Disease Diplomacy: International Norms and Global Health Security
By Sara E. Davies, Adam Kamradt-Scott and Simon Rushton
Baltimore: John Hopkins University Press, 2015
In the contemporary context of growing concern about the global spread of infectious diseases, and the need for international coordination to strengthen systems of disease control, health diplomacy is increasingly the focus of sustained attention in both the practice and study of Global Health. A notable new entry into the scholarly field is Sara E. Davies, Adam Kamradt-Scott and Simon Rushton’s Disease Diplomacy: International Norms and Global Health Security. The book analyzes how the emergence of new health threats caused the reconstruction of the International Health Regulations, leading to the implementation of new international norms in the global health regime. The outbreak of infectious diseases, such as SARS, H5N1 and H1N1, are described in Disease Diplomacy as the major triggers that have led to the reconstruction of the existing international norms and regulations in global health. The authors argue that due to the emergence of the new disease threats, health has become “a key contemporary foreign and security policy concern” (page 1). Working from a social constructivist perspective, Disease Diplomacy focuses on the activity of norm entrepreneurs and explains why some ideas are able to become generally accepted international norms, while others remain unnoticed. The key question driving the book is that of how to achieve the internalization of new international norms of International Health Regulations (IHR) by all members of the global community. In order to begin answering this question, Davies, Kamradt-Scott and Rushton adopt and elaborate on the conceptual framework of norm life cycle, developed by Finnenmore and Sikkink, which consists of three main stages: norm emergence, norm cascade, and norm internalization.
One of the central innovations of the book is that while the authors acknowledge the World Health Organization (WHO) to be at the core of the global health regime, they simultaneously view the institution not as a unitary actor but as a global hub of different agencies, where the WHO secretariat officials and other “norm leaders” are the key actors that have broken new ground in health (page 18). Based on this approach, the authors are thus able to give a fascinating and detailed account of the background, drafting, adoption, and implementation of the IHR: giving readers insights into the ‘behind-the-scenes’ operation not only of Global Health, but also of global governance more generally and the process of norm entrepreneurship. From this vantage point, the authors of Disease Diplomacy illustrate precisely how the WHO secretariat succeeded in persuading national governments to agree to revise the 1969 regulations (page 25).
Davies, Kamradt-Scott and Rushton also acknowledge that there needs to be a special trigger event (“exogenous shock”) which could help the norm entrepreneurs to push the issue of public health emergency on top of the global agenda and convince the governments to adopt and internalize the new norms. The SARS outbreak is considered by the authors of Disease Diplomacy as the trigger event that propelled the norm cascade and pushed forth the proposals of revising the 1969 IHR. The authors further argue that the outbreaks of H5N1 and H1N1 serve as the evidence of a successful internalization of the revised IHR by the international community.
The book also investigates the question of compliance with international regulations. It highlights two major reasons why some states do not comply with the international health regulations: 1. Lack of political will; and 2. Lack of technical capability. Lack of political will does not pose a significant obstacle for norm internalization according to Davies, Kamradt-Scott and Rushton, since states are pressured by the international community to conform to the norms even if they disagree with the new regulations. The authors of Disease Diplomacy believe that the lack of technical capacity is “a more serious challenge to the effectiveness of the new global health security regime than potential resistance” (page 16). Davies, Kamradt-Scott and Rushton support this claim by providing a number of data: while WHO member states unanimously adopted the IHR (2005), only 21 percent of WHO member states had indicated that they were fully compliant with the regulations (2005) (page 130). This significant gap between the signatories and the governments that have implemented the new IHR is explained as the lack of technical capacity of the developing states to adopt the new regulations of IHR due to the lack of financing and poor infrastructure. However, this gap between norm signing and norm implementation can also be explained as certain governments’ holding special interests in signing the new IHR, and then choosing not to comply with the new regulations later on. Therefore, the governments of the developing states should be convinced that it is in their national interests to adopt the new norms, thereby increasing the political will beyond putting a signature, but also adopting the new rules.
The authors of Disease Diplomacy conclude that the WHO secretariat should convince donor states to help build the technical capacity of developing countries in order to ensure the universal compliance to the new international norms. The future of global health, according to Davies, Kamradt-Scott and Rushton, looks encouraging despite some degree of uncertainty. The book argues that states may be compelled to adhere to international norms by peer pressure and moral shaming; however these mechanisms are not strong enough to coerce the powerful states to comply with the norms, especially if they do not see any national interest in the assistance of building the technical capacity of poor nations. Therefore, in order to successfully internalize the new IHR, all actors of the global community, both states, and non-governmental institutions and civil society organizations should also be convinced that it is in their interests to cooperate and work towards the common goal of global health governance. Ideas backed by interests are much more likely to be internalized and become international norms.
Interestingly enough, Disease Diplomacy does not include the concept of interest as one of the motives of norm entrepreneurship. Its authors do not consider national interests as the key factors that influence state decisions concerning compliance. More could be said about the role of both state interests and economic/corporate interests in global health diplomacy. This omission places the book in contradistinction to others in the field which focus on the special interests of states, private companies, organizations and individuals (such as Bill Gates) as the key influencers of the global health agenda. For instance, Colin McInnes and Kelley Lee have demonstrated that the special interests of powerful states and private-public foundations play a key role in influencing the global health agenda, showing that certain diseases are constructed as global health threats because this framework directly serves financial interests of certain governments, private companies or institutions (2012 p.156; Novotny et al 2013). Disease Diplomacy, in contrast argues that the WHO secretariat is not driven by special interests, but by the ideas of international cooperation and altruism. Unfortunately, the current reality of global health does not bring a lot of evidence of common goodwill of all actors of the global health regime. Nevertheless, despite the fact that altruism and special interests are two contrasting beliefs, they do not refute each other’s existence in global health governance and both influence the decision-making process in global health agenda to different extents: a focus on norms, then, could help amplify existing approaches that focus more on the roles of interests in shaping Global Health agendas. As such, this book will surely become one of the key texts in the growing field of health diplomacy studies: a position it rightly deserves.