisis management system. The Regulations on Public Health Emergencies issued by the State Council in mid May 2003, for example, require setting up an emergency headquarters right after a public health emergency is identified. By the end of 2005, 66 percent of the township and health centres, 90 percent of the health institutions at or above county level and 100 percent of the centres for disease control had built the internet-based disease reporting system, allowing hospitals to report suspected infectious disease cases directly to China CDC and the ministry of health. The epidemic also created incentives for Chinese leaders to show a new, more proactive attitude toward AIDS. Since then, discourse and action relating to HIV/AIDS have changed dramatically, with senior leaders facing the epidemic with a greater sense of awareness, openness, and responsibility. The Chinese case underscores the importance of democratic values in good governance, but democracy itself is not sufficient for effective governance during public health crises. In this regard, Canada provides a very good example that even an advanced democracy can experience serious problems in public health governance. Indeed, SARS revealed the limitations of the country’s expensive system of universal health care, prompting the federal and provincial governments to review the public health policies and infrastructure. The effects of the contagion on governance in Canada, and the problematic responses of the government at both the provincial and federal levels, therefore deserve serious investigation. Specifically, in the Canadian case the epidemic revealed that Canadian public health infrastructure was fragile, particularly in the province of Ontario, which saw the most significant outbreak of SARS outside of China. Gambling that budget cuts in public health controls would not matter, the Conservative provincial government in 2001 laid off five scientists charged with disease surveillance. Public health disasters, such as the infection of the water supply in Walkerton, Ontario, with E. coli went unheeded by a government bent on cost cutting. The provincial government subsequently paid an onerous price for such short-sightedness, complacency, and thoughtlessness. Effects on Regional Governance in the Pacific Rim As the SARS epidemic intensified, the members of the Association of South East Asian Nations (ASEAN) grew increasingly aware of the threat the contagion posed to their populace and their economies. Anxiety in this region was reinforced by prior shocks to governance, such as the Asian financial crisis of 1997–98, as well as the regional environmental effects of the haze from ubiquitous fires throughout the region during the same time. As Prime Minister Goh Chok Tong of Singapore admitted, SARS had a bigger impact on the country than the 1997–98 financial

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crisis: the country suffered only ‘collateral damage’ during the financial crisis, but this time its economy (notably tourism) was directly hit, and there was a danger of ‘total shutdown’ (‘The SARS Outbreak—Interview: Goh Chock Tong, Leading the Charge against SARS’ 2003). Indeed, fear arose in Singapore that SARS could provoke its worst crisis since independence in 1965. Singapore, of course, was not the only country that worried about SARS. As a global alert had been sounded on the disease, many travellers were avoiding Asia indiscriminately, which translated to a significant drop in tourist revenue. As Thai prime minister Thaksin Shinawatra astutely noted, ‘the fear of SARS is worse than SARS itself’ (Crampton 2003). While concerns of economic loss were shared by leaders throughout the region, the rapidly spreading epidemic also generated a strong sense of urgency for regional cooperation. On 26 April, the health ministers of ASEAN +3 (China, Japan, and South Korea) met in Kuala Lumpur to voice their willingness to cooperate. Subsequently, leaders from the ten ASEAN members attended an emergency summit in Bangkok on 29 April. The Bangkok Summit was initiated by Goh Chok Tong, who was also instrumental in framing the agenda. ASEAN became the ideal platform for discussing this issue. According to Goh, he first called leaders of three countries—Malaysia, Thailand, and Cambodia (which held the chair of ASEAN in 2003); once they agreed on the necessity of having such a meeting, he called all the other ASEAN leaders. Unlike previous Asian summits, which generated more rhetoric than action, the final communiqué of the Bangkok Summit stated that there was a ‘collective responsibility to implement stringent measures to control and contain the spread of SARS and the importance of transparency in implementing these measures’ (ASEAN 2003). ASEAN members agreed that all states in the region would immediately commence mandatory screening for SARS at their borders. The declaration further agreed on various measures to stop SARS transmission, including: • sharing information on the movement of people by building a SARS containment information network; • coordinating prevention measures by standardising health screening for all travellers (i.e., common protocols for air, land, and sea travel) and adopting an isolate-and-contain approach (rather than a blanket ban on travel) in SARS control; • establishing an ad hoc ministerial-level joint task force to decide on and monitor the implementation of the decisions made at the April 2003 meeting and the ASEAN+3 health ministers special meeting on SARS. China and representatives from Hong Kong were invited that same day to attend a follow-up summit. Recognising that the cross-boundary spread of SARS posed a common challenge to the region, Chinese premier Wen made it clear that the disease could ‘only be effectively countered by cooperative efforts at the regional and international levels’.13 The domestic–international linkage also created strong incentives for China to cooperate with ASEAN countries. Before the Bangkok Summit, Chinese leaders were already under fire in Asia for orchestrating an official

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cover-up of the disease. By calling for combating SARS in a ‘transparent and effective manner’, southeast Asian states subtly intervened in China’s domestic affairs as a compensation for their weakness at the international level (ASEAN 2003). During this special ASEAN-China leaders meeting, however, ASEAN diplomats were very careful not to criticise Beijing’s mishandling of the epidemic directly, but rather to seek China’s cooperation in dealing with a highly sensitive issue. The idea was for ASEAN leaders to agree on a set of resolutions and measures for China to sign on to. On the part of China, once the power succession issues were resolved in the NPC meeting and a consensus was reached among political elites on the urgency and the necessity for action, the government was ready to ‘face reality and the world courageously and responsibly’ (Ching Cheong 2003). Keenly aware that the image of the country and the reputation of the new leadership were at stake, Wen was very open, candid, and cooperative at Bangkok. In the joint statement, China agreed to ‘associate itself with the measures proposed by the ASEAN declaration’ (Vatikiotis 2003). This seemingly half-hearted endorsement was indeed remarkable, given that a total embracement of the measures decided by the ASEAN leaders would be perceived in China as an act of submission. To demonstrate its commitment to cooperate with ASEAN countries, China proposed the creation of a special fund to support a variety of bilateral programmes with the ASEAN countries against the SARS contagion. Ultimately the Bangkok Summit proved to be a win-win case for both China and southeast Asia. For leaders in southeast Asia, the health crisis reinvigorated their association and served to equalise relations with China. China, on the other hand, deftly used the new dynamics created by the summit to expand its influence in this region. In October, China became the first ever ‘strategic partner’ of the ASEAN members, which was regarded as a victory over the suspicions that ASEAN members have long harboured toward China because of territorial disputes and ideological conflicts. In the words of Singaporean prime minister Goh Chok Tong, the SARS crisis may have been ‘the start of a new relationship between leaders in East Asia’ (Vatikiotis 2003). Another lesson of the epidemic was that despite ASEAN’s development of significant cooperative arrangements regarding containment of the epidemic, it remained the responsibility of its sovereign member states to implement those principles and to engage in suppression of the contagion. Moreover, the rapid response of ASEAN leaders and their willingness to cooperate in the containment of SARS were doubtless influenced by prior shocks to governance in the region such as the Asian financial crisis of 1997–98, as well as the regional environmental effects of the fires raging at that time. These shocks had generated incentives for ASEAN countries to become increasingly cooperative in managing complex transboundary issues.

Effects on International Health Governance Prior to the emergence of SARS, international health regimes (as governed by the International Health Regulations [IHR]) were seriously dated, for two reasons. First,

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since their inception in 1951 (in the form of the International Sanitary Rules), the IHR had not been revised adequately in the face of emerging novel pathogens. The IHR required the reporting of only three infectious diseases: cholera, plague, and yellow fever. Second, under the IHR the reporting of pathogen-induced morbidity and mortality was exclusively the domain of sovereign states. Historically, states have long sought to suppress the flow of information regarding endogenous epidemics, because the emergence of contagion typically generates significant negative effects upon the economy and society of infected states. Such pernicious effects range from the collapse of tourism to the decline in foreign investment, to the embargo of trade goods from affected nations. Thus states have had significant material incentives not to report the occurrence of epidemics accurately to the global community. In this sense, Beijing’s early attempts to suppress the flow of information to the WHO and Canadian officials’ insistence that WHO travel advisories were erroneous both reflect this historical pattern of tension between sovereign states and the WHO. Despite these problems, some important changes have taken place in international health governance regime since the 1970s as a result of technological advances, the rise of new and re-emerging infectious diseases, and the increasing involvement of non-state actors in addressing global microbial threats. At first glance, the SARS epidemic appeared to confirm the transition to new forms of health governance, described by Fidler (2004, 7) as ‘the post-Westphalian era’ in which non-state actors have increasing influence on global governance. During meetings of the World Health Assembly (the WHO’s supreme governing body) in May 2003, member states stipulated that the organisation should redouble its efforts to collect and analyse data from non-state actors. Specifically, the assembly requested that the director general of the WHO (2003b) ‘take into account reports from sources other than official notifications’. The advent of non-state actors’ ability to communicate data directly to the WHO appears to have undermined the historical monopoly of sovereign states regarding the reporting of public health information. However, this is likely a function of the geographical emergence of SARS in the relatively advanced areas of East Asia, where access to communications technology is ubiquitous. Fidler’s arguments are weakened by the lack of substantive and effective cooperation between sovereign states, NGOs, and international organisations in the realm of other infectious diseases such as malaria, TB, and, particularly, HIV/AIDS. Therefore, the SARS epidemic appears to have temporarily increased the power and authority of the WHO vis-à-vis the sovereign state. As a result of non-state regulated information flows, the WHO found itself no longer in a subservient position relative to sovereign state actors. The organisation employed this newfound freedom to issue global alerts and travel advisories when it deemed appropriate and was not subject to the consent of affected member states. It issued its first global alert on 12 March 2003, in order to make the international community aware of the expanding SARS contagion. The organisation subsequently issued specific advisories that travellers postpone all non-essential travel to affected regions such as Toronto, Hong Kong, Guangdong, and Beijing. It is noteworthy that neither the WHO constitution nor the IHR invested the organisation with this power. Furthermore, the WHO travel

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advisories were specifically directed at travellers (i.e., individuals) and not at states. During this brief moment, global health governance temporarily shifted to a new configuration wherein non-state actors provided WHO with information, which was then analysed by the organisation and subsequently disseminated to global civil society without the consent or even the consultation of targeted countries. However, Fidler’s arguments that there is today a transformative order that effectively limits the sovereign state’s ability to compromise the process are overstated. In the domain of HIV/AIDS, the sovereign state is very much capable of thwarting international efforts to address the spread of the contagion. One need only look at the history of obfuscation and denial generated by political leaders in sub-Saharan Africa (Thabo Mbeki and Robert Mugabe in particular) to observe this process of state obstruction (see Price-Smith and Daley 2004; Price-Smith 2002b). Indeed Andrew Price-Smith and John L. Daly (2004) demonstrate that in the case of Zimbabwe, Mugabe’s Zimbabwe African National Union–Patriotic Front regime provided antiviral therapies solely to their political supporters, denying such lifesaving pharmaceuticals to the Movement for Democratic Change, the opposition party.

Conclusion By inflicting significant socioeconomic costs on affected states, the SARS epidemic exposed the vulnerability of existing governance structures, reshaped the beliefs, norms, motivations, and preferences of those individuals who weathered the crisis, and ultimately led to macro-level changes in domestic political governance while enhancing the dynamics of regional health cooperation among the Pacific Rim states. However, SARS-induced effects on the international system and the interplay between sovereign states and international organisations were largely ephemeral. The greatest effect of SARS was not so much that it constituted a significant material threat to the prosperity, effective governance and security of states, but rather that it generated significant changes in governance within affected states (particularly in Canada and China). Conversely, and contrary to Fidler’s assertions, the epidemic does not seem to have generated significantly increased compliance of sovereign states with international health regimes (or significant revisions to the IHR for that matter). Nor has the WHO retained the expanded powers it exhibited during the SARS crisis, although it could arguably employ such strategies again to contain the growing H5N1 pandemic. So why was the response to SARS so different from the international response to other pathogens? The SARS epidemic exhibited several factors that led to the empowerment of the WHO, namely the emergence of a novel virus, coupled with seemingly high levels of virulence and transmissibility, generating high levels of uncertainty and fear. This event constituted an exogenous shock that affected regional political and economic elites and presented an immediate socioeconomic crisis for the decision makers to address at the national, regional, and international levels.

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A caveat is in order. First, this revolution in global health governance may have occurred with SARS precisely because the novel coronavirus was perceived as highly lethal and extraordinarily contagious. The inexorable spread of avian influenza has generated significant concern and a desire for international cooperation in capitals around the world. In the case of H5N1, the WHO remains very involved in directing the international efforts to contain the spread of the pathogen throughout southeast Asia, and regional governments appear to be conceding authority to the organisation. However, it is increasingly apparent that the power to contain an influenza outbreak remains in the hands of sovereign states. Furthermore, one might ask whether the international community will respond in a similar manner to other pathogens that are less lethal and less communicable (e.g., malaria and HIV). In fact, such a response has not materialised, because these latter pathogens do not generate similar levels of fear as does SARS or avian influenza. This lack of concern may also result from the relatively high certainty about their epidemiology and pathology; also these pathogens do not pose an immediate danger to the material interests of industrialised states. Furthermore, HIV/AIDS, malaria, and TB do not threaten the global ‘jet set’, and are therefore perceived as diseases of the poor by global elites, which in turn results in the continuing lack of effective response (see Farmer 2003; Poku 2002). Moreover, examination of the success of various countries in controlling the epidemic demonstrates that a state with high capacity (such as Canada) had a much more difficult time in containing the infection than did states with lower capacity, particularly Vietnam. Recent epidemiological evidence suggests that SARS appears to thrive under conditions that promote nosocomial transmission (SARS Commission 2006). Therefore, the sealed hospitals of developed societies appeared to facilitate SARS transmission through internalised ventilation systems. Conversely, Vietnamese hospitals are often open air, diminishing the probability of nosocomial transmission. In other words, the SARS coronavirus appears to be more transmissible in the sealed hospital and urban environments of high-capacity nations. Ironically, then, SARS would seem to pose a greater threat to states of higher capacity. In early 2006 the consolidation of global public goods, such as improved pathogen surveillance systems, and pathogenic containment regimes resulted from two central factors, namely fear and the attendant economic loss generated by contagion. A significant amount of leadership to provide such public goods has, in fact, been provided by hegemonic pressures (i.e., the U.S.), with the assistance of many other developed countries in order to shore up surveillance and containment capacity within the developing world. This issue of regional and national capacity will continue to affect the dynamics of global health governance (Price-Smith 2002a). SARS emerged in the Pacific Rim states, which exhibit moderate to high capacity, wherein NGOs and private citizens (e.g., physicians) possessed the technical means both to acquire public health data and then to disseminate it on a global scale via high-tech communications. However, in the poorer regions of the developing world where endogenous human capital levels are rather limited, where the communications infrastructure is meagre or non-existent, and where NGOs may have a difficult time in gaining access to certain areas, collaborative public health governance will remain

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extremely problematic. For example, the power of sovereign states over domestic health governance issues concerning HIV/AIDS and malaria appears to remain largely intact. Data on the true state of HIV prevalence are leaking out to the global community through NGOs, but affected sovereign states (e.g., Zimbabwe, South Africa) have been extremely reluctant to bow to the wishes of the WHO or the international community in their handling of the HIV/AIDS pandemic. In the final analysis, the emergence and proliferation of infectious agents will logically increase as processes of globalisation accelerate; however, disease events will act as biotic countermeasures (negative feedback loops) to slow such processes of globalisation through reductions in the movement of trade goods and migrants, depletion of human capital, and constraints upon economic productivity.14 In a very real sense, then, disease acts as a negative feedback mechanism on such processes of globalisation. The optimal way to diminish the negative effects of disease on globalisation is through the following: reduce the degradation of natural environments, which slows processes of zoonotic transference; implement redistributive mechanisms to improve the basic health of the human species, particularly in the least developed countries; and construct and maintain global public health surveillance systems. The proliferation of avian influenza, particularly the H5N1 strain, from East Asia to Africa and Europe, and the significant concern it has generated suggest that political elites have begun to grasp the consequences of emerging infections for prosperity, global governance, and even national security. One can only hope that lessons gleaned from the SARS epidemic (such as increased transparency, greater intergovernmental cooperation, and investments in public health infrastructure) will be employed in the event of a pandemic influenza. Nations that choose to ignore the warning of the SARS epidemic do so at their peril.

Recommendations The optimal means to curtail future epidemics (and pandemics) is to augment the endogenous capacity of healthcare infrastructure and improve the basic health of populations throughout the developing world. This makes logical sense because disease-surveillance capacity in many developing areas is low to nonexistent. Barry Bloom (2003) argues that ‘in a world that is increasingly angry at the United States, the lesson here is that it is time to support a global war on disease. The United States should be investing efforts and funds to strengthen the health structures in countries around the world … This investment would protect our country and every other against global epidemics, save millions of lives, and change the U.S. image from one of self-interest to one of human interest.’ Julie Gerberding (2003), head of the U.S. Centers for Disease Control and Prevention, echoes these sentiments: ‘The SARS experience reinforces the need to strengthen global surveillance, to have prompt reporting, and to have this reporting linked to adequate and sophisticated diagnostic laboratory capacity. It underscores the need for strong global public health systems, robust health service infrastructures, and expertise that can be mobilized quickly

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across national boundaries to mirror disease movements.’ Such assistance in the domain of public health could significantly enhance the U.S.’s tarnished international image and augment the diminished levels of soft power (Nye 2002). The health of developed countries is increasingly affected by microbes emerging in the poorer reaches of the developing world (e.g., avian influenza, West Nile virus, SARS). Therefore, global public health can be understood as a public good, and the costs of epidemiological surveillance and containment should be borne by the international community, although continued diplomatic leadership by the hegemon (the U.S.) will doubtless be central. Furthermore, where possible, states should possess (or develop) a level of surge capacity to deal with epidemic events that generate mass morbidity and mortality. At present there is little surge capacity within the U.S. as a result of its uniquely market-driven healthcare system. Notes 1 On environmental degradation, see Price-Smith (2002a, 141–170); on trade and tourism, see Davis and Kimball (2001); on conflict, see Elbe (2002) and Ostergard (2002); and on the distribution of resources see Poku (2002) and Farmer (2003). 2 For a discussion of the adverse effects of affect (specifically fear) in decision making see Jervis (2005, 1–32). 3 On republican theory in international relations see, in particular, Deudney (2007); for a republican reformulation of realist theory see Price-Smith (2008). 4 A ‘society of states’ cooperating in this regard is the optimal way to generate global public goods such as surveillance and containment; see Bull (1995); Smith, Beaglehole, Woodward et al. (2005), and Kaul, Conceição, Le Goulven, et al. (2003). 5 On the subject of PE theory see Gould (2002, 765–768). 6 On such non-linear dynamics see Tainter (1986). 7 An example of this phenomenon is the dramatic effects on international relations resulting from World War II, which saw the formation of the entire UN system and its attendant international organisations. World War II also generated responses within Europe leading to the European Coal and Steel Community and ultimately to the emergence of the European Union as a supranational entity. 8 For a comprehensive definition of state capacity see Price-Smith (2002a). 9 Jian kang bao (Health News), 7 July 2003, p. 5. 10 Renmin ribao (People’s Daily), 14 April 2003, p. 1. 11 For more on state capacity, see Price-Smith (2002a). 12 Renmin ribao (People’s Daily), 24 November 2003. 13 Renmin ribao (People’s Daily), 30 April 2003, p. 1. 14 For a discussion of bio-social negative feedback loops see Jervis (1997, 134–135).

References Asian Development Bank (2003). ‘Assessing the Impact and Cost of SARS in Developing Asia.’ In Asian Development Outlook 2003 (Oxford: Oxford University Press) <www.adb. org/Documents/Books/ADO/2003/Update/sars.pdf> (September 2008).

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Association of South East Asian Nations (2003). ‘Joint Declaration: Special ASEAN Leaders Meeting on Severe Acute Respiratory Syndrome.’ 29 April. Bangkok. <www.aseansec. org/14750.htm> (September 2008). Bloom, Barry R. (2003). ‘Lessons from SARS.’ Science, vol. 300, no. 5620, p. 701. <www. sciencemag.org/cgi/content/summary/300/5620/701> (September 2008). Blyth, Mark (2002). Great Transformations: Economic Ideas and Institutional Change in the Twentieth Century. (New York: Cambridge University Press). Bradscher, Keith and Lawrence K. Altman (2003). ‘Isolation, an Old Medical Tool, Has SARS Fading.’ New York Times, 21 June, p. 1. Bull, Hedley (1995). The Anarchical Society: A Study of Order in World Politics. (New York: Columbia University Press). Chan, Cecilia L.W. (2003). ‘The Social Impact of SARS: Sustainable Action for Rejuvenation of Society.’ Centre on Behavioural Health, University of Hong Kong, Hong Kong. <web.hku.hk/~bhealth/Documents/articles/YPSY0006/Social_Impacts_of_SARS.pdf> (September 2008). China. National Bureau of Statistics (2002). China Statistical Yearbook. (Beijing: China Statistics Press). Ching Cheong (2003). ‘Chinese PM’s Tacit Apology.’ Straits Times, 1 May. Crampton, Thomas (2003). ‘Strategy Set to Isolate Virus: Key Asia Leaders Map SARS Steps.’ International Herald Tribune, 1 May. <www.iht.com/articles/2003/05/01/sars. php> (September 2008). Crosby, Alfred (1986). Ecological Imperialism: The Biological Expansion of Europe. (Cambridge: Cambridge University Press). Curley, Melissa and Nicholas Thomas (2004). ‘Human Security and Public Health in Southeast Asia: The SARS Outbreak.’ Australian Journal of International Affairs, vol. 58, no. 1, pp. 17–32. Davis, Robert and Ann Marie Kimball (2001). ‘The Economics of Emerging Infections in the Asia-Pacific Region.’ In A. Price-Smith, ed., Plagues and Politics: Infectious Disease and International Policy, pp. 59–75 (New York: Palgrave). Deudney, Daniel (2007). Bounding Power: Republican Security Theory from the Polis to the Global Village. (Princeton: Princeton University Press). Diamond, Jared (2005). Guns, Germs, and Steel: The Fates of Human Societies. (New York: W.W. Norton). Diehl, Paul and Gary Goertz (2000). War and Peace in International Rivalry. (Ann Arbor: University of Michigan Press). Elbe, Stefan (2002). ‘HIV/AIDS and the Changing Landscape of War in Africa.’ International Security, vol. 27, no. 2, pp. 159–177. Embassy of Switzerland (2003). ‘China Business Briefing.’ 12–18 May, No. 140. Beijing. <www.sinoptic.ch/cbb/2003/cbb030512-030518.htm> (September 2008). Farmer, Paul (2003). Pathologies of Power: Health, Human Rights, and the New War on the Poor. (Berkeley: University of California Press). Fei Feng (2006). ‘The Development of China’s Manufacturing Sector and Its International Competitiveness.’ Gaige, 12 October. <articles.e-works.net.cn/Articles/444/Article41009. htm> (September 2008). Fidler, David P. (2004). SARS: Governance and the Globalization of Disease. (New York: Palgrave Macmillan). ‘GDP Growth Revised Up for 1st Half of 2003.’ (2004). China Daily, 20 July. <www. chinadaily.com.cn/english/doc/2004-07/20/content_349887.htm> (September 2008).

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Gerberding, Julie L. (2003). ‘CDC Response to Severe Acute Respiratory Syndrome (SARS).’ Testimony before the Committee on Health, Education, Labor, and Pensions, United States Senate. United States Department of Health and Human Services, Washington DC. <www. hhs.gov/asl/testify/t030429_a.html> (September 2008). Gould, Stephen Jay (2002). The Structure of Evolutionary Theory. (Cambridge MA: Harvard University Press). Haas, Ernst B. (1964). Beyond the Nation-State: Functionalism and International Organization. (Stanford: Stanford University Press). Hirschman, Albert O. (1991). The Rhetoric of Reaction: Perversity, Futility, Jeopardy. (Cambridge MA: Belknap Press). Homer-Dixon, Thomas (2001). The Ingenuity Gap: Can We Solve the Problems of the Future? (Toronto: Vintage). Hu Angang and Hu Linlin (2004). ‘A Review of China’s Health and Development from the Perspective of SARS.’ Center for Strategic and International Studies, Washington DC. <www.csis.org/media/csis/events/040218_angang.pdf> (September 2008). Huang, Yanzhong (2003). Mortal Peril: Public Health in China and Its Security Implications. Health and Security Series Special Report No. 7. Chemical and Biological Arms Control Institute, Washington DC. Jervis, Robert (1997). System Effects: Complexity in Political and Social Life. (Princeton: Princeton University Press). Jervis, Robert (2005). American Foreign Policy in a New Era. (New York: Routledge). Johnson, Niall and Juergen Mueller (2002). ‘Updating the Accounts: Global Mortality of the 1918–1920 Spanish Influenza Pandemic.’ Bulletin of the History of Medicine, vol. 76, no. 1, pp. 105–115. Kaul, Inge, Pedro Conceição, Katell Le Goulven, et al., eds. (2003). Providing Global Public Goods: Managing Globalization. (New York: Oxford University Press). Krasner, Stephen D. (1984). ‘Approaches to the State: Alternative Conceptions and Historical Dynamics.’ Comparative Politics, vol. 16, no. 2, pp. 223–246. Little, Bruce (2004). ‘Was There a Recession in Ontario?’ Globe and Mail, 27 January, p. B4. McNeill, William (1977). Plagues and Peoples. Updated ed. (New York: Anchor Books). Morse, Stephen S. (2001). ‘Factors in the Emergence of Infectious Diseases.’ In A. PriceSmith, ed., Plagues and Politics: Infectious Disease and International Policy, pp. 8–26 (New York: Palgrave). National Advisory Committee on SARS and Public Health (2003). Learning from SARS: Renewal of Public Health in Canada. Chaired by David Naylor. Ottawa. <www.phac-aspc. gc.ca/publicat/sars-sras/naylor> (September 2008). Nye, Joseph S. (2002). The Paradox of American Power: Why the World’s Only Superpower Can’t Go It Alone. (New York: Oxford University Press). ‘Officials Need to Stay on Top of Rumour Mill.’ (2003). South China Morning Post, 12 February. Ostergard, Robert (2002). ‘Politics in the Hot Zone: AIDS and the Threat to Africa’s Security.’ Third World Quarterly, vol. 23, no. 2, pp. 333–350. Peiris, J.S., S.T. Lai, L.L. Poon, et al. (2003). ‘Coronavirus as a Possible Cause of Severe Acute Respiratory Syndrome.’ Lancet, vol. 361, no. 9366, pp. 1319–1325. Peterson, Susan (2002). ‘Epidemic Disease and National Security.’ Security Studies, vol. 12, no. 2, pp. 42–81. Pirages, Dennis (1996). Microsecurity: Disease Organisms and Human Well-Being. Environmental Change and Security Project Report No. 2. Woodrow Wilson International

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Centre for Scholars, Washington DC. <www.wilsoncenter.org/topics/pubs/ACFA6.pdf> (September 2008). Poku, Nana K (2002). ‘Poverty, Debt, and Africa’s HIV/AIDS Crisis.’ International Affairs, vol. 78, no. 3, pp. 531–546. Pomfret, John (2003a). ‘Underreporting, Secrecy Fuel SARS in Beijing, WHO Says.’ Washington Post, 17 April, p. A16. Pomfret, John (2003b). ‘Official Says China Erred on Outbreak; Rare Apology Cites “Poor Coordination”.’ Washington Post, 5 April, p. A14. Pomfret, John (2003c). ‘Doctor Says Health Ministry Lied about Disease.’ Washington Post, 10 April, p. A26. Porter, Catherine (2004). ‘SARS Toll on Film Industry: $163 Million.’ Toronto Star, 9 March, p. B3. Prescott, Elizabeth M. (2003). ‘SARS: A Warning.’ Survival, vol. 45, no. 3, p. 211. Price-Smith, Andrew (1999). ‘Ghosts of Kigali: Infectious Disease and Global Stability at the Turn of the Century.’ International Journal, vol. 54, no. 3, pp. 426–442. Price-Smith, Andrew (2002a). The Health of Nations: Infectious Disease, Environmental Change, and Their Effects on National Security and Development. (Cambridge MA: MIT Press). Price-Smith, Andrew (2002b). Pretoria’s Shadow: The HIV/AIDS Pandemic and National Security in South Africa. (Washington DC: Chemical and Biological Arms Control Institute). Price-Smith, Andrew (2008). Contagion and Chaos: Disease, Ecology, and National Security in the Era of Globalization. (Cambridge MA: MIT Press). Price-Smith, Andrew and John L. Daley (2004). Downward Spiral: HIV/AIDS, State Capacity, and Political Conflict in Zimbabwe. (Washington DC: United States Institute of Peace Press). SARS Commission (2006). Spring of Fear. Report of the commission chaired by Archie Campbell. Ontario Ministry of Health, Toronto. <www.health.gov.on.ca/english/public/ pub/ministry_reports/campbell06/campbell06.html> (September 2008). Saywell, Trish, Geoffrey A. Fowler, and Shawn W. Crispin (2003). ‘The Cost of SARS: $11 Billion and Rising.’ Far Eastern Economic Review, 24 April. Schumpeter, Joseph A. (2005). Capitalism, Socialism, and Democracy. (New York: Routledge). Singer, Peter W. (2002). ‘AIDS and International Security.’ Survival, vol. 44, no. 1, pp. 145–158. Skocpol, Theda (1985). ‘Bringing the State Back In: Strategies of Analysis in Current Research.’ In P. Evans, D. Reuschemeyer, and T. Skocpol, eds., Bringing the State Back In (New York: Cambridge University Press). Smith, Richard, Robert Beaglehole, David Woodward, et al. (2005). Global Public Goods for Health: Health, Economics, and Public Perspectives. (Oxford: Oxford University Press). Spears, John (2003). ‘SARS Impact Lingers with Lost Tourism Spending Estimated Near $1 Billion.’ Canadian Press, 14 October. Tainter, Joseph (1986). The Collapse of Complex Societies. (Cambridge: Cambridge University Press). Taubenberger, Jeffery K. and David M. Morens (2006). ‘1918 Influenza: The Mother of All Pandemics.’ Emerging Infectious Diseases, vol. 12, no. 1. <www.cdc.gov/ncidod/EID/ vol12no01/05-0979.htm> (September 2008). ‘The SARS Outbreak—Interview: Goh Chock Tong, Leading the Charge against SARS.’ (2003). Far Eastern Economic Review, 8 May.

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United States National Intelligence Council (2000). The Global Infectious Disease Threat and Its Implications for the United States. National Intelligence Council, Washington DC. <www.dni.gov/nic/PDF_GIF_otherprod/infectiousdisease/infectiousdiseases.pdf> (September 2008). Vatikiotis, Michael (2003). ‘The Sars Outbreak: ASEAN and China—United in Adversity.’ Far Eastern Economic Review, 8 May. World Health Organization (2003a). ‘Summary Table of SARS Cases by Country, 1 November 2002 – 7 August 2003.’ 15 August. Geneva. <www.who.int/csr/sars/country/2003_08_15/ en> (September 2008). World Health Organization (2003b). ‘Revision of the International Health Regulations.’ WHA65.28. Resolution of the World Health Assembly, 28 May. Geneva. <www.who.int/ gb/ebwha/pdf_files/WHA56/ea56r28.pdf> (September 2008). World Health Organization (2003c). ‘Update 95—SARS: Chronology of a Serial Killer.’ Geneva. <www.who.int/csr/don/2003_07_04/en> (September 2008). World Health Organization (2003d). ‘Summary of Probable SARS Cases with Onset of Illness from 1 November 2002 to 31 July 2003.’ Geneva. <www.who.int/csr/sars/country/ table2004_04_21/en> (September 2008). Zartman, I. William (1995). Collapsed States: The Disintegration and Restoration of Legitimate Authority. (Boulder CO: Lynn Rienner).

Chapter 3

Lessons from SARS: Past Practice, Future Innovation Carolyn Bennett

We are not tinkers who merely patch and mend what is broken … We must be watchmen, guardians of the life and health of our generation, so that stronger and more able generations may come after. —Elizabeth Blackwell In 1849, Elizabeth Blackwell, M.D.—the first woman to graduate from medical school in the United States—made some compelling observations about the importance of population health. She was not the first, however, to express a memorable sentiment of this kind. More than four millennia earlier, Shi Huangdi, China’s Yellow Emperor, outlined the importance of keeping a population healthy when he said that ‘to administer medicines to diseases which have already developed … is comparable to the behaviour of those persons who begin to dig a well after they have become thirsty, and of those who begin to cast weapons after they have already engaged in battle’. Although simplistic, these logical principles remain an ongoing challenge, integral to the foundation and growth of the Canadian healthcare system. Tommy Douglas (1984), one of the founders of universal health care in Canada in the 1960s, emphasised the importance of disease prevention and health promotion and believed that the primary objective ‘must be to keep people well rather than just patching them up when they got sick’. The emphasis on this task was underscored by Marc Lalonde (1974), Canada’s minister of health and welfare from 1972 to 1977, in a report entitled A New Perspective on the Health of Canadians: A Working Document. Laying out two objectives (reducing health risk and improving access to care), Lalonde proposed five strategies for health: promotion, regulation, research, system efficiency, and goal setting. These strategies have remained integral to Canada’s health plan ever since. With the Lalonde report, Canada led the world in the development of a population health approach. Since then, poverty, violence, the environment, education, shelter, and equity are known to be as important to the health of Canadians as the ‘sickness’ care system. This consideration of population health was again reflected in the development of the Ottawa Charter for Health Promotion, adopted by the International Conference on Health Promotion in 1986, which broadly defines health promotion as the ‘process of enabling people to increase control over, and to improve, their health’ (World Health Organization [WHO] 1986). In short, the

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simple statements of Dr. Blackwell and Shi Huangdi have presided over Canadian healthcare history. In the current post–September 11 atmosphere and post–severe acute respiratory syndrome (SARS) environment, one cannot underestimate the imperative of dealing aggressively with all determinants of health. Not surprisingly, Canada’s health goals have continued to evolve as new challenges differentiate the current global environment from its past. Those goals are different in terms of understanding one’s responsibility to the world—to make the world a healthy place for all people through leadership, collaboration, and knowledge. This chapter explores the importance of the SARS pandemic as a catalyst in this shift. Its observations are largely informed by my role as Canada’s first minister of state for public health, from 2003 to 2005, and by my subsequent experience, including participating in Global Pandemic Influenza Readiness, an international conference of health ministers from 30 countries and representatives from nine international organizations in 2005. With this experience as a backdrop, this chapter examines the way in which the encounter with SARS prompted Canada to take a leadership position in pandemic preparedness as well as the way in which this type of preparedness improves public health infrastructure in the world—in surveillance, capacity, and all of the elements that will make this a healthier planet. The by-product of preparing for a pandemic is the forced re-evaluation of existing systems and a focus on the necessity of a proper public health infrastructure around the globe. For western countries, which have recaptured an interest in public health, this has been immensely important. The focus on Douglas’s original views of medicare—keeping people healthy rather than patching them up—seems to have been blurred in favour of a sickness care system and a dependence on the development of miracle drugs that will cure all ails. In this respect, our health objectives have faltered in the ‘tyranny of the acute’. As David Naylor points out, examples of actual and potential harm to the health of Canadians from weaknesses in public health infrastructure have been mounting for years without a truly comprehensive and multi-level governmental response (National Advisory Committee on SARS and Public Health [Naylor report] 2003). As a wake-up call, the upstream reality of what Canada learned from the Walkerton experience, where seven people died as a result of E. coli contamination of the public water supply in 2000, and what should have been learned from HIV/AIDS, sounded in concert with the SARS experience. The call served as a reminder that there is a serious need for global governance on health. Canada’s response can be considered in the context of the impact of SARS on Toronto, the lessons learned from the experience of Toronto’s fellow cities of Hong Kong, Hanoi, and Bangkok, and the hope and encouragement experienced at the 2005 health ministers conference in Ottawa. However, it is important first to establish the lenses through which this examination will be viewed. First, Ursula Franklin provides an overarching perspective on governance, in particular, her decree that governance must be fair, transparent, and take people

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seriously. If this is not enforced in small organisations, then there is little hope in managing any national or global undertaking. Second, my position as minister responsible for the Public Health Agency of Canada (PHAC) provided an exceptional opportunity to take those activities that had been conducted within a government department and move them to an arm’s-length agency, with independent thinking and an opportunity to work with the provinces and territories in order to transform public health in Canada. This agency relies on real, scientifically based evidence, with a declaration to support what works to produce that evidence. Third, tied closely to Franklin’s observations on governance, is meaningful citizen engagement. It is important to be connected to human responses and to know what people are frightened of—because that is what actually changes behaviour. The public must be put back into public health. In the interest of transparency, it is important to declare that global health governance is relatively new to me. My ideology is primarily bottom up and, consequently, the task of describing what governance should look like has not come naturally in the past. However, the complexity theory, distributive models, and the adaptive principles explored in a discussion paper by Sholom Glouberman and Brenda Zimmerman (2002) for the Commission on the Future of Health Care in Canada is reminiscent of—and well complemented by—the oft-repeated H.L. Mencken quote: ‘There is always an easy solution to every human problem—neat, plausible, and wrong.’ It is imperative for both health authorities and engaged citizens to keep this in mind while conceiving the health goals for Canada’s future. Glouberman and Zimmermann (2002) highlight the differences between the responses of Brazil and African countries to HIV/AIDS. They identify Brazil’s response to a prediction by the World Bank that the country did not have sufficient resources to resist HIV infection. The events that took place in Brazil were unprecedented and, certainly, unpredictable. In spite of the harsh statements from the World Bank, the Brazilian people organised themselves in a way that no one could have predicted.1 Brazilians were not going to let a generation die off and decided not to do as they were told. Doctors and civilians managed to attain drugs and drew circles on pieces of paper to explain to people what time of day to take them; nuns and priests handed out condoms. From the bottom up, Brazilians were able to organise in a way that meant the incidence of HIV/AIDS in their country declined, while in much of Africa it went through the roof. The Brazilian experience is an impressive display of the capacity of selfmotivated citizens on the ground. In light of this type of bottom-up approach, the exploration of health governance herein is framed by the fact that one cannot impede or underestimate what communities are capable of if they are just asked. The familiar Hollywood portrayal of scientists wandering around in white lab coats and fixing everything for people is neither realistic nor feasible as a public health strategy. In this respect, the medical myth is getting in the way of what it will take for communities to find out what they need and for them to be able to ask for help

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in a way that must be respected. This, of course, became all too clear in the case of SARS.

From Tinkers to Guardians: The Effect of Canada’s Experience at Home SARS dramatically reinforced the inescapable reality of Marshall McLuhan’s 1964 characterisation of this world as a global village (National Advisory Committee 2003). It became very clear that germs do not respect borders. In this village, Canada was affected more severely than any other country in the western hemisphere. A total of 438 people became infected (Health Canada 2008); 44 of them died, including three healthcare workers. The response to the outbreak paralysed a major segment of Ontario’s healthcare system for weeks and resulted in more than 25 000 residents of the greater Toronto area being placed in quarantine. The psychosocial effects of SARS on healthcare workers, patients, and families continue to be assessed even today. However, this is only the acute human face of SARS. The overall impact extended further. When the World Health Organization (WHO) warned against unnecessary travel to Toronto in April 2003, visits to the city plummeted and rock concerts, sporting events, movie shoots, and conventions were cancelled or relocated. As the Naylor report identified, the estimates, based on the volume of business compared to usual seasonal activities, suggested that tourism sustained a loss of CA$350 million, the reduction in airport activity cost CA$220 million, and non-tourism retail sales were down by CA$380 million in 2003 (National Advisory Committee 2003, 211). Ultimately, direct and indirect costs in Ontario added up to more than CA$2 billion in revenues and tourism jobs, and the number of non-residents entering the country fell by 13 percent, affecting tourism throughout the country. For example, the province of Quebec was affected, despite not having a single reported case of SARS. The SARS experience in Canada was a failure of both communication and science. Primarily, the authorities did not know what they needed to know and therefore could not pass on crucial information. What was the mode of transmission? No one knew. What was the incubation period? No one knew. And—significantly— how could authorities reassure people, or explain what they did not know—namely, that it was a hospital-based disease spread by intimate contact? No one knew. In short, it was a tremendous failure in terms of what David Naylor later called the four C’s: collaboration, cooperation, communication, and the clarity of who does what when. As a result of this failure, the authorities were forced to re-evaluate their ability to share information within a complex federal system—across different levels of government and among hospitals, healthcare providers, and local public health offices, and even across provincial borders. In some cases, it was reported that data sets would not be shared because it was not clear who would be the principal investigator for that particular study. In other cases, the data were unclear whether infection started with one patient who went to two hospitals or two patients who went

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to two hospitals. Canadian health officials had insufficient trusted data and therefore were, rightfully, embarrassed. Inefficiencies and arguments over less pressing issues, including doctors and nurses crossing borders, ultimately, obstructed productive aid. Places with regional health authorities, such as British Columbia, seemed to perform better than the local health authorities did in Ontario. Singapore also did very well in terms of the magnitude of people affected and was able to get a few things right. There, health authorities designated one hospital to take care of all SARS patients. That institution provided a seamless liaison with public health operations. Authorities were able to trace all patients’ contacts within 24 hours of each admission, and the minister of health was the spokesperson. He held regular daily press briefings and shared the facts, uncertainties, and potential worst-case scenarios with the public, as well as provided concrete suggestions of how Singaporeans could protect themselves. In Canada, by contrast, there were multiple sites and rotating public health officials, clinicians, and politicians all appearing at different times and delivering mixed messages. Admittedly, a city-state such as Singapore offers some advantages regarding the centralisation of decision making that Canada’s multi-layered system does not offer. Nevertheless, in an emergency situation, it is necessary that Canadian municipal, provincial, and federal governments speak with one voice and be clear about who is responsible for what. It is unacceptable that in Canada—a country that has developed leading technology in mobile communication—healthcare authorities and citizens were not better able to communicate with individual physicians or front-line workers. These are the issues that should remain a concern for the public, and changes have been made in this regard. Licensing boards in all provinces and territories now require physicians to supply their contact information in case of an emergency, which is certainly a preliminary improvement in terms of communication. More generally, since 2001 initiatives have focussed on restructuring the communication channels among federal and provincial governments, the media, and the public. Federal communications were generally reactive (as Health Canada waited for the latest press conference in Ontario); in turn, provincial communications were frequently disorganised, and crisis communication to the public was similarly unacceptable. Consequently, the National Advisory Committee on SARS and Public Health immediately proposed a number of changes in the collaboration between the federal, provincial, and territorial levels of government and the media, including the possibility of a comprehensive training programme for crisis communication similar to that designed by the Centers for Disease Control and Prevention (CDC) in the United States (National Advisory Committee 2003).� Although some progress has been made in Canada, there remains a dire need to improve two-way accountability—the kind of communication that allows people to report and receive the type of data that, during the SARS crisis, was changing three times a day. Throughout that period, health authorities were continually reassessing whether the mode of virus transmission or the incubation period or the other essential factors were changing, yet the dissemination of up-to-the-minute

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information proved to be a challenge in certain parts of the country, given the existing communications infrastructure. Graphing total cases per day instead of new cases provided an alarming picture on the Health Canada website. The experience was a chilling wake-up call, and Canada is now better prepared. However, there is still much more work to do. SARS has taught the lesson that the luxury of a central command-and-control approach is not a possibility in Canada. Unlike the experience of Singapore, where all SARS cases could be seen at a single facility, even the containment of SARS within the Greater Toronto Area did not necessarily lend itself to the Singapore model given the unique conditions there, such as culture and health systems. When new information is emerging continually from the trenches, authorities must be able to interpret it. The question remains, however, how to take new information and allow the front-line responders in each area to do what they know to be best in their community or for their population base. They know whom to call. They know the infrastructure. They know who their potential partners are. How can authorities ensure, in terms of crisis governance, that local workers are not impeded from doing what they really know how to do? In essence, these issues force the realisation that the largest obstacle to managing a public health crisis successfully is a lack of a collaborative framework and ethos among different levels of government, health authorities, citizens, and practitioners. Canada has taken the lessons learned from SARS into a broader context: pandemic preparedness both at home and in the global village. David Naylor’s thoughtful report was, in fact, a blueprint of what needed to be done in this country (National Advisory Committee 2003). As the minister of state for public health my department established the PHAC and appointed the first chief public health officer, David Butler-Jones. He was then able to nurture and develop cooperation and collaboration among medical officers of health for all 13 provincial and territorial jurisdictions in the country into PHAC, so that public health could be conceived as an inclusive collective. The creation of PHAC and the position of chief public health officer of Canada allowed the deputy head of an agency—for the first time in Canadian history—to speak directly to Canadians to deliver science-based advice, rather than go through political channels. There were immediate changes within the Ontario’s Ministry of Health as well. For example, as part of an internal reorganisation, an office was established to coordinate the development of an emergency preparedness programme, integrate it into planning, identify the infrastructure requirements for its maintenance, and develop a quality improvement programme. Since its inception, this office has created a number of programmes addressing issues in emergency planning and preparedness for citizens and healthcare providers, with specific concern for influenza pandemic planning and avian influenza. Ultimately, the SARS experience reinforced the case for a collaborative and coordinated approach to public health, making it evident that systems-based thinking and coordination within a welldesigned infrastructure are as essential in a crisis as they are in the core functions of public health (212).

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Casting Weapons: Canada in the Global Village In tandem with these domestic improvements, Canada’s global public health position has also improved in its overall framework. The emergency operation centres in Ottawa and Winnipeg are linked to the provinces and territories, the U.S. Department of Health and Human Services, the CDC, and the WHO. Canadian health authorities have activated these systems several times in recent years, both in the table-top exercises with the United Kingdom and the United States and in Canada’s role as chair of the Global Health Security Action Group (GHSAG), a strong indication of Canada’s improved global health position. The GHSAG was established to improve public health security against chemical, biological, or radio-nuclear terrorism as well as pandemic influenza. It includes the G7 countries, Mexico, the European Commission, and the WHO. Moreover, Canada has become the first country to negotiate a ten-year contract (beginning in 2001) with a domestic manufacturer capable of providing a pandemic vaccine for the entire Canadian population as soon as the organism is identified, should the need arise. Canadian health authorities have created a national antiviral stockpile and committed to the production and testing of a prototype of H5N1 vaccine that will increase capacity and knowledge of the efficiency of a vaccine against this strain of avian influenza, or one that is similar. Furthermore, Canada has expanded the Quarantine Act, extending the government’s legislative authority to screen, examine, and detain arriving and departing travellers and conveyances (such as airplanes or cruise ships), including their goods and cargo, that may be a public health risk to Canadians and people world-wide. The act also includes contemporary public health measures, such as ordering treatments or other preventive measures. However, as encouraging as these measures are, Canada cannot simply shut its borders to a pandemic. If, for example, the disease renders an individual infectious for days before symptoms show, it is not possible to contain all pathogens completely given the availability of 24-hour flights from across the world. This was made painfully obvious when, in 2007, air travellers were possibly exposed to a contagious form of tuberculosis when Andrew Speaker, infected with a drug-resistant strain of the disease, flew from Paris to Atlanta by way of Prague and Montreal. In preparing for pandemics, it is important to understand that information changes so often that plans must be consistently and constantly revised. The focus may be on a bird virus, but a pandemic could originate from swine or some other animal influenza. No one knows what the source of the next one will be, but we know there will be one, someday. Pandemic preparedness plans should possess the elasticity to account for different pathogenic sources. The situation may be likened to life in an earthquake zone. Someone who purchases a condo in Vancouver, for example, will want to ensure that the building was constructed in conformity to the appropriate building code and that the City of Vancouver has sufficient rescue vehicles and an effective earthquake plan with appropriate resources, because that individual will be aware that Vancouver is in an earthquake zone. However, despite these precautions,

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one can assume that there will be unforeseen circumstances that will fall outside the plan. The same assumption applies when considering a pandemic. There is no question that it was easier to plan for the Y2K, because everybody knew they had until 31 December 1999 to put the plan in place. People could determine a critical path with their partners in business, labour, government, and nongovernmental organisations (NGOs). Work could be performed with a deadline in mind, without people’s sense of purpose flagging. The concept of emergency preparedness is different. The whole point of emergency preparedness is to have plans in place in case an unfortunate event occurs—but that event might not happen, or it might happen at some moment in the distant, unknowable future. Unfortunately, as with earthquakes, this is the reality with regard to viruses and bioterrorism. Another challenge facing Canada is that many countries are not preparing at all, and others simply do not have the capacity to prepare without Canadian aid. The WHO and Canada, together and collaboratively with other countries, have been trying to work with those countries that are currently most at risk. For example, in 2005 Vietnam sent officials and scientists to Winnipeg to learn how to build their own laboratory capacity at home. Canada invested CA$15 million in the CanadaAsia Regional Emerging Infectious Disease Initiative, in order to help build public health capacity and surveillance in southeast Asia. Some countries, regrettably, lack candour or transparency with regard to admitting the existence and severity of a problem. Working with the WHO, Canada invented the Global Public Health Intelligence Network (GPHIN), which combs the internet for media releases and newspaper clippings in seven languages for any potential health hazard (Zacher 2007, 19; PHAC 2004). The International Health Regulations (IHR) issued by the WHO are legally binding regulations adopted by most countries to contain the threats from diseases that may rapidly spread from one country to another. Such diseases include emerging infections like SARS or a new human influenza virus. The revised IHR issued in 2005 are a great improvement over their predecessor and bring disease control into the 21st century (WHO 2006). Updated to prevent, protect against, and control the international spread of disease, they provide a public health response when disease does spread internationally. However commendable, the effectiveness of these regulations depends on each country’s capacity to identify, verify, and manage critical outbreaks. When the quality of data is challenged, as has been the case in various countries, the effectiveness of the IHR becomes an issue. In other words, there are some pieces in place but no system is perfect. Many countries have trouble simply reporting their births and deaths accurately, which calls into question their ability to manage information about an outbreak. By 2003, Hong Kong had already developed various ideas and responses regarding pandemic preparedness because of its experience with the H5N1 strain since 1997. For example, in the market, unsold birds did not return home to the farm: any bird that was not sold was killed and eaten, so there was no traffic from the marketplace to the farm. Health authorities found a vaccine that had worked for another virus that had some impact on the avian influenza virus.

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Reacting to Vietnam’s experience with avian influenza, officials from the World Bank, the Food and Agriculture Organization (FAO), the Asian Development Bank (ADB), the Joint United Nations Programme on HIV/AIDS (UNAIDS), the United Nations Development Programme (UNDP), and the WHO met in Hanoi for extensive discussions about funding health systems and providing compensation for culled birds. Subsequently, various NGOs such as Vétérinaires Sans Frontières and Save the Children met. The differences between the discussion with the international organisations and the discussion with NGOs with first-hand experience in the trenches—working every day with the citizens in the communities in Vietnam—were plentiful. The activity on the ground at Thailand’s Mahidol University was fascinating in terms of bottom-up realities, surveillance, and capacity building. Their X-ray surveillance system was most impressive. In fact, Thailand’s approach was commonly referred to at the international conference of health ministers in Ottawa in 2005. Every community in Thailand identified, using a sociogram, the health volunteer for that community, who then received appropriate training. That individual was the most trusted person to whom people could go with their secrets, from whom they would seek advice—and who could provide three days of malaria pills until they could see a health professional. That individual was the one who would go to a farmer to explain that all the chickens had to be killed. This individual would, consequently, have a huge knowledge base and would have to engage in continuous learning to improve communication systems. Canada has much to learn from countries that really do not have a highly developed healthcare system, but where keeping people well is paramount to saving lives. Michael Leavitt, U.S. secretary of health and human resources, was particularly impressed by the pandemic preparedness in southeast Asia. As the former governor of Utah, where forest fires pose a considerable problem, he appreciated the measures that had been taken in Thailand to stomp out the spark before it caught, rather than investing enormous sums of money in legions of bombers to put out the fire afterward. Canadians should expect to see all levels of government collaborate responsibly in the face of a serious threat to the health of the population. As the Naylor report says, ‘the rules and norms for a seamless public health system must be sorted out in advance of a health emergency, with a spirit of partnership and shared commitment to the health of the citizenry, not on an ad hoc basis in the midst of the battle to contain a viral outbreak’ (National Advisory Committee 2003, 212). Lessons must be learned, not only from SARS but also from what happened with previous influenza pandemics and HIV/AIDS. Again, the scenario is reminiscent of Shi Huangdi’s comments. It is not acceptable to cast weapons once we have already engaged in battle. The Global Pandemic Influenza Readiness conference in 2005 was a particularly useful opportunity for international participants to discuss key policy priorities and actions in guiding international efforts. Mainly, however, the discussions focussed on changing the mindset, admitting that no one has all the right answers, and needing to share problems, challenges and proposed solutions. As with Canada’s domestic health challenges, one of the larger impediments to dealing successfully with public

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health crises internationally was the lack of a collaborative framework and ethos— in this case among different governments and organisations. In many respects, the acceptance of the need for candour began at the conference itself, as representatives from the various countries and organisations shared their experiences openly around the table. This opportunity, to be honest, was a significant outcome in a new culture of transparency about infectious disease. The conference was organised along four main themes. The first theme, in which Prime Minister Paul Martin participated in the discussions, concerned animal– human health. It is essential to the global capacity to protect human health that the risks associated with the spread of viruses—among animals and from animals to humans—be identified early and understood well. Thus the conference participants called for increased capacity for surveillance and for the exchange of information between the agriculture and health sectors at the local, national, and international level (Health Canada 2005). They also called for the expansion and integration of the network of relevant WHO collaborating centres and the reference libraries of the FAO and the World Organisation for Animal Health (OIE) for the rapid identification of virus strains, as well as a number of other collaborative reforms. The second theme, concerning capacity and surveillance, involved discussions in which all participants celebrated the practices of the Thai government. The health ministers all recognised the need to strengthen the capacity for surveillance, the early detection and diagnosis of a range of infectious diseases, and timely communication about them as well as a rapid response. The third theme was risk communication. Canada has helped the WHO develop a manual on outbreak communication designed for the 24-hour media cycle (WHO 2005). When an alarmist statement in one part of the world could potentially affect the entire globe, it is extraordinarily important that everyone is on the same page. Finally, there was a discussion about research and access to vaccines and antiviral drugs. There was general agreement that it is imperative to push hard on the research side. The current system relies on 1950s technology for developing vaccines, which involves waiting for cultures to grow; there is a clear need for work on cellular technologies and synthetic vaccines. One must always push ahead as these viruses and bacteria have the potential to mutate. The research and development (R&D) into new forms of immunisation, as in all facets of pandemic preparedness, must be diverse and adaptive so as not to end up with all one’s eggs in one basket. In this regard, the ministers agreed to include vaccines and antivirals as key components in pandemic influenza preparedness and response plans both at the national and the international levels, to work collaboratively to advance vaccine and antiviral R&D, to develop as quickly as possible mechanisms to increase production capacity, to enhance pharmaceutical delivery so that there can be equitable access world-wide, and to call for a meeting of drug-regulating authorities to develop a framework to address common regulatory challenges in order to expedite vaccine registration and availability. Again, the issue ties into the central theme: it is integral to any health initiative that the partnerships, in terms of the key stakeholders (including civil society), play important front-line roles in preparedness planning.

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Not surprisingly, there was consensus at the conference—a firm intention to do more than simply mitigate the mortality, economic, and social outcomes of an influenza pandemic. Determining that improved surveillance, collaboration, reporting, and coordinated response will save lives long before the disease outbreaks reach the pandemic level, the ministers and officials endorsed two main principles for effective global cooperation: full transparency among countries and the institutions involved in responding to the risk of pandemic influenza and full support to the leading role of multilateral institutions. Ministers, Canadian and otherwise, approached the Ottawa meeting as an important step toward securing long-term, sustained political and institutional engagement to address global pandemic preparedness. In this respect, the weapons are being cast before the battle.

Conclusions In this brief consideration of Canada’s SARS experience and the reforms subsequently proposed in the Naylor report and then implemented, the Ottawa 2005 conference, and the birth of PHAC, it is clear that Canadians have taken lessons learned into a broader spectrum, concerning national pandemic preparedness both at home and in the global village. Domestically, the creation of a network of medical officers of health for the 13 provincial and territorial jurisdictions restructured communication among federal and provincial governments, the media, and the public, allowing public health to be conceived more inclusively as a collective effort. Most basically, the SARS experience reinforced the case for a collaborative and coordinated approach to public health, forcing Canadians to realise that ‘systems-based thinking and coordination of activity in a carefully-planned infrastructure are … integral to core functions in public health, due to its population-wide and preventive focus’ (National Advisory Committee 2003, 212). Internationally, Canada has played a substantial role as chair of the GHSAG, strengthened its relationship with the U.S. Department of Health and Human Services, the CDC, and the WHO, and made substantial improvements to the Quarantine Act. Moreover, the existence and fundamental outcome of the Ottawa conference, at which representatives from the 30 countries and 9 international organisations shared openly across the table, is another substantial indicator of Canada’s dedication to global health. The conference was a source of hope, a signal of devotion to developing a culture of transparency and collectivism. Ultimately, however, the most important conclusion to draw from the experience of SARS is that these advancements, although important, are merely steps toward securing long-term, prolonged political and institutional commitment to addressing global pandemic preparedness. Things may be better than ever, but there is still much work to do. In light of this, and with continued emphasis on communication, transparency, collaborative problem solving, and sustained engagement on the issues surrounding global health, it is appropriate to conclude by addressing some enduring problems.

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One issue that demands further attention is that of animal–human health— having vertical silos of knowledge, when there are horizontal problems, is worthy of concern. If 80 percent of new and emerging diseases come from the furry and feathery clients of the veterinarians, there needs to be a direct line of communication between public health officials and animal health workers because public health institutions must know up front what will be the future threat. In this regard, Canada has taken the lead by linking the Canadian Food Inspection Agency and the National Microbiology Laboratory in Winnipeg. This is tied to another problem, however, in regard to horizontal issues: if organisations such as the WHO only deal with health ministers, how can a whole-of-government response be possible? A second issue, related to data, again deals with a similar fault in representation and communication. If only health ministers are represented at the WHO and not the governmental departments of statistics, how can the two groups collaborate effectively to produce more trusted data? Moreover, the WHO’s disability-adjusted life year (DALY) and all those things that were not tried are not trusted anymore. What can be done with countries where even births and deaths are not recorded? How can the numerator be dealt with when the denominator is unknown? For example, a Canadian parliamentary sub-committee on people with disabilities was obliged to work with almost ten-year-old census data, which made it difficult to plan. Yet that is the norm in many countries. How can technology, such as the internet, be used to ensure that knowledge is translated for public access in real time and is rapidly disseminated, widely accessible, and scientifically reviewed? How does one ensure that citizens are initiating healthy public policy because they have received good information on the real science in a sensible way? It is sometimes much easier for citizens to pull out what is healthy public policy than it is for governments to be pushing it. People need to know how important it is to wash their hands, for example, but that information can also help change the behaviour of their healthcare providers. Once the technology issue has been resolved, publicly influenced policy making can be a very healthy step forward. Unfortunately, on top of these issues about dissemination, there are further complications with regard to research ethics. A good example is the ethical complications of working with the 1918 influenza virus, when there was no international oversight or control of the dreaded microbe. Should this work have been allowed to proceed without international approval and oversight? If not, who should have provided it? What kind of permission would be required to proceed on that kind of research? More generally, what must be done to make sure there is a normative function for a multilateral organisation, like the WHO? How should that normative function be created to ensure that the organisation sets global norms and standards and is a container of global information while at the same time relies on sound science? How should political interests be managed so that, for example, a nutrition resolution is not pushed through by the sugar-producing countries, or a life-saving measure is rejected because of a country’s religious beliefs about reproductive health?

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Governance may be firmly based on science, but the political thrust must not affect the authority of international institutions. Another closely linked fundamental issue is the determination of the mandate of organisations such as the WHO. Should they stick to reporting and standard setting in global health governance or should they have a responsibility to be on the ground, treating individuals and performing the tasks that might be done better by others? How can fairness and transparency be guaranteed? How can the accountability of a director general be assured, and how can NGOs and donors be part of the selection process of a director general? How can the funding for international organisations be made adequately stable so that, after countries have paid their annual dues, their workers do not have to spend so much of their time fundraising for the next important initiative, such as pandemic preparedness? Over time, the extraordinary socioeconomic inequities that exist among countries must become very much a part of the equation, if and when the world finally gets it right. Wealthy countries should not simply send aid cheques to poor ones, relying on geographic distance to keep them safe from the problems relayed on the nightly newscasts. In this respect, the reform of the G8 may be beneficial. The annual meeting of the most powerful economies has a large impact on the structure of the international system. Within the G8 framework, there is a distinct possibility that the agendas set will not appropriately reflect the needs of emerging economies. If the G8 were expanded to include the five outreach countries of Brazil, China, India, Mexico, and South Africa, then international health solutions crafted at that level would better reflect these needs. This type of expansion, however, demands much further research, given the current set of critiques regarding the G8’s efficiency and legitimacy (see Cooper 2007). In essence, the world must do more to share best practices. Many countries are doing extraordinarily interesting things, such as Thailand. It is particularly important to understand that everyone is in this together. It is essential to accept that we are one people, or we will destroy ourselves. In other words, despite the evolving health goals in today’s drastically different international milieu from the one of Shi Huangdi and Elizabeth Blackwell, their simple observations from centuries ago remain pertinent today: we cannot reduce ourselves to the role of tinkers who merely patch and mend what is broken. Rather, we must take a collaborative role as the guardians of the life and health of our generation, so that stronger and more able generations may come after us.

Note 1 Glouberman and Zimmerman (2002) say that Brazil ‘managed to falsify the World Bank prediction that it did not have the resources to resist HIV infection and would have 1.2 million cases of HIV/AIDS by 2000’.

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References Cooper, Andrew F. (2007). ‘The Logic of the B(R)ICSAM Model for G8 Reform.’ CIGI Policy Brief No. 1. Centre for International Governance Innovation, Waterloo ON. <www.cigionline.org : Publications : Policy Briefs> (September 2008). Douglas, Tommy (1984). ‘The Future of Medicare.’ <www.healthcoalition.ca/tommy.html> (September 2008). Glouberman, Sholom and Brenda Zimmerman (2002). Complicated and Complex Systems: What Would Successful Reform of Medicare Look Like? Commission on the Future of Health Care in Canada, Discussion Paper No. 8. Ottawa. <www.hc-sc.gc.ca/english/pdf/ romanow/pdfs/8_Glouberman_E.pdf> (September 2008). Health Canada (2005). ‘Communiqué.’ Global Pandemic Influenza Readiness: An International Meeting of Ministers of Health. 24–25 October. Ottawa. <www.hc-sc.gc.ca/ahc-asc/media/ nr-cp/2005/2005_fin_e.html> (September 2008). Health Canada (2008). ‘SARS.’ <www.hc-sc.gc.ca/dc-ma/sars-sras/index-eng.php> (September 2008). Lalonde, Marc (1974). A New Perspective on the Health of Canadians: A Working Document. Minister of Supply and Services Canada, Ottawa. <www.hc-sc.gc.ca/hcs-sss/com/fed/ lalonde_e.html> (September 2008). National Advisory Committee on SARS and Public Health (2003). Learning from SARS: Renewal of Public Health in Canada. Chaired by David Naylor. Ottawa. <www.phac-aspc. gc.ca/publicat/sars-sras/naylor> (September 2008). Public Health Agency of Canada (2004). ‘Global Public Health Intelligence Network.’ Ottawa. <www.phac-aspc.gc.ca/media/nr-rp/2004/2004_gphin-rmispbk_e.html> (September 2008). World Health Organization (1986). Ottawa Charter for Health Promotion. (Geneva: World Health Organization). <www.who.int/healthpromotion/conferences/previous/ottawa/en> (September 2008). World Health Organization (2005). WHO Outbreak Communications Guidelines. Geneva. <www.who.int/infectious-disease-news/IDdocs/whocds200528/whocds200528en.pdf> (September 2008). World Health Organization (2006). ‘International Health Regulations.’ Geneva. <www.who. int/csr/ihr/en> (September 2008). Zacher, Mark W. (2007). ‘The Transformation in Global Health Collaboration since the 1990s.’ In A.F. Cooper, J.J. Kirton, and T. Schrecker, eds., Governing Global Health: Challenge, Response, Innovation, pp. 19–27. (Aldershot: Ashgate).

Chapter 4

The WHO and SARS: The Challenge of Innovative Responses to Global Health Security Adam Kamradt-Scott

The role, authority, and autonomy of international organisations (IOs) remain a fiercely debated issue in contemporary international relations. Criticised for their democratic deficit, their (apparent) incapacitating politicisation, inefficiency, professed failures or perceived inaction, IOs are regularly condemned by policy makers, governments, activists, and academics alike (Pollack 2003; Esty 2006; Ruggie 1985). Indeed, even when IOs are widely observed to have acted in accordance with their delegation contract, they can still attract criticism. Given this state of affairs, it is often difficult to assess whether such criticisms are justified and whether IOs are truly the selfaggrandising, self-seeking tyrants that some suggest (Barnett and Finnemore 1999). This chapter examines one IO—the World Health Organization (WHO)—and a number of the criticisms that have been made of its role, authority, and autonomy in responding to the first new pandemic of the 21st century, namely severe acute respiratory syndrome (SARS). The emergence of SARS as a global threat in 2003 has been documented in considerable detail elsewhere (see Brooks 2005; Abraham 2005; WHO 2006c, and Chapter 3 in this volume). In this chapter, only the basic facts need revisiting. The disease originally began circulating in southern China in late 2002. It was carried to Hong Kong by an unsuspecting doctor in early 2003, who transmitted the virus to a number of international travellers, each of whom spread the disease to others upon their arrival at various destinations around the world. Some five months later, the disease had spread to 32 countries, had infected 8422 individuals, and had caused the deaths of some 916 people (WHO 2003b).1 The pandemic additionally contributed to massive social and political upheaval (particularly in those countries worst affected) and caused substantial economic damage estimated to be between US$11 billion to US$100 billion.2 Nevertheless, through an unprecedented, combined effort by public health experts, scientists, governments, and the WHO, the first new pandemic of the 21st century was not only contained in a remarkably short period of time, but was eradicated as well.3 Given that this was one instance when an IO appears to have performed beyond expectations, it is somewhat perplexing that a number of academic commentators

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have since questioned whether the WHO bureaucracy acted appropriately. For example, it has been argued that it acted as ‘international health police’ (Schnur 2006), that it engaged in agency slack (Cortell and Peterson 2006), and that it exercised ‘independent power’ (Fidler 2004). This chapter evaluates the last set of claims, namely, that the WHO engaged in agency slack or independent power in containing SARS by taking unauthorised, unprecedented, and undesired actions. These claims, advanced by David Fidler and by Andrew Cortell and Susan Peterson, additionally suggest that the WHO exceeded its authority and mandate, effectively engaging in ultra vires activities that contravened the preferences of its member states. However, while the methods the WHO employed may be considered unconventional, when compared against the organisation’s mandate, its delegation contract with member states to eradicate disease, and customary practice, the bureaucracy’s actions were consistent with the organisation’s envisaged role, authority, and autonomy. Moreover, although the WHO acted unilaterally (or autonomously) in the context of SARS, the actions taken by the bureaucracy had been previously authorised by member states and were in fact congruent with the intentions of its collective membership at the time of the pandemic. In conducting this analysis, this chapter contributes to the wider debate about the role of IOs and, in particular, the role of the WHO in global health governance. It also assesses the organisation’s ability and scope to engage in innovative means to fulfil its mandate of advancing global public health and the international community’s willingness to accept such innovation.

Post-SARS Claims Summarised Within a year of the WHO’s declaration that SARS had successfully been contained worldwide, Fidler (2004; 1998; 1999; 2001) published SARS, Governance, and the Globalization of Disease, which drew together a number of themes from previous publications to suggest that a new era of ‘post-Westphalian’ health governance has arrived. Although he claims that this new epoch had been developing for some time, Fidler (2004, 42–60) states that the 2003 SARS pandemic marked ‘the point at which a new governance paradigm for global infectious disease threats truly came of age’. The WHO’s actions in responding to SARS represented a ‘governance tipping point’ that established a precedent for how future disease outbreaks would be managed (187–189). One of the intrinsic elements in this new style of communicable disease governance, however, was the WHO’s apparent usage of ‘independent power’ (142). Intriguingly, Fidler never explicitly outlines the exact meaning of the phrase ‘independent power’. However, it appears that the WHO’s alleged independence relates to its issuance of geographically specific travel advisories and global alerts. As Fidler (2004, 188–189) summarises, WHO’s exercise of independent power during the SARS outbreak in issuing global alerts and geographically specific travel advisories … represent unprecedented developments

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in the history of the world politics of public health and perhaps even in the history of international organizations.

Fidler (2004, 139–145) also suggests that these recommendations were unauthorised, issued without consultation, and economically damaging to certain member states. The claims of WHO independence thereby relates not only to the substance of the recommendations and the manner in which the organisation issued them, but also their effect. This argument is best summarised as follows: In issuing alerts and advisories, WHO exercised significant power in the absence of any agreed policy or legal framework and without deference to the sovereignty of affected states. These actions revealed WHO as an autonomous actor influencing events directly rather than just acting as a convenient device for coordinating the sovereign behaviour of its member states. Without any express policy or legal basis for its actions, WHO took steps with serious political and economic consequences for states affected by SARS (Fidler 2004, 142).

A similar argument has been offered by Cortell and Peterson (2006, 255–271), who cite the WHO’s actions in containing the SARS pandemic as one case of an IO successfully engaging in ‘agency slack’ and ultimately amending its operational procedures and mandate. Combining principal-agent theory and constructivist approaches, they argue that the WHO demonstrated this slack, which has been defined as when an agent takes ‘independent action undesired by the principal’ (Hawkins et al. 2006, 8), first when it used public health information from nongovernmental sources to criticise China publicly, and second when it issued the global alerts and travel advisories (Cortell and Peterson 2006, 269–270). Cortell and Peterson contend that these actions demonstrated that the WHO’s bureaucracy (the agent) formed independent preferences distinct from its member states (the principals). Using the full range of institutional manoeuvring available to them, WHO staff then asserted their own preferences despite member states’ intentions to the contrary. Cortell and Peterson (269, 279–280) conclude, as a result, that the WHO used the 2003 SARS pandemic as an opportunity to engage in agency slack. While themes related to Fidler’s thesis do emerge (the most striking being the considerable similarity between independent power and agency slack), Cortell and Peterson’s (257) critique seeks to ‘explain when IOs can engage in slack and speculate on when they actually do’.4 Prior to evaluating these claims, however, it is necessary first to outline why they are significant. By arguing that the WHO’s bureaucracy engaged in agency slack, Cortell and Peterson have suggested, perhaps unwittingly, that the autonomy exercised by the organisation was in some way inappropriate. According to the framework they employ, only two forms of slack are possible: shirking, defined as ‘when an agent minimizes the effort it exerts on its principal’s behalf’, or slippage, which has been defined as ‘when an agent shifts policy away from its principal’s preferred outcome and toward its own preferences’ (Hawkins et al. 2006, 8). Although Cortell and Peterson argue that it was this latter form of agency slack that was affected by

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the WHO in the context of SARS, both forms of slack attract negative connotations (8–9). Agency slack has even been cited as evidence of dysfunctional or pathological IO behaviour (Barnett and Finnemore 1999, 715–716). The claims Cortell and Peterson advance thus suggest that while the eradication of SARS may have been a beneficial, even desirable, outcome, the role, authority, and autonomy the WHO’s bureaucracy displayed was nevertheless unanticipated, and consequently improper. An even more serious implication arising from the arguments of Fidler, Cortell, and Peterson is their bearing on the legal status of the WHO’s actions. By asserting that certain elements of its response were not authorised, Fidler, Cortell, and Peterson have classified the WHO response as ultra vires under international law. Where it can be determined that an IO has acted ultra vires or outside its authority and competence, the legality of that action may also be challenged (Akande 2003, 285; see also White 1996, 119). Until now no member state has disputed the legal status of the WHO’s actions, but these claims nevertheless cast significant doubt over them. Even if such charges were never raised, the suggestion of impropriety can still have serious ramifications. For instance, were the claims about the WHO’s so-called independence proven (or even assumed) to be correct, certain select member states, traditionally suspicious of the role and authority of IOs, could conceivably react by seeking to constrain how the WHO operates even further. New checks and balances on its constitutional authority may be adopted. Its powers to respond to such events may be curbed. Conversely, in an attempt to prevent objections over the management of an issue or event arising later, the WHO may decide to curtail its own activities. It may, for example, decide to refrain from issuing travel advisories if member states would likely later challenge their legality (and, by default, the legitimacy of the organisation). Both sets of circumstances remain, for the moment, hypothetical suppositions. Yet were they to arise, they would undoubtedly have a damaging effect on the WHO’s activities if only because the organisation’s attention would be temporarily diverted from its primary focus of improving health for all. By challenging the veracity of these claims, this chapter is not suggesting that asking probing questions about the actions of IOs is wrong. Rather, the behaviour of IOs, like states, should be regularly scrutinised and questioned. The key issue for academics and policy makers, however, is how to identify IO mission creep when it actually occurs. How can an IO perform as intended (or perhaps more accurately, how should an IO be performing) be distinguished from an IO that is exerting its own preferences above those of its member states? Can it be considered agency slack when the preferences of member states and the IO appear to be aligned? And, even more significantly, given the negative connotations associated with the term, can agency slack also be viewed as a positive development, a change for good that should be encouraged?

The WHO’s Actions Assessed The following analysis shows that some of these issues are not as straightforward as they seem. Indeed, the case presented below offers one view of the WHO bureaucracy’s

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behaviour in the case of SARS. Importantly, however, it focuses only on those aspects of the WHO’s response to SARS that Fidler, Cortell, and Peterson have identified as unauthorised, unprecedented, and conflicting with the preferences of its member states. This includes the WHO’s issuance of global alerts, geographically specific travel advisories, and criticism of the Chinese government. As little or no mention has been made of the other features of the WHO’s response, it has been assumed that the remaining elements are accepted as falling within the organisation’s general competence and authority. Thus, the argument here concentrates on establishing that the WHO was authorised to issue the global alerts and travel advisories and to criticise of one of its member states. Several assumptions underpin this argument and the context in which the WHO acted. The first is that IOs are actors in their own right (Hawkins et al. 2006; see also Barnett and Finnemore 2004, 1–10, 20–44). The second assumption is that the 2003 SARS pandemic was an exceptional epidemiological event. More precisely, although the Chinese authorities’ decision to break with customary international law of reporting disease outbreaks was not in itself particularly abnormal, their decision to ignore their responsibility aided the new contagion’s emergence and rapid dissemination. When the nature of the contagion then combined with spreading events and international air travel, governments, public health officials, and the WHO alike were presented with multiple, simultaneous outbreaks of a previously unknown disease. The subsequent numbers of affected healthcare workers and facilities additionally converged with the pervasive uncertainty surrounding the rapid international spread of the SARSassociated coronavirus, and, in contrast to many other disease outbreaks, the new and unknown disease directly threatened the populations of developed countries. When viewed collectively, these factors culminated in a very atypical epidemiological event materialising—one that was arguably exceptional. Equally significant is the context in which the WHO took these controversial actions. At the time that the SARS-associated coronavirus began to spread internationally the WHO was in the midst of revising the International Health Regulations (IHR) (Fidler 2004, 142). As the only treaty designed to combat the international spread of infectious diseases, the IHR is an integral component of the WHO’s diseaseeradication delegation contract with its member states. In 1995, recognising that the IHR legislation was inadequate to the task, the WHO’s member states authorised its bureaucracy to undertake an extensive reform of the policies and methods it used to combat infectious diseases (WHO 1995b; WHO 1995a). To that end, at the 48th World Health Assembly (WHA) the member states passed two resolutions: WHA48.7 Revision and Updating of the International Health Regulations and WHA48.13 Diseases Prevention and Control: New, Emerging, and Re-emerging Infectious Diseases. These required the director general to instigate a comprehensive programme to evaluate and update the legislative framework and to develop new ‘strategies enabling rapid national and international action to investigate and to combat infectious disease outbreaks and epidemics’ (WHO 1995a). It was intended that any changes to the WHO’s modus operandi would then be reflected in new draft legislation, which, once ratified by member states, would create a revised

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disease eradication framework (WHO 1995b). The key factor was that the WHO had been granted considerable discretionary capacity to experiment with developing new policies and disease-eradication procedures at the time SARS was spreading internationally. This is an important caveat that Fidler, Cortell, and Peterson appear to overlook in their criticisms of the WHO’s actions, but one that is integral to determining whether the organisation can be deemed to have engaged in independent actions undesired by its member states. Unauthorised, Unprecedented Actions The constitution of the WHO is the single most important document for determining the scope of the organisation’s authority and power. Throughout the 82 articles comprising the WHO’s constitutive treaty are a number of explicit rights, responsibilities, duties, and functions that the organisation has been authorised by its member states to perform. These capacities are commonly referred to as express powers, which are those powers ‘expressly granted by the constitution’ (Amerasinghe 2004, 100). Where expressly granted, these powers are classified as intra vires, or within the scope and authority of the organisation concerned. Some of the more prominent examples of the WHO’s express (intra vires) powers include the WHA’s authority to adopt regulations pertaining to sanitary and quarantine measures (WHO 2006a, art. 21[a]), the director general’s power to establish relations with other IOs undertaking health-related activities congruent with the WHO’s (art. 33), and the executive board’s authority to implement emergency measures when responding to events such as epidemics (art. 28[i]). Like the constitutive treaties of many IOs, however, the WHO’s constitution also has a number of limitations. Specifically, by virtue of its nature, it sets out the object and purpose of the organisation in very broad terms. Ascertaining the definitive boundaries of the WHO’s authority and the extent of the powers the organisation is entitled to affect on a daily basis can therefore be a complex and, at times, problematic exercise (Sands and Klein 2001, 445). One of the more serious implications of this limitation is that the actions or decisions of an IO may occasionally be viewed as unconstitutional and classified as ultra vires. The inevitable question that subsequently arises then is who is authorised to interpret an IO’s constitutive treaty. It is now widely accepted in the international legal tradition that where no one body has been explicitly named within an IO’s constitutive treaty to interpret the document, the organs of that particular organisation will provide the interpretation in the first instance.5 Like any treaty concluded between governments, however, the constitutive treaties of IOs are subject to a number of general rules of treaty interpretation, including that the treaty is to be interpreted in good faith, that ordinary meaning is to be ascribed to the text of the treaty, that the treaty should be interpreted in its context and in the light of its object and purpose, that subsequent practice is to be accepted as a form of interpretation and any subsequent agreements are to be taken into consideration, and that the meaning of the treaty should not be left ambiguous or unclear in any way (Evans 2005, 130–136).

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In addition, however, IO constitutive treaties have been recognised as possessing special character deserving of uncommon interpretive techniques. This principle, established by the International Court of Justice (ICJ) in its advisory opinion on the Legality of the Use by a State of Nuclear Weapons in Armed Conflict, stipulates that while the ‘well-established rules of treaty interpretation apply’, IO constitutive treaties, are also treaties of a particular type; their object is to create new subjects of law endowed with a certain autonomy, to which the parties entrust the task of realizing common goals. Such treaties can raise specific problems of interpretation owing, inter alia, to their character which is conventional and at the same time institutional; the very nature of the organization created, the objectives which have been assigned to it by its founders, the imperatives associated with the effective performance of its functions, as well as its own practice, are all elements which may deserve special attention when the time comes to interpret these constituent treaties (ICJ 1996, 4).

By virtue of this dual nature and the difficulties it raises, adjudicative bodies such as the ICJ have tended to adopt a more flexible approach when interpreting IO constitutive treaties. Special prominence has been attached to two features: the object and purpose of the treaty, and the role of subsequent practice. In the context of the WHO, the object and purpose of the treaty were to create a universal organisation charged with ensuring the ‘attainment by all peoples of the highest possible level of health’ (WHO 2006a, art. 1). Health, which was described by the WHO’s founders as ‘a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity’ (preamble), presupposes the absence of disease. The eradication of any disease such as SARS is thus a core component in achieving this objective—one entirely consistent with the object and purpose of the IO’s constitutive treaty. Correspondingly, it is likely that should a case about the WHO’s handling of SARS ever be brought before the ICJ, considerable latitude would be accorded to the WHO’s bureaucracy for its actions. In fact, several provisions within article 2 of the WHO constitution are particularly relevant to evaluating the WHO’s actions. The first two provisions of immediate significance—‘to act as the directing and co-ordinating authority on international health work’ (WHO 2006a, art. 2[a]) and ‘to stimulate and advance work to eradicate epidemic, endemic and other diseases’ (art. 2[g])—establish the organisation’s overall authority to respond and, importantly, to take the lead role throughout the 2003 SARS-inspired global emergency. Particularly in terms of the WHO’s authority to issue the global alerts, geographically specific travel advisories, and disease outbreak information to non-state entities, however, the follow provisions may be interpreted as further authorising the aforementioned activities: k) to propose conventions, agreements and regulations, and make recommendations with respect to international health matters and to perform such duties as may be assigned thereby to the Organization and are consistent with its objective (WHO 2006a, art. 2);

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Furthermore, under article 2(v) of the constitution, the WHO has been additionally empowered to ‘generally take all necessary action to attain the objective of the Organization’, which, as indicated previously, is the attainment of all peoples of the highest possible level of health. In reviewing these various provisions, it becomes difficult to agree with the view that the WHO’s recommendations throughout SARS were unauthorised. The WHO’s global alerts and travel advisories are classified as non-binding recommendations that the organisation is authorised to issue under article 2(k) of the constitution. Similarly, the WHO’s dissemination of disease outbreak notifications and updates via its website and the international media could clearly be interpreted as permissible activities under article 2(q) and (r). Lastly, eradicating the SARS-associated coronavirus was entirely consistent with both the overall objective of the WHO—the attainment of all peoples of the highest possible level of health—and its duty to eradicate disease. Thus, even from a brief overview of the WHO’s constitutional powers, it is reasonable to surmise that the bureaucracy’s actions were authorised. Likewise, a case can be made that established or customary WHO practice substantiates the validity of the organisation’s authority to issue the global alerts and travel advisories. First, the WHO has regularly issued global alerts pertaining to disease outbreaks whenever it has deemed them necessary. Prior to the mid 1990s these alerts were only generally published in the WHO’s weekly periodical, Weekly Epidemiological Record. However, since 1996, they have also been published on the WHO website (WHO 2008; 2006b). More specifically in relation to the geographically specific travel advisories, the WHO secretariat maintains that it has taken comparable action on at least one prior occasion, following the 1994 outbreak of plague in Surat, India. In this instance the WHO issued a recommendation that avoiding travel to the affected region was unnecessary (WHO 1994a; 1994b). Although the content of the recommendation was therefore technically the reverse of the SARS advisories (and as such, the case for customary practice is certainly debatable), the WHO secretariat maintains that this advisory established a precedent for the 2003 travel advisories.6 Strengthening the bureaucracy’s case, it is not only the practice of the organisation itself but also the reaction of member states that can provide new insight into the powers and authority of an IO. As Jose Alvarez (2005, 80) observes, action taken by a member with respect to an organization, if unchallenged by the organization or other members, may also constitute, de facto, an interpretation with such effects. The same is true of action taken for the first time by an institutional organ, if unchallenged by the membership. Even an interpretation by the legal department of the secretariat, if accepted by the membership, is presumed to be intra vires and may be cited as authoritative the next time a similar issue arises.

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It follows, then, that because member states failed to raise any specific objections to the Surat advisory at the time in 1994, they tacitly signalled their endorsement of this type of measure, laying the foundation for the 2003 SARS advisories. Indeed, the WHO legal department appears to have adhered to this line of reasoning. In extending this principle even further, the fact that no member state sought to challenge the legal status of the WHO’s actions throughout the 2003 pandemic negates the possibility that the organisation’s actions could be classified as ultra vires. Instead, by not challenging the WHO’s actions, member states concurred with the interpretation provided by the WHO bureaucracy that its actions in the context of SARS were authorised and within acceptable limits of IO behaviour (Osieke 1983).7 This is not to suggest, however, that no aspect of the WHO response to the 2003 SARS pandemic was unprecedented. Nor were the nature of the recommendations and the attention they subsequently generated lost on the WHO bureaucracy. As one senior WHO official overseeing the revision of the IHR observed, what I think was relatively new for WHO, at least in the immediate consciousness of the world, was that people looked very much to the organisation and what it said. And not just health experts or various ministries of health, but other people looked at it and took it very seriously. That is unusual. There’s nothing in our mandate that says it shouldn’t be done or that is an inappropriate thing for us to do. But I think the balance then between the organisation saying something and that then being interpreted, moderated, and adapted by member states, and then given to the public, was a little lost with many of the things WHO was saying being of direct interest and directly influencing not just members of the public, but other institutions, other organisations … that caused some change, a shift in how people perceived the organisation.8

In fact, it could be conversely argued that the WHO’s bureaucracy was not only entitled to take the actions it did, but also that it was actually obliged to do so, whether those actions were unprecedented or not. This was possibly no more readily apparent than in relation to the controversial travel advisories, as pointed out by David Heymann, who was the executive director of the WHO Communicable Diseases Cluster at the time of the pandemic: Before we started making our recommendations there were many countries that had made advisories that weren’t based on anything more than insurance concerns. One government, for example, recommended no travel to Vietnam. They also recommended that government employees’ families living in that country be returned home. These recommendations were made because the government could not ensure return flights should their citizens abroad become ill.9

The case could be made that the WHO, as the world’s independent authority on health matters, had a duty to provide an impartial assessment of the danger to and from the international public. The WHO’s bureaucracy was thus obliged to take the action it did, the authority to do so flowing naturally from its constitutional powers

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and established practice and, additionally, from its duty of care as an impartial, technical organisation charged with ensuring the eradication of disease. Indeed, if any aspect of the WHO’s management of the 2003 SARS pandemic was classified as an example of independent power or agency slack, it would be the bureaucracy’s earlier decision to send a team of scientists to China without a prior invitation from the Chinese government. This action, which precipitated the bureaucracy’s criticism of the Chinese authorities, clearly violated article 2(d) of the WHO constitution. By sending the team without any specific request or invitation, the bureaucracy appeared to contravene both its constitutional authority and the sovereignty of one of its member states. Again, however, it is important to note the context in which the WHO bureaucracy took this action prior to classifying it as an example of independent action undesired by its principal. As highlighted above, the WHO (1995a, para. 3(1–6)) had previously been commissioned to explore new disease-eradication policies and procedures. This request, issued by member states in 1995 in association with an express request to revise the IHR, granted the WHO bureaucracy additional discretionary capacity to explore new policies and operational procedures that would enhance its ability to fulfil its delegation contract to eradicate communicable disease threats. Moreover, at the time the 2003 SARS pandemic commenced, the IHR revision process was ongoing. As such, it can be assumed that the WHO’s bureaucracy was authorised to exercise discretion in how it responded to the SARS threat given that no formal legal framework had been established and given the fact that the additional capacity to explore alternative disease-eradication policies and procedures had not been rescinded. Furthermore, and especially significantly, member states had already tacitly sanctioned the WHO’s interventionist approach to communicable disease threats when they passed resolution WHA54.14 Global Health Security: Epidemic Alert and Response in 2001. In passing this resolution, member states expressed their unambiguous support for the multiple programmes and initiatives that the WHO’s bureaucracy had begun testing under the authority to revise the IHR (see WHO 2001a, esp. para. 1.3, 3.1–3.3). By default, they also sanctioned several new diseaseeradication operational policies and procedures, including the Global Outbreak Alert and Response Network (GOARN), which had been established in April 2000 (WHO 2000). According to this framework, the WHO is required to send a rapid response team whenever a disease outbreak is reported to conduct a risk assessment, offer technical advice and support, initiate field investigations, assemble epidemiological data and conduct research, and communicate any findings with the wider international community (WHO 2001b). Thus, the bureaucracy’s actions were entirely reasonable and consistent with the authority it had been previously granted by member states. Undesired Actions As noted above, it has been suggested that in issuing the global alerts and travel advisories and publicly criticising the Chinese government, the bureaucracy took actions that were undesired by member states (Fidler 2004, 141; Cortell and Peterson

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2006, 269–270, 279). However, on examination, the case supporting this observation falls down. The WHO is composed of 193 member states, all of which can possess divergent preferences and views. Given this reality, it is entirely reasonable to expect that member states will, from time to time, disagree with each other over the organisation’s planned course of action or activities. It is also entirely possible that while one or even a few member states will object to the direction or actions, not all member states will. This places the WHO’s bureaucracy in a precarious situation whereby the actions it takes may be congruent with the (often silent) majority of member states but vehemently objected to by a small minority. In the context of SARS, it is evident that the majority of member states fully supported the WHO’s decision to issue the alerts and travel advisories, and later to criticise the Chinese government, by the fact they declined to renounce the WHO’s behaviour. Only China formally objected to the WHO’s actions (the only protest from Canada was at a provincial level—the federal government did not object)— and even then the Chinese government declined to push the matter due to mounting pressure from the international community to cooperate with the WHO. In fact, evidence of the international community’s support for the WHO’s actions was made very apparent at the 56th WHA, convened in May 2003 at height of the pandemic. Throughout the assembly as well as the subsequent plenary meetings that followed in June, representatives from Sweden, the United Kingdom, Japan, the Maldives, South Korea, Brunei Darussalem, Turkey, Mongolia, Finland, the Czech Republic, Hungary, Singapore, Thailand, Pakistan, Jamaica, Zambia, Zimbabwe, the European Commission, and Vietnam announced their governments’ appreciation and continued support for the WHO’s management of the 2003 SARS pandemic (WHO 2003c, 160, 184; 2003d, 20–34; 2003e, 3–46). Aside from a comment made by the Chinese government representative, no mention was made that the WHO had overstepped its mandate or that it had taken actions that were either unauthorised or unprecedented. Even in private conversations there appears to have been no protest raised. As Heymann recalls, I’ve had the honour of speaking with the heads of many affected countries, and in those encounters there was never any telling WHO that we’d overstepped our mandate. What was said was ‘we understand the criteria, we understand why we’ve been put on this list. We want to get off as soon as we can’.10

Moreover, many member states pressed the WHO to take affirmative action. As one senior WHO legal official noted, it wasn’t done without demand for that to be done coming from member states. In other words, although there was no process, member states were asking us to take action in that timeframe, of that type. But there was not a consensus amongst the member states per se. There were individual demands from many member states. That we responded to such demands is entirely within what we are supposed to be doing according to our constitution.11

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Thus, given that demands were being made by individual member states without strident opposition from the vast majority of other state parties, it is reasonable to conclude that the majority of member states in fact supported the WHO’s methods, with their silence equating to tacit approval. It can similarly be concluded that the WHO’s actions in the context of the SARS pandemic were consistent as opposed to conflicting with the intentions of its collective membership. This argument is perhaps best summarised by the same senior WHO legal official, who stated: I don’t think WHO exercises independent power. What WHO does is respond to the direction of its member states, but at any one time not all member states will agree about what WHO’s actions should have been or should be. And WHO sometimes has to act, particularly in emergencies, on the basis of its mandate without consulting or getting agreement from all member states. Having said that, the basis that it acts then is on the basis of the expertise and the authority it has as an expert body in public health. Even having said that, it would still always seek to have, to inform, and to take into account the views of as many member states as it can, particularly those that are directly involved in the emergency. And so I wouldn’t call it independence; I’d call it some kind of moderated independence where we will act sometimes, and while not everyone of our member states will always agree with our actions, we would not act without agreement of at least many of our member states, and without consulting member states.12

Independent Action? This is not to suggest, however, that the WHO’s response to the 2003 SARS pandemic was orthodox. In what may be a highly unusual, even exceptional move, the WHO bureaucracy did act independently, rapidly, and forcefully to the SARS threat—a point that acknowledged by several senior WHO officials on more than one occasion, as well as in several official publications (WHO 2003f, 5–7) and by Gro Harlem Brundtland, former director general of the WHO.13 The observation that the organisation did not seek any specific permission from member states prior to responding to the SARS threat is not, therefore, in question. The WHO’s senior leadership took full advantage of the discretionary capacity granted to it, reallocating the organisation’s temporal, financial, material, and normative resources to combat the SARS virus. This point, however, does not equate to arguing the WHO’s leadership took these actions without regard to their impact upon member states. Nor is it being suggested that the WHO failed to advise member states of the action its bureaucracy was taking. Rather, it has been reported that the key decision makers were very well aware of the potential impact of their actions on member states, and these were discussed with the governments of those countries directly affected by SARS prior to the action being taken. As Heymann has noted, the director general in her deliberations and in her thinking asked ‘does this fit in with what the mandate of the Organization?’. We were very careful in how we approached this—we

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discussed with countries in advance of making the recommendations so that they knew that they were coming, and took into consideration any comments that they might have. It didn’t change our decision, but it did bring into consideration any comments that they had before we actually made the recommendations public.14

Similarly, in commenting on whether the issuance of travel advisories constitutes independent power, Bill Kean, WHO Director of Governance in 2003, stated that certainly Dr. Brundtland thought about that very carefully as to whether it was the right thing to do public health–wise. But as for the economic impact, was she able to act alone? [Brundtland] decided that she was. So independent? Well, it was independent of other bodies. I mean [Brundtland] didn’t consult the WTO [World Trade Organization] on the trading considerations or WTO tourism [World Tourism Organization] on the tourism implications … but the member states were advised that this action was happening.15

Although it is thus openly acknowledged the WHO’s bureaucracy did act unilaterally, the decision was approached cautiously and with regard to the impact upon member states. Indeed, the organisation’s ability to act autonomously was ultimately one of the key strengths of its response to the 2003 SARS pandemic. Had the bureaucracy failed to respond rapidly and forcefully, it is highly likely that SARS would have become yet another endemic disease, periodically reappearing to cause further human suffering and death. It was the WHO’s ability to act independently, without the requirement to convene committees and sit through extensive debates about the potential consequences of each decision, that enabled SARS to be contained and eradicated within four months of its spreading internationally. While it is agreed that there are inherent dangers associated with allowing IOs too much freedom, the 2003 SARS pandemic powerfully demonstrated that the autonomy of IOs can have positive outcomes.

Conclusion The very features that some have suggested were unauthorised, unprecedented, and undesired were, in the end, critical to the WHO’s success in containing and eradicating SARS. In issuing the global alerts and travel advisories, and in criticising the Chinese government for its lack of action, the WHO put the world on alert and embarrassed a recalcitrant member state into amending its behaviour. By acting autonomously, it was able to institute a variety of constitutionally authorised measures that proved effective in both rapidly containing the SARS-associated coronavirus and preventing its further dissemination. These methods were somewhat unconventional, particularly for the WHO—which has historically sought to avoid controversy. However, member states had explicitly requested that the organisation undertake a comprehensive programme of reforming its disease-eradication policies

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and procedures in the process of revising the IHR—a process that was incomplete at the time of SARS. Given that, compared to past pandemics, the 2003 SARS pandemic was an exceptional epidemiological event, the WHO was required to respond in an exceptional, innovative way. Furthermore, while the WHO did act unilaterally it did so with an awareness of the potential impacts of its actions on its members, and it followed a clearly defined, constitutionally valid course of action that was based on sound public health principles. A number of the bureaucracy’s actions, such as sending an uninvited team of experts to China without the government’s explicit request, were based on customary practice, having been previously endorsed by the WHA with the creation of the GOARN in 2000. Furthermore, at least at the time of the 2003 crisis, the WHO’s actions were entirely consistent with the preferences of its collective membership, given that when the WHO did take these unconventional measures, the majority of member states failed to denounce them. It is always valuable in the wake of tragic international events to reflect on the roles of actors and whether things could, or should, have been done differently. The questions that Fidler, Cortell, and Peterson raise about the WHO’s behaviour are therefore important if for no other reason than they make one pause to consider how much authority and autonomy the international community is willing to cede to IOs. When the WHO was created in 1946 its founders anticipated the organisation would evolve, developing new and innovative means to fulfil its mandate. In the context of SARS the WHO exceeded expectations, demonstrating that many of the former restrictions on the notification of disease outbreaks and how the organisation responded to these events more generally required a substantial re-think. Of course, one should not assume that the WHO is merely a benevolent public servant. The actions and behaviour of IOs require constant monitoring to avoid unwanted mission creep. At the same time, they are required to walk a very delicate line where, on one side, they must fulfil their mandates in a constantly changing world while, on the other, they must meet the (at times very diverse) expectations of member states. It is an unenviable, and quite often tenuous, position—one that the world continues to place them in. Perhaps analysts should be a little more lenient, therefore, and embrace the innovative attempts of IOs to respond to new global challenges, particularly when most individual states would concede that these challenges are well and truly beyond them to manage.

Notes 1 Note that this figure includes deaths due to nosocomial causes that were not part of the original pandemic but occurred afterward. 2 Estimates on the final costs attributed to the 2003 pandemic vary considerably; see, for example, U.S. General Accounting Office (2004, 4, 32), Asian Development Bank (2003, 75–77), and Brower (2003, 651), as well as page 30. 3 The WHO (2003a) declared the SARS pandemic contained on 5 July 2003.

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4 With the exception of Cortell and Peterson’s claim that a second episode of agency slack occurred when the WHO criticised China, the terms ‘agency slack’ and ‘independent power’ are otherwise so alike in content and analysis that for the purposes of this chapter they have been taken to be synonymous. 5 This general principle of international institutional law originally arose from the 1945 San Francisco conference establishing the United Nations. However, it has also since been endorsed by the International Court of Justice (ICJ) in the Certain Expenses of the United Nations case, which concluded that ‘each organ [of the UN] must, in the first place at least, determine its own jurisdiction’ (Jennings 1962, 1177). Although in one sense this principle elevates the organs of an IO above that of its member states, it nevertheless has become widely accepted due to the fact that the IO organs are charged with executing the organisation’s delegated duties, and therefore, the organs are deemed to be the most competent authority to interpret the charter (see Alvarez 2005, 80). 6 Interview with David Heymann, 15 November 2005, WHO, Geneva. This view was also supported Senior WHO Official A, 18 November 2005, WHO legal department, Geneva. 7 This default position is made even stronger whenever an IO explicitly asserts that its actions were taken in the fulfilment of its mandate (Akande 2003, 285–296; Shaw 2003, 1196; Schermers and Blokker 2003, 154, 163). 8 Interview with WHO Official B, 18 November 2005, WHO, Geneva. 9 Interview with Heymann. 10 Interview with Heymann. 11 Interview with Senior WHO Official A. 12 Interview with Senior WHO Official A. 13 Email correspondence with Gro Harlem Brundtland, 13 April 2006. 14 Interview with Heymann. 15 Interview with Bill Kean, WHO Director of Governance, 15 November 2005, WHO, Geneva.

References Abraham, Thomas (2005). Twenty-First Century Plague: The Story of SARS. (Baltimore: Johns Hopkins University Press). Akande, Dapo (2003). ‘International Organizations.’ In M.D. Evans, ed., International Law. (Oxford: Oxford University Press). Alvarez, Jose (2005). International Organizations as Law-Makers. (Oxford: Oxford University Press). Amerasinghe, Chittharanjan F. (2004). Principles of the Institutional Law of International Organizations. 2nd ed. (Cambridge: Cambridge University Press). Asian Development Bank (2003). Outlook 2003 Update: Trends, Analysis, Projections. (Manila: Asian Development Bank). Barnett, Michael and Martha Finnemore (1999). ‘The Politics, Power, and Pathologies of International Organizations.’ International Organization, vol. 53, no. 4, pp. 699–732. Barnett, Michael and Martha Finnemore (2004). Rules for the World: International Organizations in Global Politics. (Ithaca: Cornell University Press). Brooks, Tim (2005). Behind the Mask: How the World Survived SARS. (Washington DC: American Public Health Association).

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Brower, Vicki (2003). ‘Health Is a Global Issue.’ EMBO Reports, vol. 4, no. 7, pp. 649–651. <www.nature.com/embor/journal/v4/n7/full/embor892.html> (September 2008). Cortell, Andrew and Susan Peterson (2006). ‘Dutiful Agents, Rogue Agents, or Both? Staffing, Voting Rules, and Slack in the WHO and WTO.’ In D.G. Hawkins, D.A. Lake, D.L. Nielson, et al., eds., Delegation and Agency in International Organizations, pp. 255–280. (Cambridge: Cambridge University Press). Esty, Daniel C. (2006). ‘From Local to Global: The Changing Face of Environmental Challenge.’ SAIS Review, vol. 26, no. 2, pp. 191–197. Evans, Malcolm D., ed. (2005). Blackstone’s Statutes: International Law Documents. 7th ed. (Oxford: Oxford University Press). Fidler, David P. (1998). ‘Microbrialpolitik: Infectious Disease and International Relations.’ American University International Law Review, vol. 14, no. 1, pp. 1–53. Fidler, David P. (1999). International Law and Infectious Diseases. (Oxford: Oxford University Press). Fidler, David P. (2001). ‘Return of “Microbialpolitik”.’ Foreign Policy, no. 122, pp. 80–81. Fidler, David P. (2004). SARS: Governance and the Globalization of Disease. (New York: Palgrave Macmillan). Hawkins, Darren G., David A. Lake, Daniel L. Nielson, et al. (2006). ‘Delegation under Anarchy: States, International Organizations, and Principal-Agent Theory.’ In D.G. Hawkins, D.A. Lake, D.L. Nielson, et al., eds., Delegation and Agency in International Organizations, pp. 3–38. (Cambridge: Cambridge University Press). International Court of Justice (1996). Legality of the Use by a State of Nuclear Weapons in Armed Conflict (Request for Advisory Opinion by the World Health Organization). 8 July. Geneva. <www.icj-cij.org/docket/files/93/10405.pdf> (September 2008). Jennings, R.Y. (1962). ‘International Court of Justice. Advisory Opinion of July 20, 1962.’ International and Comparative Law Quarterly, vol. 114, no. 1169–1183. Osieke, Ebere (1983). ‘The Legal Validity of Ultra Vires Decisions of International Organizations.’ American Journal of International Law, vol. 77, no. 2, p. 248. Pollack, Mark (2003). The Engines of European Integration: Delegation, Agency, and Agenda Setting in the European Union. (Oxford: Oxford University Press). Ruggie, John G. (1985). ‘The United States and the United Nations: Towards a New Realism.’ International Organization, vol. 39, no. 2, pp. 343–356. Sands, Philippe and Pierre Klein (2001). Bowett’s Law of International Institutions. 5th ed. (London: Sweet and Maxwell). Schermers, Henry G. and Niels M. Blokker (2003). International Institutional Law. 4th rev. ed. (Boston: Martinus Nijhoff). Schnur, Alan (2006). ‘The Role of the World Health Organization in Combating SARS, Focusing on the Efforts in China.’ In A. Kleinman and J.L. Watson, eds., SARS in China: Prelude to a Pandemic. (Berkeley: Stanford University Press). Shaw, Malcolm N. (2003). International Law. 5th ed. (Cambridge: Cambridge University Press). United States General Accounting Office (2004). Emerging Infectious Diseases: Asian SARS Outbreak Challenged International and National Responses. United States General Accounting Office, Washington DC. <www.gao.gov/cgi-bin/getrpt?GAO-04-564> (September 2008). White, Nigel (1996). The Law of International Organisations. (Manchester: Manchester University Press).

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World Health Organization (1994a). ‘Plague, India.’ Weekly Epidemiological Record, vol. 69, no. 39, p. 290. World Health Organization (1994b). ‘Plague, India.’ Weekly Epidemiological Record, vol. 69, no. 40, p. 295. World Health Organization (1995a). ‘Communicable Diseases Prevention and Control: New, Emerging, and Re-emerging Infectious Diseases.’ WHA48.13. Geneva. <policy.who.int/cgibin/om_isapi.dll?infobase=wharec-e&softpage=Browse_Frame_Pg42> (January 2007). World Health Organization (1995b). ‘Revision and Updating of the International Health Regulations.’ WHA48.7. Geneva. <policy.who.int/cgi-bin/om_isapi.dll?infobase=wharece&softpage=Browse_Frame_Pg42> (January 2007). World Health Organization (2000). Global Outbreak Alert and Response: A Report of a WHO Meeting. WHO/CDS/CSR/2000/3. Geneva. <www.who.int/csr/resources/publications/ surveillance/WHO_CDS_CSR_2000_3/en> (September 2008). World Health Organization (2001a). ‘Global Health Security: Epidemic Alert and Response.’ WHA54.14, 21 May. Geneva. (May 2008). World Health Organization (2001b). A Framework for Global Outbreak Alert and Response. WHO/CDS/CSR/2000/2. Geneva. <www.who.int/csr/resources/publications/surveillance/ WHO_CDS_CSR_2000_2/en> (September 2008). World Health Organization (2003a). ‘Update 96—Taiwan, China: SARS Transmission Interrupted in Last Outbreak Area.’ 5 July. Geneva. <www.who.int/csr/don/2003_07_05/ en> (September 2008). World Health Organization (2003b). ‘Summary Table of SARS Cases by Country, 1 November 2002 – 7 August 2003.’ 15 August. Geneva. <www.who.int/csr/sars/country/2003_08_15/ en> (September 2008). World Health Organization (2003c). Fifty-Sixth World Health Assembly: Summary Records of Committees and Round Tables, Reports of Committees. (Geneva: World Health Organization). World Health Organization (2003d). Provisional Verbatim Record of the Second Plenary Meeting: Address by the Director-General. (Geneva: World Health Organization). World Health Organization (2003e). Provisional Verbatim Record of the Second Plenary Meeting: Address by the Director-General, Continued. (Geneva: World Health Organization). World Health Organization (2003f). Severe Acute Respiratory Syndrome (SARS): Status of the Outbreak and Lessons for the Immediate Future. 20 May. Geneva. <www.who.int/csr/ media/sars_wha.pdf> (September 2008). World Health Organization (2006a). ‘Constitution of the World Health Organization.’ 45th ed. Geneva. <www.who.int/entity/governance/eb/who_constitution_en.pdf> (September 2008). World Health Organization (2006b). ‘Disease Outbreak News.’ Geneva. <www.who.int/csr/ don/archive/year/1996/en> (September 2008). World Health Organization (2006c). SARS: How a Global Epidemic Was Stopped. (Geneva: World Health Organization). World Health Organization (2008). ‘WHO Epidemic and Pandemic Alert and Response.’ Geneva. <www.who.int/csr/don/en> (September 2008).

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Part III Preparing for Pandemics: Avian Influenza

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Chapter 5

SARS and Avian Influenza in China and Canada: The Politics of Controlling Infectious Disease Sonny Shiu-Hing Lo1

Since the outbreak of avian influenza in Hong Kong in December 1997, infectious disease has become a human and national security threat to the Asia Pacific region (Osterholm 2005). In Asian cities where population density is high, such as Hong Kong, Singapore, and Macao, the emergence of any influenza pandemic endangers the lives of all citizens. In geographically spacious countries, notably the People’s Republic of China (PRC) and Indonesia, any looming pandemic would be socially destabilising and politically delegitimising. In the United States the Spanish influenza that broke out in 1918 resulted in civil disorder and riots in some cities (Garrett 2005). Public health crises have been numerous in the Asia Pacific region: avian influenza in Hong Kong in late 1997; dengue fever in Macao in 2000; severe acute respiratory syndrome (SARS) in mainland China, Hong Kong, and the Republic of China (ROC) or Taiwan in early 2003; avian influenza in China in 2004 and intermittently in 2005 and 2006; avian influenza in Indonesia and Thailand in 2005 and 2006; the H5N1 virus in South Korea in November 2006; and a suspected mysterious influenza that killed four children in Hong Kong in early 2008. In early 2007, avian influenza erupted in Japan, Thailand, and Indonesia (‘Bird Flu Strikes Again in Thailand’ 2007). All these health crises in Asia stemmed from infectious diseases, the most important of which include avian influenza and SARS. Infectious diseases are viruses that can be transmitted either from animals to humans or from humans to humans. This chapter focusses on the respiratory type of infectious disease, notably avian influenza and SARS. In this era of globalisation, avian influenza and SARS can extend their tentacles swiftly, especially if they can be transmitted from animals to humans and then from humans to humans. The intensity of air travel in the world means that any contagious disease in Asia has immediate economic, social, and political repercussions in other parts of the world (Thomson and Hoe 2004). Due to Canada’s proximity to Asia and their frequent human interactions, any influenza pandemic in Asia will wreak havoc on the Canadian economy. The

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SARS outbreak in greater China—the PRC, Taiwan, Hong Kong, and Macao— severely affected Toronto, although Vancouver was largely spared from the crisis. In the wake of SARS, avian influenza has become the foremost health threat confronting Asia and the world. As the World Health Organization ([WHO] 2004a) warns, ‘of the 15 avian influenza virus subtypes, H5N1 is of particular concern for several reasons. H5N1 mutates rapidly and has a documented propensity to acquire genes from viruses infecting other animal species … isolates from this virus have a high pathogenicity and can cause severe disease in humans’. The migratory routes of birds from Siberia cover Asia and Europe. In February 2007, the H5N1 virus killed 2500 turkeys on a British poultry farm. If the H5N1-infected birds pose an increasing human security threat to many states and cities, the continuous surveillance of their migratory patterns by satellites is critical to the well-being of all the people around the world. Margaret Chan stressed the need to set up a global surveillance system to monitor health crises during her campaign for election as director general of the WHO in November 2006. After all, the H5N1 virus entails the possibility of person-to-person transmission in Thailand in 2004 (Ungchusak et al. 2005). If so, it is urgent for states to ‘stockpile anti-viral drugs and strain-specific vaccines’ and to share their intelligence data on the H5N1 virus with the WHO and other countries (Monto 2005, 325). According to the Canadian Influenza Pandemic Plan, any outbreak of the influenza An epidemic will have an immediate impact on Canada’s society and economy. An estimated 4.5 million to 10.6 million Canadians would become clinically ill and lose their working capacity (Public Health Agency of Canada [PHAC] 2004, 18). An estimated 2.1 million to 5 million people would require outpatient care; between 34 000 and 138 000 people would require hospitalisation; and between 11 000 and 58 000 people would die in Canada alone. The economic impact has been estimated to cost between CA$10 billion and CA$24 billion. This chapter analyses the governance of Asian states in response to respiratory infectious disease, particularly avian influenza and SARS. Lessons can be drawn from the Asian experience for Canadian governments at the federal, provincial, and municipal levels. Indeed, Canada has much to learn from the bitter lessons of SARS and the ways in which some Asian cities such as Singapore and Hong Kong dealt with it. Being a democratic country does not necessarily endow federal and sub-federal governments with the capacity to control an influenza pandemic effectively. Arguably, governmental decisiveness during any such pandemic would be far more important than the protection of civil liberties. Provincial variations in Canada have already revealed on how differently those governments perceive an influenza pandemic. Yet if Canadian governments at the federal, provincial, and municipal levels together with the private sector all implement a common action plan, Canada’s governance in response to any possible influenza pandemic would be substantially enhanced. For the purposes of this chapter, the concept of health governance is defined narrowly as how governments respond to the outbreak of infectious disease. It refers here to government’s capacity or ability to take decisive and emergency measures. How a government reacts can have a direct bearing on the regime’s legitimacy. The

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more effective the governmental response is, the stronger the regime’s legitimacy will be. However, the external ramifications of the domestic response to infectious disease are outside the scope of this chapter. Indeed, the weaker the governmental response to the outbreak of infectious disease, the stronger the likelihood of the spread of the disease to the outside world. This narrow definition of health governance contributes to a deeper understanding of the political impact of infectious disease on a particular regime, even if many scholars define health governance as embracing various external and internal actors, such as the WHO, civil society, and nongovernmental organisations (NGOs).

Governmental Capacity to Respond to Infectious Disease in Asia The improvement of health governance is the most important challenge in globalisation. Both human security and national security are at stake because of the speed at which infectious diseases can be transmitted to a large segment of the local population. SARS is a typical example. Since the origin of the disease was related to the consumption of civet cats among Chinese residents in Guangdong province, the PRC’s health governance can be measured in terms of its ability to prevent its citizens from eating wild animals from live-animal markets that have been thriving since the country’s economic boom (Paterson 2004; Bonn 2003). Other barometers that measure China’s health governance include the flow of communications between the central government and provincial as well as local governments during an outbreak of infectious disease, the ability of the central government to mobilise in order to contain the spread of the deadly virus, and the compliance of provincial and local authorities in tackling the health crisis. Three indicators are critical to enhancing governmental capacity: preparedness, openness, and responsiveness. In the case of SARS, governments in Asia and Canada were totally unprepared.2 Canada was as poorly prepared as Hong Kong. Table 5-1 shows that the case fatality ratio in Canada was 17 percent, the same as that of Hong Kong, where SARS left an indelible imprint and a painful memory. Other Asian states witnessing a relatively high ratio of case fatality were Singapore, Thailand, Taiwan, Malaysia, the Philippines, and Vietnam. The PRC had the largest number of people infected with SARS. Although its case fatality ratio was claimed to be 7 percent, 349 people died of the mysterious disease (WHO 2004b).Canada’s performance during the SARS outbreak might not be an accurate indicator of how it would react to another new epidemic. Some argue that SARS did not appear to necessitate any stringent or draconian measures from the Canadian government. This argument is flawed. True, the SARS crisis was unprecedented and microbiologists could not quickly predict whether it would be temporary or not. But given the case fatality ratio in Canada, Ottawa and the provincial governments underestimated the speed at which SARS could affect the Canadian population. Canada learned a bitter lesson from its SARS experience. The report published by the National Advisory Committee on SARS and Public Health (2003a) recommended a better mechanism

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for the federal and provincial governments to strengthen their disease surveillance programmes. It also recommended harmonising public health legislation at both levels of government (215). The report concludes: ‘The challenge now is to ensure not only that we are better prepared for the next epidemic, but that public health in Canada is broadly reviewed so as to protect and promote the health of all our present and future citizens’ (220). Other critics pointed to many cases of misdiagnosis of Table 5-1: SARS and the Impact on Various Countries and Places, 1 November 2002 to 31 July 2003  

Cumulative number of cases

No. of Case fatality Onset first Onset last Areas Female Male Total deaths ratio (%) probable case probable case Australia 4 2 6 0 0 26 Feb 2003 1 Apr 2003 Canada 151 100 251 43 17 23 Feb 2003 12 Jun 2003 China 2674 2607 5327 349 7 16 Nov 2002 3 Jun 2003 Hong Kong 977 778 1755 299 17 15 Feb 2003 31 May 2003 Macao 0 1 1 0 0 5 May 2003 5 May 2003 Taiwan 218 128 346 37 11 25 Feb 2003 15 Jun 2003 France 1 6 7 1 14 21 Mar 2003 3 May 2003 Germany 4 5 9 0 0 9 Mar 2003 6 May 2003 India 0 3 3 0 0 25 Apr 2003 6 May 2003 Indonesia 0 2 2 0 0 6 Apr 2003 17 Apr 2003 Italy 1 3 4 0 0 12 Mar 2003 20 Apr 2003 Kuwait 1 0 1 0 0 9 Apr 2003 9 Apr 2003 Malaysia 1 4 5 2 40 14 Mar 2003 22 Apr 2003 Mongolia 8 1 9 0 0 31 Mar 2003 6 May 2003 New Zealand 1 0 1 0 0 20 Apr 2003 20 Apr 2003 Philippines 8 6 14 2 14 25 Feb 2003 5 May 2003 Ireland 0 1 1 0 0 27 Feb 2003 27 Feb 2003 Korea 0 3 3 0 0 25 Apr 2003 10 May 2003 Romania 0 1 1 0 0 19 Mar 2003 19 Mar 2003 Russia 0 1 1 0 0 5 May 2003 5 May 2003 Singapore 161 77 238 33 14 25 Feb 2003 5 May 2003 South Africa 0 1 1 1 100 3 Apr 2003 3 Apr 2003 Spain 0 1 1 0 0 26 Mar 2003 26 Mar 2003 Sweden 3 2 5 0 0 28 Mar 2003 23 Apr 2003 Switzerland 0 1 1 0 0 9 Mar 2003 9 Mar 2003 Thailand 5 4 9 2 22 11 Mar 2003 27 May 2003 United Kingdom 2 2 4 0 0 1 Mar 2003 1 Apr 2003 United States 13 14 27 0 0 24 Feb 2003 13 Jul 2003 Vietnam 39 24 63 5 8 23 Feb 2003 14 Apr 2003 Source: Based on WHO (2004b).

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SARS because of a guiding protocol saying that patients with a cough, fever, and shortness of breath exhibited symptoms of tuberculosis (TB) (Bugl 2007, 710). Clearly, Canada must learn from any inadequacies in its crisis management of SARS. The Asian experience revealed variations in the openness of different states and cities under the onslaught of infectious diseases. In late 1997, when the H5N1 virus loomed in Hong Kong, there was speculation that it might have originated in South China. At the beginning, the Hong Kong Special Administrative Region (HKSAR) government was tightlipped on the origin of the avian influenza for fear of antagonising Beijing. Encountering the mysterious death of a few citizens, a crossdepartmental coordination committee headed by Anson Chan, former chief secretary for administration, boldly decided to slaughter 1.2 million chickens and birds to prevent the spread of the virus. The Hong Kong government extracted samples of chickens imported from China to see whether they were infected with H5N1—a move that marked the abandonment of its politically correct stance. Hong Kong’s relative openness in dealing with the avian influenza was mainly attributable to its vibrant mass media and dense population. In heavily populated cities like Hong Kong and Singapore, governments cannot afford the luxury of being slow in dealing with infectious disease. Singapore responded to SARS quickly and effectively, forcing suspected SARS carriers and patients into compulsory confinement where surveillance cameras were put in place.3 The relative openness of the Hong Kong and Singapore governments in tackling SARS contrasts sharply with the PRC. At the early phase of the outbreak of the mysterious virus, Beijing encountered a cover-up by local governments in Guangdong province. In April 2003, when President Hu Jintao dismissed the minister of health and the mayor of Beijing for mishandling SARS, the central government began to mobilise the localities and mass media to address the crisis (Zhang and Fleming 2005). Due to the need to protect China’s image as a regional and global power, its leadership sensed the urgency of containing the infectious disease (Saich 2006). Any failure to do so would undermine the PRC’s global image as a responsible international actor controlling the transnational transmission of infectious disease. China’s belated openness was partly attributable to pressure from the WHO. Its representatives in Beijing pushed the central government to be more transparent about the occurrence of SARS cases. Still, when WHO delegates were sent to inspect Beijing’s 301 Military Hospital, the Hong Kong media revealed that SARS patients had already been transferred to other places outside the purview of WHO investigators. The WHO issued travel advisories that recommended that travellers consider postponing their trips to Hong Kong and the PRC between April and May 2003, an action that was arguably too mild and yet diplomatic. China’s response to SARS was comparable to other Asian states affected by avian influenza. In February 2004, Indonesia admitted that an outbreak of avian influenza had occurred August 2003 (Revill 2005, 183). Thai authorities were alleged to have covered up an outbreak of avian influenza for the sake of protecting the country’s exports of poultry (see Greger 2006). While Singapore responded

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to SARS decisively, China’s reaction and that of Indonesia and Thailand to avian influenza showed that Asian regimes differed in their infectious disease control. The governmental capacity of Singapore and Hong Kong was forced to be strong, due mostly to their congested nature. In geographically spacious states, such as China and Indonesia, the problem of localism represents a fundamental obstacle to any fight against infectious disease. Table 5-2 shows that the larger a country, the more relaxed its approach to public health crises. Endowed with a large territory, PRC leaders at the central and local levels were at first relaxed about the outbreak of SARS, until it affected other parts of the world and generated international concern. If a regime is more open toward infectious disease control, it tackles the crisis more effectively. Although Singapore is viewed by some scholars as being an authoritarian polity, it displayed a relatively high degree of openness in controlling SARS.4 Similarly, the media scrutiny of Hong Kong’s administration and its transparency in reporting the development of SARS illustrated the government’s openness. However, given the lack of decisiveness and poor coordination by Hong Kong leadership, it was less effective in infectious disease control than Singapore (see Table 5-3). Regime openness in tackling health crises and the size of a state or a city directly determine that effectiveness. Furthermore, leadership decisiveness and departmental coordination are both critical to the responsiveness to the outbreak of infectious diseases. Overall, the effectiveness in disease control is shaped by such factors as the size of a state Table 5-2: Infectious Disease Control, Regime Openness, and Size Regime openness in disease control Size of a state or city

Low degree

High degree

Small

Moderate degree of effectiveness High degree of effectiveness in in disease control infectious disease control (Singapore)

Large

Low degree of effectiveness (People’s Republic of China)

Moderate degree of effectiveness

Table 5-3: Infectious Disease Response, Leadership Decisiveness, and Departmental Coordination Leadership decisiveness in disease control Departmental Coordination

Low degree

High degree

Weak

Low degree of responsiveness to disease outbreak (Hong Kong)

Strong

Moderate degree of responsiveness High degree of responsiveness to to disease outbreak disease outbreak (Singapore)

Moderate degree of responsiveness to disease outbreak

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or city, regime transparency in tackling health crises, and regime responsiveness, which embraces leadership decisiveness and departmental coordination. Responsiveness is an indispensable indicator of governmental capacity. It involves the degree to which political leaders take action to cope with infectious disease, whether departmental agencies communicate and coordinate with each other without squabbling, whether sufficient surveillance and quarantine measures are taken, whether public and private sectors cooperate with each other and mobilise citizens against communicable disease, whether citizens are resilient in coping with the health crisis, whether international collaboration is forged, whether the epidemiological diagnosis of the virus is swift, and whether vaccines are utilised fairly and effectively. In brief, responsiveness embraces political leadership, interdepartmental communication and coordination, surveillance and quarantine measures, public-private partnerships, public resilience, international cooperation, and epidemiological treatment. In Hong Kong, political leadership was wanting in the initial phase of the avian influenza outbreak in December 1996 and early January 1997. As more people succumbed to the deadly virus, the intergovernmental coordination committee had no choice but to slaughter all the chickens—a turning point in the evolution of political leadership. Nevertheless, it took the HKSAR government eight years from the outbreak of avian influenza to decide in 2008 that all the chickens and ducks would have to be slaughtered in a centralised house in 2010. By contrast, in Singapore, since 1993 all poultry has been required to be processed at a slaughtering plant approved by the Agri-Food and Veterinary Authority (Legislative Council of the HKSAR 2006, 3). The different approaches adopted by Hong Kong and Singapore fully revealed the former’s indecisive indecisiveness and the latter’s political will. Communication and coordination proved to be the weak dimensions of disease control in Hong Kong, Taiwan, and Mainland China. At the beginning of the 1997 avian influenza outbreak, the former chief of Hong Kong’s Department of Health, Margaret Chan, announced that she ate chickens every day—a remark that provoked severe criticisms later as more people infected with the disease passed away.5 In 2003, communication between the HKSAR government and the public was initially plagued by a bureaucratic refusal to admit the severity of the problem. Yeoh Engkiong, the secretary of health, welfare, and food, maintained that the mysterious virus did not spread to the community. Yet the deadly disease penetrated the society rapidly and soon the critical situation discredited him. Although the HKSAR government later daily reported the number of citizens infected with SARS, the entire crisis demonstrated the problems in communication and coordination between the Hospital Authority and the public, and between the Hospital Authority and private hospitals. The privately owned Baptist Hospital failed to report the conditions of suspected SARS patients to the Hospital Authority and the government. Moreover, Chan reportedly had reservations about whether the suspected SARS-infected residents in Amoy Gardens, in Kowloon, should be segregated and quarantined.6 When the index patient carrying the SARS virus from China stayed in Ward 8A of the Prince of Wales Hospital, opinions between the hospital authorities from the

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Chinese University of Hong Kong and government officials differed. The former wanted to shut down the hospital, but the latter refused to do so. In early 2003, during the SARS crisis, communication between PRC health authorities and their Hong Kong counterparts was by no means institutionalised. China and Hong Kong have since improved their cross-border communication by reaching an agreement on information sharing, informing the other side of any health crisis and conducting collaborative research on infectious disease. The Macao government has also been incorporated into the regional communications network, facilitating health information exchange. In early 2008, the outbreak of influenza in Hong Kong, Macao, and South China prompted the three governments to hold health awareness and information meetings to hammer out solutions and enhance mutual cooperation. With regard to surveillance and quarantine measures, during the SARS outbreak the HKSAR government installed infrared temperature-testing equipment at the airport and ports so as to identify potential disease carriers. The equipment was a useful tool by which immigration and health officials tracked down SARS-infected victims. Singapore’s surveillance was the most impressive in Asia, mobilising nurses and doctors dressed in fully protective gowns and masks to treat SARS patients, who had to use cordless phones and video-conferencing to communicate with their close relatives.7 Public-private partnership could be seen in Hong Kong’s tackling of SARS. Government and civil society organisations mobilised to resist the mysterious disease. The media contributed tremendously to the processes of scrutinising governmental management of SARS, exposing the problem of inadequate facilities and criticising reckless remarks made by government officials and Hospital Authority leaders. In contrast, China’s media organs were relatively weak, failing to reveal the spread of the disease until the central government gave the green light to launch an antiSARS campaign. The pressure on the media in mainland China to censor themselves was particularly strong during the annual meeting of the National People’s Congress (NPC) in Beijing in March 2003. Without the determination of President Hu and Premier Wen Jiabao to tackle the problem of SARS, it is doubtful whether the local media in the SARS-infected provinces could have triggered the alarm first and openly reported the health crisis. Public resilience was prominent in both Hong Kong and China, where numerous healthcare workers tragically succumbed to the disease. Despite the rising number of deaths in both places, health workers displayed their professionalism and loyalty by resisting the SARS epidemic to the end. Yet, psychologically, many ordinary citizens of Hong Kong suffered tremendously from the continuous reports of deaths in the early half of 2003. Healthcare workers in Taiwan experienced a certain degree of demoralisation. A few were so frightened of the disease that they escaped from their hospital by jumping out of its windows. Hospital chiefs squabbled over the SARS solutions—a phenomenon complicated by the politicised nature of hospital administrators loyal to political parties of differing ideologies. Exacerbating Taiwan’s weak capability was its inability to partake in the WHO as a member. Taiwan’s limited governmental

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capacity arose because it lacked experience, unlike the HKSAR, which had earlier endured the assault from avian influenza. In May 2006, Taiwan’s tenth attempt to achieve observer status at the WHO failed. The Taiwan government complained that it was due to the PRC opposition.8 In June 2006 the WHO website listed Taiwan as one of the areas apart from the PRC infected with avian influenza. Taiwan’s foreign ministry protested because the information provided on the website was misleading and hurt the island republic’s image in tourism, international trade, and human security.9 Both the United States and Canada supported Taiwan’s participation in the WHO as an observer, but the PRC insisted that Taiwan is part of China and therefore was ‘ineligible’.10 Although as director general of the WHO Margaret Chan vowed to assist Taiwan in its participation in WHO technical activities, it remains to be seen how it can be effectively brought under the WHO umbrella for combating infectious disease.11 In the wake of the victory of the pro-reunification candidate Ma Ying-jeou in Taiwan’s presidential election in 2008, prospects for rapprochement between Taipei and Beijing appear to be cautiously optimistic. Ma’s KMT has advocated that Taiwan should enter the WHO under the name of Zhonghua Taiwan [Chinese, Taiwan]. Obviously, the KMT has tried to test the diplomatic position of the PRC side. Regardless of the political tug of war between Taiwan and mainland China, Taiwan’s entry into the WHO would undoubtedly help the island prevent itself from being plagued by another outbreak of a SARS-type disease. Both Hong Kong and China cooperated with the WHO during the SARS crisis in 2003. The outbreak of avian influenza in China in 2005 and 2006 raised the question of sharing samples for virus testing with the WHO, but WHO representatives in China complained that Beijing was reluctant to provide samples for further experiments. Chan, however, vowed to remain impartial toward the PRC, which had lobbied many countries to vote for her. Indeed, with the election of Canadian-trained Chan as its head, the WHO is encountering the challenge of engaging China to bring it into the orbit of improved cooperation.12 In the SARS and avian influenza crises, governmental capacity in infectious disease control was the strongest in Singapore, followed in order of effectiveness by Hong Kong, South Korea, Vietnam, China, and Taiwan. In November 2006, South Korea took immediate action to slaughter 125 000 chickens, and 236 000 poultry as well as pigs, dogs, and cats during the outbreak of H5N1.13 Vietnam was viewed as a successful example of containing its spread in 2003. However, its success should not be exaggerated: due to the small number of SARS cases, Hanoi could contain the virus by adopting a tight monitoring system. It remains to be seen whether Vietnam can contain the spread of avian influenza. In fact, chickens smuggled from China to Vietnam carry the danger of transmitting H5N1 across the border.14 With an increase in human traffic and trade flows across the Sino-Vietnamese border, infectious disease can penetrate Vietnam rapidly but invisibly. China’s response to SARS was divided into two phases, including an earlier stage in which a sluggish response was compounded by localism and a later stage where leadership from the top was intertwined with full-scale mobilisation of the public

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to combat SARS. Although Taiwan is politically democratic, its capacity in disease control turned out to be weak. On average in 2006, a nurse in Taiwan had to take care of 20 to 30 patients and there was total shortage of 20 000 nurses.15 The relatively underdeveloped healthcare system and the lack of an effective surveillance system in mainland China and Hong Kong render Taiwan an isolated island under the threat of any influenza epidemic. Although informal interactions between health workers in all three places continue, it is hoped that formal discussions on infectious disease control can be developed and enhanced in the near future so that South China as a whole will collectively strengthen its capacity of dealing with any regional health crisis. Macao remains untested in its governmental capacity to tackle SARS. Surprisingly, it did not have a single case of SARS. However, non-respiratory infectious diseases such as dengue fever occasionally broke out in 2003. The Macao government swiftly contained the dengue fever, thanks to its network of neighbourhood associations that successfully acted not only as an effective intermediary between the government and its citizens but also as a mobilising vehicle against mosquitoes, which carry the disease. Whenever cases of avian influenza have broken out in China, the Macao government dispatches officials to visit the mainland and look into the situation.16 In early 2008, when the mysterious influenza affected some schoolchildren in Hong Kong, Macao was on high alert and prepared for a similar outbreak in the territory. Vigilance has become a critical factor shaping Macao’s health governance. Implications for Canada: Difficult Choices Ahead The varying degrees of preparedness, openness, and responsiveness of Asian governments in handling of infectious disease have implications for Canada. Canadian preparedness in anticipation of an influenza epidemic remains insufficient. A gap exists between the health elites, who appear to be more prepared, and the citizens, who are relatively unprepared. An indispensable ingredient of preparedness is crisis consciousness. Surprisingly, even after the SARS crisis, a majority of Canadians appear to treat the influenza epidemic as a non-issue, at least in the short run. None of the candidates who participated in Ontario’s municipal and mayoral elections in November 2006 raised the issue of how the province should tackle any outbreak of the influenza pandemic. The Ontario municipal elections in October 2007 also ignored the issue. The question of the influenza pandemic was virtually absent in public debates and candidates’ platforms. When schoolchildren in Hong Kong died in early 2008, apart from the Chinese-Canadian press and some electronic media outlets, the Canadian media were uninterested. As hundreds of thousands of overseas Chinese reside in Canada’s major cities, and as many of them travel frequently between Hong Kong and Canada, Canadian health officials must maintain a vigilant attitude toward any outbreak of influenza in South China. Canadian mainstream media, which tend to display a North American and European bias in their news coverage, should cover more Asian news, especially the ongoing health developments that affect Canadians swiftly.

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The Canadian Influenza Pandemic Plan does illustrate the high degree of governmental preparedness at the federal level. Yet the plan merely ‘encourages’ provincial and municipal governments to educate citizens on the influenza crisis. The federal government thus has shifted the responsibility for education and publicity to the provincial and local governments. Except for the occasional television and newspapers advertisements on influenza shots, publicity on the influenza pandemic has remained very weak. Perhaps the provincial and municipal governments wish to avoid creating any unnecessary public panic. Nonetheless, more publicity on the influenza pandemic would heighten the crisis consciousness of most Canadians, in addition to educating them on the need to wash their hands frequently to protect against any influenza virus. It would also deepen the public’s understanding of how it would be mobilised in the event of an epidemic, which is imperative. The updated Canadian Pandemic Influenza Plan for the Health Sector has put forward detailed recommendations to strengthen preparedness, including surveillance, vaccines, antivirals, health service emergency planning, public health measures, and communications (PHAC 2006). The plan mentions the creation of the Health Emergency Communications Network to improve federal and provincial interactions in response to the SARS, and the formation of a communications sub-committee, but it remains unclear how these bodies coordinate with each other. From a critical perspective, additional layers of bureaucracy appear to be an effective remedy; nonetheless, the actual operations of these committees will have to be reviewed and tested in simulation exercises. Otherwise, bureaucratisation in the form of setting up new agencies may not guarantee a significant improvement in intergovernmental communications and overall governmental preparedness for a new epidemic. The example of Hong Kong’s chaotic hospital response to SARS proved that interdepartmental coordination was critical to an effective response. The plan sets out the National Emergency Response System, which involves interactions between the prime minister and the provincial premiers, between the Cabinet Committee for Security, Public Health, and Emergencies and provincial ministers, and between federal deputy ministers and their provincial counterparts (PHAC 2006, annex L). However, the vertical chain of command remains long and complicated. This bureaucratised approach raises two serious questions: whether the line of accountability will be clear to all actors and whether it will generate a cumbersome process unintentionally detrimental to a swift crisis response. It is doubtful whether the updated plan can significantly ameliorate Canada’s preparedness and response to any new epidemic. Furthermore, while Canadian society is far more open or transparent than many Asian states, Canadian mass media generally have up to now been insufficiently interested in probing influenza pandemics. Perhaps the mass media at the national, provincial, and local levels have been preoccupied with other salient issues, such as politics, Canada’s involvement in Afghanistan, Quebec’s status, transport, crime, education, the environment, and tax issues. Ironically Canada is endowed with highly sophisticated mass media, but they have not yet developed an inquisitiveness in investigating the many issues surrounding any imminent influenza pandemic,

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especially public preparedness and governmental responsiveness. If crisis consciousness and preparedness are weak in Canada, responsiveness becomes the most critical variable the shape the Canadian government’s capacity to control any influenza pandemic. The Asian response has an important bearing on Canada. Singapore’s swift response to enforce a strict quarantine of people suspected of having SARS in safe houses deserves Canadian attention. Critics must question whether the Singapore model jeopardised the individual rights of SARS-infected victims. Arguably, centralisation and perhaps authoritarianism are necessary in any swift governmental response to infectious disease. Tight surveillance of the SARS victims, who were put in solitary confinement, constituted an effective deterrent to further infection. Unlike Hong Kong, where individual rights were emphasised in a way that may have endangered public safety during the outbreak, the Singapore government was free from the political burden of protecting individual rights in the fight against SARS. In Hong Kong, where the business sector was concerned about the impact of border control on the economy; by contrast Singaporean business did not constrain the governmental handling of the crisis. The Singaporean experience pointed to the tremendous state power and unified societal forces that could be galvanised to prevent the spread of infectious disease. In a small city like Singapore, administrative centralisation and political authoritarianism are virtues in preventing the population from being wiped out during the outbreak of a rapidly transmitted infectious disease. Authoritarianism is usually denounced by liberal academics as undesirable in the process of western-style democratisation, but it is the most effective response against the encroachment of an influenza pandemic. However, the Singapore model is not applicable to Canada. The argument that authoritarianism is necessary is surely unacceptable to most Canadians, who champion individual liberties. If an influenza pandemic takes place in Canada, it is very doubtful whether the public will reach a consensus on any swift action by the Canadian government to contain it. Any strict quarantine measure through forced segregation would be easily seen as a violation of individual rights. Trade unions, which have been traditionally powerful in Canada, would likely object to measures that would quarantine their members. It remains doubtful whether healthcare workers’ unions would support the Canadian government’s emergency measures during an outbreak. Business groups would likely argue against temporarily closing the border with Asia, not to mention with the United States, because they perceive border security measures as detrimental to trade and commerce. As in Hong Kong, where the procapitalist and pro-business government hesitated to impose border control prior to the apex of SARS because of its fear of any adverse economic impact, Canada’s capitalist state would most likely encounter very difficult choices in the event of an influenza pandemic, although it too would be anxious about negative impacts. Provincially and locally, there would most probably be a fragmentation of elite opinion, including both politicians and businesspeople, on the scope of border control measures, thus complicating the federal government’s decisions. Yet the

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experience of Hong Kong and Singapore in the SARS crisis demonstrated that at a critical juncture, their governments had to impose border control measures, enforce strict quarantine, and forbid the arrival of air flights from infected areas. These measures would be very difficult to implement in Canada if vociferous trade unions, influential business chambers, and opposition politicians were squabbling with the governments at the federal and provincial levels. At a particular juncture where infectious disease entails human-to-human transmission, the Canadian government would have to evoke emergency regulations, applied to federal, provincial, and municipal levels, so that decisive actions would be legalised to stem the inflow and outflow of an influenza pandemic.17 Ideally, the House of Commons would pass a motion in support of the government’s decision to declare a national emergency. Internal national security would be of paramount importance to Canada regardless of how the critics would react to decisive measures. A significant potential danger during an outbreak would be the precedence given democratic rights over national security. At a critical juncture, all Canadians, including opposition parties, business groups, and trade unions, must be united in supporting whatever measures are adopted by governments at all levels to combat the onslaught of the influenza pandemic. It is tempting to argue that any democratic regime has to strike a balance between democratic rights and national security in the event of a pandemic. As with the fight against terrorism, western states have been under severe criticism for trampling individual rights for the sake of protecting themselves against terrorist attacks. An influenza pandemic is tantamount to biological terrorism. In response, decisiveness and authoritarianism would thus be the sine qua non to contain deadly infectious disease. If, for example, a lottery system is proposed as a way to decide who would receive vaccines instead of determining a priority list of citizens, the Canadian government’s capacity would be severely curtailed. Such a lottery system would generate governmental clumsiness. Fairness must be observed in the governmental treatment of citizens receiving vaccines, because citizens at the lower end of the priority list might be treated later. Groups and individuals ought to be allowed to voice their views freely, but such views should not usurp the authoritative power of the government to allocate resources in times of crisis. Governmental capacity, which also embraces the freedom to distribute resources and mobilise human resources, will have to be maintained. Canadians will have to appreciate that any influenza pandemic would be comparable to another world war, instead of thinking of it as SARS-type mayhem on a grander scale. As with the Asian situation, Canada’s governmental capacity in disease control will be shaped by political leadership. Hong Kong’s response to the SARS crisis revealed serious problems in departmental coordination, especially in communications between the Department of Health and the Hospital Authority.18 When the authorities at the Prince of Wales Hospital planned to close the entire emergency ward to prevent any members of the community from being infected, the health department held a different view. The case of Hong Kong demonstrated that

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a fragmented health system without sufficient communication and decisive political leadership could have catastrophic consequences. The implications for Canada are obvious. Health Canada would have to communicate with all hospitals intensively and accurately. Provincial health authorities must frequently coordinate with their federal counterparts, and local health officials would need to report accurately on the health circumstances and statistics to municipal governments. Given the three levels of government in Canada, coordination and communication will surely become complicated. Here, simulation exercises are particularly needed to test the channels of communication between federal and provincial health authorities and between municipal and provincial health officials. Timing is also a problem that requires political leadership. When the HKSAR government under C.H. Tung considered installing infra-red temperature-testing equipment at various border checkpoints, it would have taken at least a week to buy, prepare, test, and install the sophisticated detectors. Critics said that the government should have made that decision much earlier. Before the HKSAR government decided to implement temperature tests on all primary and secondary schoolchildren, it had hesitated until parents complained vociferously about the safety of their children.19 The timing of all decisions relating to infectious disease will be a similarly huge challenge to Canada’s federal, provincial, and municipal governments. Canada’s healthcare system, like Taiwan’s, lacks enough doctors and nurses. This shortage in Canada must be addressed urgently. In the event of a pandemic, there would inevitably be a gradual attrition of hospital staff. Some workers would succumb to the virulent infectious disease, as happened with SARS. To replenish the loss, Canada would have to mobilise reserve workers, including medical students and all immigrants with healthcare backgrounds. The Canadian government at both the federal and the provincial levels must accelerate the process of recognising the medical qualifications of its large pool of immigrants, whose skills should be fully available in their new and permanent Canadian home, especially in a crisis situation. Canada can also learn from Hong Kong that its health system can be consolidated by privatising healthcare delivery so that the federal and provincial governments would have more available resources. These resources could be allocated to increasing the pay of hospital staff, supplementing human resources by matching immigrants with the markets that need their skills, and improving coordination among all the hospitals and the provincial and municipal governments.

Toward a 20-Point Action Plan for Canada An unknown variable affecting Canada and the world is, of course, the length of any influenza pandemic. While this factor is perhaps uncontrollable, both the private and public sectors can take preventive measures to tackle the influenza pandemic. Here a 20-point action plan is appropriate.

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First, all Canadian companies should test their emergency plans. The Canadian Manufacturers and Exporters (CME) have assisted various corporations in formulating such plans to respond to an influenza pandemic. They produced an impressive 20-point checklist, including identifying a manager responsible for the pandemic plan, determining the pandemic’s financial impact, building confidence among employees, preparing for an absenteeism rate of 35 percent to 50 percent during a two-week peak period, and appealing to all companies to test and share their plans with the government (CME 2006). However, the number of companies that have shared their influenza pandemic plans with the local governments is unknown. In a sudden influenza crisis, the impact on Canadian business would perhaps be much larger if there were no simulation exercise with regard to the influenza pandemic plan prepared by various companies. Second, governmental communication with poultry workers and farmers must be enhanced. They have already been alerted to the likelihood of the outbreak of avian influenza. The Chicken Farmers of Ontario vowed to try its best to prevent the spread of any avian influenza from farms to the community. During an avian influenza pandemic, it would be critical to know how to separate locally produced poultry from imported poultry. If the local farms were safeguarded against the crisis, the extent to which they could continue to supply food would need constant assessment, necessitating a partnership between agricultural and health officials on the one hand and farmers on the other. Third, in the event of an influenza pandemic, it is unclear how pets would be managed at the provincial and municipal levels. Ideally, pets would have to be segregated to prevent human beings from being infected more easily. Yet such segregation would arouse the opposition of pet owners. A moderate solution is to encourage them to have their pets undergo voluntary quarantine and medical checkups. During the peak of an influenza pandemic, tougher measures may have to be considered. Any emergency regulation by the federal government to deal with an influenza pandemic must incorporate pet management so that provincial and territorial governments would be legally empowered to act as needed. Fourth, it is estimated that there are 200 000 illegal immigrants in Canada (Keung 2006). Their fate and possible access to health care would become critical issues in the event of the influenza pandemic, because they tend to be afraid of visiting the doctors for fear of being deported. Yet urgent medical care would have to be provided to this underground population, who would be required to register with the authorities. A partial amnesty may be required; otherwise, illegal immigrants without access to healthcare services would become an extremely vulnerable segment of the society. The federal government must collaborate with the provincial governments on the future of illegal immigrants, whose susceptibility to an influenza outbreak would directly or indirectly affect the death toll in Canada. Fifth, during the high tide of an influenza pandemic, Canadian citizens residing overseas who return to Canada may have to be segregated into camps remote from urban communities. The idea is not to discriminate against them, but to provide safeguards against the likelihood of any returnees who may be infected with the

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influenza virus. Indeed, the question of evacuating Canadian citizens from places where an influenza pandemic has erupted would be a tricky one. Hong Kong would surely become a place necessitating emergency planning due to the 250 000 Canadian citizens residing there. The 1.2 million Canadians in the United States would also call for special policy consideration. If evacuation were implemented, the spread of the virus could be facilitated practically, but if it were discouraged, then returned Canadians may be quarantined at a relatively remote place for a certain period. During the SARS outbreak, 13 000 Torontonians who travelled to infected areas quarantined themselves voluntarily for several days to prevent others from possibly being infected, but such a self-driven initiative would have a very limited impact in the event of an influenza pandemic.20 Police efforts to track down the whereabouts of travellers who returned to Canada from affected places would be insufficient during a pandemic unless all returnees were temporarily quarantined in safe houses. Sixth, at the apex of the influenza pandemic, all schools in Canada should be closed, thus disrupting the studies of hundreds of thousands of children. Kindergarten, elementary schools, high schools, and universities would have to terminate their classes, affecting teaching and research on an unimaginable scale. Each school should be required to test its emergency plan at least once per year. There should be a plan in place to continue classes using email and internet facilities. Otherwise, a lack of preparedness would generate massive panic and frustration at the grassroots level. Seventh, the health authorities should regulate the sale of anti-influenza drugs and vaccines to prevent their sale through illicit channels including the internet. During a pandemic, criminal elements may take advantage of the crisis to sell sub-standard vaccines and drugs through various means. Similarly, the promise of Tamiflu could trigger criminal syndicates to produce fake antiviral drugs.21 Eighth, at the apex of the influenza crisis, the borders with Asia, Africa, Europe, the United States, and other parts of the world would have to be temporarily closed to prevent the virus from being transmitted further afield. Yet this measure would have calamitous consequences on the domestic economy and transportation industries. Air and ground transport, so crucial in this globalised era, would have to be temporarily suspended. Critics have already questioned the effectiveness of an air travel ban. Ninth, the already strained staffing situation in hospitals would mean that health workers would endure even more stressful work conditions. But the government would have to solicit their unreserved support. Complaints about any public maladministration of hospitals could arise, ranging from inadequate masks to insufficiently strict quarantine measures for influenza-infected patients. Effective hospital management would constitute the determining factor shaping Canada’s resistance to the influenza epidemic. Tenth, quarantine measures must be modified and adapted to the circumstances. The Singaporean model of using cell phones and video conferencing for communications between patients and their families should be considered. Family members must be persuaded of the complexities of the infectious disease. Without widespread public education, a sudden influenza pandemic would likely split society. Some observers have rightly noted that the Canadian government needs

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a more assertive publicity campaign so the public better comprehends the origins, complexities, and consequences of any influenza pandemic.22 Eleventh, a large-scale educational campaign should be launched to increase the crisis consciousness of all Canadians about any influenza pandemic. In the event of such a crisis, some ethnic communities would become inactive, forcing citizens to stay home and suffer from the psychological impact of reported deaths among their communities, especially in Vancouver and Toronto where there are large numbers of immigrants. In the worst-case scenario, members of some ethnic groups would run the risk of being stereotyped as ‘undesirable’ virus carriers due to the origin of the influenza pandemic in their ‘home countries’, even though they may have long treated Canada as their permanent homes.23 Racial discrimination would unfortunately re-emerge, making ethnic groups point their accusing fingers at others. Unless Canadian governments at all levels launch an appropriate, extensive education campaign for all citizens, ethnic misunderstandings could be a time bomb undermining Canada’s social harmony. In the event that most members of the public remain complacent, their relative lack of preparedness would render social mobilisation against the spread of an influenza pandemic difficult and time consuming. Educating the public extensively about a pandemic does not create panic. Instead, it paves the way for social unity and mobilisation during a crisis. Twelfth, the Canadian government must rigorously augment its reserves of antiinfluenza vaccines, which have already been increased from 16 million shots to 50 million shots.24 The stockpiles must be consolidated if Canada is to construct an effective shield against an influenza pandemic. Thirteenth, in light of the fact that many hospitals in China had their windows open to improve air circulation during the SARS crisis, the Canadian government must ensure that the ventilation system of public hospitals, government buildings, and all other public places is frequently inspected and cleaned. Due to the weather conditions in Canada, many hospital and buildings have their windows tightly closed, a phenomenon that could increase the transmission of infectious disease. The outbreak of Legionnaires’ disease in the Seven Oaks Home for the Aged in Toronto in 2005 revealed the problematic ventilation system in some Canadian hospitals. Fourteenth, municipal governments need a two-pronged strategy to educate the public on the influenza pandemic and to improve their capacity. It is reported that Toronto would not have the ability to cope with a large-scale influenza pandemic, that 2.6 million citizens would be unable to receive timely vaccinations, and that 35 percent of the population of Ontario would be infected with the influenza virus.25 Municipal leaders should be required to conduct exercises to enhance their influenza management capacity. An auspicious sign is that many municipal regions, such as Ontario’s Peel and York regions, have formulated emergency plans to cope with infectious disease such as an influenza pandemic and the West Nile virus.26 Nevertheless, simulation exercises must be carried out to improve municipal preparedness. Fifteenth, since Canada is endowed with a vast physical space, it has tremendous potential to develop makeshift hospitals, quarantine camps, and special funeral

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services to tackle an influenza pandemic. Municipal governments must identify specific sites for public cemeteries to dispose of the bodies of influenza victims. Corpse management will require technical details that must be hammered out between the funeral service specialists and health officials. Canada should take full advantage of its physical vastness to cope with any influenza pandemic. Sixteenth, Canada’s airports must consider emergency measures, such as the installation of infra-red temperature-testing detectors and detailed recording of passengers’ personal data, including addresses and final destinations in Canada. While it would be costly for all airports to instal the equipment, airports in all cities, especially Vancouver, Toronto, Ottawa, and Montreal, will need temperaturetesting equipment, and any airport with international flights and connections to other Canadian cities would need tighter measures against an influenza pandemic. Seventeenth, all public-private partnerships should require their private sector partners to test their emergency plans. A simulation exercise that takes several hours involves minimal economic costs but will equip more Canadians with the basic skills necessary to ward off any national health crisis. Eighteenth, simulation exercises must be conducted involving the federal and provincial governments, as well as each provincial or territorial government and its municipalities and each municipal administration and local communities. Ontario and British Columbia have published their emergency influenza pandemic plans in detail, but Nunavut appears to lack a sophisticated plan on its website.27 Quebec provides comprehensive and elaborate structure on the specific agencies responsible for coordination and communication. A careful reading of the websites shows that not all provinces or territories agree on the definitions of coordination and communication, with some stressing the interprovincial dimension and others showing a more balanced view of internal departmental cooperation and federalprovincial partnerships. Perhaps due to the province’s experience with SARS, Ontario’s plan mentions the need for media conferences, video-conferences, and teleconferencing interactions with public health officials. The discrepancies in provincial plans demonstrate their varying cultures and attitudes in response to the danger of any influenza pandemic. Nineteenth, Canadians in general are complacent and relatively relaxed about the likelihood of an influenza pandemic. This attitude must change. More nationwide publicity must educate the public on coping with an influenza pandemic and increase awareness of how to respond to an abrupt crisis. While multiculturalism is usually hailed as a strength in Canada’s political system and social mosaic, the country’s diversified cultural groups must be made aware of how to act collectively in the event of something as serious as a pandemic outbreak or, for that matter, a bio-terrorist attack. Otherwise the eruption of an influenza pandemic could plunge Canadian society and its governments into turbulence. Twentieth, officials of the Canadian federal government must become more sensitive to a possible influenza crisis. Canada needs to discuss emergency planning with the United States, particularly with regard to border controls in the event of an influenza pandemic.28 Moreover, Canada’s official representatives in Asia must

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enhance their information-gathering activities with regard to the development of infectious disease. Equipped with updated information provided by the Canadian consular and embassy officials in Asia, Ottawa can draw an accurate picture of the ongoing development of avian influenza in the Asia Pacific region.

Conclusion A crucial indicator of effective health governance is the ability of a city or state to cope with a public health crisis, especially one involving respiratory infectious diseases. Canada has much to learn from the bitter lessons of SARS and the ways in which Singapore and Hong Kong dealt with SARS. Being a democracy does not necessarily mean that a country’s federal and sub-federal governments have the capacity to control the influenza pandemic effectively. Governmental decisiveness during any influenza pandemic is far more important than the protection of civil liberties. Coordination among government departments at all levels is a critical variable in shaping the Canadian government’s response to an influenza pandemic. Emergency regulations must be enacted by the House of Commons so that Canadians will remain united across the country to fight against the attack. Provincial differences in Canada have already revealed the varying emphases on how provincial governments perceive an influenza pandemic. Yet if Canada’s governments at the federal, provincial, and municipal levels, together with the private sector, implement the 20-point action plan proposed in this chapter, the country’s governmental capacity for managing an influenza pandemic would be substantially enhanced. Canadians must not be complacent. Detailed pandemic preparedness plans may have been published, but serious questions remain about governmental coordination, public education, crisis consciousness, and social mobilisation, and these issues are critical to the effective health governance, public safety and national security of all Canadians.

Notes 1 This is a revised version of a research project of the Asia Pacific Foundation of Canada. 2 On Asia’s vulnerability during the SARS outbreak, see Caballero-Anthony (2005). 3 In Singapore people exposed to SARS were required to stay home, were watched by a camera, and sometimes were tagged with an electronic wristband. They could be imprisoned if they left home (‘Singapore’s SARS Measures Welcome’ 2003). The Singapore police not only tested the temperature of those quarantined twice daily but also set up a temporary lock-up centre at the old Jurong Police Station to deal with suspected SARS carriers (‘Police Take Precautionary Measures against SARS’ 2003; see also Fung 2003). Unlike Hong Kong, where schools were closed after much governmental hesitation, the Singaporean government moved decisively to close nearly all schools on 25 March, mainly due to the concern of parents. 4 For the view that Singapore is an authoritarian polity, see Rodan (2005). An opposite view can be found in Bellows (2006).

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5 For Chan’s controversial remarks during the avian influenza crisis in 1997, see World Journal, 10 November 2006, A21; see also Richburg (1998). 6 Ming Pao, 9 November 2006, A15. 7 Strait Times, 30 April 2003. 8 Sing Tao Daily, 24 May 2006, B15. An Austrian journalists association complained that Taiwan journalists were barred from covering the WHO meeting because the WHO said that Taiwan was not a member of the United Nations. 9 Ming Pao, 11 March 2006, A11. 10 In 2005, a Conservative member of Canada’s Parliament initiated a private member’s bill that supported Taiwan’s participation in international the WHO, which was approved by the Foreign Affairs Committee in the House of Commons. World Journal, 20 May 2006, A7 (see also Standing Committee on Foreign Affairs and International Trade 2005). A joint letter was signed by 151 members of House of Commons and the Senate to appeal to the WHO to accept Taiwan as an observer because the outbreak of any influenza pandemic there would severely affect Canada, which has about 150 000 citizens visiting Canada every year. For the American support of Taiwan, see Ming Pao, 20 May 2006, A25. 11 ‘Chan Praises Healthy Cooperation’, China Daily, 28 November 2006. 12 Chan is a Canadian citizen who holds a doctorate in medicine from the University of Western Ontario. 13 ‘South Korea to Kill Cats, Dogs over Flu Fears’, Associated Press, 27 November 2006. Some critics said that South Korea overreacted. 14 In 2006 30 smuggled chickens from China to Vietnam were found to have H5 virus. Ming Pao, 7 April 2006, A11. 15 United Daily Evening News (Taiwan), March 30, 2006, cited in Today Daily News, March 31, 2006, p. B10. 16 When avian influenza broke out in Guangdong in March 2006, Macao officials went to Zhongshan and Zhuhai to inspect the situation. TVB News, 7 March 2006. 17 The executive summary of Learning from SARS, the report of the National Advisory Committee on SARS and Public Health (2003b), pinpoints that ‘the F/P/T [federal/ provincial/territorial] legislative frameworks for health emergencies have not been analyzed for comparability and interoperability’. 18 A useful review of how the Hong Kong government coped with the SARS crisis can be found in Loh (2004, 117–138). 19 The author wrote a commentary in Ming Pao advocating that the HKSAR government should close the schools, after which he received a phone call from a parent saying that his demand echoed the views of many worried parents. 20 Sing Tao Daily, 19 April 2006, A12. 21 In 2006, fake anti-influenza vaccines were found in China and Hong Kong. It is noteworthy that Tamiflu was reported to be linked to neurological disorders in a few cases. 22 Harris Ali has accurately observed that compared to publicity campaigns in Hong Kong and Singapore, Canada lags behind in terms of appealing to citizens to wash their hands frequently, avoid contacts with birds, and shun the practice of feeding birds. Ming Pao, 19 April 2006, A4. 23 Some members of the Chinese community felt that during the SARS outbreak the Canadian Chinese in Toronto were unfairly labelled by other Canadians as potential virus carriers. 24 Ming Pao, 14 May 2006, A8. 25 Today Daily News, 16 April 2006, A4.

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26 Ming Pao, 15 April 2006, p. A2, and Sing Tao Daily, 29 May 2006, A8. Some other municipalities have pandemic-related information on their websites. The Ontario city of Waterloo, for example, updates its website from time to time. It was estimated that in the worst-case scenario, 127 000 people in the Waterloo region would need outpatient care; up to 2400 would have to be hospitalised and 700 would die (Kelly 2006). 27 See ‘Pandemic Influenza’ at <www.influenza.gc.ca>. 28 The U.S. has been deeply concerned about the development of avian influenza in Asia, conducting a close surveillance of the routes of migratory birds, banning the import of chicken from China in May 2006 when the PRC had cases of avian influenza, and stockpiling Tamiflu in preparation for the influenza pandemic. Ming Pao, 2 March 2006, A11, and 4 May 2006, A10; World Journal, 14 April 2006, A2.

References Bellows, Thomas (2006). ‘Economic Challenges and Political Innovation: The Case of Singapore.’ Asian Affairs, vol. 32, no. 4, pp. 231–255. ‘Bird Flu Strikes Again in Thailand.’ (2007). Scientific American, 2 February. Bonn, Dorothy (2003). ‘Closing In on the Cause of SARS.’ Lancet Infectious Diseases, vol. 3, no. 5, p. 268. Bugl, Paul (2007). ‘Review of SARS in Context: Memory, History, Policy.’ Lancet Infectious Diseases, vol. 7, p. 710. Caballero-Anthony, Mely (2005). ‘SARS in Asia: Crisis, Vulnerabilities, and Regional Responses.’ Asian Survey, vol. 45, no. 3, pp. 475–495. Canadian Manufacturers and Exporters (2006). Influenza Pandemic: Continuity Planning Guide for Canadian Business. Ottawa. <www.cme-mec.ca/pdf/CME_Pandemic_Guide. pdf> (September 2008). Fung, Alan (2003). ‘SARS: How Singapore Outmanaged the Others.’ Asia Times, 9 April. <www.atimes.com/atimes/China/ED09Ad03.html> (September 2008). Garrett, Laurie (2005). ‘The Next Pandemic?’ Foreign Affairs, vol. 84, no. 4, pp. 3–13. <www.foreignaffairs.org/20050701faessay84401/laurie-garrett/the-next-pandemic.html> (September 2008). Greger, Michael (2006). Bird Flu: A Virus of Our Own Hatching. (Herndon VA: Lantern Books) (September 2008). Kelly, Anne (2006). ‘Region Sets Up Pandemic Website.’ Record (Kitchener-Waterloo), 28 April, p. B2. Keung, Nicholas (2006). ‘Illegals Afraid to See a Doctor.’ Toronto Star, 23 May, p. A4. Legislative Council of the Hong Kong Special Administrative Region (2006). Report on the Duty Visit to Study the Operation of Poultry Slaughtering in Singapore. LC Paper No. CB(2)3134/05-06. <www.legco.gov.hk/yr05-06/english/hc/papers/hc1006cb2-3134-e. pdf> (September 2008). Loh, Christine and Civic Exchange, eds. (2004). At the Epicentre: Hong Kong and the SARS Outbreak. (Hong Kong: Hong Kong University Press). Monto, Arnold S. (2005). ‘The Threat of an Avian Influenza Pandemic.’ New England Journal of Medicine, vol. 352, no. 4, pp. 323–325. National Advisory Committee on SARS and Public Health (2003a). Learning from SARS: Renewal of Public Health in Canada. Chaired by David Naylor. Ottawa. <www.phac-aspc. gc.ca/publicat/sars-sras/naylor> (September 2008).

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National Advisory Committee on SARS and Public Health (2003b). Learning from SARS: Renewal of Public Health in Canada—Executive Summary. Chaired by David Naylor. Ottawa. <www.phac-aspc.gc.ca/publicat/sars-sras/naylor/exec-eng.php> (September 2008). Osterholm, Michael T. (2005). ‘Preparing for the Next Pandemic.’ Foreign Affairs, vol. 84, no. 4, pp. 24–37. <www.foreignaffairs.org/20050701faessay84402/michael-t-osterholm/ preparing-for-the-next-pandemic.html> (September 2008). Paterson, Rachel (2004). ‘SARS Returns to China.’ Lancet Infectious Diseases, vol. 4, no. 2, p. 64. ‘Police Take Precautionary Measures against SARS.’ (2003). Strait Times, 29 April. Public Health Agency of Canada (2004). Canadian Pandemic Influenza Plan. Ottawa. (September 2008). Public Health Agency of Canada (2006). The Canadian Pandemic Influenza Plan for the Health Sector. Ottawa. <www.phac-aspc.gc.ca/cpip-pclcpi> (September 2008). Revill, Jo (2005). Everything You Need to Know about Bird Flu and What You Can Do to Prepare for It. (London: Rodale). Richburg, Keith B. (1998). ‘Hong Kong Faulted on Handling of “Bird Flu” Crisis.’ Washington Post, 4 January, p. A17. <www.washingtonpost.com/wp-srv/inatl/longterm/china/stories/ kong010498.htm> (September 2008). Rodan, Garry (2005). ‘Embracing Electronic Media but Suppressing Civil Society: Authoritarian Consolidation in Singapore.’ Pacific Review, vol. 18, no. 3, pp. 393–415. Saich, Tony (2006). ‘Is SARS China’s Chernobyl or Much Ado about Nothing?’ In A. Kleinman and J.L. Watson, eds., SARS in China: Prelude to Pandemic?, pp. 71–104 (Stanford: Stanford University Press). ‘Singapore’s SARS Measures Welcome.’ (2003). New York Times, 22 April. Standing Committee on Foreign Affairs and International Trade (2005). Evidence. 6 October, No. 055, First Session. Ottawa. (September 2008). Thomson, Elspeth and Yow Cheun Hoe (2004). ‘The Hong Kong SAR Government, Civil Society, and SARS.’ In J. Wong, ed., Zheng, Yongnian, pp. 199–220 (Singapore: World Scientific). Ungchusak, Kumnuan, Prasert Auewarakul, Scott F. Dowell, et al. (2005). ‘Probable Personto-Person Transmission of Avian Influenza A (H5N1).’ New England Journal of Medicine, vol. 352, no. 4, pp. 333–340. World Health Organization (2004a). ‘Avian Influenza: Fact Sheet.’ 15 January. Geneva. <www.who.int/csr/don/2004_01_15/en> (June 2006). World Health Organization (2004b). ‘Summary of Probable SARS Cases with Onset of Illness from 1 November 2002 to 31 July 2003.’ 21 April. Geneva. <www.who.int/csr/ sars/country/table2004_04_21/en> (September 2008). Zhang, Ernest and Kenneth Fleming (2005). ‘Examination of Characteristics of New Media under Censorship: A Content Analysis of Selected Chinese Newspapers’ SARS Coverage.’ Asian Journal of Communication, vol. 15, no. 3, pp. 319–339.

Chapter 6

The Role of Civil Society in Pandemic Preparedness Kathryn White and Maria Banda1

Today, in an interconnected world, bacteria and viruses travel almost as fast as e-mail and financial flows. Globalization has connected Bujumbura to Bombay and Bangkok to Boston. There are no health sanctuaries. No impregnable walls exist between a world that is healthy, well-fed, and well-off and another that is sick, malnourished, and impoverished. Globalization has shrunk distances, broken down old barriers, and linked people. Problems halfway around the world become everyone’s problem. —Gro Harlem Brundtland, former director general, World Health Organization The rise of civil society is indeed one of the landmark events of our times. Global governance is no longer the sole domain of Governments. The growing participation and influence of non-State actors is enhancing democracy and reshaping multilateralism. Civil society organizations are also the prime movers of some of the most innovative initiatives to deal with emerging global threats. —Fernando Henrique Cardoso, chair of the United Nations Panel of Eminent Persons on the United Nations–Civil Society Relations This chapter sets out a framework by which civil society actors can identify their role in preparing for, mitigating, and confronting one particular international threat, namely avian influenza. Governments and multilateral organisations have recognised the need to work with civil society across a range of issues. For example, in response to avian influenza and its alarming human mortality rate, as well as the resulting crosssectoral economic and societal damage, in October 2005 the Canadian government convened a meeting of 30 health ministers in an attempt to coordinate transnational planning and response. At the same time, the United Nations Association in Canada (UNAC) called for the full engagement of civil society in this critical dialogue. The chapter is in fact an example of knowledge transfer among the civil society organisations, governments, multilateral organisations, the private sector, and, ultimately, citizens who must be ready, able, and trusted to slow the next threat.2 Civil society organisations range from strong international groups with their own health, agriculture, and security experts to volunteer-based groups that are much closer to the ground and focussed on protecting their communities. As such, civil

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society organisations have historically undertaken both grassroots work and highlevel advocacy. This chapter aims to encourage civil society—and its partners—to identify issues, challenges, and opportunities they would face in preparing, planning, and engaging in such a crisis. In 2005 when the Canadian government and the UNAC were working on the issue of avian influenza, all signs were ominously suggesting that a pandemic of proportions not witnessed since the Spanish influenza of 1918 was imminent (World Health Organization [WHO] 2005; Osterholm 2005). But this time the world had an opportunity to defend itself before the pandemic struck.3 Once the alarm bells had gone off in the public health community, it was time for a more reflective analysis on the part of civil society about its responsibilities and role in pandemic preparedness planning. Civil society, as defined by the Panel of Eminent Persons on United Nations–Civil Society Relations (2004, 13), spans voluntary associations of citizens (outside their families, friends, and businesses) formed to ‘advance their interests, ideas and ideologies’. It includes groups as diverse as mass organisations (for example, farmers, women, seniors), trade unions, professional associations, social movements, indigenous people’s assemblies, faith-based organisations, academe, and nongovernmental organisations (NGOs) devoted to environment, development, human rights, and peace. It is easy to see the tremendous source of ingenuity, cooperation, and innovation that could be tapped by activating and engaging such a transnational network. The UN has recognised that the achievement of the health-related Millennium Development Goals (MDGs) and other global objectives will depend on a collaborative approach made possible through civil society partnerships (UN Secretary General 2002). Before harnessing the global civic actor’s latent power across the multitude of its activities, a greater understanding of the social determinants and securitisation of health is needed. Avian influenza presents interrelated economic, agricultural, security, developmental, and ecological challenges; therefore, the approach to the looming pandemic must take an equally integrated, cross-sectoral, cross-regional perspective in order to develop a common platform of understanding among stakeholders. Although the threat of avian influenza in 2005 represents one specific crisis scenario, it can be placed within a broader context of a global healthcare crisis, poverty, insecurity, and environmental degradation. A survey of how all of these issues feed into the pandemic potential clearly reveals the need for a comprehensive, sustained, multidimensional—and multilateral—strategy. With common challenges and shared responsibilities inherent in fighting an infectious disease in the age of globalisation, it is necessary to catalyse complementary actions beyond the health sector’s existing services and programmes. The first part of this chapter thus follows the virus on its whirlwind track since 1996 as it travelled across Eurasia and made a brief foray into Canada in the spring of 2004. The second part discusses the global public health architecture and looks in particular at the role of civil society in institution building. The third part shifts the focus from the structures, participants, and processes of governance to its

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negotiations agenda and substantive issues. The fourth part summarises the main intellectual approaches to infectious disease control, from which it distils the best practices in order to propose a new integrated model of transnational, multi-actor governance. Raising public awareness is one effective way to promote appropriate health and agriculture actions, especially if it engages at-risk communities and sectors in developing responses and solutions. All too often ‘indifference becomes fear only after catastrophe hits, when it is already too late to implement preventive or control measures’ (Osterholm 2005). The next pandemic is overdue and inevitable (WHO 2005). The only question is whether an institution sturdy enough to withstand its lethal blow will be built in time. The Global Evolution of Avian Influenza Globalisation has made the world a smaller place, but it has also made humanity more vulnerable to microbial threats. Ecological disruption, population growth, increased human mobility, poverty, wars and famine, migration, urbanisation, and global production and distribution channels of food have all served as facilitating variables or disease amplifiers that have eased the epidemiological transition of microbes into more pathogenic forms (Price-Smith 1998; see also Evans et al. 2004). Few microbes have caused more concern than the avian influenza virus, in particular the H5N1 strain, due to its rapid genetic mutations, ability to acquire genes from viruses infecting other species, and very high pathogenicity (WHO 2006). First identified in wild geese in China’s Guangdong province in 1996, the virus spread rapidly through the country’s large domestic duck population of 660 million, with pigs serving as a ‘mixing vessel’ from which the virus could cross a species barrier (WHO 2005).4 The first human infection was documented during a massive outbreak of H5N1 in Hong Kong in 1997 and traced to Guangdong, when the virus jumped directly from birds to humans, killing 6 and sickening 18 others (Garrett 2005a). Hong Kong’s rapid destruction of its entire poultry population of 1.5 million (within three days) probably averted a global pandemic (WHO 2006). Yet H5N1 itself was not eliminated. It merely retreated to southwest China and again in December 2003 in a super-virulent form—more pathogenic, resilient, adaptable, and capable of killing a broader range of species, including rodents, tigers, and humans. The outbreaks that followed in 2004 were the largest and deadliest on record: never before were so many countries ravaged by the avian influenza at the same time, and never with such a high fatality rate—both bird and human (WHO 2005). The lethal strain first infected flocks in Korea, Thailand, and Vietnam, and then travelled to Japan, Tibet, Russia, including Siberia, to reach Europe’s southeastern shores by October 2005. It had infected 109 people and killed 59 of them by May 2005, thus achieving a high morbidity rate (Garrett 2005a). By early 2005, with more than 140 million chickens killed by the virus or destroyed and customers shying away, outbreaks ravaged Asia’s poultry industry, with losses expected to

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have exceeded US$15 billion.5 Even in the absence of further human infection, the damage from another outbreak was set at US$50 billion to US$60 billion (WHO 2005, 54). Yet the worst was by no means over: the evolution of the virus suggested a deepening threat (5). The H5N1 strain had become endemic in southeast Asia, having found a permanent ecological niche in domestic poultry and asymptomatic ducks. Despite individual control measures, avian influenza continues to spread, creating further economic, ecological, and human devastation. Russian authorities warned that ‘the infection cannot be contained, and it is impossible to isolate’ and that the avian influenza ‘will have serious consequences for the environment, the economy, and primarily for human health’, making it imperative to legislate comprehensive anti-epidemic, sanitary, and veterinary measures (‘Bird Flu Confirmed in 45 Russian Settlements: Chief Veterinary Inspector’ 2005). Highly Pathogenic Avian Influenza Strikes Canada In Canada, a slightly higher number of dead chickens (8–16 per day) was reported in one barn in Fraser Valley, British Columbia, on 6 February 2004. Low-pathogenic avian influenza (LPAI) was confirmed on 16 February (Tweed et al. 2004). Although the flock was quickly quarantined and depopulated by the Canadian Food Inspection Agency (CFIA), within three weeks a highly pathogenic strain (H7N3) was detected in another flock on the same premise, killing 2000 birds in two days. With this started the largest outbreak of highly pathogenic avian influenza (HPAI) in Canada—the first since 1960 (Chicken Farmers of Canada 2004, 6). Despite the containment efforts, the virus continued to spread, infecting more than 50 commercial and backyard farms. More drastic measures, including the destruction of 17 million chickens, turkeys, and ducks, stopped the viral progress by 4 June. But it took another two months of disinfection for all the remaining restrictions to be lifted (5). Those six months of the HPAI scare had a significant negative impact on the province of British Columbia chicken industry in terms of farm sales, cleaning and disinfecting costs, increased bio-security, and industry coordination. As trade partners banned various poultry imports—from all of Canada—the total losses for the chicken industry were estimated at CA$100 million in the first year of recovery (Chicken Farmers of Canada 2004, 7). The Fraser Valley outbreaks also represented the first known case of human H7N3 infections.6 Lessons Relearned British Columbia’s frightening episode was not without precedent: SARS should have been an eye opener for the whole world. SARS had jumped to humans from infected animals that were sold and slaughtered in unsanitary and crowded markets in China’s Guangdong province, from where it travelled to five countries within 24 hours and across six continents in several months, causing 8000 infections worldwide, with a 10 percent mortality rate (Osterholm 2005). The crisis demonstrated that a lack of proper agricultural practices and sanitary standards in one corner of the

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world can imperil the livelihoods of people an ocean away, that infectious pathogens can encircle the globe in a matter of days in the age of international travel, and that the public’s fearful reaction can deliver the final blow to an already crippled economy. This should have underlined the urgent need to strengthen the global capacity for disease surveillance, increase reporting transparency, and improve regional cooperation (FAO and OIE 2005a). Public health authorities did try to increase the control of microbes in the aftermath of SARS. Yet it remains doubtful that the critical lessons that SARS should have taught have been internalised. Despite the critical need for a stronger global public health infrastructure, the international community continued to under-invest in an efficient and effective global system of outbreak surveillance and response (Evans et al. 2004). A virus is most lethal where the target population is already immuno-compromised by disease, malnutrition, and poor sanitation, or where the health infrastructure is unable to contain it. It is impossible to estimate the extra impact of avian influenza on cramped refugee camps, on famine-stricken areas, on sprawling slums lacking clean water and medical facilities, or on the 33.2 million people living with HIV/AIDS (Garrett 2005a; WHO 2005). So how can one prepare, in the context of inadequate global health care, for a pandemic far deadlier and far more difficult to control than SARS, one that would indiscriminately affect every sector of society (Osterholm 2005)?

Global Governance versus Microbial Globalisation Global collaboration is the only way to fight epidemics in the age of globalisation: a global disease requires a global health policy and global governance framework that involves a multiplicity of actors—including national governments, international agencies, private and corporate actors, and civil society (Aginam 2004). Avian influenza, by its nature, lies at the complex interface between farming practices, livestock trade, food safety, and public health security (FAO and OIE 2005a). This section therefore explores the overlapping layers of the global health architecture to underscore the need for participatory processes, multi-stakeholder consultations, cross-sectoral linkages, and local engagement in the transnational pandemic plans, starting with the UN.7 International Coordination of Preparedness Planning Although it was relatively localised and contained, the shock of the Asian tsunami in December 2004 exposed the poor shape of the UN’s inter-agency coordination. It also prompted critical review of the UN’s role in national preparedness plans in different countries—and a far more immediate response to avian influenza.8 The World Health Organization (WHO) is the default agency when it comes to health-related issues.9 But the complexity of avian influenza makes it necessary to engage other actors that are better placed to address the zoonotic or security side of

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health. Nothing less than an integrated international health network, comprising the WHO, the World Food Programme (WFP), the Food and Agriculture Organization (FAO), the United Nations Environment Programme (UNEP), the United Nations Development Programme (UNDP), national health institutions, and civil society representatives is needed. Since the control of emerging infectious diseases lies ‘beyond the responsibilities of any one organization’ (Bradford and Linn 2004, 4), defeating HPAI calls for an inter-sectoral, inter-institutional approach. The WHO has already been working alongside the FAO and the World Organisation for Animal Health (OIE) to create a ‘master coordination plan [that would] be prepared with a global vision defining the road map and time frames for the short-, medium- and long-term priority activities, to be endorsed and supported by individual countries ���������������������������� and regional organisations��’ (FAO and OIE 2005b). That was the first step toward elaborating a global strategy for the control of HPAI. However, the OIE—like all other agencies—is weakened by its exclusive reliance on the information supplied by its member states and their voluntary (and often problematic) compliance (Otte et al. 2004, 43). Global economic institutions also cannot remain on the sidelines. In cooperation with the WHO, the International Monetary Fund (IMF) and the World Bank should relax the strictures that have a negative impact on the health sector (Carin 2005). The World Trade Organization (WTO) should develop pro-health trade incentives and revise its Agreement on the Application of Sanitary and Phytosanitary Measures (SPS Agreement), which provides a framework for the protection of human, animal, and plant health and life; at the same time, it should prevent unjustified trade barriers from being erected (Otte et al. 2004, 44). The International Labour Organization (ILO), for its part, could sponsor a global health workforce summit to address the troubling migration of health practitioners from developing countries (Carin 2005). National Preparedness Plans: State Responsibilities in the Borderless World of Microbes However, for all their expertise, international agencies lack public accountability, and hence authority, to impose and enforce the far-reaching measures required in a pandemic. For better or worse, this responsibility rests with national governments (Bradford and Linn 2004). It is encouraging that most governments have taken steps, to varying degrees, to deal with avian influenza. Yet there is far more to be done, beginning with a detailed blueprint of how to get their citizens through one to three years of a pandemic (Osterholm 2005). Every country’s policy makers must develop a contingency plan at the domestic level for the worst-case scenario involving quarantines, weakened armed forces, dwindling hospital space, and vaccine scarcity—and engage all key components of the society (Garrett 2005a).10 The committed leadership of countries such as Canada, with direct experience of a pandemic and the resources to contain a new outbreak, is key in strengthening global health governance.

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Profit and Responsibility: The Place of the Private Sector in Disease Control Businesses and farmers have a significantly greater responsibility to monitor, inspect, and report outbreaks in a system where privatisation, deregulation, and decentralisation of animal health services have eroded the governments’ ability to control and regulate emerging infectious diseases (Otte et al. 2004; Osterholm 2005). It is debatable, however, whether voluntary codes of conduct can replace mandatory regulation in the context of a looming pandemic. The private sector’s attention to the bottom line has meant that the overall record, around the world, has not been encouraging. This has made it increasingly necessary to enlist the broad potential of civic responsibility—including that of consumers as civic actors—to lobby their governments and exert pressure on businesses to ensure compliance with the minimum standards of socially responsible corporate behaviour. Bolstering Defence from the Ground Up: The Role of Civil Society The nature of civil society players is varied—and varies by country—but engaging their local knowledge and global reach in avian influenza policy is crucial for reducing cross-sectoral losses. Who can best support, and often deliver, local health care? Respond to humanitarian crises? Identify farmers sidestepping regulation because of poverty or recalcitrance? Mobilise the public in non-coercive ways? Who enjoys public trust? Early engagement of civil society can provide legitimisation for difficult policy choices. Neither international agencies nor national governments can match the level of public trust in civil society organisations. Civil society can also play a unique role in awareness raising, in terms of both prevention and risk management (for example, by exposing the risk from poultry products). It can also help identify gaps in regulation, press for compliance, and advocate for change. But civil society’s responsibility goes beyond public advocacy to include key aspects of both implementation and delivery. Many developing countries depend on health-related NGOs to make up for their own institutional weakness and impaired public health delivery. Civil society is essential for the sustainability of technical assistance by ensuring that aid can actually be absorbed by national health authorities—and translated into real care (Kuchenbecker 2004). Civil society is also a source of expertise, analysis, and policy formulation, and makes a significant contribution to public policy debates. With their grassroots engagement and their function as a channel for communitybased knowledge, civil society organisations also often have a clearer picture of human and technical needs and capacities. This means that public or private partnerships with community groups can significantly increase returns on health and agricultural investment. Civil society actors also perform disease surveillance, which is a key component in the fight against pandemics. When the Chinese government refused to disclose the magnitude of the SARS outbreak, it was the WHO’s ability to tap the

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nongovernmental sources of epidemiological information that helped contain the epidemic (Fidler 2004b). Not surprisingly, the WHO has struggled for years to make ‘germ governance’ more inclusive—and effective—by relying on nongovernmental or civil society organisations to challenge the state’s monopoly on public health. Governments alone cannot handle global microbial threats (Fidler 2004b). However, donor governments and international agencies often assume, wrongly, that developing countries have a civil society network capable of participating in policy formulation, monitoring, and implementation (Kuchenbecker 2004). Yet the nongovernmental sector in many recipient countries is weak or subordinated and it cannot make up for the weaknesses in state capacity. This means that health investment must be coupled with strategies to develop a local civil society capable of administering that aid. This great risk of avian influenza and similar global challenges represent an opportunity to build on the work of the high-level panel on UN and civil society, chaired by former Brazilian president Fernando Henrique Cardoso. This initiative should begin by looking at the issue of trust in civil, corporate, and public actors and capacity building. It should explore the role of the private sector in seeding civil society organisations in countries where they would not otherwise flourish (such as through the International Ministerial Conference on Avian and Pandemic Influenza that was held in Bamako in 2006 and the subsequent technical meeting held in New Delhi in 2007). At the same time, civil society actors, given their non-elected status, also need to be more self-critical and accountable. The response to the 2004 Asian tsunami brought into sharp relief the lack of coordination and the mandate creep of multilateral agencies. It showed equally that both the best and the worst of civil society organisations can tarnish the credibility of all. Ultimately, it eroded their ability to work effectively with full trust. Adding the Building Blocs: Policy Harmonisation and Institutionalisation As a basic step, it is necessary to address right at the start a series of institutional deficits, jurisdictional overlaps, and procedural gaps. First, there is a regulatory and policy vacuum that spans human and animal health and agriculture. It must be replaced by an institutionalised, law-based (and thus enforceable) regulatory framework that governs bio-security, vaccination, the administration of antibiotics, animal movement, border control, the culling and disposal of carcasses, farmer compensation, the restructuring of the poultry industry, and so on. Harmonisation must occur within government bureaucracies as well as across government agencies on the basis of the best practices available. Ultimately, the institutional deficit between public and animal health services needs to be resolved. It is no coincidence that the countries most affected by HPAI are the ones with deficient veterinary services, farm bio-security measures, and animal disease information systems (FAO and OEI 2005a). In other cases, there is no clear division of labour between the principal international agencies, which costs millions of dollars every year in duplication. Civil society should be empowered to work

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in these inter-institutional spaces as a watchdog providing oversight, facilitating coordination and strategic linkages, ensuring accountability, and offering a critical analysis of the nature of institution building. The same holds true of institution building at the national level. Scrapping institutions every time disaster strikes and starting from scratch is impractical. This costly habit wastes human resources, erases institutional memory, and cheats public expectations. Instead, existing institutions should be equipped to deal with any threat, be it Y2K, September 11, flooding, a new infectious disease, or a biological attack.

The Global Agenda Poverty and Ill Health: Breaking the Cycle There would be far less cause for concern if medical capacity around the world were adequate. Yet the capacity to respond to global threats is severely unbalanced, as the state of global public health has reached crisis proportions (Bradford and Linn 2004). Countries are nowhere near meeting the MDGs on health by 2015. Most world governments lack sufficient funds to act. No national health infrastructure today would be able to handle, at once, the combined burden of a pandemic, social disruption, and ensuing public unrest, but the international community would still look to the United States, Canada, Japan, and the European Union for answers, vaccines, cures, money, and hope (Garrett 2005a). So would their own citizens. There is no easy solution to this crisis. But certain structural changes could help mitigate its causes—and lessen the impact of avian influenza. Because it tends to afflict those countries that lack the capacity to contain it, defeating the virus requires breaking the ‘deadly partnership of poverty and ill health’ (Aginam 2004).11 If a mere US$34 per person per year were allotted to health care, education, and sanitation, 8 million lives could be saved every year by 2010—with direct and indirect economic benefits totalling US$360 billion annually (Commission on Macroeconomics and Health 2001). But public health systems in rich countries have also come under strain. The anthrax scare in the U.S. in 2001 underscored the inability of federal and local health agencies to respond effectively either to bioterrorism or epidemic threats (Garrett 2005a). Because of budget cuts in recent years, one of the greatest weaknesses that each country must address is the inability of its hospitals to deal with a sudden surge of patients. The historically unprecedented HPAI outbreaks in southeast Asia’s poultry industry in 2004 also revealed a direct correlation between national intervention capacity and industrial practices on the one hand and viral spread on the other. Japan and Korea fared best, because the disease remained limited to commercial farms, and was rapidly detected and hence effectively contained. Control measures were less successful in Thailand and Vietnam, where nearly every household kept a flock of intermingling chickens and ducks. Cambodia and Laos were even worse off,

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because they could not raise sufficient funds to contain the spread. Indonesian health authorities had to contain a huge outbreak of the dengue fever (which had infected 58 000 people and left 650 dead), sparing few resources to handle an animal disease (WHO 2005). The big success stories—the countries that managed to control and eradicate the HPAI infection on their chicken farms—were a handful of wealthy states in Europe and North America (FAO and OIE 2005a). This was not merely a matter of having the resources for a rapid response, but also of having the right preconditions—an organised and sanitary commercial poultry industry, which, in turn, is a function of domestic resources and health standards. Having an integrated private sector with robust state support helps absorb the potential financial loses of preparedness. With other social priorities and diseases competing for scarce resources, preparing for another emergency or containing a ‘mere’ animal infection may seem like a luxury. Yet the world cannot afford to ignore HPAI. Preparedness planning, by its very nature, cannot wait until the onset of the catastrophe: it calls for preventive measures, from early warning to vaccine development (WHO 2005). Making Money Work: Capacity Building and Technical Assistance Financing is critical to the success of the global response. But beyond the price tag lies the far greater challenge of making money work (Soni 2004). Sustainable policies require investment in technical assistance and absorptive capacity, tackling the politically tricky question of health worker brain drain and providing leadership on trade (including drug access). Civil society must be engaged in all these activities, both as a watchdog and a trusted implementing partner. First, the framework for managing avian influenza must not turn out to be a shortterm fix like too many other health investments.12 Civil society organisations must be empowered to monitor the states’ delivery on their promises and to ensure that funds are not funnelled to other activities. Second, a good portion of the investment ought to be devoted to local capacity building. The situation with HIV/AIDS, tuberculosis (TB), and malaria in developing countries carries important lessons for efforts to manage avian influenza; even where donors have marshalled sufficient resources and will, they have encountered the challenge of implementing accelerated, large-scale programmes in resource-poor settings. Inadequate capacity in recipient countries has been a principal limiting factor for stamping out infectious diseases.13 Any healthrelated financial aid package must incorporate the technical assistance needed to help countries run their programmes independently, develop the local public health infrastructures capable of absorbing the large influx of aid, and facilitate the training of local personnel. This also raises the issue of transparency of financial aid, in which the independent voice of civil society and its freedom of action become the critical guarantee that multilateral assistance would reach its target population. In essence, civil society organisations provide ‘servant leadership’, acting at once as watchdogs, advocates, and partners in knowledge transfer.

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Preparing for the Long Haul: Taking an Integrated Approach to Human and Animal Health Animal Health: Vanguard Defence With potentially catastrophic human losses, it is easy to forget that avian influenza is principally an animal disease and its effective prevention lies in the domain of animal health. Given that the causative viral strains in all three major influenza pandemics in the 20th century originated from animals and the staggering economic damages from livestock-disease outbreaks, a ‘global system of animal health protection is a global public good’ (Otte et al. 2004, 15; see also FAO and OIE 2005a). Most countries cannot handle alone the costs of prevention and control of transboundary animal diseases. This implies a need for collectively agreed, funded, and managed responses (Otte et al. 2004). In effect, humanity’s first line of defence against avian influenza rests with responsible farming practices—which is a global responsibility. Containment through Agricultural Reform The WHO has concluded that fundamental changes in agricultural practices may well be the only viable long-term solution to stop avian influenza (WHO 2005). Outbreaks in rural areas in southeast Asia are the main source of increased human exposure, where live poultry markets are considered the ‘missing link in the epidemiology of influenza’ and asymptomatic domestic ducks are a ‘reservoir of disease’ (FAO, OIE, and WHO 2005,1 6; FAO and OIE 2005a, 17).14 Although costly and controversial, the necessary measures must address the high-risk practices related to poultry farming and marketing, including live bird markets and farm hygiene (FAO and OIE 2005a). Regulating (and, ultimately, reducing) the prevalence of duck and chicken farming is the most effective strategy to deny the virus access to its human hosts. Farming reform must simultaneously provide an alternative source of protein, income, and employment through rural development, education, and financial aid. This underlines the role of national governments in monitoring, educating, and enforcing—and of the international community, including civil society organisations—in underwriting these efforts. Aquatic viruses are more likely to spread to domestic animals—and then humans—in China than anywhere else in the world (Garrett 2005a). One cause is the country’s severe ecological disruption. Another is its particular agricultural system (where raising chickens, ducks, and pigs together in tiny backyards has greatly increased the risk of infection), as is the interface of economic development and poor sanitation. China’s rising gross domestic product (GDP) has increased the taste of its 1.3 billion people for meat; as such, its growing chicken industry (with more than 13 billion birds) is starting to rival U.S. farms in scale, but it lags behind in hygienic standards (Garrett 2005a). Beijing’s partner governments need to secure its cooperation and support its domestic awareness-raising programmes, but transnational civil society networks equally need to aid their Chinese counterparts in creating grassroots organisations capable of launching local plans to sensitise China’s large farming community to the risks of avian influenza.

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Beyond such production practices, other factors are amplifying avian influenza’s deadly potential. These include unsustainable consumption patterns and dietary demands, which make it necessary to address the problems of agricultural antibiotics, antimicrobial resistance, vaccine scarcity, intellectual property, and international trade regulations. Consumption Patterns, Agricultural Antibiotics, and Antimicrobial Resistance Most animal and plant antibiotics that are added daily to livestock feed, aquaculture waters, and seed stocks are used to promote growth, and the industry is indisposed to give them up: bigger animals, fish, and fruit bring bigger profits. Yet many compounds, being chemically identical to medicinal antibiotics, cause microbial resistance to human antibiotics (Garrett 2005a). By limiting the efficacy of lifesaving health technologies and making the public more vulnerable to microbial mortality, the routine use of growth promoters for non-medicinal purposes poses a direct threat to global health (Garrett 2005a; Fidler 2004a). Since antimicrobial resistance is as much about economics as it is about health, government regulation (and even proscriptions in some cases) of antimicrobial drugs in domestic agriculture may be necessary to end their misuse. This is a policy on which the EU has already taken the lead. In the interest of public health, other countries should consider following the European example (even ahead of an international agreement) and issuing similar guidelines on high-risk meat imports.15 In Defence of the Precautionary Principle: Public Health and International Trade Although justified from the public health perspective, such actions remain open to a legal challenge under international trade rules (Fidler 2004b). Trade policy profoundly affects health; yet there have been few incentives to adopt health-minded policies in trade negotiations. Trade rounds have more often tended to limit access to life-saving drugs via agreements on intellectual property rights (Fidler 2004b) or to abolish the right of governments to resort to the precautionary principle in the interest of public health. There is some scope for progress, however, as the global response to the AIDS epidemic illustrates. A confluence of civil society pressure on western governments and producers in recent years helped bring down the price of the AIDS cocktail from US$15 000 to US$150 per person per year (Keusch et al. 2006). It also paved the way for the WTO’s Declaration on the TRIPS Agreement and Public Health in 2001, which gave this growing consensus a basis in law (Soni 2004; Fidler 2004b). The transatlantic trade war that erupted in 1999 over the EU ban on hormonetreated beef offers a cautionary tale. The Europeans blocked beef imports for public safety reasons, citing the precautionary principle, which requires authorities to proceed cautiously to avoid irreversible damage in situations where there is insufficient scientific evidence but the possible damage could be significant. The American and Canadian governments denounced this action as a non-tariff trade barrier, took the EU to the WTO’s dispute panel, and won—three times. Preventing a similar dispute from erupting in the future would require Ottawa and Washington

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to rethink the relevant provisions under the North American Free Trade Agreement (NAFTA) and the WTO. Consumer groups have a key duty in this context to elevate the public’s consciousness about health and to promote responsible consumer behaviour. The price of reining in the spread of avian influenza or future threats may yield smaller tomatoes and fewer chicken eggs, which may perhaps be a reasonable cost to the consumers in wealthy countries. The establishment of a joint WHO/FAO commission could reduce the incidence of trade disputes, which are damaging both to the economy and health.16 In the meantime, individual country guidelines on (international) standards on antibiotics and vaccination in agriculture must be implemented in close consultation with the domestic farming community—which not only is responsible for operationalising new rules but which will also experience their effects on its bottom line. It is one thing to get farmers and agronomists in Canada to agree to abide by these rules and quite another in southeast Asia, say, where the HPAI virus has become endemic and where the smallholder poultry industry accounts for some 70 percent of the total chicken production and involves some 200 million poor farmers—with little or no access to preventive treatment, disease information, and veterinary services (FAO and OIE 2005a). This makes civil society’s advocacy and monitoring efforts critical for the success of any national action plan. Too Little, Too Late: Global Vaccine Scarcity The trouble with the H5N1 virus, unlike with the more common varieties of avian influenza, is that the vulnerable age group cannot be predicted—which means that any individual who comes into contact with the virus is at risk, although in Turkey in January 2006 there was significantly higher mortality among those younger than 15. For the U.S. alone, this translates into a need for at least 300 million doses of vaccine, which is the amount the whole world together produces in a year (Garrett 2005a). Furthermore, vaccines are produced commercially in just nine countries—Australia, Canada, France, Germany, Italy, Japan, the Netherlands, the United Kingdom, and the United States—home to barely 12 percent of the world’s population, while companies still lack financial incentives to invest in a product that may never reach the market and thus never turn a profit (Garrett 2005a; Osterholm 2005).17 In 2003, the entire world market for vaccines, from polio to measles to influenza, made up less than 2 percent of the global pharmaceutical trade (Garrett 2005a). Indeed, if the entire U.S. vaccine production system was devoted to making a vaccine to combat an avian influenza pandemic, it could inoculate barely 5 percent of its population (Butler 2005). The U.S. government was stockpiling the vaccine; but if American vaccine production were to falter, as it did in the 2004 influenza season, it could not rely on Canada and Germany to bail it out as in 2005, because, in a ‘global scramble for vaccine’, governments might block foreign access to their supplies, ban exports, nationalise the domestic production facilities, or refuse to share their vaccine (just as Washington did in 1976, in anticipation of the H1N1 swine influenza) (Garrett 2005a; Osterholm 2005).18

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Ultimately, global scarcity of the influenza vaccine is only marginally relevant to most of the world’s 6 billion people, who would go unvaccinated, even though between 30 percent and 50 percent would get infected in a pandemic (Garrett 2005a).19 Yet national pandemic influenza preparedness, by its nature, is an international issue: in a world lacking equitable access to the cure, even the vaccinated would face devastation if the global economy were to stop in its tracks (Osterholm 2005). Instead of hoarding the vaccine, the West ought to release it to the most vulnerable, because the regions the first to be hit would also be the first line of defence. Thus the whole world must rely on the wealthy countries enlightened self-interest to develop a vaccine against this pandemic virus—a complex and costly undertaking (WHO 2005)—and to share it first with the poor. Not only is stockpiling ineffective from the standpoint of global containment, but it is not even feasible: a true pandemic vaccine (which must match the actual strain of the virus) must wait for its onset, while virtually every other piece of medical equipment would also be in short supply.20 In brief, vaccine development must not detract from the need to invest in broader preparedness plans (see Butler 2005).

Threat Perceptions: Reframing Public Health and Infectious Disease Control Up to this point, discussion has centred on the significant structural obstacles to implementing a global action plan in the context of limited state capacity or traditional farming practices. But the problem of ideational discrepancies or divergent priorities must also not be underestimated. Different stakeholders approach the issue of human influenza from different angles, which need to be reconciled in order to develop a plan that is truly global in nature and executable in practice. In this section, the dominant perspectives on global public health are considered—namely, developmental, human rights, security, and environmental—focussing on what each has to contribute to our understanding of the impending challenges. The Human Development Paradigm: Locating Avian Influenza on the Development Agenda The growing attention to avian influenza outbreaks in southeast Asia could help galvanise action. But it could also crowd out the broader public health strategies needed for long-term sustainability. Among the key questions facing national and international public health authorities is the issue of how to launch a global influenza action plan that would simultaneously strengthen public health infrastructures in poor countries. Global health problems must be addressed within a multi-sectoral approach consistent with the MDGs, while any health plan ought to be set in motion with complementary global action plans in education, environment, water, and sanitation.21 A human development paradigm brings together these interconnected imperatives in a single policy framework, making it evident that broad systemic and

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institutional changes are required to lead humanity out from the shadow of another influenza pandemic. Developing countries might still view it as hypocritical or self-serving that the new global health agenda has put a premium on those diseases that pose a threat to the wealthy (such as Ebola, SARS, and now avian influenza), while discounting the non-acute or non-epidemic infections (such as cholera or typhoid) that remain largely confined to the global South. But an influenza pandemic is different from other emerging infectious diseases given its frightening potential to overwhelm the entire international system—a risk never associated with either HIV or malaria, despite their destructive impact on individual countries (Osterholm 2005). It is necessary to balance the narrow focus on containing avian influenza with a broader public health strategy to solve the healthcare crisis in general. However, these are two interconnected imperatives: a preparedness plan for avian influenza would automatically feed into the parallel efforts to strengthen the public health system, while investment in national healthcare infrastructures and development is an investment in the global future. The Human Rights Perspective: Fundamental Liberties, Social Cohesion, and Distributive Justice Human rights considerations, if embedded in national public health legislation and supported by monitored international agreements, can help communities maintain the delicate balance between public health and individual rights in the face of quarantines, isolation, civil liberties, triage, and restrictions on work, trade, immigration, assembly, and travel. The refusal of one healthcare worker to comply with voluntary isolation measures was responsible for infecting dozens with SARS in a Toronto religious community. Draconian measures may be unavoidable in some cases, but civil society must be able to ascertain that such measures are transparent, lawful, and warranted. By the same token, civil society organisations must also ensure that their members respect the voluntary or mandatory codes in the interest of public safety, be they local trade unions, faith groups, or community associations. Civil society’s higher rate of popular trust imposes on it a special obligation to take community leadership on these issues. There is also a danger that a pandemic could create ethno-racial fissures rather than unity and inter-communal tolerance if, for instance, a disease erupts predominantly in a single ethnic group. A human rights approach could help a multicultural society such as Canada avert this outcome to dispel the perception of racism-minded marginalisation or ghetto-isation of ethnic neighbourhoods especially hard hit by avian influenza. The same human rights perspective should guide policy makers in managing the legal and socioeconomic consequences of the pandemic—an issue altogether separate from managing the outbreak. The need for distributive justice and fairness, so frequently emphasised by civil society groups, sits squarely within this framework.

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Public Health Security: The Risks and Benefits of Securitising Health With a growing concern about bioterrorism since September 11, 2001, security has become the lens through which policy makers in the West increasingly view public health issues.22 Securitising health is by no means uncontroversial, but a pandemic influenza would be a public security threat as much as it would be a public health one. The security dimension of infectious disease could be severe: from the direct effect of human incapacitation to domestic instability (SARS caused the worst crisis for China’s leadership since Tiananmen Square) and cross-border tensions (Garrett 2005a; Osterholm 2005; Price-Smith 2008). Security will especially be at stake where avian influenza combines with overpopulation, environmental degradation, and resource scarcity to induce mass exoduses over state borders from poor to wealthy countries (Price-Smith 2008). States will be tempted to close their borders or impose quarantines in an attempt to protect their own citizens even though, short of disrupting trade, travel, and productivity, these measures rarely work (Garrett 2005a). Disease pathogens do not respect the territorial boundaries of sovereign states, thus rendering isolationism a futile and counterproductive public health strategy in an era of global epidemics (Aginam 2004). Many critics fear that this approach may divert essential resources and attention from the more critical diseases plaguing the world’s poor (‘Meeting Report’ 2004). But these two dimensions of international disease control are mutually reinforcing: investing in the global health security infrastructure through capacity building would advance the same goals as a health-based framework focussed on primary health care, just as bolstering emergency preparedness to respond to infectious diseases would equip individuals for any eventuality—even that of bioterrorism (Fidler 2004b; Heymann and Drager 2004). Environmental Security: Ecological Disequilibrium and Human Health Global ecological disequilibrium is directly tied to the threat of emerging infectious diseases. The virulence of existing pathogens has increased, thanks to the rapid destruction of the biosphere, soaring population densities and mass migrations, and ozone depletion, not to mention ‘green’ agricultural revolutions that turn rainforests into ranches and farms into mass production factories, and introduce antibiotics that seep into livestock feeds. These developments have not only increased the virulence of existing pathogens, but have also released entirely new infectious vectors (PriceSmith 1998, 2008; Otte et al. 2004). Most critically, global climate change is expanding the breeding ground for viruses at the same time as it is weakening many countries’ ability to cope with natural disasters, food and water shortages, and public health threats. Evidence of intensifying climate change is thus particularly troubling in terms of humanity’s ability to prevent and fend off or adapt to a global epidemic. Protecting the natural environment can no longer be postponed. And it must be done with the full force of the law. But mainstreaming environmental considerations

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into public health planning across agencies demands a more inclusive framework discussed in the last section (Otte et al. 2004).23

Conclusions and Recommendations Back to Basics: Human Security as the Answer? One thing is clear: avian influenza and similar global epidemics cannot be defeated as long as its multiple causes are not eliminated. First, we need a genuine commitment to human development, which implies tackling the structural and institutional sources of deprivation, disempowerment, and inequitable access to health services (‘Meeting Report’ 2004). Second, we need a dependable human rights system to protect the feeble, the poor, and the marginalised during any crisis of vast proportions, just as we require a humanised public security framework to awaken policy makers to the security threats presented by ill health and structural violence. Third, we need to take environmental responsibilities seriously, while the interaction with animals and the handling of animal production, processing, and marketing for food all need to change (FAO, OIE, and WHO 2005). These are complex long-term agendas, and the time and resources of international policy makers are more likely to be focussed on more immediate issues. Yet these processes need to unfold in tandem, because trade, aid, financing, drug production, hygiene, dietary patterns, animals, birds, and humans all feed into the H5N1 mix. This situation leaves two timeframes and multiple, seemingly disjointed concerns. Poor countries worry about diverting attention from development. Different government agencies in the wealthy countries prioritise either public health or security. NGOs tend to stress the potential human rights implications. The private sector calculates the economic impact of avian influenza. Yet containing and, ultimately, eliminating the virus depend critically on the ability to obtain the maximum support of all societal actors. Taking the perspective of human security—which places health, wealth, security, prosperity, and sustainable development within one inclusive framework—is one way to bring these divergent elements together. Unlike more traditional approaches to security, human security addresses the more mundane questions of daily survival: hunger, disease, poverty, environmental degradation, and conflict. Most importantly, it is results-oriented: as noted in the 1994 Human Development Report, ‘in the final analysis, human security is a child who did not die, a disease that did not spread, a job that was not cut, an ethnic tension that did not explode into violence, a dissident who was not silenced … Human security … is a concern with human life and dignity’ (UNDP 1994, 22). By providing a common language among stakeholders—veterinarians, environmentalists, chief executive officers, civil servants, farmers, diplomats, military chiefs, and health practitioners— human security might help mobilise support and establish a broad consensus on the policies and strategies needed to wean societies away from high-risk practices.

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On the other hand, there is also a need to take risks, including the risk involved in working together to seek solutions from policy to implementation. This proposal is not revolutionary, least of all in Canada: several lessons can be taken away from the so-called ‘Track II’ governance model that has served so well in the past: first, partnership delivers—if governments and NGOs can overcome their mutual apprehensions about teamwork (see Cameron 1998). Second, even small powers, united in a coalition of the likeminded and acting jointly with global civil society, can mobilise to serve the marginalised. Third, traditional mechanisms, which work as long as states are willing to move as fast as the slowest in the pack, can—and should—be bypassed when they stand in the way of urgent action (Cameron 1998). ‘Ad hoc multilateralism’ or coalitions of the likeminded may be preferable in crisis situations. Nevertheless, Canada’s ‘new multilateralism’—an attempt to engage both state and non-state actors on key global issues in a variety of traditional and innovative forums—should fit within the UN matrix and not act as a substitute for it; it should move the consensus forward, without detracting from the inclusiveness and universality of the UN’s framework. Ottawa’s health ministerial in October 2005 was a real-life example of such a response. The potential emergency presented by avian influenza warrants the Track II human security model every bit as much as landmines did. It also justifies governments reaching out to their civil society partners for help, expertise, guidance, legitimisation, delivery capabilities, and support. Civil society organisations, for their part, are obliged to provide capacity, directions, and solutions, as well as to raise red flags when necessary, including on their own culpabilities. And if the avian influenza never comes, will this all have been a flap over nothing? Clearly not: today no one is adequately prepared to face any virulent, bioterrorist, or cataclysmic enemy. The approach put forward in this chapter is an integrated, law-based, human security strategy, designed not only to bolster defences against this specific fearsome virus but also to build system resilience—to build true emergency preparedness. Forging partnerships and increasing fairness, equity, and transparency in general, beyond the immediate time horizons, will leave individuals better equipped to repel other threats. The global perspective will also encourage adequate redistribution of resources (envisaged in the MDGs) by channelling scarce supplies first to those in greatest need. This is a good investment, whatever the future brings. It will never be possible to create a disease-free world (Garrett 2005b). But if the big epidemic comes, individuals will be more likely to be ready. Civil Society Action Civil society has the opportunity to collectively identify and address concerns about avian influenza. Civil society must raise the same issues: cooperation (of civil society organisations), vaccine development and access, surveillance and capacity. There are other questions on technical capacity, apart from advocacy or aid delivery. Answers to the challenging questions of capacity, both human and technical, will need to move from national or bilateral to multilateral. A study at the Brazilian Institute of

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Social and Economic Analysis has suggested that civil society is also changing, and a separation between advocacy and delivery of aid is emerging—and the ‘freelancing’ unaffiliated advocate. This process does not focus on the larger question of what (or who) is civil society, but, after the Cardoso report, this question is worthy of its own focus. It is hoped that this chapter will expose opportunities and gaps for the grassroots and international civil society organisations that are already working at containing the effects or spread of avian influenza in creative partnerships with governments, citizens, and the private sector.

Notes 1 The opinions expressed here are those of the authors and not of the United Nations Association in Canada. 2 Indeed, the discussions and recommendations in an earlier draft of this chapter had a direct influence on the work done by the special appointee of the United Nations secretary general and on the International Federation of Red Cross, among other organisations. 3 One factor divides society from total disaster: the virus has yet to develop efficient human-to-human transmission (WHO 2005; Food and Agriculture Organization [FAO], World Organisation for Animal Health [OIE], and WHO 2005). 4 In an infected pig cell, avian influenza mutates from an avian to a mammalian virus, which can lead to a human epidemic. The H5N1 virus had moved to pigs by April 2005 (FAO and OIE 2005a; WHO 2006; Garrett 2005a). 5 The poultry farm losses in 2004 cost Thailand US$1.2 billion, Vietnam US$0.3 billion, and all of Asia as much as US$15 billion (WHO 2005, 54). 6 Avian influenza was suspected in 57 persons, confirmed in two, and killed none (Tweed et al. 2004). The results would have been more severe had it been the H5N1 strain. 7 On the need for multi-stakeholder collaboration, see FAO and OIE (2005a), Colin Bradford (2005), and M. Otte, R. Nugent, and A. McLeod (2004). 8 For example, the UN secretary general (2005) appointed a senior system coordinator for avian and human influenza in 2005. 9 The WHO took the unprecedented step in 2003 of independently issuing global alerts and travel advisories about SARS-affected countries without their authorisation, causing serious economic damage. Although some complained, including Canada, none publicly challenged the WHO’s authority during the outbreak (see Chapter 4). In May 2003, its members formally empowered it to take such actions in the future (see Fidler 2004b). 10 In January 2005, Vietnam, for instance, established an inter-agency working group consisting of technical experts and senior staff members from ministries of health, agriculture, and rural development all in close consultation with the international agencies (WHO 2005, 55; Osterholm 2005). 11 On the issue of mutual interest, see David Heymann and Nick Drager (2004). 12 Despite a rhetorical commitment to disease financing, aid not only continues to fall short of the WHO targets, but has also been cut in recent times (Soni 2004; Garrett 2005b). 13 Some 50 percent of the projects submitted to the Global Fund to Fight AIDS, Tuberculosis, and Malaria for financing are never approved due to technical imperfections, especially a lack of absorptive capacity (Kuchenbecker 2004). The Global Fund took back its money earmarked for Ukraine for that reason. According to Ricardo Kuchenbecker

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(2004), bilateral initiatives, such as the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), might offer an ‘advantage over the Global Fund, which simply making grants’. 14 Some 20 percent of the chickens sold in Hong Kong’s live poultry markets were infected with the H5N1 virus and later identified as the source of infection in its chicken farms in 1997; H5N1 was also discovered in the geese sold in the live poultry markets in Vietnam three years before the chicken farms outbreaks in 2004 (FAO, OIE, and WHO 2005). Studies in Vietnam have confirmed that some 20 percent of seemingly healthy ducks are constantly shedding the HPAI virus. Yet vaccination is not feasible because ducks react differently to the vaccine from chickens, and even continue to excrete the virus in increased quantities (FAO, OIE, and WHO 2005; WHO 2005). 15 For example, in Canada, as a result of bovine spongiform encephalopathy (BSE), the CFIA (2008) enhanced regulations to control ‘specified risk material’ in the animal feed chain (i.e., to prevent bovine remains from being fed to other farm animals). The agency ought to review the animal feed restrictions in order to ensure that risk material would also encompass parts from dead chickens and should consider banning the imports of meat that may have been fed in such a way. 16 Such a commission could be tasked with reviewing the use of all growth promoters and identifying the ones that play a role in increased drug resistance (Garrett 2005a). It could also develop a global action plan for antibiotic resistance with country-level monitoring and reporting (Fidler 2004b), as well as enforcing standards that, caused by short-term need, might also produce long-term equity. 17 It might be worth considering a 1976 piece of U.S. legislation that assigned corporate liability to the federal government in order to encourage the quick development of the swine influenza vaccine; that pandemic never happened, and Congress has not passed a similar law (Garrett 2005a). 18 The WHO convened a meeting in November 2004 to map out the respective responsibilities of all the key stakeholders—major influenza vaccine manufacturers, regulatory authorities, governments, and the WHO itself—to ensure a sufficient supply of the vaccine. It determined that the predicted shortfall could only be overcome through collaboration in the form of public funding, research, and partnerships. The pharmaceutical industry made some headway in research and development following the initial H5N1 alert in January 2004, but more remains to be done (WHO 2005). 19 The real impact of vaccines remains unclear. Despite the rapid vaccine development in 1957 and 1968, limited production capacity meant it arrived too late to be effective (WHO 2005). 20 For example, two U.S.-based companies produce most of the world’s masks from multiple component parts imported from various countries. If travel and transport were restricted in a pandemic, neither would be able to meet a jump in demand—in fact, masks may not be produced at all (Osterholm 2005). 21 Of the eight MDGs, three are health goals and other five are crucial to health (see Bradford Jr. 2005). 22 For example, the ministers of health of Canada, France, Germany, Japan, Italy, United States, United Kingdom, Mexico, and the European Commission created the Global Health Security Initiative, initially to deal with bioterrorism in 2001. 23 Mainstreaming environmental considerations would also help inform the decisions of all those governments that ban free-range farming (in favour of less humane indoor facilities) and order the slaughter of millions of wild waterfowl or culling of domestic birds.

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References Aginam, Obijifor (2004). ‘Between Isolationism and Mutual Vulnerability: A South–North Perspective on Global Governance of Epidemics in an Age of Globalization.’ Temple Law Review, vol. 77, pp. 297–312. ‘Bird Flu Confirmed in 45 Russian Settlements: Chief Veterinary Inspector.’ (2005). Ria Novosti, 6 September. Bradford Jr., Colin I. and Johannes F. Linn (2004). ‘Global Economic Governance at a Crossroads: Replacing the G7 with the G20.’ Brookings Institution Policy Brief 131. <www.brookings.edu/~/media/Files/rc/papers/2004/04globaleconomics_colin%20i%20 %20bradford%20%20jr/pb131.pdf> (September 2008). Bradford Jr., Colin I. (2005). Global Health and Global Governance: Prioritizing Health within the Framework of the Millennium Development Goals. Brookings Institution, Washington DC. <www.brookings.edu/papers/2005/0114development_bradford.aspx> (September 2008). Butler, Declan (2005). ‘Bird Flu Vaccine Not Up to Scratch.’ Nature News, 10 August. <www. nature.com/news/2005/050810/full/news050808-9.html> (September 2008). Cameron, Maxwell A. (1998). ‘The Landmine Ban: Globalization of Civil Society?’ Review, vol. 2, no. 1. <www.nsi-ins.ca/english/publications/review/v2n1/05.asp> (September 2008). Canadian Food Inspection Agency (2008). ‘Enhanced Animal Health Protection from BSE.’ Fact sheet. Ottawa. <www.inspection.gc.ca/english/anima/heasan/disemala/bseesb/enhren/ enhrene.shtml> (September 2008). Carin, Barry (2005). ‘The L20 Rationale and Conjectures on Its Values Added.’ Paper prepared for the India-Canada Policy Dialogue, New Delhi, 12–13 April. Asia Pacific Foundation of Canada and Centre for Policy Research. Chicken Farmers of Canada (2004). Annual Report 2004: Standing Together. Ottawa. <www.chicken.ca/app/DocRepository/1/Annual_Report/2004_English_AR.pdf> (September 2008). Commission on Macroeconomics and Health (2001). Macroeconomics and Health: Investing in Health for Economic Development. World Health Organization, Geneva. <www.cid. harvard.edu/archive/cmh/cmhreport.pdf> (September 2008). Evans, Timothy, Nick Drager, Ariel Pablos-Mendez, et al. (2004). ‘L20 and Global Public Health.’ Commissioned briefing notes prepared for the conference on ‘HIV/AIDS and Other Infectious Diseases’, Costa Rica, 12–13 November. Centre for International Governance Innovation, Waterloo. <www.cigionline.org : Conference Papers and Reports : Leaders’ 20 (L20) Project : Infectious Diseases and Global Health : Backgrounder> (September 2008). Fidler, David P. (2004a). ‘L20 Communiqué on Global Health.’ Paper prepared for the conference on ‘HIV/AIDS and Other Infectious Diseases’, Costa Rica, 12–13 November. Centre for International Governance Innovation, Waterloo. <www.cigionline.org : Conference Papers and Reports : Leaders’ 20 (L20) Project : Infectious Diseases and Global Health> (September 2008). Fidler, David P. (2004b). ‘Germs, Governance, and Global Public Health in the Wake of SARS.’ Journal of Clinical Investigation, vol. 113, no. 6, pp. 799–804. Food and Agriculture Organization and World Organisation for Animal Health (2005a). A Global Strategy for the Progressive Congrol of Highly Pathogenic Avian Influenza (HPAI). <www.fao.org/ag/againfo/resources/documents/empres/AI_globalstrategy.pdf> (September 2008).

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Food and Agriculture Organization and World Organisation for Animal Health (2005b). ‘Recommendation No. 1: The Ho Chi Minh City Declaration on Investments.’ Second FAO/OIE Regional Meeting on Avian Influenza Control in Asia, Ho Chi Minh City, 23–25 February. <www.oie.int/eng/avian_influenza/HPAI HCMC Recommendations_ March 05.pdf> (September 2008). Food and Agriculture Organization, World Organisation for Animal Health, and World Health Organization (2005). FAO/OIE/WHO Consultation on Avian Influenza and Human Health: Risk Reduction Measures in Producing, Marketing, and Living with Animals in Asia. Kuala Lumpur, 4–6 July. <www.wpro.who.int/NR/rdonlyres/38A980D7-8577-400A8024-7D27F34309D1/0/FAO_OIE_WHO_Consultation.pdf> (September 2008). Garrett, Laurie (2005a). ‘The Next Pandemic?’ Foreign Affairs, vol. 84, no. 4, pp. 3–13. <www.foreignaffairs.org/20050701faessay84401/laurie-garrett/the-next-pandemic.html> (September 2008). Garrett, Laurie (2005b). ‘Leaders Summit on Global Infectious Disease: Toward an L20?’ Paper prepared for a conference on ‘L20 and Preventing Pandemics‘, 15 May, Geneva. <www.cigionline.org : Conference Papers and Reports : Leaders’ 20 (L20) Project : Pandemics>. Heymann, David L. and Nick Drager (2004). ‘Emerging and Epidemic-Prone Infectious Diseases: Threats to Public Health Security.’ Paper prepared for the conference on ‘HIV/ AIDS and Other Infectious Diseases’, Costa Rica, 12–13 November. <www.cigionline. org : Publications : Conference Papers and Reports : Leaders’ 20 (L20) Conference Papers and Reports : Infectious Diseases and Global Health> (September 2008). Keusch, Gerald T., Olivier Fontaine, Alok Bhargava, et al. (2006). ‘HIV/AIDS Prevention and Treatment.’ In D.T. Jamison, J.G. Breman, A.R. Measham, et al., eds., Disease Control Priorities in Developing Countries (Washington DC: World Bank and Oxford University Press) <www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=dcp2.chapter.2124> (September 2008). Kuchenbecker, Ricardo (2004). ‘The Inverse Capacity Building Law: From Technical Assistance to Technical Cooperation towards Global Health.’ Paper presented at the conference on ‘HIV/AIDS and Other Infectious Diseases’, Costa Rica, 12–13 November. Centre for International Governance Innovation, Waterloo. <www.cigionline.org : Conference Papers and Reports : Leaders’ 20 (L20) Project : Infectious Diseases and Global Health> (September 2008). ‘Meeting Report.’ (2004). Prepared after the conference on ‘HIV/AIDS and Other Infectious Diseases’, Costa Rica, 12–13 November. Centre for International Governance Innovation, Waterloo. <www.cigionline.org : Conference Papers and Reports : Leaders’ 20 (L20) Project : Infectious Diseases and Global Health : Meeting Summary> (September 2008). Osterholm, Michael T. (2005). ‘Preparing for the Next Pandemic.’ Foreign Affairs, vol. 84, no. 4, pp. 24–37. <www.foreignaffairs.org/20050701faessay84402/michael-t-osterholm/ preparing-for-the-next-pandemic.html> (September 2008). Otte, M., R. Nugent, and McLeod A. (2004). ‘Transboundary Animal Diseases: Assessment of Socio-Economic Impacts and Institutional Responses.’ Livestock Policy Discussion Paper No. 9. Food and Agriculture Organization, Rome. (September 2008). Panel of Eminent Persons on United Nations–Civil Society Relations (2004). We the Peoples: Civil Society, the United Nations, and Global Governance. A/58/817, 7 June. (September 2008).

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Price-Smith, Andrew (1998). ‘Contagion and Chaos: Infectious Diseases and Its Effects on Global Security and Development.’ Centre for International Studies Working Paper 1998/001. University of Toronto, Toronto. Price-Smith, Andrew (2008). Contagion and Chaos: Disease, Ecology, and National Security in the Era of Globalization. (Cambridge MA: MIT Press). Soni, Anil (2004). ‘Leaders Summit on Global Infectious Disease: Toward an L20?’ Paper prepared for the conference on ‘HIV/AIDS and Other Infectious Diseases’, Costa Rica, 12–13 November. Centre for International Governance Innovation, Waterloo. <www. cigionline.org : Conference Papers and Reports : Leaders’ 20 (L20) Project : Infectious Diseases and Global Health> (September 2008). Tweed, S. Aleina, Danuta M. Skowronski, Samara T. Savid, et al. (2004). ‘Human Illness from Avian Influenza H7N3, British Columbia.’ Emerging Infectious Diseases, vol. 10, no. 12. <www.cdc.gov/ncidod/EID/vol10no12/04-0961.htm> (September 2008). United Nations Development Programme (1994). Human Development Report. (New York: United Nations Development Programme). United Nations Secretary General (2002). Strengthening of the United Nations: An Agenda for Further Change. A/57/387, 9 October (see also A/58/387/Corr.1). (September 2008). United Nations Secretary General (2005). ‘Secretary-General Appoints Dr. David Nabarro as Senior UN System Coordinator for Avian and Human Influenza.’ SG/A/946. 29 September. New York. <www.un.org/News/Press/docs/2005/sga946.doc.htm> (September 2008). World Health Organization (2005). Avian Influenza: Assessing the Pandemic Threat. Geneva. <www.who.int/csr/disease/influenza/H5N1-9reduit.pdf> (September 2008). World Health Organization (2006). ‘Avian Influenza (“Bird Flu”): Fact Sheet.’ February. Geneva. <www.who.int/mediacentre/factsheets/avian_influenza/en> (September 2008).

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Chapter 7

In-Flew-Enza: Pandemic Influenza and Its Security Implications Yanzhong Huang

Infectious disease has historically affected world politics more extensively than most imagine (McNeill 1976; Watts 1999). Yet despite its impact on the course of history and the fate of nations, for a long time the concept of security focussed on the use of military power to protect national borders and interests abroad. A paradigm shift did not occur until the 1990s, when global health evolved from a humanitarian issue to one of development, governance, and security (Pirages 1996; Garrett 1996; Price-Smith 1999). The nascent field of health security became salient in 2000 when the United States National Intelligence Council (2000) issued its estimate on the threat to U.S. national interests posed by infectious disease. In responding to this new development, countries such as Canada and Japan have explicitly included issues of health security and human security in their foreign policies. In the post– September 11 era there has been a surge of scholarly activity within the field of health and international affairs. A voluminous literature explores the impact of public health problems—framed in terms of human security, health security, microsecurity, or biological security—on national and international security. This chapter is concerned with the effects of a future influenza pandemic on security primarily at it relates to stability both within and among states. Following Richard Ullman (1983), security is defined in a broad manner, covering the pandemic’s potential impact on world economy, sociopolitical stability, and international relations.1 Of course, not all infectious diseases are considered serious security threats—to most, the influenza that costs 36 000 lives annuallly annually in the United States is more a nuisance than a national security concern. To address all infectious diseases as a security challenge not only risks diluting the true meaning of security but also provides policy makers with little guidance for prioritising competing policy objectives (Paris 2001). Uncertainty is another challenge in examining the potential security implications of a future pandemic. While history can be a guide, it cannot foretell the future. In this sense, a straightforward extrapolation from the U.S. experience with the Spanish influenza can be misleading—not only because the world is quite different from 1918, but also because the impact even of a global pandemic will likely vary across countries, economies, and societies. This makes it

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necessary to analyse the nature of the pandemic as well as the context in which it unfolds. After a discussion of the potential characteristics of the pandemic influenza and the international context, this chapter addresses its economic, sociopolitical, and military and strategic implications. It ends with some policy recommendations on how to mitigate the security risks of the pandemic.

How Nasty Is the Bug? Most infectious disease experts agree that the world now stands at the edge of an influenza pandemic (Knobler et al. 2005). While there is no hard science to support that position, an examination of the timeline of influenza over the past 100 years suggests a disproportionate increase in the number of reports of novel sub-types in humans and in the number of animal and bird species involved (Webby and Webster 2003).2 In part, this is because influenza is an RNA virus, which is prone to mutation. According to the World Health Organization ([WHO] 2005), all prerequisites for the start of a pandemic have been met save one: efficient humanto-human transmission. While scientists cannot determine exactly which viruses might cause pandemics, recent outbreaks of avian influenza in Asia make the H5N1 virus the most likely candidate to spark the next influenza pandemic (Lee Jong-wook 2005). Unlike most avian influenza viruses, which emerge briefly and are relatively localised, H5N1 is spreading widely among birds in Asia and has unusual staying power (WHO 2005). A report published in 2005 by the Institute of Medicine of the National Academies (IOM) in the United States called the H5N1 avian influenza in Asia ‘unprecedented in its scale, in its geographical distribution, and in the economic losses it has caused’ (Knobler et al. 2005, 12). It may be just a matter of time before H5N1 adapts to humans, since the virus behind the 1918 Spanish influenza was derived completely from an avian source (Taubenberger et al. 2005). Although the timing of the next pandemic cannot be predicted, efforts have been made to estimate its demographic consequences. The upcoming pandemic will likely resemble the mild influenza pandemics in 1957 and 1968 (both strains were the result of reassortment, meaning an exchange of genetic material between human and avian viruses), which killed 3 million people worldwide. According to research by the Centers for Disease Control and Prevention (CDC), hybrid viruses that combine seasonal human influenza virus and the H5N1 virus fail to spread efficiently, at least in ferrets (Kaiser 2006). It is expected that the longer H5N1 lives in wild birds, the more likely it will become mild (Orent 2005). Modelled on the pandemic of 1968, the best-case scenarios predict that 2 million to 7 million people would die and tens of millions would require medical attention (WHO 2004). Chances are that the next pandemic may not be as mild as the one in 1968. Research on the newly recovered 1918 virus suggests that it completed an avianto-human transfer without gene reassortment, while the number of mutations to get from the avian variant to the human one was relatively small (Taubenberger

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et al. 2005). Moreover, similarities between H5N1 and the 1918 virus (which led to the death of 20 to 50 million people world-wide) have been suggested in the gradual adaptation of an avian virus to a human one, the severity of disease, and its concentration in young and healthy people (WHO 2004). For good Darwinian reasons, pathogens tend to evolve in less lethal directions when mutations allow them to spread more effectively.3 Available evidence, however, seems to point to the spread of a highly transmissible and lethal virus that kills between 80 percent and 100 percent of the birds it infects. By 19 June 2008, it had killed 243 people, with a case fatality rate (CFR) of more than 60 percent (WHO 2008). While such a high CFR is obviously deceptive, the prospect of the emergence of a virulent strain has led at least one public health expert to predict a statistical possibility of as many as 360 million deaths world-wide (Osterholm 2005).4 The potential demographic effects of the pandemic influenza rival a current pandemic, HIV/AIDS. Since 1981, HIV/AIDS has wiped 25 million people off this planet (UNAIDS 2008, 31). Yet unlike HIV, which has an incubation period of up to ten years and spreads gradually from high-risk groups to the general population, a pandemic influenza virus can make a global impact in a matter of months, if not weeks. In the words of John Barry (2005), the 1918 Spanish influenza ‘killed more people in 24 weeks than AIDS has killed in 24 years’. It is therefore necessary to make a distinction between two types of epidemics, outbreak events and attrition epidemics (WHO 1996, 39). The impact of HIV/AIDS as an attrition epidemic is mainly long term, given its long incubation period and the relatively high certainty about its morbidity, mortality, and pathways of transmission. By contrast, an outbreak event like pandemic influenza or severe acute respiratory syndrome (SARS) can generate significant shocks over a very short period, and this impact can be exacerbated by the difficulty to control the behaviour that causes the transmission of the disease. The potential long-term impact of pandemic influenza must not be overlooked, however. After all, the challenge is going to be much bigger than SARS, which killed 916 people and infected 8422 worldwide. Not only is the influenza virus much more contagious and virulent than SARS, but asymptomatic carriers can shed the virus as well, making it difficult to contain its spread through quarantine and isolation.

A Different World The nature of the pathogen is not the sole factor determining the impact of the future pandemic. As works of Alfred Crosby (2003) and John Barry (2004) have suggested, World War I, degree of political commitment, and civil society engagement all affected how the 1918 influenza was transmitted and felt in U.S. society. To the extent that contextual variables matter, an analysis of the impact of the pandemic needs to address the following question: what makes the world of today different from 1918? An easy answer is that there is no world war. During World War I, the conditions of trench warfare on the western front and the American efforts to send troops to the

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battlefield as quickly as possible created an ideal environment for influenza epidemic to thrive (Byerly 2005). Preoccupied with winning the war, political leaders were caught off guard by the disease outbreak, and also had little interest in opening another front to fight the disease. While concerns about morale led to the cover-up of the spread of the influenza, a series of bond-purchasing activities and parades only aggravated the epidemical situation in the United States (Crosby 2003, 53). Today, political leaders are much more conscious than their predecessors about the significant new challenges to the security and prosperity of the citizens over which they preside. As recognised in the United Nations High-Level Panel Report, even though military conflicts between sovereign states remain a major threat, warfare predominantly takes the form of intra-state conflicts (i.e., civil wars), which are closely associated with poverty, environmental degradation, and infectious disease (UN 2004). Drawing lessons from previous epidemics and natural disasters, policy makers have attached more importance to public health, which is being elevated from a ‘low politics’ issue to something salient on their agenda. Indeed, the UN Millennium Development Goals (MDGs) have suggested that health has become a ‘pre-eminent political value’ of 21st-century humanity (Fidler 2005, 184). Political leaders in many countries have demonstrated strong commitment to preparing for the next disease outbreak. According to Laurie Garrett (2005b), the WHO determined that by November 2005 about 60 percent of countries had unveiled some type of pandemic preparation strategy. With advances in biotechnology and widespread use of antiviral drugs, vaccines, and other powerful antimicrobials, the ability to combat pandemic influenza appears to have strengthened. In 1918, these were no antibiotics, no vaccines, no intensive care—indeed, influenza viruses were not known to exist at that time. It is estimated that most of the 1918 deaths were from secondary bacterial infections (not viral pneumonia) that today could be treated effectively by antibiotics (Fumento 2005). Critical gaps nevertheless continue to exist. Many countries do not have sufficient resources to prepare for an influenza pandemic adequately. Despite the growing political commitment and the availability of new medicines and treatments, most countries continue to have weak surge capacity in addressing a pandemic outbreak. A 2006 survey of 183 U.S. cities found that nearly three quarters were not prepared to handle an influenza pandemic outbreak (U.S. Conference of Mayors 2006). International production of most vaccines is still based on the technology from the 1950s, which uses chicken eggs infected with the influenza virus for vaccine development and production. The existing system of manufacturing vaccine is fragile (because chickens themselves could be wiped out in a pandemic) and inefficient (it requires waiting four to six months after the onset of the pandemic, but an outbreak would have to be contained within three weeks). Because of limited production capacity, with this technology only about 14 percent of the world’s population would be vaccinated within a year of the pandemic (Osterholm 2005). As with antiviral drugs, by October 2005 40 countries had ordered Tamiflu, yet the orders take considerable time to be processed and delivered. There is a huge gap between developed and developing countries in terms of the capacity of preparing

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for the pandemic. Most of the world’s influnza vaccine is produced in only nine developed countries, with Europe producing 70 percent of the world’s vaccines. Access to vaccines in the rest of the world is thus limited, especially countries in the developing world: countries with production facilities may limit or ban the export of vaccine to other countries after the onset of the pandemic (‘Preparing for a Pandemic’ 2005). The lack of health system capacity is particularly a problem in front-line countries, such as Vietnam and Indonesia, where lack of financial support has already compromised government capacities in containing the spread of bird influenza (Bradscher 2005). In still other countries such as China, where rural people lack access to health care and incentives to cover up remain strong, a disease outbreak could quickly be out of control and spread around the globe before the international community even became aware of it. The likelihood of a rapid spread of infectious disease is related to another important development: globalisation. A centuries-old dynamic, globalisation today is different in that it features the rise of new tools, new actors, new rules, and new markets (United Nations Development Programme [UNDP] 1999, 30). With the spread of democracy and civil society groups, the emergence of global networks of nongovernmental organisations (NGOs), and the availability of new tools such as the internet, cellular phones, and media networks, more direct power is given to individuals than any time in history (Friedman and Ramonet 1999). As a result, a complete government information blackout becomes not only impossible but also counterproductive (see Huang 2004). Meanwhile, globalisation leads to the adoption of new rules that become more binding for national governments. In May 2003, in response to SARS, the WHO was formally authorised to garner and analyse data from non-state actors and to issue global alerts when international public health was threatened by an infectious disease. Given that states historically have sought to suppress the flow of information regarding endogenous epidemics, the use of non-state information sources will expedite the flow of information to the WHO, and therefore strengthen its outbreak alert and response activities. In May 2005, the World Health Assembly (WHA) adopted the revised International Health Regulations (IHR), which provide an international legal framework for preparedness for and responses to outbreaks. With the new IHR, the WHO has a clearer framework to provide leadership on public health emergencies. In this sense, globalisation promises to increase international disease surveillance capability and mitigate the consequences of the pandemic when it occurs. Yet globalisation is a double-edged sword. While the tools of globalisation can be used to expose cover-ups and report disease outbreaks in a timely fashion, they can also be used to spread panic, thus magnifying the negative impact of the disease. Indeed, as ‘the shrinking space, shrinking time and disappearing borders’ link people’s lives ‘more deeply, more intensely, more immediately than ever before’ (UNDP 1999, 1), the vulnerability to disease outbreaks has only increased. As Singapore’s senior minister Lee Kuan Yew (2004) observed, in earlier times new viruses would have killed nearby villagers, but then the danger would have passed; with much greater and faster movement of people and goods, the viruses travel swiftly and far.

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Even before commercial air travel, the Spanish influenza managed to circumnavigate the planet five times in 18 months. It would certainly take much less time for it to wreak havoc world-wide today. Indeed, virtually any city in the United States today can be reached by commercial flight within 36 hours, less than the incubation period for most infectious diseases. As the distinction between domestic and international public health is blurred, so is the difference between national and international economy. The increasing linkage of economic entities by production, marketing, and investment means that a disease-caused economic shock in China can be felt immediately in other parts of the world. Since globalisation is a process integrating not just markets but culture and governance, the impact will go beyond the economic sectors and have important implications for sociopolitical and international stability. Other changes since 1918–19, such as population explosion, have made pandemic influenza a greater threat, not a lesser one. Between 1918 and 2008, the world population increased nearly four fold, from 1.8 billion to 6.7 billion. Meanwhile, the percentage of population at risk for secondary infection caused by a pandemic influenza is growing rapidly, as the population today includes more elderly and more people with a weakened immune system (owing to aging, immunosuppressive medication, and concurrent infections such as HIV infection) (Osterholm 1996). HIV/AIDS poses a particular challenge to mitigating the consequences of the pandemic influenza. If a pandemic influenza arrives, it will be the first time for humans to experience two pandemics at the same time. While still unsure of how H5N1 will interact with the HIV virus, scientists speculate that because of the immunosuppression associated with the infection, HIV-positive populations either will be rapidly devastated or will serve as ‘an ambulatory Petri dish’, incubating and possibly spreading new forms of the virus (Garrett 2005b). Such demographic changes, coupled with urbanisation and exponential growth in foreign travel, have made significantly more people vulnerable to the risks of infectious diseases, including a influenza pandemic. In sum, the world is different from that in 1918. While certain factors (e.g., increasing political commitment) could reduce the negative impact of the pandemic influenza, other developments (e.g., lack of surge capacities, growing interdependence, and population explosion) can make the influenza pandemic much more devastating than ever before. In any case, the impact of the pandemic can still be considerably lessened, provided that political leaders recognise the economic, sociopolitical, and international threats that the pandemic poses and responds accordingly. The remainder of this chapter will explore the implications of the pandemic influenza in all these three dimensions.

Effect on World Economy In An Essay on the Principle of Population, Malthus (1798) posited that disease served as a ‘positive check’ of population growth by affecting food supply growth. The role of disease as a great population regulator was demonstrated by the bubonic

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plague (Black Death) in the 14th century, when the drastic depopulation resulted in decades of continent-wide crop and livestock deficiencies (Herlihy 1997). Contemporary epidemics such as SARS led to a substantial decline in consumer demand, especially for travel and retail sales services. According to the World Bank, SARS caused an immediate economic loss of about 2 percent of East Asian regional gross domestic product (GDP) in the second quarter of 2003 (Brahmbhatt 2005). An estimate made by Bio Economic Research Associates placed the cost of SARS to the global economy as high as US$50 billion (Newcomb 2005). Most economic analysts agree that depending on the severity of the disease and sustainability of its impacts, spread of an influenza pandemic would take a much heavier toll on the national, regional, and global economies. The World Bank estimates that the global costs could reach US$800 billion in one year (see Table 7-1). A report published by Conference Board of Canada (2005) claims that a large-scale influenza pandemic would ‘throw the world into a sudden and possibly dramatic global recession’. Another report from BMO Nesbitt Burns concurs, stating that the pandemic’s economic impact could be ‘comparable, at least for a short time, to the Great Depression of the 1930s’ (Cooper and Coxe 2005). All these estimates and predictions suggest a negative dynamic between infectious disease and the economy. In reality, though, the economic impact of epidemics is much more complex than originally thought. As Maureen Lewis (2001) pointed out, apparently obvious microeconomic effects might not be reflected in macroeconomic Table 7-1: Estimates of the Economic Damage from Pandemic Influenza

Scope

Estimated economic damage US$88 billion to US$206 billion in current dollars

Comments Assumes 89 000–207 000 deaths and 314 000– 734 000 hospitalisations in the U.S.; excluding disruptions to commerce National and society (United States) US$181 billion in direct and Not including disruptions indirect health costs (for a in trade and other costs to moderate pandemic with business and industry no interventions); US$450 billion (worst-case scenario) US$113.4 billion or 2.6% of Assumes an attack rate of regional GDP (mild shock); 20% and a case fatality Regional US$296.9 billion or 6.8% rate of 0.5%; does not (Asia) of regional GDP (severe include disease-associated shock) medical costs Total costs could reach Assumes a case fatality Global US$800 billion in one year rate of less than 0.1% in the U.S. Note: GDP = gross domestic product.

Source Centers for Disease Control (Meltzer et al. 1999)

U.S. Department of Health and Human Services (2005)

Asian Development Bank (Bloom, de Wit, and CarangalSan Jose 2005, 6–7, tables 1, 2) World Bank (Brahmbhatt 2005; Newcomb 2005)

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data: the relationship between the costs inflicted at the micro level and those on the society in aggregate can vary considerably across epidemics. A disease that kills the weak and the very young can even have the perverse effect of raising the GDP per capita, provided that those at the most productive ages survive but there are fewer people in total to share the wealth (‘Epidemics and Economics: The Economic Consequences of Disease’ 2003). This provides yet another reason to explore the nature of a forthcoming pandemic. To be sure, each influenza outbreak is different and it is not possible to predict what groups will be at highest risk (Simonsen et al. 2005). Given the broad similarity between the 1918 virus and the H5N1 virus, however, the pandemic influenza is expected to be different from a typical influenza that strikes hardest among the elderly, the very young, and people with underlying chronic conditions. Instead, the pattern of the pandemic-induced population shock is likely to take a ‘W’ shape because of its devastating impact on the economically active population in addition to the very young and the elderly.5 In the latter case, half of those killed in the pandemic could be between the ages of 18 and 40 (Osterholm 2005). The sickness and premature deaths of income earners have important implications for economy at the micro level. Disease-associated medical costs and the value of workdays lost due to the illness reduce the disposable income for households. As savings are replaced with current expenditures, the rate of capital accumulation (savings and investment) declines. The more lethal and contagious the virus, the more bread earners will get sick or die, and the higher the number of households that will be pushed below the poverty line. The pandemic thus reinforces income inequality, since poorer households bear a much greater economic burden as a result of infection than their wealthier counterparts. As demonstrated in the HIV/AIDS pandemic, because of the loss of family members and sales of assets to pay healthcare costs, many poor households may never recover their initial income (Cohen 1997). For firms, the reduction in labour due to incapacity and mortality would increase wage and replacement costs, forcing many to increase the prices of their products. Likewise, the costs inflicted upon individual households and firms will contribute to economic shocks at a macro level. Like SARS, the influenza pandemic will affect consumer confidence and alter consumption and social patterns. Yet unlike SARS, where the main impact was on the demand side (Fan 2003), an influenza pandemic will cause supply shocks by affecting the health of the labour force. Research suggests that if 25 percent or more of a population is infected, fuel and food supplies will be significantly reduced, which will deal a serious blow to the economy unless effective measures are taken to maintain basic services with a reduced labour force (Coulombier and Ekdahl 2005). The U.S. Homeland Security Council (2005, 13) predicts that at the peak of an influenza pandemic as many as 40 percent of workers in U.S. firms could be absent, including those who are sick, people who need to care for others, and people who stay home because of safety concerns. Depending on the epidemiological features and the psychological impact of the pandemic, the demand and supply shocks will vary. In general, the more pathogenic and contagious of the virus, the greater the supply shock (due to higher level of

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absenteeism of otherwise healthy workers) and demand shock (due to reduced consumer confidence and activities). The impact of the pandemic on demand, though, may not be always negative. As happened with the bubonic plague, with a high attack rate and a high CFR, people in the affected regions may discount their future so heavily that they adopt a today-we-drink-for-tomorrow-we-die attitude, leading to an increase in consumer demand (Hays 1998). Also, the longer the psychological impact of the outbreak lasts, the more significant reduction it may cause in consumption and export of services (as consumers in directly affected countries reduce their activity, and as the rest of the world reduces its consumption, affecting trade and investment). Assuming that the psychological impact of the outbreak lasts longer and seriously affects demand for one year, the Asian Development Bank (ADB) placed the estimated loss of nine Asian economies at approximately 6.5 percentage points of GDP in 2006, which means that growth in the region would essentially come to an abrupt halt (Bloom, de Wit, and Carangal-San Jose 2005). A battered regional economy will result in significant disruptions to the highly integrated global economy. Difficulties in trade and travel are likely to interrupt the flow of goods and services, ‘with cascading effects in industries with tightly linked supply chains that depended heavily on supplies in the affected countries’ (Newcomb 2005). Indeed, most of the cost of the SARS epidemic was incurred not by its direct economic impact (i.e., the medical treatment costs and lost productivity associated with absenteeism) but by the indirect economic impacts such as disruption of trade, travel, and investment, the interruption of product supply lines, and fear-induced behavioural changes in consumers, travellers, and businesses (Newcomb 2005). A well-connected world economy is very sensitive to exogenous shocks. According to the ADB, if a disease outbreak leads to the shut-down of the Asian economy, global GDP will contract 0.6 percent and the global trade of good and services will shrink about 14 percent (with a total cost of $2.5 trillion) (Bloom, de Wit, and Carangal-San Jose 2005, 5). With foreign companies shifting manufacturing to China that country has become a workshop for the world. A world economy that depends so heavily on China as an industrial lifeline can become increasingly vulnerable to a major supply disruption caused by a pandemic outbreak in this country. Additional secondary effects on the economy are equally important. First, if people avoid social contact, epidemics could adversely affect labour productivity due to restricted labour mobility (which inhibits labour from moving to where it is most productive) (Jong-Wha Lee and McKibbin 2004, 95). Second, fear and uncertainty may lead people to rush to purchase daily necessities, and this panic buying threatens to trigger a ‘bank run’ that could disrupt seriously a country’s financial industry. Third, it is likely that government and international response to the disease (e.g., quarantines, import bans) exacerbates the economic impact by sustaining the psychological impacts and reinforcing a tendency for markets to overreact. If the pandemic lasts longer than a year, quarantines could lead to widespread business failures, mass unemployment, and further decline of consumer demand. The impact of pandemic influenza is unlikely to be the same for all economies. Quarantine-induced economic shocks in an affected country, for example, may

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depend on the country’s economic size and global importance. David Fidler (2005) has suggested that countries would be more willing to restrict trade and travel aggressively with Indonesia than with China because of the latter’s sheer market size and importance in global economy.6 The SARS outbreak suggests that open economies, economies that are significant exporters, and economies with a prominent service sector are particularly vulnerable to international economic shocks (JongWha Lee and McKibbin 2004, 95). The connection between open economies and short-term economic shocks is suggested in Table 7-2. By taking into account the openness of the economy and healthcare costs, Bio Economic Research Associates developed a composite index to measure the relative economic risk of influenza pandemic in selected countries. According to this index, China, Hong Kong, and Singapore are the Asian economies most exposed to the risk of the pandemic, and the U.S. is the most vulnerable among five members of the Organisation for Economic Co-operation and Development (OECD) assessed (Newcomb 2005, figure 4). In emphasising the significant negative dynamics between infectious disease outbreaks and economic prosperity, however, short-term impact during the pandemic is often not differentiated from the impact in the immediate aftermath of the pandemic. While in general the short-term impact is negative during the pandemic, in the aftermath it may not be entirely negative. The Spanish influenza, for example, did not lead to a drop in per capita income growth across the U.S. in the 1920s, nor did it have any significant impact on acreage sown per capita in India (Crosby 2003). Indeed, a study of its effects on the growth of income per capita in the U.S. between 1919 and 1930 revealed that the states with the highest mortality rates and highest business failure rates grew fastest (Brainerd and Siegler 2003; quoted in ‘Epidemics and Economics: The Economic Consequences of Disease’ 2003). In Table 7-2: Total Exports as Share of Gross Domestic Product and Estimated Economic Shocks

Economy Singapore Hong Kong Malaysia Thailand Korea Philippines China Indonesia

Total Exports as Share of GDP 258.3 186.8 125.4 68.2 56.4 48.9 45.2 42.0

Estimated Reduction in Annual GDP Growth, 2006 (percentage points) 22.8 17.5 11.3 11.7 6.3 3.0 5.3 2.8

Notes: The economic shocks include both demand and supply shock. The estimate assumes four quarters of strong demand contraction globally. GDP = gross domestic product. Source: Bloom, de Wit, and Carangal-San Jose (2005).

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2003, the containment of SARS was followed by swift and strong economic growth in Asia, particularly China (Doven 2003). The potential of economic rebound in the immediate aftermath of the pandemic cannot be denied, although the speed and strength of the economic revival may depend on the duration of the pandemic and the damage it does to the manufacturing sector (Newcomb 2005). Although an influenza pandemic is described as an outbreak event and its economic impact is likely to be mainly short term (as with SARS), its long-term economic consequences cannot be dismissed. Unlike SARS, a pandemic can lead to significant drop in physical capital (due to reduced investor confidence in the future of the affected economies) and human capital (as a result of mass morbidity and mortality). The destruction of human and physical capital will reduce an affected economy’s long-term economic growth potential. A study by Douglas Almond (2006), with the support of the National Institutes of Health and the National Institute of Aging in the U.S., suggested a broad spectrum of persistent effects of the 1918 Spanish influenza: cohorts in utero during the height of the pandemic typically displayed reduced educational attainment, lower socioeconomic status, and increased rates of physical disability. It also found that ‘persons born in states with more severe exposure to the pandemic experienced worse outcomes than those born in states with less severe pandemic exposures’. While there are no solid data to examine a pandemic’s long-term impact on investment, it is not hard to imagine that if the pandemic persists in an affected country and begins to disrupt global production lines, multinational corporations (MNCs) will be forced to reconsider their investment strategy. The increased risk profile in doing business in an affected country will reduce foreign investment and exports, which will eventually hurt the manufacturing sector. Nonetheless, human societies and economies can be highly resilient in the long run. A negative shock to population growth caused by the bubonic plague, for example, actually led to faster accumulation of capital and subsequently faster output growth. The scarcity of labour in the century after 1350 also encouraged more technological innovation (for example, the rapid spread of water mills and windmills in Europe; see Hays 1998). To summarise, a pandemic can cause tremendous damage to a highly interconnected global economy. Depending on the nature of the pandemic and its international context, the impact can vary considerably across economies, and there can be wide variation between its immediate impact and its impact in the immediate wake of the outbreak, as well as between its short- and long-term effects.

Sociopolitical Stability The onset of an influenza pandemic will combine with economic instability and other factors to create volatile social and political situations. Uncertainty about the nature of the disease could produce significant worry, anxiety, fear, panic, and even mass hysteria in an affected society. As suggested during the SARS outbreak, government mishandling of an outbreak can intensify the fear and facilitate the spread

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of rumours, pushing the panic to an even higher level. Because of its psychological effect, a disease outbreak often acts as a multiplier factor on social stability. During the plague outbreak in Surat, India, in 1994, for instance, the fear of an epidemic was so intense among the city residents that within four days, one quarter of the population fled the city (World Resources Institute 1996). While only 56 people died nationwide, the outbreak and mass exodus generated considerable anxiety throughout India and the world, with the fear that plague might be transported far and wide by Surat refugees. Historical cases also suggest that the fear factor associated with a pandemic can be as potent and destructive as the virus itself. During the bubonic plague, Jews were commonly accused of spreading the disease and therefore subject to mass killings as a part of the hysteria (Hays 1998, 50). During the SARS outbreak, disease-associated stigma and discrimination were reported in countries including China, Canada, and the United States. According to a survey conducted during the outbreak by the Harvard School of Public Health, 16 percent of Americans avoided people whom they thought might have recently travelled to Asia, while 14 percent shunned Asian restaurants and stores (Stein 2003). This problem may be amplified in a future pandemic, because people will be advised to minimise, if not avoid, social interactions. As the pandemic becomes part of a national lexicon, rumour, suspicion, and misinformation could lead to profiling and discrimination against people from or associated with the affected regions. If Asia turns out to be the epicentre of the next pandemic, it is likely that every immigrant or visitor from the region will be viewed as a Typhoid Mary. Government measures such as forced quarantine will only reinforce the vicious cycle of discrimination against this group, who will be perceived as diseased or dangerous. Such xenophobia and racism could be used by the politically ambitious to influence election outcomes. While the potential dangers in this scenario should not be exaggerated, the 2002 presidential election in France highlights the danger of such an issue being exploited by political extremists to challenge the foundation of a liberal democracy (Huang 2003). The psychological impact and changing social pattern will increase the likelihood of lawlessness and violence by fostering more intense rivalries between different ethnic and religious groups, between the socially privileged and the marginalised, and between state and society. Pandemic-induced mass unemployment and rising income inequality could bring to the surface long-standing grievances of haves against have-nots and intensify the conflicts between different classes and groups. The bubonic plague, for example, increased the tensions between the rich and poor in Europe, leading to peasant riots in England, France, Belgium, and Italy (Hays 1998). In the meantime, the pandemic may be so overwhelming that people with shortened time horizons could engage in all kinds of risky behaviour (such as crimes and riots). As documented by Thucydides, the plague of Athens in the fifth century BC triggered ‘a state of unprecedented lawlessness’ because ‘men, not knowing what would happen next to them, became indifferent to every rule of religion or law’ (Thucydides 1952, 155). Protests and riots also occurred in China during the SARS outbreak. In late April 2003, thousands of residents of a rural town near Tianjin

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ransacked a building they believed would be used to house potentially ill SARS patients (Eckholm 2003). The need for a capable state to respond effectively to the spread of disease and the social problems that flow from it occurs at a time when the capacity of the state is reduced by the pandemic. Added to the likely labour shortages among government employees, staff fatigue and loss of institutional memory are associated with high staff turnover. By debilitating law enforcement agencies and by decimating the ranks of skilled administrators, the pandemic will not only cause policy consistency and enforcement problems, but will also diminish the reach or responsiveness of government institutions, or reduce their resilience. In addition, the pandemic could compromise the state capacity to respond adequately to the pandemic by affecting elite or election politics. History is full of examples of the political instability triggered by disease-caused deaths among reigning families (McNeill 1976, 260). In China during the SARS crisis, conflicts over how to respond to the disease outbreak exacerbated factionalist politics and contributed to initial policy immobility (Huang 2004). The reduced ability of the government to respond can only foster public discontent with the government and create greater pressures on government structures (Chemical and Biological Arms Control Institute [CBACI] and Center for Strategic and International Studies [CSIS] 2000). As the pandemic may increasingly highlight a government’s incapacity in crisis management and in providing adequate public and health services, the government would face legitimacy problems—meaning its ability to have its rule accepted by the populace and political opposition will be eroded. This negative synergy between state and society would make it even more difficult to break the downward spiral of disease, social instability, and weak government structures. As suggested by China’s experience with SARS, confused and shocked people may turn to non-state sources of moral authority and spiritual well-being.7 In the worst scenario, poor government response could embolden a political opposition that resorts to violence in an attempt to topple the government (CBACI and CSIS 2000, 11). Will the pandemic lead to social breakdown? In examining the impact of the Spanish influenza on the U.S. society, John Barry (2004, 350) suggested that society began to break apart because ‘a fear and panic of the influenza akin to the terror of the Middle Ages regarding the Black Plague, [was] prevalent in many parts of the country’. Noting that doctors and nurses were kidnapped and victims were starving to death ‘not from lack of food but because the well [were] afraid to help the sick’, Barry (2005) suggests that if the pandemic had continued to build, ‘civilization could easily disappear from the face of the earth within a few more weeks’. However, even during the pandemic, the psychological and sociopolitical impacts of a pandemic on individuals and societies can be very mixed. Psychologically, fear and panic over a disease outbreak often coexist with passion for the sick and poor; socially, mass hysteria and social discrimination of infected persons are often juxtaposed with social cohesion and collective problem solving (Chan 2003). In contrast to Barry’s pessimism, Alfred Crosby (2003, 115) observed a picture in which the pandemic actually increased social cohesion in the United States: despite the deep schism in

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the society, ‘Americans did lend each other a helping hand’. Even with ‘occasional harshness’, the 1918 influenza pandemic did not demonstrate a general pattern of race or class antagonism. Similarly, in the political sphere, the dynamics among disease, instability, state capacity, and political legitimacy may not be entirely negative. The U.S. government cover-up and inaction during the Spanish influenza did not cause any legitimacy problems for the government (Crosby 2003, 115). In fact, even with its disruption to U.S. society, the pandemic did not seem to have had a significant impact on fundamental governmental and social institutions. While contextual factors such as World War I played an important role in this process, enthusiasm from a robust civil society offset the government capacity deficit in the battle with the influenza (Crosby 2003, 115–116). The mixed political outcome was also shown in the case of SARS in China. Despite the initial cover-up and inaction, the Chinese government’s ability to contain the spread quickly shored up its legitimacy (Huang 2004). Meanwhile, the SARS debacle opened a political window for central leaders to reinforce control over lower-level officials and to pursue a more balanced development agenda. Even in the absence of an autonomous and civil society, strong state capacity helped the government to weather the most severe sociopolitical crisis facing the Chinese leadership since the 1989 Tiananmen crackdown. Both cases suggest that the socioeconomic impacts can vary, depending on the level of civil society engagement and state capacity in battling the pandemic (see Table 7-3). As suggested in Table 7-3, the ideal outcome is that a strong state works closely with a robust civil society to contain the spread of the pandemic and mitigate its potential sociopolitical outcomes. ‘Strong state’ means high state capacity to respond not only on the health front but more generally (e.g., ability to maintain social order and to provide essential commodities and services). State capacity is more Table 7-3: State Capacity, Civil Society Engagement, and Sociopolitical Impacts

High

Low

High

Negative sociopolitical consequences minimised

Coexistence of social dislocations and social cohesion/cooperation; no fundamental change in sociopolitical structures (e.g., the United States during the Spanish influenza)

Low

Civil society engagement

State Capacity to Respond

Initial dislocations in the society and polity likely, but mitigated by strong and effective state engagement later (e.g., China during SARS)

Negative downward spiral among pandemic, sociopolitical instability, state capacity, and political legitimacy; social breakdown or state failure highly likely

Note: SARS = severe acute respiratory syndrome.

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effective if it partners with a robust civil society. With a well-developed pandemic preparedness plan, a consolidated democracy can have the potential for the bestcase scenario. The negative spiral is most intense in countries where state capacity is already severely limited yet effective civil society engagement is not expected. In such a situation, countries have few human, financial, and other resources from which to draw to break the negative spiral, and the pressures on the already fragile or weak governments can cause them to collapse. While it is difficult to predetermine state capacity to respond and the level of civil society engagement, some countries in southeast Asia or sub-Saharan Africa might well become victimised by this scenario. The situation might be even worse in sub-Saharan Africa, where governments are fragile and burdens of HIV/AIDS are heavy. Given the similarity between the H5N1 and 1918 viruses, and the fact that both the 1918 Spanish influenza and HIV/AIDS typically attack individuals in the prime of their economically productive lives, it is highly likely that the spread of pandemic influenza to East Africa would quickly destroy the regional economies, exacerbating the humanitarian crisis. Fuelling this death, destitution, and destruction are the discontent of excluded, disadvantaged, or repressed groups and the greed of warlords, which could lead to a Hobbesian world of a war of everyone against everyone. In short, the onset of the pandemic has a strong potential to cause sociopolitical dislocations in affected countries and set in motion a vicious cycle among disease, social stability, and state capacity. The sociopolitical impacts nevertheless can be mixed and may vary across countries, depending on the state capacity to respond and the effectiveness of civil society engagement. The negative consequences can be minimised or mitigated in countries with a strong state or a robust civil society engagement. By contrast, the negative dynamics are very likely to lead to social breakdown or state collapse in countries where state capacity is already severely constrained and a robust civil society engagement is absent.

Military Security and International Stability In Leviathan, Thomas Hobbes claimed that the central functions of the state are to protect its citizens from both internal and external forms of predation. The presence of a pandemic influenza will not only limit state capabilities to impose sociopolitical order, but will also jeopardise state capabilities to fend off external aggression. According to Crosby (2003, 11), the Spanish influenza killed ‘nearly as many American soldiers as died in battle, ten times and over that number of American civilians, and twice as many people in the world as died in combat on all fronts in the entire four years of the war’. Through the debilitation of military personnel, the pandemic can degrade human resources and reduce force strength. Provided that the future pandemic influenza resembles the 1918 influenza in that the adult males who were most vulnerable were those of military age (who are also the most susceptible to secondary complications such as pneumonia), the pandemic will also jeopardise the pool of physically qualified candidates for the new recruits. Meanwhile, the spread

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of the pandemic will soon create an immunosuppressed military force, which by its very nature will be highly vulnerable to biological and chemical weapons. Military readiness and capabilities can be further compromised when the burden of disease generates costs that limit defence budgets (CBACI and CSIS 2000). For states that are already in political chaos, even the perception of a weakened military can make them susceptible to foreign aggression. It is noteworthy that pandemics historically had little effect on humankind’s desire to make war. Striking at the very heart of the Hundred Years War, the Black Death saw the continuous search of Edward III of England for the human resources and treasure to sustain the war with France (Bray 1996, 69). Similarly, Woodrow Wilson insisted that the lives lost to the Spanish influenza must be balanced against those that could be saved with a speedy end of World War I. By depleting the number of troops available for combat and support, the pandemic also has the potential to affect military operations, even war outcomes. In her testimony before the U.S. Senate Committee on Foreign Relations, Laurie Garrett (2005b) asked this question: If a nation is fighting wars on two fronts involving more than 200,000 troops, and H5N1 turns out to mirror the 1918 flu in that it takes its highest toll among young adults, how can the armies continue to carry out their operations? If, in addition, their enemy practices suicide bombings, and therefore cares not whether it is infected with a deadly virus, how might the pandemic affect the course of the wars?

The 1918 Spanish influenza provides the most recent case to examine the impact of the pandemic on the course of war and war outcome. The pandemic slowed perceptibly military operations on both sides. It forced the British troops to postpone their scheduled attack on La Becque and made it harder for the Germans to advance and harder to retreat (Crosby 2003). The pandemic nonetheless did not stop military operations, nor did it affect the final outcome of the war (largely because a pandemic usually affects each side equally) (Crosby 2003). Provided that neither side of the conflict enjoys ‘epidemiological superiority’ (McNeill 1977), the future pandemic is less likely to become a significant contributor of the final outcome. That being said, in certain cases ‘differential immunity’ did exist and made military forces from certain countries more susceptible to an infectious disease (Kelley 2000). The military effect of this differential immunity has been well recorded in the past. For example, the plague of Athens affected the course and outcome of the Peloponnesian War by devastating Athens but not the Peloponnese. Owing to differential immunity, the Old World epidemics became the ‘strongest ally’ and ‘deadliest weapon’ of the Spaniards in conquering the Aztec and Inca empires (Karlen 1995, ch. 7). While the armed forces of the U.S., Canada, and other developed countries are among the best trained and organised in the world, the fact that their soldiers grow up under good hygienic conditions also means that they are at more risk of contracting exotic pathogens from foreign military theatres than members of many potential opposing forces who spend their childhood in hygienic squalor (Kelley 2000). If the upcoming pandemic

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indeed features this differential immunity, forces from developing countries can pose a significant health threat to those from developed ones, which can affect the course of war. The pandemic has important implications for regional stability as well. First, some of the countries that are likely to be most affected by the pandemic, such as China and Indonesia, are significant regional or global players in international politics. Indonesia, with the largest Muslim population, has played a crucial role not only in the global efforts against international terrorism but also in sustaining regional stability. Second, political leaders in authoritarian states might choose to engage in foreign excursions to deflect public attention from domestic sociopolitical turmoil caused by the pandemic. Alternatively, dictatorship can be strengthened in certain countries as the leaders embrace hyper-nationalism to rally the masses and restore political order. Third, the pandemic could inhibit the military’s ability to participate effectively in international peacekeeping. On the one hand, the pandemic may reduce a contributing state’s willingness to participate in peacekeeping operations, especially in countries that are suffering high morbidity and mortality because of the pandemic. On the other hand, states may become less willing to host peacekeeping missions when troops from affected countries are seen as vectors for the proliferation of the pandemic. As a result, international ability to enforce peace agreements or ceasefires will be compromised, and this could rekindle international conflicts or civil wars in flashpoint regions. Government and international response to the pandemic can potentially be politicised and can have important implications for North–South relations. Quarantines or restrictions on trade imposed by the developed countries could exacerbate socioeconomic crises in those countries. In addition, because most of the drug patent holders are in the developed countries, apathy toward sharing patents, antiviral drugs, or vaccines with the developing world will fuel hatred and resentment against the North. Populist leaders in the South may find it expedient to blame the North for their own lack of capacities in handling the outbreak. Strained North–South relations could play into the hands of international terrorism and further destabilise the western world. The pandemic influenza is also set to be a factor in the very balance of power in the world. The proliferation of the virus can lead to changes in power in both absolute and relative terms. In absolute terms, the pandemic-induced effect on physical and human capital as well as on fighting capabilities will change a state’s level of power over the long run, if power is measured in terms of GDP or military strength. In relative terms, since the economic and sociopolitical impacts vary across states and economies, some states will suffer less damage than others and therefore enjoy an advantage in the relative distribution of capabilities between states. History abounds with cases of infectious disease outbreaks unsettling the balance of power and changing the international and strategic landscape. The Plague of Justinian led to the collapse of Byzantine Roman Empire in the sixth century. Black Death intensified military exposure to disease, especially to bubonic plague, and was considered a real factor in undermining Mongol military might in the 14th century (McNeill

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1977). Black Death also had a devastating impact on the fortunes of the city-state of Venice, reducing it from a regional power to a ‘museum city’ (Watts 1999, 20–21). In a somewhat more recent case, infectious disease contributed to the collapse of an entire imperial holding. When Napoleon Bonaparte attempted to regain control of Haiti in 1802, the French army was struck by a combination of Haitian resistance and yellow fever, so that by the following year he had abandoned the French claim altogether (Hays 1998, 205). Epidemics nonetheless have had little or no effect upon institutions when they were on the rise, as in the Roman Empire (Bray 1996, 11). Given this line of reasoning, it is likely that a truly global pandemic would accelerate the global shift of balance of power in the favour of China or India, at the expense of the United States.

Policy Recommendations Predicting the impact of an impending pandemic influenza is a risky business for two reasons. First, a prophecy itself can be self-fulfilling. In the words of Thomas Schelling (1960, 91), ‘what is most directly perceived as inevitable is not the final result but the expectation of it, which, in turn, makes the result inevitable’. In this sense, the publication of alarmist reports would only reinforce the widespread expectation of a catastrophe and this expectation can create a vicious downward cycle between pandemic and international stability as predicted by scaremongers. As the Nobel Prize–winning virologist David Baltimore (2003) observed during the SARS epidemic, the ‘media-transmitted epidemic of concern for personal safety’ could outpace the risk to public health from the actual virus. This chapter provides a balanced, history-related, and science-based analysis of the security implications of the pandemic. It suggests that the upcoming pandemic threatens to set in motion a series of developments that will slow economic growth, endanger social stability, hurt political legitimacy, and compromise military readiness. But it also conveys the message that the relationship between pandemic influenza and international stability and security is a very complex one. First, the immediate impact of the pandemic on economy, society, polity, and security can be mixed even within an affected country. Second, the impact can vary across countries, economies, and societies due to a confluence of factors, including the nature of the disease and the context in which it exists. Third, a distinction should be made between its impact during the pandemic and that in its immediate aftermath, between short-term and long-term impacts, and between its direct consequences and its secondary effects. Another problem is the stakes involved in predicting the impact of the pandemic. There will be a pandemic, but no one knows when it will come, what its origin will be, and where the first outbreak will occur—indeed, even today there is no clear idea about the origin of the Spanish influenza. Policy makers preparing for the pandemic therefore face a constant political dilemma: how can governments justify committing already scarce public health and other resources to an unpredictable but potentially catastrophic event? Very often, the political and economic stakes are so

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high that politicians choose to err on the side of caution. In 1976, when facing a potential swine influenza outbreak that promised to kill 1 million Americans, the Ford administration decided to inoculate every man, woman, and child in the United States. The administration paid dearly for this decision. The swine influenza never occurred. The direct cost of the campaign notwithstanding, the U.S. government ended up paying claimants some US$90 million for taking over companies’ liability. The episode also weakened U.S. government credibility in public health and helped undermine the political stature of President Gerald Ford (Garrett 2005a). Decision makers sometimes can be so overwhelmed by the consequences of being wrong that they may not be able to tell the difference between consequences and likelihood, which can lead them to make ‘wrong’ decisions in disease preparation. The varied impact of the pandemic and the experience with the swine influenza are no excuse for complacency or inaction. What this chapter suggests is that economic, sociopolitical, and security costs incurred by a pandemic can be mitigated, if not avoided, by a holistic and harmonised strategy featuring high-quality surveillance, transparency, effective pharmaceutical and non-pharmaceutical interventions, mobilisation of civil society, and international cooperation. An effective strategy should include the following elements: • reorienting the security policy agenda from warfare to welfare. This means committing significantly more resources to areas of immediate concern to the people, and also paying more attention to the poor, the weak, and the pariahs, who are at particularly high risk for infectious diseases; • expanding government surge capacity to respond to public health emergencies, and more generally to ensure the provision of basic public goods and services during an outbreak; • encouraging the active engagement of civil society groups (e.g., NGOs promoting public health, local communities) in pandemic preparation; • improving risk communication with the public. Effective communication entails providing the public with scientific information about the disease, its spread, and its consequences in an honest and timely manner; • narrowing the critical gap between the developed and developing countries in pandemic preparation. For developed countries, this means sharing with developing countries, especially those front-line states, their experiences, technologies, vaccines, and antiviral drugs in combating pandemic influenza. There should be a regional network to coordinate the distribution of antiviral drugs and vaccines and ensure the demands of countries in most need are met swiftly; • prioritising the needs of different age and occupational groups in the allocation of vaccines and antiviral drugs to maximise the survival rate yet minimise the impact on the economy, governance, and security. Special attention should be paid to the military and police, healthcare workers, officials in key posts, workers in their most productive years, and pregnant women; • coordinating international and government responses to outbreaks to reduce disruption to the world economy caused by restrictions on travel and trade; and

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• balancing the need to fight an impending influenza with other infectious diseases, such as HIV/AIDS, to minimise the cost of the interaction of different pathogens. Ninety years ago, when the Spanish influenza was wiping out populations across the globe, children in the United States used to sing: I had a little bird And its name was Enza I opened the window And in-flew-enza. Today, the window is open again. The difference is that by acting now and working together, it is possible to turn it into a window of opportunity to strengthen the global public health infrastructure and emergency response capabilities. It is in the interest of all states, particularly those in the developed countries, to give up the fortress mentality and develop effective strategies for international cooperation if the macabre tales of dreadful death and disease are to be avoided.

Notes 1 Ullman (1983, 133) defines a threat to national security as ‘an action or sequence of events that (1) threatens drastically and over a relatively brief span of time to degrade the quality of life for the inhabitants of a state, or (2) threatens significantly to narrow the range of policy choices available to the government of a state or to private, nongovernmental entities (persons, groups, corporations) within the state’. 2 The intervals between pandemics have ranged from 10 to 55 years over the last two centuries. With only three incidents per century, however, there is no statistical basis for a firm prediction (Weiner 2006). 3 This is what happened to the 1918 influenza after the western front was abandoned in World War I. In a little more than a year, the virus lost its virulence and evolved into an ordinary influenza (see Orent 2005). 4 Even the 1918 influenza, ‘the mother of all pandemics’, had a CFR of a bit more than 2.5 percent (Taubenberger and Morens 2006). The WHO data counted only lab-confirmed cases, and milder, non-fatal cases were likely not included. This is particularly a problem in many affected countries, where surveillance and healthcare facilities remain inadequate and only the very sickest cases go to the hospital. In Vietnam the reported mortality rate fell from 70 percent to 35 percent as more people learned about the disease (Weiner 2006). 5 This is suggested by research conducted by the University of Hong Kong (see Chan et al. 2005). For the distribution of mortality among different ages, see Crosby (2003, 24). 6 See also personal communication. 7 Renmin ribao, 14 May 2003, p. 11.

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References Almond, Douglas (2006). ‘Is the 1918 Influenza Pandemic Over? Long-Term Effects of In Utero Influenza Exposure in the Post-1940 U.S. Population.’ Journal of Political Economy, vol. 114, no. 4, pp. 672–712. Baltimore, David (2003). ‘The SARS Epidemic: SAMS—Severe Acute Media Syndrome?’ Wall Street Journal, 28 April. Barry, John M. (2004). The Great Influenza: The Epic Story of the Deadliest Plague in History. (New York: Penguin). Barry, John M. (2005). ‘Lessons from the 1918 Flu.’ Time, 9 October. <www.time.com/time/ magazine/article/0,9171,1115641,00.html> (September 2008). Bloom, Erik, Vincent de Wit, and Mary Jane Carangal-San Jose (2005). ‘Potential Economic Impact of an Avian Flu Pandemic on Asia.’ ERD Policy Brief Series No. 42, November. Asian Development Bank, Manila. <www.adb.org/Documents/EDRC/Policy_Briefs/ PB042.pdf> (September 2008). Bradscher, Keith (2005). ‘The Front Lines in the Battle Against Avian Flu Are Running Short of Money.’ New York Times, 9 October. <www.nytimes.com/2005/10/09/international/ asia/09birdflu.html> (September 2008). Brahmbhatt, Milan (2005). ‘Avian Influenza: Economic and Social Impacts.’ 23 September. World Bank, Washington DC. Brainerd, Elizabeth and Mark V. Siegler (2003). ‘The Economic Effects of the 1918 Influenza Epidemic.’ DP3791. Center for Economic Policy Research. <www.cepr.org/pubs/dps/ DP3791.asp> (September 2008). Bray, R.S. (1996). Armies of Pestilence: The Impact of Disease on History. (New York: James Clarke). Byerly, Carol R. (2005). Fever of War: The Influenza in the U.S. Army during World War I. (New York: New York University Press). Chan, Cecilia L.W. (2003). ‘The Social Impact of SARS: Sustainable Action for Rejuvenation of Society.’ Centre on Behavioural Health, University of Hong Kong, Hong Kong. <web.hku.hk/~bhealth/Documents/articles/YPSY0006/Social_Impacts_of_SARS.pdf> (September 2008). Chan, M.C., C.Y. Cheung, W.H. Chui, et al. (2005). ‘Proinflammatory Cytokine Responses Induced by Influenza A (H5N1) Viruses in Primary Human Alveolar and Bronchial Epithelial Cells.’ Respiratory Research, vol. 6, no. 135, pp. 1–13. Chemical and Biological Arms Control Institute and Center for Strategic and International Studies (2000). Contagion and Conflict: Health as a Global Security Challenge. Center for Strategic and International Studies, Washington DC. Cohen, Desmond (1997). ‘Poverty and HIV/AIDS in Sub-Saharan Africa.’ HIV and Development Programme, Issues Paper No. 27. United Nations Development Programme, New York. <www.undp.org/hiv/publications/issues/english/issue27e.html> (September 2008). Conference Board of Canada (2005). The World and Canada: Trends Reshaping Our Future. Performance and Potential 2005–06, Key Findings. October. Ottawa. Cooper, Sherry and Donald Coxe (2005). An Investor’s Guide to Avian Flu. Special Report, August. BMO Nesbitt Burns Research, Toronto. <www.bmonesbittburns.com/economics/ reports/20050812/avian_flu.pdf> (September 2008). Coulombier, Denis and Karl Ekdahl (2005). ‘H5N1 Influenza and the Implications for Europe.’ British Medical Journal, vol. 331, no. 7514, pp. 413–414.

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Crosby, Alfred (2003). America’s Forgotten Pandemic: The Influenza of 1918. (New York: Cambridge University Press). Doven, Ben (2003). ‘In Asia, Signs of Revival after SARS.’ Wall Street Journal, 15 August, p. A6. Eckholm, Erik (2003). ‘Thousands Riot in Rural Chinese Town over SARS.’ New York Times, 28 April. ‘Epidemics and Economics: The Economic Consequences of Disease.’ (2003). Economist, 12 April. Fan, Emma Xiaoqin (2003). ‘SARS: Economic Impacts and Implications.’ ERD Policy Brief No. 15, May. Asian Development Bank, Manila. <www.adb.org/Documents/EDRC/ Policy_Briefs/PB015.pdf> (September 2008). Fidler, David P. (2005). ‘Health as Foreign Policy: Between Principle and Power.’ Whitehead Journal of Diplomacy and International Relations, vol. 6 (Summer/Fall), pp. 179–194. Friedman, Thomas L. and Ignacio Ramonet (1999). ‘Dueling Globalizations: A Debate Between Thomas L. Friedman and Ignacio Ramonet.’ Foreign Policy, no. 116, pp. 110–127. Fumento, Michael (2005). ‘Fuss and Feathers: Pandemic Panic over the Avian Flu.’ Weekly Standard, 21 November. (September 2008). Garrett, Laurie (1996). ‘The Return of Infectious Disease.’ Foreign Affairs, vol. 75, no. 1, pp. 66–79. <www.foreignaffairs.org/19960101faessay4172/laurie-garrett/the-return-ofinfectious-disease.html> (September 2008). Garrett, Laurie (2005a). ‘The Next Pandemic?’ Foreign Affairs, vol. 84, no. 4, pp. 3–13. <www.foreignaffairs.org/20050701faessay84401/laurie-garrett/the-next-pandemic.html> (September 2008). Garrett, Laurie (2005b). ‘Responding to the Threat of Global, Virulent Influenza.’ Written testimony before a hearing of the Committee on Foreign Relations, United States Senate, 9 November. Council on Foreign Relations, New York. <www.cfr.org : By Publication Type : Testimony> (September 2008). Hays, J.N. (1998). The Burdens of Disease: Epidemics and Human Response in Western History. (New Brunswick NJ: Rutgers University Press). Herlihy, David (1997). The Black Death and the Transformation of the West. (Cambridge MA: Harvard University Press). Huang, Yanzhong (2003). Mortal Peril: Public Health in China and Its Security Implications. Health and Security Series Special Report no. 7. Chemical and Biological Arms Control Institute, Washington DC. Huang, Yanzhong (2004). ‘The SARS Epidemic and Its Aftermath in China: A Political Perspective.’ In S. Knobler, A. Mahmoud, S. Lemon, et al., eds., Learning from SARS: Preparing for the Next Disease Outbreak, pp. 116–136 (Washington DC: National Academies Press). Jong-Wha Lee and Warwick J. McKibbin (2004). ‘Estimating the Global Economic Costs of SARS.’ In S. Knobler, A. Mahmoud, S. Lemon, et al., eds., Learning from SARS: Preparing for the Next Disease Outbreak (Washington DC: National Academies Press). Kaiser, Jocelyn (2006). ‘Avian Influenza: Hybrid Viruses Fail to Spread.’ Science, vol. 313, no. 5787, pp. 601–602. <www.sciencemag.org/cgi/content/full/313/5787/601a?rss=1> (September 2008). Karlen, Arno (1995). Man and Microbes: Disease and Plagues in History and Modern Times. (New York: Touchstone). Kelley, Patrick (2000). ‘Transnational Contagion and Global Security.’ Military Review, vol. 80, no. 3, pp. 59–64.

In-Flew-Enza

151

Knobler, Stacey, Alison Mack, Adel Mahmoud, et al. (2005). The Threat of Pandemic Influenza: Are We Ready? Workshop summary prepared for the Forum on Microbial Threats and the Board on Global Health. National Academies Press, Washington DC. (September 2008). Lee Jong-wook (2005). ‘Speech on Human Pandemic Influenza.’ 12 October. World Health Organization, Geneva. <www.who.int/dg/lee/speeches/2005/avianinfluenza_singapore/ en> (September 2008). Lee Kuan Yew (2004). ‘New Viruses in Asia.’ Forbes, 19 April. Lewis, Maureen (2001). ‘The Economics of Epidemics.’ Georgetown Journal of International Affairs, vol. 2, no. 2, pp. 25–31. Malthus, Thomas Robert (1798). An Essay on the Principle of Population. (London: Macmillan and Co.). McNeill, William (1976). Plagues and Peoples. (New York: Anchor Press). McNeill, William (1977). Plagues and Peoples. Updated ed. (New York: Anchor Books). Meltzer, Martin I., Nancy J. Cox, and Keiji Fukuda (1999). ‘The Economic Effects of Pandemic Influena in the United States: Priorities for Intervention.’ Emerging Infectious Diseases, vol. 5, no. 5. <www.cdc.gov/ncidod/EID/vol5no5/meltzer.htm> (September 2008). Newcomb, James (2005). ‘Economic Risks Associated with an Influenza Pandemic.’ Written testimony before a hearing of the Committee on Foreign Relations, United States Senate, 9 November. Bio Economic Research Associates, Cambridge MA. <www.senate.gov/ ~foreign/testimony/2005/NewcombTestimony051109.pdf> (September 2008). Orent, Wendy (2005). ‘Battling an Epidemic of Fear.’ Los Angeles Times, 27 October. Osterholm, Michael T. (1996). ‘Emerging Infectious Diseases: A Real Public Health Crisis?’ Postgraduate Medicine, vol. 100, no. 5. Osterholm, Michael T. (2005). ‘Preparing for the Next Pandemic.’ Foreign Affairs, vol. 84, no. 4, pp. 24–37. <www.foreignaffairs.org/20050701faessay84402/michael-t-osterholm/ preparing-for-the-next-pandemic.html> (September 2008). Paris, Roland (2001). ‘Human Security: Paradigm Shift or Hot Air?’ International Security, vol. 26, no. 2, pp. 87–102. Pirages, Dennis (1996). Microsecurity: Disease Organisms and Human Well-Being. Environmental Change and Security Project Report No. 2. Woodrow Wilson International Centre for Scholars, Washington DC. <www.wilsoncenter.org/topics/pubs/ACFA6.pdf> (September 2008). ‘Preparing for a Pandemic.’ (2005). Economist, 22 September, pp. 113–114. Price-Smith, Andrew (1999). ‘Ghosts of Kigali: Infectious Disease and Global Stability at the Turn of the Century.’ International Journal, vol. 54, no. 3, pp. 426–442. Schelling, Thomas C. (1960). The Strategy of Conflict. (Cambridge MA: Harvard University Press). Simonsen, L., D.R. Olson, C. Viboud, et al. (2005). ‘Pandemic Influenza and Mortality: Past Evidence and Projections for the Future.’ In S.L. Knobler, A. Mack, A. Mahmoud, et al., eds., The Threat of Pandemic Influenza: Are We Ready? (Washington DC: National Academies Press). Stein, Rob (2003). ‘Americans Changing Habits Because of SARS, Poll Finds.’ Washington Post, 30 April, p. A12. Taubenberger, Jeffery K. and David M. Morens (2006). ‘1918 Influenza: The Mother of All Pandemics.’ Emerging Infectious Diseases, vol. 12, no. 1. <www.cdc.gov/ncidod/EID/ vol12no01/05-0979.htm> (September 2008).

152

Innovation in Global Health Governance

Taubenberger, Jeffery K., Ann H. Reid, Raina M. Lourens, et al. (2005). ‘Characterization of the 1918 Influenza Virus Polymerase Genes.’ Nature, 6 October, pp. 889–893. Thucydides (1952). History of the Peloponnesian War, trans. R. Warner. (London: Penguin). Ullman, Richard H. (1983). ‘Redefining Security.’ International Security, vol. 8, no. 1, pp. 129–153. UNAIDS (2008). 2008 Report on the Global AIDS Epidemic. UNAIDS, Geneva. <www. unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008> (September 2008). United Nations (2004). A More Secure World: Our Shared Responsibility. New York. <www. un.org/secureworld> (September 2008). United Nations Development Programme (1999). Human Development Report 1999: Globalization with a Human Face. (New York: Oxford University Press) (September 2008). United States Conference of Mayors (2006). Five Years Post 9/11, One Year Post Katrina: The State of America’s Readiness, A 183-City Survey. 26 July. Homeland Security Monitoring Center, Washington DC. <www.usmayors.org/pressreleases/documents/ disasterpreparednesssurvey_2006.pdf> (September 2008). United States Department of Health and Human Services (2005). ‘HHS Pandemic Influenza Plan, Part 1: Strategic Plan.’ Washington DC. <www.hhs.gov/pandemicflu/plan/part1. html> (September 2008). United States Homeland Security Council (2005). National Strategy for Pandemic Influenza: Implementation Plan. Washington DC. <www.whitehouse.gov/homeland/nspi_ implementation.pdf> (September 2008). United States National Intelligence Council (2000). The Global Infectious Disease Threat and Its Implications for the United States. National Intelligence Council, Washington DC. <www.dni.gov/nic/PDF_GIF_otherprod/infectiousdisease/infectiousdiseases.pdf> (September 2008). Watts, Sheldon (1999). Epidemics and History: Disease, Power, and Imperialism. (New Haven: Yale University Press). Webby, Richard J. and Robert G. Webster (2003). ‘Are We Ready for Pandemic Influenza?’ Science, vol. 302, no. 5650, pp. 1519–1522. <www.sciencemag.org/cgi/content/ full/302/5650/1519> (September 2008). Weiner, Sanford L. (2006). ‘Pandemic Influenza: Learning the Lessons from the Swine Flu Affair’. MIT, Cambridge MA. Unpublished manuscript. World Health Organization (1996). World Health Report. World Health Organization, Geneva. <www.who.int/whr/1996/en> (September 2008). World Health Organization (2004). Estimating the Impact of the Next Influenza Pandemic: Enhancing Preparedness. 8 December. World Health Organization, Geneva. <www.who. int/csr/disease/influenza/preparedness2004_12_08/en> (September 2008). World Health Organization (2005). Strengthening Pandemic Influenza Preparedness and Response. Report to 58th World Health Assembly. A58/13, 7 April. World Health Organization, Geneva. <www.who.int/gb/ebwha/pdf_files/WHA58/A58_13-en.pdf> (September 2008). World Health Organization (2008). Cumulative Number of Confirmed Human Cases of Avian Influenza A/(H5N1) Reported to WHO. 19 June. World Health Organization, Geneva. <www.who.int/csr/disease/avian_influenza/country/cases_table_2008_06_19/en> (September 2008). World Resources Institute (1996). World Resources 1996-97: The Urban Environment. (New York: Oxford University Press) <www.wri.org/publication/world-resources-1996-97urban-environment> (September 2008).

Part IV Accessing Affordable Medicines

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Chapter 8

Coming to Terms with Southern Africa’s HIV/AIDS Epidemic Hany Besada

In 2007, 33.2 million people worldwide were thought to be living with HIV/AIDS (UNAIDS and World Health Organization [WHO] 2007). Sub-Saharan Africa, with just over 11 percent of the world’s population, was home to 68 percent of all adults (22.5 million), 90 percent of all children living with the deadly virus, and 76 percent of the deaths. Meanwhile, more than 2.9 million children and adults died of AIDSrelated illnesses. Among young people aged 15 to 24 in the region, an estimated 61 percent of adults living with the disease in 2007 were women. Nowhere in Africa has the virus affected as many lives and disrupted more social and economic structures than in southern Africa. Indeed, the region remains the epicentre of the world’s devastating AIDS epidemic (see Table 8-1). HIV/AIDS affects approximately 20 percent of the population aged 15 to 49, in the region of southern Africa, comprising Swaziland, Lesotho, Malawi, Zambia, Zimbabwe, South Africa, Botswana, Namibia, and Mozambique. Nowhere in the world has the virus hit on the same scale, devastating so many lives, destroying local and national economies, undermining the limited healthcare services in place, and taking a heavy toll on the social structures in its path. At least 22.5 million Africans have died of AIDS since the virus was first identified in 1981 (‘AIDS in Africa’ 2008; World Bank 2008). Countries in the region continue to ponder how best to tackle this devastating disease. For years, their slow, inadequate and ad hoc responses to the onslaught of the disease profoundly exacerbated the already worsening situation. As Alexander de Waal (2006, 9) notes: AIDS kills millions every year, more than war and famine combined. It kills adults, devastating families and leaving orphans. But governments are not being overthrown. Indeed, with a few exceptions such as Botswana, African leaders’ responses lack urgency and scale. Governments find resources for many things, but AIDS programmes are rarely near the top of their list. There are straightforward reasons for this neglect. African electors are not demanding that their governments make AIDS a priority. Society is neither collapsing nor being transformed in revolutionary ways. African rulers, with a sound appreciation of how power functions, know that they will not be removed from office or even face political threats on account of AIDS.

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Current Situation in Southern Africa Unacceptable HIV prevalence rates exists in the vast majority of southern African states. In 2007, the region accounted for approximately 35 percent of all people living with the disease as well as roughly 32 percent of all new HIV infections and AIDS-related deaths (UNAIDS and WHO 2007). Countries such as Lesotho, Swaziland, Botswana, and Namibia have HIV prevalence rates exceeding 30 percent among pregnant mothers. Meanwhile, there is little indication that the prevalence of HIV is on the decline in these states. Swaziland In Swaziland, the epidemic has reached unprecedented proportions. According to the Central Statistical Office in Swaziland, approximately 26 percent of adults were infected in 2007. Data issued by the Ministry of Health indicate that the HIV prevalence rate among pregnant mothers has increased from 34 percent in 2000 to a record high of 43 percent in 2004 (UNAIDS 2005b). Those health ministry officials have indicated that there is little regional variation in the prevalence of HIV measured among women. In total, approximately 31 percent of all women were infected with the virus in 2007 (Swaziland Central Statistical Office 2008, xxvii). Table 8-1: Regional Comparison of HIV/AIDS, 2001 and 2007

Sub-Saharan Africa Middle East/North Africa South and Southeast Asia East Asia Latin America Eastern Europe and Central Asia Western and Central Europe North America

2007 2001 2007 2001 2007 2001 2007 2001 2007 2001 2007 2001 2007 2001 2007 2001

Adults and Adults and Adult Adult and children living children newly prevalence child deaths (%) with HIV infected with HIV due to AIDS 22.5 million 1.7 million 5.0% 1.6 million 20.9 million 2.2 million 5.8% 1.4 million 380 000 35 000 0.3% 25 000 300 000 41 000 0.3% 22 000 4.0 million 340 000 0.3% 270 000 3.5 million 450 000 0.3% 170 000 800 000 92 000 0.1% 32 000 420 000 77 000 0.1% 12 000 1.6 million 100 000 0.5% 58 000 1.3 million 130 000 0.4% 51 000 1.6 million 150 000 0.9% 55 000 630 000 230 000 0.4% 8000 760 000 31 000 0.3% 12 000 620 000 32 000 0.2% 10 000 1.3 million 46 000 0.6% 21 000 1.1 million 44 000 0.6% 21 000

Source: UNAIDS and World Health Organization (2007).

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Tragically, there is little indication that young adults and teenagers are engaging in safe sex practices. Women tend to be more affected than men. Considerable social pressure is also placed on women by their male partners not to insist on the use of condoms. Most African societies have patriarchal structures. In 2004, according to the Ministry of Health, up to 56 percent of pregnant mothers aged 25 to 29 years were diagnosed with the disease. It comes as no surprise that this country has had the world’s worst HIV epidemic since 2004 (United States Agency for International Development [USAID] 2004; Laurance 2008). Since 2004 it has had the largest percentage of HIV cases for the size of its population. In response to this national crisis, Swaziland’s government created the National Emergency Response Council on HIV/AIDS to come up with policy recommendations on how best to control the spread of the virus. However, the government’s capacity to respond effectively and comprehensively was undermined by depleting human and financial resources in its health as well as other sectors. The country is also faced with one of the many negative impacts of HIV/AIDS, namely the increasing number of orphans and other affected children who are left to fend for themselves without any social safety nets in the absence of their mothers, who are either dying or already dead. Botswana In Botswana, meanwhile, the situation is even more dire, although there are signs that the epidemic could be stabilising. The country has one of the world’s highest HIV prevalence rates: an estimated four out of every ten Botswanans carry the disease. The national HIV prevalence rate among pregnant mothers has remained between 35 percent and 37 percent since 2001. Among pregnant teenagers, the prevalence rate is stubbornly high at 18 percent in 2005. Because of insufficient funds, bureaucratic procedures as well as poor coordination and uncoordinated HIV/ AIDS policy among different departments, Botswana’s government has only recently begun to take serious steps to address the plight of thousands of Botswanans either directly infected or indirectly affected by the disease. The HIV infection level among pregnant women aged 25 to 49 was put at 32 percent in 2006, a slight improvement on the 2001 figures of 31 percent. This suggests that perhaps the epidemic is close to reaching its peak and the government could finally see gradual improvements in the fight to control the disease. Botswana’s National AIDS Council, with technical and financial support from the National AIDS Coordinating Agency (2003), has introduced a well-planned and coordinated multi-sectoral response, with HIV/AIDS as the focal interest of the national development plan. Currently, the National Strategic Plan on HIV/AIDS for 2003–2009 focusses on enlarging and improving the management of this multisectoral response and incorporating both the private and public sectors to assist government in fulfilling its pledge to stem the virus. In 2003, the government began introducing routine HIV testing to help identify the extent of the disease among the general population and to allow sufficient time for the introduction of antiretroviral therapy (ART) to HIV-positive patients.

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Zambia Next door from Botswana in Zambia, the situation is not any better. In 2007, more than 17 percent of Zambians were thought to be living with HIV/AIDS (United States President’s Emergency Plan for AIDS Relief [PEPFAR] 2008). There have been at least 800 000 cases of death as a result of AIDS-related illnesses and a further 710 000 children orphaned since 2006. It is projected that by 2015, AIDS will have taken the lives of at least 2.8 million Zambians, an 83 percent increase (Garbus 2003). By 2050 6.2 million Zambians are expected to have died from AIDS-related illnesses since the virus first appeared in the early 1980s (Garbus 2003). The disease is believed to have spread throughout the country, particularly in urban areas, hitting the most vulnerable groups hard, namely young women and girls. The HIV prevalence rate among antenatal women tested in major cities increased from 5 percent in 1985 to 27 percent in 1992, and has remained at that level ever since (UNAIDS 2004). In terms of the impact of the virus on the country’s macroeconomy, the International Labor Organization (ILO) projects that the country will experience a loss of up to 5.8 percent of its gross domestic product (GDP) per capita; of this percentage, there will be a loss of 1.7 percent to the capital/labour ratio, 1.0 percent to total factor productivity, and 3.1 percent to aggregate skills and knowledge of the workforce (cited in Garbus 2003). It also projects that Zambia will shed some 19.9 percent of its labour force by 2020, compared to what it would have been without HIV/AIDS. To deal with the effects of the disease in recent years, the Zambian government has sought the assistance of donor communities, the private sector, and state resources. It has received financial assistance over the years from a number or sources, including some US$42 million from the World Bank’s Multi-Country HIV/AIDS Program for Africa, a grant of US$18.5 million from the U.S. Agency for International Development (USAID) in 2002 to help support the national HIV/ AIDS programme, and an additional US$92 million in grants from the Global Fund to Fight AIDS, Tuberculosis, and Malaria in 2002 for HIV/AIDS prevention and mitigation (Garbus 2003).1 By 2003, new global initiatives designed to address the global HIV/AIDS pandemic earmarked millions of dollars for HIV/AIDS prevention and treatment programmes in Zambia. In 2007, USAID’s programme in the country provided the government with more than US$116 million, using PEPFAR funding.2 Meanwhile, the Zambian government restructured the National HIV/AIDS/ STD/TB Council, established in 2000, to serve as the single, high-level body responsible for technical and national leadership, effective coordination of all government and civil intervention, and strategic management. In 2002, Parliament passed the HIV/AIDS Act, which allowed the council to solicit funding. Since late 2003, the council has been shaped by a strategic framework designed to increase the distribution of ART to HIV-positive patients, de-stigmatise HIV/AIDS, promote community-based support to orphans, reduce high-risk behaviour (such as unprotected sex and multiple partners), promote behavioural change that includes abstinence and mutual fidelity, and introduce multi-sectoral responses to cope with the onslaught of the disease.

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Zimbabwe Only in Zimbabwe are there signs that the government is winning the battle to curtail the spread of the disease. In 2007, using the Epidemic Projection package and Spectrum software, the HIV prevalence rate was estimated to be around 15.6 percent, following a gradual decline from the 2001 figure of 26.5 percent (Zimbabwe National Monitoring and Evaluation Taskforce 2008, 4).3 Evidence from the government’s surveillance system shows that HIV prevalence among pregnant mothers, one of the most vulnerable groups in the country, has declined to 17.7 percent in 2006, down from 25.8 percent in 2004 (4). Studies from local nongovernmental organisations (NGOs) working with HIV-positive patients have categorically supported these findings. In Harare, HIV prevalence in women attending antenatal clinics dropped from 26 percent in 2002 to 18 percent in 2006 (10). This decline was also reflected in declines among men and women, aged 15 to 49, particularly in the rural areas (Zimbabwe Ministry of Health and Child Welfare 2007). Of particular importance is the fact that national statistics show a decline in HIV prevalence among young women aged 15 to 24 from 21 percent in 2000 to 13 percent over the same period. Other studies show similar developments among male factory workers in Harare and among antenatal women in other urban areas. Government officials contend that changes in sexual behaviour, consistent usage of condoms, and the successful National AIDS Coordination Programme (NACP) have contributed to these declines. According to national surveys, condom usage among sexually active partners has reached record levels of 83 percent among women and 86 percent among men (Mahomva 2004). There is further research indicating that Zimbabweans aged 15 to 49 are having fewer sexual partners on average (Mahomva 2004). Studies show that changes in sexual behaviour have led to mortality rates levelling off in some parts of the country, particularly in rural areas, leading to a decline in HIV prevalence rates (see UNAIDS 2005a; Mahomva et al. 2006; Mugurungi et al. 2007; Zimbabwe Ministry of Health and Child Welfare 2007). Meanwhile, the NACP was widely credited as advancing a sound policy to address the crisis. Officials are quick to point out that they were slow to respond to the crisis during the late 1980s when the first cases of AIDS were reported. During this period, discussion of HIV/AIDS was minimal and the country’s president, Robert Mugabe, rarely discussed the subject in public. It remained a taboo subject for many Zimbabweans until the mid 1990s. Even though the NACP was established in 1987, it was not until 1999 that the country’s first HIV and AIDS policy was announced. In 2000, the government began implementing that policy through the newly formed National AIDS Council, which replaced the outdated NACP. Since then, the government has introduced an AIDS levy on all tax payers to pay for the work of the council. Proponents of the NACP and the council credit them with helping to promote safe sex education and counselling for HIV-positive patients through state-sponsored media broadcasts on state television and radio and in public clinics and hospitals. Beginning in 2006, the government launched the National Behaviour Change Strategy for 2006 to 2010

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Innovation in Global Health Governance

to raise awareness of the disease and intensify its efforts to address the root causes of risky behaviour. The strategy included provisions for reducing multiple sexual partners, condom usage, promoting faithfulness, and advocating for women’s rights. Also in 2006, the government in Harare scaled up its multi-sectoral response to the virus by launching the four-year Zimbabwe National and HIV/AIDS Strategic Plan. The plan builds on the lessons and recommendations from the National AIDS Policy of 1999 as well as the National HIV/AIDS Framework (2000–04), which was credited with the recent successes through a well-planned advocacy and educational policy. Studies show that the declines in HIV prevalence rate in Zimbabwe are largely due to behavioural changes among sexually active adults (Hallett et al. 2006). Studies indicate that in the eastern part of the country more men and women are increasingly avoiding high-risk practices, such as sex with non-regular partners. Moreover, more women insist on consistent use of condoms (Gregson et al. 2006). In recent years, the country has been able to fund its HIV/AIDS programmes through various funding mechanisms. As a signatory to the 1998 Abuja Declaration to roll back malaria, Mugabe’s regime has committed a minimum 15 percent of the government’s budget to the national healthcare sector. The government, through taxes and the National AIDS Trust Fund, earmarked a further 3 percent levy collected and administered by the Ministry of Finance from all taxable income in order to fund HIV/AIDS-related initiatives (Zimbabwe National Monitoring and Evaluation Taskforce 2008, 5–6). This represented roughly 13.7 percent of total government spending on the health sector in 2007. Contributing to Harare’s ambitious HIV/ AIDS programmes, the international community further provided US$41.93 million in 2006 and US$64.30 million the previous year. Meanwhile the United Nations contributed US$24.14 million and $10.43 million in 2006 and 2005 respectively. Zimbabwe also received additional funding for the period from the Global Fund in the amount of US$60 million. Consequently, the availability of medical care provided by the government and NGOs to HIV-positive patients has increased in recent years due to efforts to promote access to treatment, although it still does not meet the needs of all who desperately need treatment. Voluntary counselling and testing programmes have been expanded over the past five years and are currently administered either free of charge or at a nominal fee. In 2006, one month’s ART, without additional tests, cost approximately Z$500 000 (US$5) per month in the public sector and