Overcoming Constraints of State Sovereignty: Global Health Governance in Asia

Author(s): Michael A. Stevenson and Andrew F. Cooper

Source: Third World Quarterly , 2009, Vol. 30, No. 7 (2009), pp. 1379-1394
Published by: Taylor & Francis, Ltd.

Stable URL: https://www.jstor.org/stable/40388189

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Third World Quarterly,
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MICHAEL A STEVENSON & ANDREW F COOPER

Abstract In an increasingly globalised world effective internationa

nicable diseases control requires states to embrace basic norms inform
health governance. However, recent international public health cr
shown that states continue to use national sovereignty to justify non-c
with these norms. In this article we use three recent high-profile exam
Asia in which the tight hold of state sovereignty cut into the e
implementation of international communicable disease control efforts
together, the three cases illustrate a wider trend in which states hist
diminished in structural power or subject to imperialist intrusion con
legitimacy of global governance initiatives if they are perceived to be
vehicle for the imposition of exogenous norms that do not reflect the
goals of that state. In response to these challenges, three strategies ar
for how the actors involved in protecting public health might ove
constraints of state sovereignty to more effectively address global pub
threats created by the fluid movement of pathogens across borders.

This article examines the persistence of a fundamental constraint to t

term implementation of new mechanisms of global health govern
tendency of states to defend their actions of non-compliance via reco
the doctrine of Westphalian sovereignty when faced with intern
pressure to embrace norms and rules seen as being in conflict wit
interests. While the article focuses exclusively on three cases in
phenomenon of states invoking sovereign rights to contest emergi
informing global governance is by no means limited to a par
geographical area. Instead the cases were selected because all effe
illustrate the tension between emerging (principally Western) glob
norms and the perception on the part of states historically subject to
intervention, or excluded from the process of establishing the institu
rules governing international systems, that global health govern
merely a vehicle for imposing yet another set of exogenous norms th
reflect the states' values or goals.1

Michael A Stevenson and Andrew F Cooper are both at the Centre for International Governan
and the University of Waterloo. Emails: mstevensonCi^balsillieschool.ca; acooper@cigionline.o

ISSN 0143-6597 print/ISSN 1360-2241 online/09/071379-16 © 2009 Third World Quarterly

DOI: 10.1080/01436590903152686 1379

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 MICHAEL A STEVENSON & ANDREW F COOPER

The receptivity of states to two specific norms informing glob

governance is of particular relevance here. The first is that health is
right that must be safeguarded by states. The second is that safe
public health is an essential element of preserving collective sec
today's globalised world. Obvious reservations persist among sta
regard to embracing governance models that demand adherence
informed by exogenous norms, and the ceding of control over d
policy decisions - especially when the benefits of ceding such sovereig
not immediately obvious. Yet, because global collective action pr
particularly those related to public health - demand a commitme
part of states to general principles and codes of conduct, there is
need to identify strategies to overcome the impediment of sovereign
Three cases are used to illuminate sovereignty as an imped
progressive global health governance. The first examines the ga
China's public commitments to the principles of global health g
and its actions related to communicable disease control, both dom
and in concert with the international community. It is contend
although China aspires to be a global leader, it continues to
constrain the application of exogenous norms. This resistance is e
strong in those areas pertaining to human rights, including the
health, which China feels impinge upon its sovereign right
determination. As such it is argued that China continues to exh
reservations about the legitimacy of norms informing glob
governance. At the same time existing empirical evidence suggest
central government's capacity to protect the health of its citizens
markedly reduced in the past two decades, a timespan during wh
health protection and healthcare delivery have been significantly dele
sub-state jurisdictions. As a result, Beijing has far less control over e
that its commitments to public health protection are carried out t
before reorienting the country to become a global economic powe
The second case examines the conduct of Indonesia, which in Januar
began withholding avian influenza virus samples from the Worl
Organisation's (WHO) Global Influenza Surveillance Network,
violation of the revised International Health Regulations. The In
government has claimed that, under the Convention of Biodivers
within its sovereign right to safeguard genetic materials from what
are exploitative practices by Northern governments and large pharm
companies, which use virus samples primarily from developing co
manufacture a product that such countries will probably not derive p
protection from in the event of an influenza pandemic. Indonesia
has been severely criticised for challenging the norm that states mus
to rules created to safeguard public health for collective security.
while Indonesia's actions may be misguided and set a dangerous pre
is argued here that its challenge highlights an existing structural ine
global governance arrangements which, in the case of developing
access to vaccines, has yet to be addressed other than in de
pronouncements by the World Health Assembly (WHA), the plenar
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 GLOBAL HEALTH GOVERNANCE IN ASIA

the WHO.3 Addressing this inequity is wholly consistent with ensurin

protection of health as a human right. Indeed, the legitimacy of the autho
of any system of governance rests not only on its effectiveness, but also on
perception of its fairness and legitimate social purpose by those subject to
system's power.4
The final case examines the exhibition in Burma (also known as Myan
of outright defiance towards both the concept of health as human right (
to human rights in general), and to the expectation that states sh
contribute to the collective security of the society of states thr
investment in and a commitment to public health domestically. For o
decade epidemiological evidence has been mounting that suggests
despite its political isolation, the Burmese military regime has allowed pub
health and health services to deteriorate to such a degree that the country
now regarded as a disease reservoir fuelling regional epidemics of the
important infectious diseases in Southeast Asia.5Indeed, Burma's lack
action to safeguard public health within its borders is greatly underm
infectious disease control efforts in neighbouring states. Moreover, while
certainly the case that the Burmese regime lacks the capacity and political
to address determinants of infectious disease spread, neighbouring s
(most notably India, China and Thailand) could have a far larger impac
mitigating the regional effects of Burma's ongoing public health crises
their current performance signifies. The article points to an embedd
cautiousness that is revealing.
Although there is no single best approach to protecting public hea
humanity's collective experience would suggest that there are certain gene
rules that states should follow to reduce communicable disease transmission.
Transparency of process, the timely sharing of information between agencies
and governments, scientific co-operation in lieu of competition, harmonised
approaches to treatment, and the commitment on the part of states to
strengthening public health systems and healthcare delivery while seeking to
address social and environmental determinants of health, all play a role in
reducing the burden of disease.
It is true that many actors influencing global health policy and discourse
exhibit bias in terms of how collective action problems should be
approached. However, while 'effective' global health governance is certainly
normative, it should not be viewed as the product of a particular cultural,
epistemological or political lens.
With these tensions in mind, the final section of this article briefly examines
three strategies to increase trust between states and other actors in global
health, with the goal of strengthening the legitimacy of global health
governance from the point of view of those state actors that are resisting
adoption of the basic norms that inform it. These three strategies are: 1)
respecting the heterogeneity of national health governance models provided
there is general commitment to the fundamental norms informing global
health governance; 2) facilitating the expansion of transnational epistemic
communities committed to further embedding these norms within the
societies where they operate; and 3) addressing structural inequities within
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 MICHAEL A STEVENSON & ANDREW F COOPER

international regimes that have the potential to undermine trust

operation between states and thus jeopardise advances made in ho
health is governed.

Globalization drives global health governance

The article is premised on a number of assumptions of how the wo

changed as a result of the globalisation process, and infers that, bo
perspective on world politics and as a functional approach to solvin
problems, global governance is closely linked to globalisation.
The first such assumption is that over the past 30 years a rapid incr
the number of transnational linkages has facilitated the spread o
diverse entities as ideas, capital, trade, pollutants and pathogens, result
unprecedented change both in temporal and spatial scales. These c
have presented significant challenges to the interstate system, p
through the 'uncoupling' of territorialism and the resulting loss of con
states over their domestic spheres, which has blurred a once clear dist
between the domestic and foreign. New mediums of information-e
have made government-policy-driven public health crises difficult to c
while the capacity of any state to limit its exposure to health crises orig
outside its borders has been greatly reduced.6
A second assumption pertains to the number of actors and gove
arrangements that seek to influence outcomes that were once solely
upon by sovereign states. Global health governance stands ou
exemplar of this trend, and David Fidler has aptly referred
heterogeneity of actors, mechanisms and funding structures involved
delivery of health care and public health protection globally as 'unstru
plurality'.7 While mechanisms of global governance predating the
globalisation do exist, the majority are comparatively new entitie
than having some influence over global health outcomes, perhaps t
attribute all of these actors share is the tendency to resist governance
that may limit their own form of autonomy.
Finally, because global governance no longer exists as the ex
domain of states, it is assumed here that states are no longer the so
modifying the norms that shape global health governance, a shift F
labelled 'open-source anarchy'.8
Yet, despite these changes, the structural elements of public health pr
and healthcare delivery are still overwhelmingly controlled by either
governments or sub-state jurisdictions. As a result, states are still
important actor in determining whether health is assigned a high prior
horribly neglected. Under these conditions states remain the princi
keepers between global health governance in theory and practice.9

State reservations on adapting governance models for a globalised wo

The Westphalian model of world order is based on the premise that sta
the ultimate and legitimate controllers of their territories and po
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 GLOBAL HEALTH GOVERNANCE IN ASIA

and, as a collective - despite marked cultural, economic and geog

diversity - are equally committed to upholding the principles
intervention in the domestic affairs of individual states, and of
based international law.10 Despite an obvious established hie
within the system of states, sovereign equality remains the basi
membership.11
In contrast, the emerging post-Westphalian model views states as
set (albeit still the most important) of a complex of multiple actor
have some degree of legitimacy in both inter- and intra-state governa
the context of health governance these include international orga
such as WHO, non-governmental organisations like Médians sans F
(msf), private philanthropic foundations such as the Bill and Meli
Foundation, and public-private partnerships (PPPs) like the Glob
where business actors partner with public actors in the provision o
related goods. The post-Westphalian model is commonly linked w
the globalisation process (in terms of raison d'etre), and wit
governance (in terms of recognition of multiple authorities).
In terms of health governance the transition from a Westphalian to
Westphalian model is significant in both its descriptive and n
aspects. For example, electronic surveillance and information
networks such as Health Canada's Global Public Health Intelligence
Network - which legitimises the role of non-state actors in public health
surveillance - greatly reduce the likelihood that states can suppress news of
health emergencies occurring within their borders (as was the case with
SARS). This dynamic means a real net loss in the ability of the state to control
the flow of information across its borders.12
The normative aspects of the post-Westphalian model are even more
significant, in that states are increasingly under pressure to implement
approaches shaped by exogenous norms, which are themselves increasingly
produced by non-state actors, yet which are nonetheless being institutiona-
lised within mechanisms of global governance. Perhaps the most notable
example of this trend in global health governance is how states have been
shamed by civil society groups into publicly committing to (and thus
acknowledging the legitimacy of) ensuring universal access to antiretroviral
medication for HIV-positive individuals, even if they are actually unable to
ensure such access. As argued by Fidler, the post-Westphalian logic is at its
core fundamentally norm-driven, containing key assumptions about what
constitutes good governance, and it includes a commitment to transparency
of process and to actively working to protect the health of citizens.1

Contesting global health norms

The invocation of the Westphalian doctrine as a means of contestation

appears centred around two well established health norms in global health
governance that inform the responsibilities of states within the domains of
healthcare delivery and public health protection. The two norms in questions
are: 1) that health is a human right that must be safeguarded by states; and 2)
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 MICHAEL A STEVENSON & ANDREW F COOPER

that safeguarding public health is an essential element of preserving

security in today's globalised world.14 According to these norms,
thus expected to continuously strive to protect population health wi
respective territorial jurisdictions, particularly those segmen
population deemed especially vulnerable to poor health and diseas
same time states are expected to adhere to internationally agreed-
and standards related to public health, such as those spelled out in th
International Health Regulations (ihr).
While these norms have been institutionalised through their in
international agreements, adherence to them requires that states
the legitimacy of an external authority when formulating domes
which is generally construed as a voluntarily ceding of element
sovereignty. However, sovereignty is not easily ceded, and pub
crises have not proven to be an exception in this regard.
In all three cases the doctrine of Westphalian sovereignty has been
justify non-compliance with one or both of these norms, notwit
widespread condemnation by both state and non-state actors. A
these challenges involves Asian states, there is a great deal of s
attached to this type of repeated challenge. Has global health g
moved to the front lines in the conflict between universal norms and
Asian-state defence of sovereignty? Alternatively, is health go
now perceived as another mechanism for unwelcome forms o
intervention?

China

SARS was first detected in Guandong province in China in November 2002.

However, the Chinese authorities only informed the WHO of the epidemic in
February 2003, and even then it was not until April 2003 that the Chinese
government acknowledged that the outbreak was effectively out of control,
having spread from Guandong to Beijing.15 That the first instincts of the
Chinese government was to suppress information about a disease it could not
control starkly illustrates a sensitivity about involving the international
community in what was deemed to be a domestic health crisis. Whereas the
international spread of SARS, and the public rebuke of the Chinese
government's actions by WHO forced Beijing eventually - and publicly - to
embrace transparency of process and the timely sharing of health-related
information, it is misleading to say that the resistance to external intervention
has been substantially eroded. Indeed, China appears to have deep
reservations about the legitimacy of norms informing global health
governance.

Domestic approaches to disease control inconsistent with principles of global

health governance. Thus far, the actions of the Chinese government indicate
little receptivity to embracing the post-Wesphalian model as it pertains to
global health governance. This is particularly so regarding arguments that
health is a human right and that increasing numbers of non-state actors have
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 GLOBAL HEALTH GOVERNANCE IN ASIA

a legitimate role to play in solving health problems. If anything,

approach to SARS is consistent with the state's approach to dealing with
public health crises, most notably the country's HIV/AIDS epidemic.
Yoon makes a convincing argument that, with Hiv/AIDS and again
SARS, the Chinese government has dramatically changed its polic
because of a commitment to the tenets of post-Westphalianism, but so
to jeopardise its political and economic reputation as a rising powe
logic suggests that the post-Westphalian model tarnishes this reput
the eyes of Beijing in two ways: first, by weakening the face of power
projected by the state both domestically and externally in suggesting t
state cannot control its own crises; and, second, by signalling a re
foreign interference in the affairs of a state deeply affected by its past
domination and exploitation, and continuously wary of US heg
advances in the present. Taken together these perceptions impede
incorporation into the post-Westphalian global health governance
work.16
Chan et α/'s research into Chinese perceptions of global gover-
nance reinforces these arguments. The authors suggest that China's has
made concessions regarding some external norms relating to the economic
and environmental spheres, so as not to jeopardise economic and
development goals. However, it is argued, the central government
remains unwilling to discuss ceding sovereignty on issues relating to
territoriality.17

Contesting foreign influence while off-loading responsibilities for health

protection. Although the WHO, individual states and civil society
organisations have all pressured China to conform to norms underlying
global health governance, China's assertion of its sovereign right to
manage its population health according to its own national interests comes
at a time when the central government appears to have voluntarily ceded
considerable influence over domestic public health outcomes to sub-state
jurisdictions.
Beijing's purposeful offloading of the responsibilities associated with
safeguarding the health of its populations to sub-state authorities illuminates
the latter's importance in aiding or undermining the implementation of
global health governance agendas. It was only after the SARS crisis had
abated that officials from Guandong province admitted being motivated to
cover up the epidemic so as not to compromise the region's pre-set targets for
economic growth, despite the fact that doing so ultimately undermined the
Communist Party's legitimacy.18 Yet public health crises attributed in some
way to local-level corruption, negligence or managerial incompetence
continue to emerge in China, as recent melamine-contaminated products
(most notably baby formula and pet food) serve to illustrate.19 Undoubtedly
such incidents damage the reputation of the Chinese brand in international
markets, but, for the purposes of global health governance, they reinforce the
idea that China's central government has limited powers to ensure quality
assurance in domestic and export-oriented products.
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 MICHAEL A STEVENSON & ANDREW F COOPER

Indonesia

Indonesia has borne the brunt of avian influenza (Al) in that it has
experienced the highest number of Al human infections, with a staggering
case-fatality rate of over 80%. 20 Nonetheless the global health community's
sympathy for Indonesia has been markedly reduced since early 2007, when it
began officially to withhold physical virus samples from new infections from
the who's Global Influenza Surveillance Network. For over 50 years the
network has served as a mainstay of international influenza surveillance, with
the samples being used to facilitate vaccine production. Indonesia's
continued actions are widely interpreted as being in clear violation of revised
international health regulations which came into effect in July 2007. On top
of this the country has demanded that samples previously submitted to WHO
be returned, and has threatened to close the United States Naval Medical
Research Unit (NAMRU-2) located in Jakarta.21

What is being contested and how it is being contested. Indonesia's explicit non-
compliance provides an opportunity to examine how sovereignty is used to
contest a health regime because of a perception that it is unjust and thus
illegitimate as a governance tool. The Indonesian government justified its
non-compliance with a central norm of global health governance - a
commitment to the collective security of the society of states - on the
grounds that its long-standing contribution to global health security in the
form of samples was merely contributing to the profits of vaccine producers
(transnational pharmaceutical corporations) and informing a final product -
vaccines - from which its citizens will probably not derive protection in the
event of a pandemic. This is because Northern governments consistently
secure majority access to a finite supply despite the fact that it is developing
countries such as Indonesia who bear the brunt of morbidity and mortality
each year. In 2008 Indonesia's Health Minister, Dr Siti Fadilah, claimed the
government was invoking its right to 'viral sovereignty', a concept that
suggests viruses circulating within any state fall under the exclusive sovereign
control of said state. By extension of this logic the Indonesian government
suggested that viruses are like any other form of biodiversity, and thus fall
under the convention of biodiversity (CBD) - the international environmental
regime created primarily to protect developing countries from proprietary
exploitation carried out by bio-prospectors intent on patenting indigenous
life-forms within which the principle of prior informed consent (PIC) features
prominently.22
WHO has attempted to diffuse the crisis by soliciting promises from the
world's large pharmaceutical companies not to exploit existing international
viral repositories for commercial gain, while the WHA has attempted to arrive
at a compromise solution: by passing a resolution (albeit not legally binding),
calling for the timely sharing of samples as well as for equitable and
transparent sharing of benefits derived from the generation of knowledge and
health-related technologies, and through the creation of a global influenza
stockpile.23
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 GLOBAL HEALTH GOVERNANCE IN ASIA

Structural inequity in regimes poses a challenge for global health gover

There is no doubt that invoking sovereign rights over disease-

microbes is problematic, simply because it is not biologically plau
ensure that naturally circulating viruses remain within territorial
Furthermore, this position constitutes a dangerous precedent,
epidemiological interdependence demands inter-state co-operation
public condemnation of such action without acknowledging the legitim
Indonesia's grievance will only exacerbate the crisis, and ultimately dim
the legitimacy of global health governance in the eyes of already s
states.

A more compelling argument against Indonesia's use of the CBD as

justification for its non-compliance with the revised IHR, has been advanced
by David Fidler. Fidler makes the case that, whereas the primary global goal
with regard to influenza has always been to eradicate a collective threat, the
CBD was created to ensure sustainable management of biodiversity and
safeguard against acts of biopiracy. As such, according to Fidler, the CBD has
no relevance to pathogens, and is being misused.25
In fact, Indonesia's invocation of the CBD appears entirely consistent with
the spirit of the convention, in that it is used to highlight existing structural
inequality in how vaccines are created and who benefits from their production
(financially and physically), especially at times of global crises. Indonesia's
actions illustrate why this structural inequity needs to be addressed.
This failure on the part of global health governors - exemplified by the
WHA response to Indonesia's contestation (if only a non-binding resolu-
tion) - illustrates what Miriam Miller demonstrated in the domain of
environmental governance over a decade ago, namely that regime theory is
typically silent about the hierarchy within and among regimes. Some states
(primarily developing countries), have had very little influence in the
construction of global institutions, which accordingly rarely reflect their
interests and concerns. Miller's research showed that only in situations of
biological interdependence (eg commons problems) can these marginalised
actors yield significant power. Indonesia's defiance of the IHR is exactly the
kind of situation described by Miller, as non-compliance gives Indonesia
leverage that it lacks structurally, which creates a unique problem for global
health governance.
While the WHO has been the principal target of the Indonesian
government's concerns on this issue, it is certainly beyond the scope of the
organisation to resolve autonomously structural inequalities between regimes
that have the potential to jeopardise the functioning of mechanisms of health
governance. The reality is that, under current conditions, the IHR (which is
akin to the CBD) is devoid of teeth in that there is no mechanism for enforcing
rules, or for punishing those who contravene them. However, its political
masters, working in concert with their counterparts in other international
organisations and regimes, can and must rectify this, if global health
governance is to function effectively. Unless there is substantive change, there
is little to suggest that similar crises will be averted or resolved.
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 MICHAEL A STEVENSON & ANDREW F COOPER

Burma

Burma's HIV epidemic began in the late 1980s and today it is estimated that
3.5% of reproductive-age adults are infected with the virus, although
prevalence among high-risk populations, notably sex-worker and intrave-
nous drug users, is considerably higher.27 An estimated 40% of the Burmese
population is thought to be infected with tuberculosis and 60%-80% of
Burmese infected with HIV are believed to be co-infected with TB. Burma has
the highest mortality rate in Southeast Asia among hiv/tb co-infected
patients, as well as experiencing the region's highest number of annual deaths
attributed to malaria.28
Instead of moving to protect vulnerable populations, the Burmese regime
appears to have heightened vulnerability. For example, despite direct
involvement in sustaining the heroin industry, the junta has taken a punitive
approach to intravenous drug-use, ensuring amplification of transmission via
needle sharing at 'tea-stall' injection sites. In conflict-affected regions, most
notably Karen State, the regime deliberately undermines public health. It is
only because of the innovation and perseverance of civil society entities like
the Karen Department of Health and Welfare (kdhw) that tens of thousands
of people have access to any form of health care.30
Health as a human right is a concept that is completely ignored by the
Burmese regime. Despite the severity of the multiple and synergistic public
health challenges facing Burma's population, the regime has a well
established track record of interfering with largely apolitical non-state
foreign actors who have the capacity to offer much needed help. In 2004 the
Global Fund awarded Burma a series of grants totalling almost US$100
million towards controlling TB, malaria and HI v/ AIDS. This funding was
subsequently withdrawn in 2005 when the organisation decided that
government interference was making implementation of funded programmes
impossible. The regime has also been publicly rebuked by the World Food
Programme for interfering with food aid, by the International Committee of
the Red Cross (ICRC), which suspended prison visits in 2006 because of
repeated human rights violations committed against detainee populations,
and by MSF, which also withdrew from Burma in 2005. 31

Neighbouring states as agents of change in Burma. Because of the regional

implications of Burma's governance-driven public health crises, and the
regime's refusal to take responsibility for addressing the political determinants
of disease spread, such responsibility must increasingly fall to neighbouring
states - namely Thailand, India and China - that are being adversely affected
and have the capacity to influence outcomes. All three states have such
capacity to respond, both through domestic and foreign policy, individually
and in concert with one another. Yet they are failing to do so.
This failure is evident in domestic policy gaps, such as Thailand's failure to
sufficiently protect the health of the estimated 400000 indigenous Shan
refugees residing in the northwest of the country, who through no fault of
their own experience a high burden of disease in their country of origin. Yet,
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 GLOBAL HEALTH GOVERNANCE IN ASIA

within Thailand, this vulnerable population continues to experience

alisation to the detriment of public health, because most Shan
recognised as refugees but instead as 'economic migrants'. As such t
limited rights to services afforded to vulnerable groups such a
education, in spite of the fact that HIV/AIDS is the most commonly re
disease among Shan migrants, and that Shan sex workers are far less li
use condoms than their Thai counterparts.32 Marginalising this po
risks perpetuating the cycle of infection. The plight of the Shan in Th
serves to illustrate why all states must be proactive in safeguarding th
of particularly vulnerable populations, and particularly how th
bordering Burma can mitigate the health effects of the junta'
governance through domestic policy.
The border states, particularly India and China, have considerable
with which they can influence the Burmese regime, both throug
individual actions and working in concert with other states. Ongoing s
for the regime occurs through arms sales and provision of capital f
to Burma's significant oil and gas reserves, and this investment is
devoid of conditions that would force the hand of the regime with reg
human rights and expenditure on health. Perhaps the greatest impedim
collective punitive action related to Burma is continued regional op
to the principles of sovereignty as responsibility, and to territorial inc
(breaching Westphalian norms) on humanitarian grounds, as evide
collective inaction after the regime's abysmal response to hurricane

The status quo imperils global health. Political determinants

distribution of adverse health-related events will inevitably play
prominent role in shaping foreign policy and global governance de
Through its direct involvement in the production and export of op
methamphetemine the Burmese junta has played a critical role expandin
prevalence of intravenous drug use both within Burma and in th
regions of neighbouring states. Intravenous drug use is the principal d
the Hiv/AIDS epidemic in the golden triangle, and is responsible for th
HIV diversity that characterises the region, which together incre
likelihood of individuals becoming infected with multiple antigen
distinct clades (organisms evolved from a common ancestor) of H
called 'superinfection'. This in turn increases the likelihood of inc
virulence and antimicrobial resistance in new infections.33 The emerge
2006 of the highly infectious, virulent and extremely drug-r
tuberculosis (xdr-tb) among Hiv-infected hospital patients in South
clearly demonstrates that antimicrobial resistance is just as much an in
of poor health governance as it is of sub-optimal antimicrobial use.
The states bordering Burma, let alone the larger international sy
states, cannot continue to allow that country to be a reservoir of in
States must understand that, at the very least, failing to address B
overlapping health crises increases the likelihood of greater clinical com
ity, while decreasing the number of finite therapeutic options for som
most important infectious diseases in the world today.
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 MICHAEL A STEVENSON & ANDREW F COOPER

Overcoming the constraints of sovereignty

Respecting heterogeneity of national health governance models provided

general commitment to the basic norms informing global health gover

Effective global health governance does not necessarily deman

detailed architecture, or more law related to public health. Informa
heterogeneity by contrast ensure the requisite flexibility, provide
are able to agree to basic principles and a few rules to guide beha
safeguarding public health.35 By explicitly providing states w
discretion as to how they controlled the epidemic provided th
common adherence to basic norms, the WHO illustrated during t
crisis what leadership in global health looks like in a post-Wes
world.36 Given sovereignty's significant impediment to globa
governance, a non-coercive approach is far more likely to re
positive response from individual states than top-down tech
dictation.37
Accordingly, encouraging heterogeneity could allow for greater
ment in regional bodies; which would seem like a logical rou
resolving the challenge posed by Burma's ongoing self-imposed is
Given its member states' historical concern over foreign interfere
preference for consensual decision making, The Association of So
Asian Nations (ASEAN) may be a more appropriate mechanism to
health problems ultimately rooted in poor governance, than
distant, and perceived to be 'Western' authority. Thus far, howev
organisation's ability to alter the junta's governance practices
limited.38
ASEAN's ability to influence the domestic policy of its members in the face
of a regional transboundary health crisis has been similarly limited. During
the SARS crisis, while some ASEAN members - notably Singapore and
Vietnam - fared comparatively well thanks to innovative and proactive
policies, ASEAN as a whole was unable to solicit a unified response among
member states.39
ASEAN's historic strength as a regional organisation lies in its commitment
to political stability, which has been informed by the norm of non-
interference by member states. Yet this norm is also its inherent weakness
when forced to confront threats to public health rooted in poor governance
by the organisation's members. As suggested by Kuhonta, ASEAN needs to
rethink its attachment to the norm of non-interference and instead frame
sovereignty as responsibility.40
Encouraging heterogeneity in how disease control is approached is not
without criticism. If, however, global health governance is framed as a
project designed to address health-oriented global collective action
problems and one that contains a significant normative component, then
the debate is not about whether more or less health governance is needed.
Rather, it is about what the end goals should be, and how to embed the
norms required to ensure these goals remain an overarching priority for
states.

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 GLOBAL HEALTH GOVERNANCE IN ASIA

Facilitating the expansion of transnational epistemic communities comm

further embedding key norms within the societies where they operate

A second strategy for increasing trust in the pursuit of effective glo

governance, is to strengthen networks of professionals with rec
expertise and competence in their respective domains and author
claims to policy-relevant knowledge - so-called 'epistemic commu
whose shared normative goals are largely consistent with those exa
this paper.41 This can be accomplished by providing material and
support for the expansion of transnational networks operating in the
of public health.
Because states have become less effective at addressing challenges
their orders, a generalised global network society, in which multip
and informal networks shape and link the policies of individual
viewed by many as the defining structure of global governance. In
global network model addresses both the structural and ideational
that typify global governance as a perspective. Structural in
inherently an extension of states and the resources and power they y
also ideational in that the effectiveness of disaggregated sovereignty
selling ideas through persuasion - so-called soft power.
Peter Haas has effectively demonstrated that epistemic communi
the power to institutionalise their respective norms when gi
opportunity to do so within the international policy arena, despit
that doing so may run counter to the stated preferences of
governments.42 Accordingly, a key goal of public health-oriented
networks is to embed their norms in states where sovereignty has
prevented their being embedded.
A promising vehicle for expanding both public health-oriented e
communities and transnational public health governmental networ
International Association of National Public Health Institutes
established in 2006 by some 39 national public health institute directo
share a commitment to expanding public health capacity globally. Fun
the WHO and by the Rockefeller and Bill and Melinda Gates Fou
this professional association seeks to foster leadership develop
countries where it is perceived to be lacking, building within its mem
common vision of what such leadership should look like in term
norms and practices that should be embraced. Through mento
providing funds, IANPHI works to expand the number of nation
health institutes around the globe.43
And yet IANPHI cannot be seen as a global public health panace
viewed as an agent of US private philanthropic foundations; the s
for the WHO - an organisation still regarded with suspicion b
developing countries because of its dependence on funding from th
wealthiest countries. At the same time there is no doubt that pub
experts face similar challenges arising from the transboundary
communicable diseases, and thus have vested interests in seeing interg
mental agreements related to common practices materialise. In or
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 MICHAEL A STEVENSON & ANDREW F COOPER

viewed by all states as legitimate global public health authorities,

communities committed to the core global health norms examine
paper should actively and openly strive to expand their membership
help of as broad a range of state and non-state actors as possible.
political isolation created by Westphalian sovereignty is overcome, th
of public health-oriented epistemic communities like ianphi to sh
health outcomes will remain limited.

Addressing structural inequities within international regimes that have the

potential to undermine trust and co-operation between states and thus
jeopardise advances in global health governance
The most complex, least developed, but perhaps the most important of these
strategies for further embedding basic health-oriented norms within the
collective conscious of the society of states revolves around diplomatic
initiatives to address structural inequalities within and between international
regimes that have proven to undermine trust and co-operation between
states. Indonesia's justification for its non-compliance with the revised IHR
illustrates how existing inequity in costs and benefits associated with
membership in international regimes can lead to tensions that impede the
functioning of those regimes and governance arrangements. State-sponsored
health diplomacy is the key to overcoming this source of tension. For
example, although international trade has always adversely affected
population health, only recently have the WHO and WTO begun co-ordinating
their efforts so as to both prevent policy overlap and identify policies that
may jeopardise the other's goals.44
Global governance cannot be conceived as efforts limited to a single
domain or initiative. It must instead be conceived as 'the principles, norms,
rules, and procedures that come into play when two or more regimes
overlap, conflict, or otherwise require arrangements that facilitate
accommodation among the competing interests'. Health diplomacy is
thus not simply about engaging individual actors on health issues; it is
about engaging regimes and the sources of norms and sets of rules that
have the potential to adversely affect both population health and health
governance arrangements.
By way of conclusion, therefore, this article reinforces the argument that
continued 'discord' related to public health is too significant to allow an
Orwellian world of distrustful regions to develop.46 In the context of multiple
overlapping global health crises, the main impediment is non-compliance
with known solutions on ideological grounds, and adherence to rules of a
game that has changed so substantially as to make them obsolete.

Notes

An earlier version of this paper was presented at the 50th Annual International Studies Association
Convention, New York, 15-18 February, 2009.
1 D Fuchs, 'The commanding heights? The strength and fragility of business power in world polities',
Millennium, 33 (3), 2005, pp 771-802.

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 GLOBAL HEALTH GOVERNANCE IN ASIA

2 L Jacobs & PB Potter, 'Selective adaptation and human rights to health in China', Health an
Rights, 9 (2), 2006, pp 112-134.
3 DP Fidler, 'Influenza virus samples, international law, and global health diplomacy',
Infectious Diseases, 14 (1), 2008, pp 88-94.
4 R Cox, Approaches to World Order, Cambridge: Cambridge University Press, 1996; and M B
R Duvall, 'Power in international polities', International Organization, 59 (1), 2005, pp 39
5 C Beyrer, V Suwanvanichkij, L Mullany, A Richards, Ν Franck, A Samuels & Τ Lee, 'Resp
AIDS, tuberculosis, malaria and emerging infectious diseases in Burma: dilemmas of po
practice', PLoS Medicine, 3 (10), 2006, pp 1733-1740.
6 JA Schölte, Globalization: A Critical Introduction, New York: Palgrave Macmillan, 2005; and
'Global governance as disaggregated complexity', in A Ba & M Hoffman (eds), Contending Pers
Global Governance: Coherence and Contestation, New York: Routledge, 2005, pp 131-153.
7 DP Fidler, 'Architecture amidst anarchy: global health's quest for governance', Glo
Governance, 1 (1), 2007, ρ 3.
8 Ibid, ρ 7.
9 Ibid.
10 DP Fidler, 'SARS: political pathology of the first post-Westphalian pathogen', Journal of Law, Medicine
ά Ethics, 31 (4), 2003, pp 485-505.
1 1 SW Yoon, 'Sovereign dignity, nationalism and the health of a nation: a study of China's response in
combat of epidemics', Studies in Ethnicity and Nationalism, 8 (1), 2008, pp 80-100.
12 D Heymann, 'The international response to the outbreak of SARS , Philosophical Transactions of the
Royal Society of London, 359 (1447), 2004, pp 1 127-1 129.
13 Fidler, 'SARS'.
14 Health as a right tor all human beings was enshrined in original WHO documentation in 1^4», and
reiterated in the Alma-Ata declaration of 1978, but only in the past two decades have states begun to
experience significant pressure from both state and non-state actors to comply with it.
15 M Curley & Ν Thomas, 'Human security and public health in Southeast Asia: the SARS outbreak',
Australian Journal of International Affairs, 58 (1), 2004, pp 17-32.
16 Yoon, 'Sovereign dignity, nationalism and the health of a nation .
17 LH Chan, PK Lee & G Chan, 'Rethinking global governance: a China model in the making?',
Contemporary Politics, 14 (1), 2008, pp 3-19.
18 Yoon, 'Sovereign dignity, nationalism and the health of a nation'.
19 See, for instance, the New York Times' s editorial, 'China's baby formula scandal , 19 September 2008,
A18.
20 AL Caplan & DR Curry, 'Leveraging genetic resources or moral blackmail? Indonesia and avian flu
virus sample sharing', American Journal of Bioethics, 1 (11), 2007, pp 1-2.
21 WHO has stated it is willing to return Indonesia's H5N1 samples provided the Indonesian government
can demonstrate they have the laboratory capacity (BSL-3) to handle samples safely. M Enerink &
D Normile, 'More bumps on the road to global sharing of H5N1 samples', Science, 318 (5854), 2007,
ρ 1229; and R Holbrooke & L Garrett, '"Sovereignty" that risks global health', Washington Post, 10
August 2008, B07.
22 Holbrooke & Garrett, '"Sovereignty that risks global health .
23 Ibid; Caplan & Curry, 'Leveraging genetic resources or moral blackmail: ; World Health Assembly,
'Pandemic influenza preparedness: sharing of influenza viruses and access to vaccines and other
benefits', wha, 60.28, 23 May 2007; and Fidler, 'Influenza virus samples, international law, and global
health diplomacy'.
24 In May 2008 India's Health Minister endorsed the concept, and the Non-Aligned Movement has
considered endorsing it.
25 Fidler, 'Influenza virus samples, international law, and global health diplomacy'.
26 M Miller, The Third World in Global Environmental Politics, Boulder, CO: Lynne Rienner, 1995.
27 Β Williams, D Baker, M Buhler & C Pétrie, 'Increase coverage of HIV and AIDS services in Myanmar ,
Conflict and Health, 2 (3), 2008, pp 1-10.
28 WHO Southeast Asia Regional Office, 'Social determinants and tuberculosis in South-East Asia',
Regional Consultation on the Social Determinants of Health, WHO/SEARO, New Delhi, 15-16
September 2005; and Beyrer et al, 'Responding to AIDS, tuberculosis, malaria and emerging infectious
diseases in Burma'.
29 C Chelala & C Beyrer, 'Drug use and Hiv/AIDS in Burma', Lancet, 354 (9183), 1999, ρ 1119.
30 A Richards, L Smith, L Mullany, C Lee, E Whichard, Κ Banek, M Mahn, ΕΚ Shwe Oo & Τ Lee,
'Prevalence of Plasmodium falciparum in active conflict areas of eastern Burma: a summary of cross-
sectional data', Conflict and Health, 1 (9), 2007 pp 1-10.
3 1 Beyrer et al, 'Responding to AIDS, tuberculosis, malaria and emerging infectious diseases in Burma ; and
R MacDonald, 'Human rights abuses threaten health in Burma', Lancet, 370 (9585), 2007 pp 375-376.

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 MICHAEL A STEVENSON & ANDREW F COOPER

32 V Suwanvanuchkij, 'Displacement and disease: the Shan exodus and infectious disease implications for
Thailand', Conflict and Health, 2 (4), 2008, pp 1-5.
33 J Blackard, D Cohen & Κ Mayer, 'Human immunodeficiency virus superinfection and recombination:
current state of knowledge and potential clinical consequences', Clinical Infectious Diseases, 34 (8),
2002, pp 1108-1114.
34 XDR-TB is resistant not only to isoniazid and rifampicin (the normal criterion for classification as multi-
drug resistant (MDR) tuberculosis), but also to at least three classes of second-line drugs. Ν Gandhi,
A Moll, A Sturm, R Pawinski, Τ Govender, U Lalloo, Κ Zeller, J Andrews & G Friedland,
'Extensively drug-resistant tuberculosis as a cause of death in patients co-infected with tuberculosis and
HIV in a rural area of South Africa', Lancet, 368 (9547), 2006, pp 1575-1580; R Smith, J Coast,
M Millar, Ρ Wilton & AM Karcher, 'Interventions against antimicrobial resistance: a review of the
literature and exploration of modeling cost-effectiveness', Global Forum for Health Research,
September 2001, pp 1-170; and A Van Rie & DA Emerson, 'AXDR-tuberculosis: an indicator of
public-health neelieence'. Lancet. 368 (9547Ì. 2006. nn 1 554^1 SS6
35 Fidler, 'Architecture amidst anarchy'; and R Cox, 'Beyond empire and terror: critical reflections on the
political economy of the world order', New Political Economy, 9 (3), 2004, pp 307-323.
36 Jacobs & Potter, 'Selective adaptation and human rights to health in China'.
37 As argued by Calain, because the IHR contains no punitive mechanism (eg economic sanctions) for states
that fail to comply with them, WHO is limited in its coercive capacity. Ρ Calain, 'Exploring the
international arena of global public health surveillance', Health Policy and Planning, 22 (1), 2007, pp 2-12.
38 Kuhonta, 'Walking a tightrope: democracy versus sovereignty in ASEAN's illiberal peace', Pacific
Review, 19 (3), 2006, pp 337-358.
39 Curley & Thomas, 'Human security and public health in Southeast Asia'.
40 EM Kuhonta, 'Towards responsible sovereignty: the case for intervention', in DK Emmerson (ed),
Hard Choices: Security, Democracy and Regionalism in Southeast Asia, Stanford: Walter Shorenstein
Asia-Pacific Research Center. 2008. pp 292-313.
41 Ρ Haas, 'Introduction: epistemic communities and international policy coordination', International
Organization (special issue), 46 (1), 1992, pp 1-35.
42 Ρ Haas, 'Do regimes matter? Epistemic communities and Mediterranean pollution control',
International Organization, 43 (3), 1989, pp 377^03.
43 G Rodier, A Greenspan, J Hughes & D Heymann, 'Global public health security', Emerging Infectious
Diseases, 13 (10), 2007, pp 1447-1452.
44 Ν Drager & D Fidler, 'Foreign policy, trade and health: at the cutting edge of global health
diplomacy', Bulletin of the World Health Organization. 85 (3). 2007. η 162.
45 J Rosenau & EO Czempiel (eds), Governance without Government, Cambridge: Cambridge University
Press, 1992, ρ 9.
46 R Thakur & L Van Langehove, 'Enhancing global governance through regional integration', Global
Governance, 12 (3), 2006, pp 233-240.

Notes on Contributors

Michael A Stevenson is a PhD Candidate at the Balsillie School of

International Affairs, University of Waterloo. Andrew F Cooper is Associate
Director and Distinguished Fellow at the Centre for International Govern-
ance Innovation (CIGI) and Professor in the Department of Political Science
at the University of Waterloo. His recent books include Innovation in Global
Health Governance: Critical Cases, co-edited with John J Kirton (2009);
Celebrity Diplomacy (2008); and Governing Global Health: Challenge,
Response, Innovation, co-edited with John J Kirton and Ted Schrecker
(2007).

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