Book Review: Building Leadership in Global Disease Response

World Health Organization Director General Margaret Chan tours Ebola response sites. Freetown, Sierra Leone, December 20, 2014. (Evan Schneider/UN Photo)

The development of what is being hailed as a breakthrough Ebola vaccine by a “global partnership of researchers, governments, NGOs, companies, and funders” has shown the value of greater international cooperation in preventing, detecting, and responding to outbreaks of infectious disease. Advocates have increasingly promoted coordinated disease responses that mirror those toward other international crises. “We need a global call to action,” wrote Bill Gates in April in an article for the New England Journal of Medicine, “to prepare for [epidemics] and prevent millions of deaths.”

But according to an excellent new book, Disease Diplomacy: International Norms and Global Health Security, by scholars Sara E. Davies, Adam Kamradt-Scott, and Simon Rushton, convincing countries of the need to work together to fight infectious disease outbreaks has been an exceedingly lengthy and difficult process. The authors—two of who have previously conducted International Peace Institute research—trace the evolution of global public health norms from the 1990s until the period after 2009, the year of the H1N1 influenza epidemic, known as Swine Flu, in order to explain how expectations of “appropriate outbreak response” have changed over time.

Davies, Kamradt-Scott, and Rushton claim that the role of leadership, diplomatic skill and persuasion, and years of intense negotiations at the World Health Organization (WHO) have been equally as important in highlighting the need for international disease responses as material changes, such as developments in the rate of spread of disease brought about by globalization.

Drawing heavily from the “norm life cycle” framework developed by fellow scholars Martha Finnemore and Kathryn Sikkink, the authors argue that “norm entrepreneurs” within the WHO were able to convince WHO member states to reconstitute the global public health regime to take more seriously the threat of infectious disease outbreaks. Officials such as David Heymann leveraged the global panic surrounding the SARS, H5N1, and H1N1 outbreaks to push for major reforms.

The authors note that “the WHO secretariat as a norm entrepreneur played an active part in constructing its own role rather than being a mere passive recipient of authority.” This may be surprising given that the international health body governs through non-binding “soft law” and has virtually no enforcement capability.

Disease Diplomacy draws upon social constructivist theory to explain how WHO member states have internalized new attitudes towards “global health security,” culminating in the 2005 International Health Regulations (IHR), a non-binding agreement setting out how nations should respond to infectious disease outbreaks.

Responsible behavior was not always the norm in global health circles. During the 2002-2003 SARS outbreak in Asia—which is described as a major trigger for drafting the IHR—China deliberately concealed hundreds of cases of the disease on its territory. Egypt culled as many as 400,000 pigs during the 2009 Swine Flu outbreak, in contradiction with WHO technical recommendations. The authors cite these and other examples to demonstrate that international behavior in this area has largely gone from being based in secrecy, fear, and superstition to transparency, cooperation, and science-based decision-making.

It is unfortunate that Disease Diplomacy was written just before the start of the Ebola outbreak in West Africa. This was the largest public health emergency in recent history, killing over 11,000 people since March 2014 and continuing to spread. But instead of rendering the authors’ conclusions obsolescent, it reveals their prescience, as the book predicts a major outbreak that would prey on what they call the “material shortfalls” of infectious disease surveillance, such as lack of capacity and resources in low-income countries.

The authors argue that while most countries today comply with the new norms contained with the IHR, incidents of non-compliance are usually due to a lack of capacity rather than a lack of political will. “The flesh may be weak even where the spirit is willing” characterizes the main challenge facing countries seeking to strengthen their disease surveillance systems, the majority of which are located in two regions, Africa and Asia-Pacific. This conclusion is deduced by analyzing data revealing the extent of non-compliance with the IHR, as well as rhetorical statements made against those countries which fail to comply. The warning is clear: Unless further action is taken by the WHO to work with wealthy donor countries to invest in the disease detection and response capacity of low-income countries, then the system of global health security risks unravelling.

The Ebola outbreak would seem to bear this out perfectly. If anything, the crisis has further galvanized the need for the WHO to coordinate more closely with the broader United Nations system in prioritizing the IHR. This was echoed in the recent WHO Report of the Ebola Interim Assessment Panel, which stated that “if the world is to successfully manage health threats … then the Regulations need to be strengthened.”

I spoke with the authors of Disease Diplomacy about whether the Ebola outbreak stands to affect any of the book’s other conclusions. They said that the reputation and credibility of the WHO has been severely damaged after the outbreak, calling into question whether it can muster the same normative leadership it showed in the past. They also wonder after the UN General Assembly’s recent approval of the post-2015 Sustainable Development Goals—which lack any reference to the IHR—if states are serious about their responsibility for working with the WHO, and vice versa, in funding the IHR core capacity requirements.

The authors ultimately succeed in advancing our understanding of international norm compliance. They take a famous model by Abram Chayes and Antonia Chayes and modify it to show how “norm compliance is arguably even more fraught when governments are confronted by a rapidly changing, unpredictable, and unquantifiable event.” However, experts on international norm diffusion might take issue with the sometimes imprecise handling of terms like socialization and internalization, which seem to be used interchangeably (see Ryan Goodman and Derek Jinks’ book on Socializing States).

While Disease Diplomacy may not be as accessible for those without a background in public health, this should not detract from what ought to be required reading for scholars and practitioners of the WHO and global health.  The book is a clarion call for donor nations to invest more strongly in disease prevention, surveillance, and response capacity in developing nations, underpinned by “a greater sense of international solidarity.” It is also a reaffirmation of the role of leadership and diplomacy in shaping the system of global health governance. The ideas generated in the halls of international organizations can shape the public health behaviors of countries around the world for the better, in turn saving lives.