Outbreaks of deadly infectious diseases are a great and growing concern for governments worldwide. Over the course of the last two decades, this concern has provided the political and diplomatic impetus toward having a better system in place for the international management of outbreak risks. This system, organized according to International Health Regulations (IHR) and coordinated by the World Health Organization (WHO), is challenged by ideational factors as well as material ones. As such, it is a worthy subject of attention by scholars working at the intersection of public health and international relations.
In Disease Diplomacy, Sara Davies, Adam Kamradt-Scott, and Simon Rushton make a timely and valuable contribution to the store of knowledge about why and how states work collectively to strengthen disease surveillance systems and outbreak response capacity worldwide. Whereas previous analyses of IHR adherence have tended to be oriented primarily toward issues of international law and public health practice, the fresh perspective offered by this book is one that is informed by social constructivist theory. The authors’ focus is on the importance of norms in shaping and driving the political behavior of national governments and international institutions. Specifically, the aim is to show how the process of revising the IHR, and the subsequent effort to encourage state compliance, has effectively codified a new set of expectations about how a “responsible state” should behave in the event of an infectious disease outbreak that could spread across borders (p. 3).
The book is built upon a strong foundation of research, and its findings are sure to be devoured eagerly by anyone who has a long-standing interest in the WHO. Newcomers to the field of global health governance might find the subject matter a little dry, but any apparent dryness is amply tempered by the authors’ elegant use of language and their careful explanations of concepts and events. The analysis is helpfully structured throughout by reference to the “norm life cycle” framework devised by Martha Finnemore and Kathryn Sikkink, and there are frequent citations of a 1998 article in International Organization (52, 4) by Finnemore and Sikkink entitled “International Norm Dynamics and Political Change,” In presenting their arguments in this way, the authors of Disease Diplomacy enable the reader to discern and readily comprehend the emergence, socialization, and internalization of norms with particular regard to IHR compliance. The book is thus doubly innovative in the contribution it makes. In shining the light of norm theory upon the politics surrounding the IHR, it refreshes our understanding of global health governance. And the book serves also to demonstrate, in the context of health policy, the value of such theory for the purpose of explaining international political phenomena. Despite the appearance of Global Health Security in the subtitle, the book is mainly about international norms. The authors refer to “global health security” as a term of art used in recent global health-governance discourse, and fortunately, the logic of their overall argument does not require a painstaking unpacking of that term (e.g., whose security, against what, to be pursued at what cost?).
The authors’ central concern is the decision taken by WHO member states in 2005 to revise the IHR (which had remained virtually unchanged since 1969) in a way that changed the expectations that states have of one another in the event of an infectious-disease outbreak emergency. Since the new IHR came into force (in 2007), WHO member states have been formally obliged to build and maintain adequate capacity to detect disease outbreaks, engage in timely and transparent reporting of a wide variety of outbreak events, avoid unnecessary interference with international travel and trade, and recognize the right of the WHO to act and issue advice based on information received from sources other than WHO member states. The authors explain well the extent to which adherence to these requirements has been a function of political will on the part of national governments. However, the more intriguing part of the story they tell is that which tracks the role played by WHO bureaucrats (e.g., David Heymann, Gro Harlem Brundtland, Guénaël Rodier, and Margaret Chan) across time as promoters and defenders of IHR norms. The discursive and bureaucratic efforts of such actors are traced back as far as the mid-1990s when, according to the authors, those norms began to take shape and gain strength.
As described in Chapter 1, a revision of the IHR was eventually made politically possible by politicians, scientists, and bureaucrats who constructed an association between (in)security and infectious disease outbreaks. For several years before timely disease reporting and rapid responses to outbreaks became requirements under international law, “security talk” (p. 17) helped sustain the notion that a state’s refusal to disclose the occurrence and details of outbreaks within their territory would be reprehensible (albeit not illegal). Evidently, a process of norm building to that effect was under way, and the experience with the viral disease SARS (in 2003) and bird flu (from 2004) showed that the concealment of outbreaks was by then widely regarded as deviant and damaging behavior.
Government responses to these two outbreaks are explored in Chapters 2 and 3, and here the authors argue persuasively that IHR norms were having an effect on political behavior even before they were codified into law in 2005. In Chapter, 4 they go on to examine the resilience of those norms after the IHR entered into force, presenting evidence of state actions and declarations during the time of the 2009–10 swine flu pandemic. Finally, Chapter 5 explores the way in which WHO members states and the organization’s secretariat sought to draw lessons for global health governance from the swine flu experience. This process, the authors argue, evidenced further international progress toward internalization of IHR norms, but it also served as a reminder that many states remain materially incapable of acting on their normative commitments (e.g., to detect and report disease outbreaks quickly).
Overall, Davies, Kamradt-Simon, and Rushton do an excellent job of substantiating their claim that “most states want to comply with their [IHR] obligations most of the time but . . . in some cases material and infrastructural shortfalls remain a significant obstacle to their ability to do so” (p. 8). The main message to readers of Disease Diplomacy is that a lack of political commitment to IHR norms is less of a problem than a lack of capacity, in many developing countries, to act accordingly. It remains to be seen, however, whether this message is overly optimistic. After this book went to press, the largest-ever outbreak of Ebola occurred in West Africa, and governments in other parts of the world reacted differently. Some rushed to assist, but others responded by banning travel to and from West Africa, despite WHO advice that doing so was unnecessary and counterproductive. This nonadherence to the IHR rule against unnecessary interference with international traffic might since have generated an expectation that reporting disease outbreaks will prompt international abandonment rather than assistance. If so, the future willingness of states to adhere to IHR norms should not be taken for granted.
