In 2005 global health governance underwent a significant set of reforms, which resulted in the revision of the International Health Regulations (IHR). The reforms focused in particular on disease surveillance and reporting mechanisms, and signaled a shift from a focus on a predetermined set of diseases toward a broader consideration of issues that can potentially entail health risks of international proportions. In what can be interpreted as a reconfiguration of the balance between the international community and the state, the IHR also opened the way for the intervention of nonstate actors in disease notification, making it more difficult for governments to hide or deny outbreaks.
In Disease Diplomacy, Sara E. Davies, Adam Kamradt-Scott, and Simon Rushton provide an empirically rich and theoretically sophisticated account of the implementation of this reform process. Additionally, they make an excellent contribution to two other debates. The first pertains to agenda-setting in global health. The question of which issues, regions, or groups get prioritized in global health policymaking is very often explained as an epiphenomenon of the interests of powerful actors and donors. This is a superficial explanation—one that takes these interests for granted and fails to question how they are being formed. Disease Diplomacy, by contrast, convincingly shows how states were able to “reconceptualize their interests in ways that favored cooperation over isolationism” (p. 143).
Key to the argument is the authors’ social constructivist lens, which emphasizes the role of ideas and identity in determining state behavior. This enables the authors to examine how external shocks (such as the 2002 to 2004 SARS outbreak) were interpreted in a broad ideational context. Rather than assuming interests to be self-evident, the book thus asks how states’ preferences were shaped by identity concerns, particularly emerging ideas about what constitutes responsible international behavior—ideas that have a concrete effect in terms of the kinds of actions that are rewarded or punished under the new IHR. This ideational background helps to explain the realignment of state preferences.
As the authors show, even though there have been instances of noncompliance, states often adjust their behavior to meet new expectations—sometimes years before the formal approval of new norms. Their argument is that the IHR revision process constituted the “codification of a new set of expectations” (p. 3) that had been developing for some time. Ideas are a crucial part of this story, and the book does a good job in explaining how these ideas emerged and how they were disseminated by norm entrepreneurs at the World Health Organization. This rich explanation of the IHR thus offers a useful template that could potentially be used to analyze other global health governance mechanisms.
The second debate to which this book contributes is that of global health security. During the formulation of the IHR, security concerns played a crucial role in the reconceptualization of states’ interests and identities. Unlike most academic works on this topic, the book's main focus is not the concept of health security per se, but rather the impact of security upon the global health agenda. Focusing on what security does—rather than on what security is—is a refreshing starting point, and it is used here to explore the ideational conditions that made IHR possible. The authors show the extent to which a security vocabulary and, more broadly, a security rationality were fundamental in the process leading to the implementation of the IHR. International anxieties about health security threats—which had been present since at least the 1990s in relation to emerging infectious diseases, bioterrorism, and the weaponization of disease agents and were rekindled by the 2002 SARS outbreak—were instrumental in breaking the sovereign deadlock. The “crucial zeitgeist of the securitization of infectious disease” (p. 21) and the mobilization of a security discourse helped to convince states that it was in their interest to cooperate more closely and to establish mechanisms that would enable both more transparency in disease reporting and a more effective and proportionate international response.
This is not the story one usually hears when the political impact of security is brought to the fore. Accounts of securitization processes tend to focus on how the mobilization of security leads to the breaking of established rules and laws (for example, the circumvention of democratic processes of deliberation). Securitization is often connected with emergency measures and regimes of exception, rather than with the development and implementation of new norms. In this regard, Disease Diplomacy provides a welcome contrast to pessimistic readings of health security, which concentrate rather one-sidedly upon its undemocratic, exclusionary, and even violent facets. As the book shows, security can also prompt positive outcomes by raising awareness and building political resolve to solve certain problems and, consequently, sometimes break political deadlocks.
Interestingly, the book argues that the mobilization of a security rationale happened against the backdrop of a changing sense of what it means to be secure from disease threats. Previous iterations of the IHR (1969) focused on safeguarding “uninfected zones from disease importation” (p. 39), which helps to explain the preference for quarantines and sanitary cordons. Under the new regulations, the focus became containment at the source, before a disease spreads across borders. This signals a broad shift toward a collective understanding that achieving global health security entails a coordinated effort, and thus one that emphasizes the need for cooperative networks of information-sharing and response.
In this context, it is worth making two comments on how the argument of the book could have been taken further. First, given the attention devoted to security, the authors could have engaged more deeply with what is arguably one of the most significant developments in the assumptions of the new IHR: the emergence of a risk-based mentality to supplement the rationale of earlier international legal mechanisms, which were overwhelmingly based on clear and present threats. A crucial underpinning of the legal status of a Public Health Emergency of International Concern (PHEIC) in the new IHR is the notion of a public health “event” that may constitute a risk for international health. In other words, the focus is placed not only on actual dangers but also more broadly on uncertain future possibilities.
The most recent PHEIC declaration is a good example of this. It was made not in relation to the Zika virus, but in relation to the (then unexplained) association between Zika and the spike in microcephaly and other neurological disorders. In sum, the IHR and global health governance more generally have broadened their remit from merely the response to identifiable threats to an attempt to calculate uncertain risks.
The second point pertains to the idea of “collective” security that underpins the IHR. Here, the book identifies an important tension but does not venture very far into its deeper causes. The mobilization of security in global health occurred against the backdrop of a narrative that “stressed the interconnectedness of states and sought to construct the world as a ‘community of common fate’” (p. 56). The idea that all countries are in some way linked or that they share a common experience of vulnerability to disease is now a common trope in global health. However, if in some circumstances this assumption of convergence has buoyed international discussion and cooperation, it has also contributed to obscuring the persistence of inequalities.
The authors acknowledge that questions need to be asked about who is benefiting from the current global health security regime and suggest that existing arrangements are still geared toward the interests of Western nations. Nevertheless, this important insight could have been supplemented by a closer analysis of the forms of power that underpin claims to collective security—in other words, how the construction of the “we” of global health reproduces the subordination of certain regions of the world. In addition to its other qualities, Disease Diplomacy offers a good starting point to this crucial agenda in global health research.
