Sara E. Davies. Containing Contagion: The Politics of Disease Outbreaks in Southeast Asia. Baltimore: Johns Hopkins University Press, 2019. 224 pp. $54.95 (paper), ISBN 978-1-4214-2739-3.
Reviewed by Eva Hilberg (Hebrew University of Jerusalem/ University of Sussex)
Published on H-Diplo (March, 2020)
Commissioned by Seth Offenbach (Bronx Community College, The City University of New York)
In a time that increasingly questions the efficacy of diplomacy and multilateral treaties, Sara E. Davies’s most recent work serves as a well-researched reminder of the transformative potential that can reside in the making of agreements and in the creation of diplomatic structures between regional partners. Containing Contagion focuses on the politics of disease outbreaks in Southeast Asia, where recent epidemic outbreaks of severe acute respiratory syndrome (SARS) and H5N1 (avian influenza or “bird flu”) created a strong political will for cooperation in response to public health emergencies—which by their very nature do not respect boundaries and thus are truly transnational. Against the backdrop of the simultaneous implementation of the World Health Organization’s (WHO) International Health Regulations (IHR, revised in 2005), this book explores the different ways this cooperation was institutionalized and made to work in Southeast Asia, all the while asking the core question of whether diplomacy can actually make a measurable difference—and if so, why and how? This question goes to the heart of the study of international relations, and this book is a valuable contribution not only to the study of global health diplomacy but also to wider discussions within this field.
Challenging the prevailing perception of a general failure of IHR implementation, this book presents a meticulously researched reevaluation of state performance with regard to the eight core capacities enshrined in the revised IHR. This account is contextualized with different layers of institutional international organizations that are region specific to Southeast Asia—including the two WHO regional offices that cover this geographical area, Western Pacific Regional Office (WPRO) and South-East Asia Regional Office (SEARO); the preexisting Association of Southeast Asian Nations (ASEAN); the extended ASEAN Plus Three (including Japan, China, and South Korea); the regional Mekong Basin Disease Surveillance (MBDS) network; and the unique organization specifically created for the implementation of the IHR in Southeast Asia, the Asian Pacific Strategy for Emerging Infectious Diseases (APSED). The region’s combination of technical and political institutions in the field of disease diplomacy is particularly notable as Southeast Asia is known for its long-standing commitment to the principle of noninterference, making the implementation of the IHR an unusual case in which states “acquiesce to an international regulation coupled with a framework that permitted evaluations, even interference and judgment, from an international organization, the WHO” (p. 4). Davies argues that what emerges from this “curious case” of collaboration in a noninterference environment is an empirical account of “compliance pull” through informal processes (p. 8).
The book’s central argument focuses on the effectiveness of APSED, which is a region-specific framework supporting the implementation of the IHR that has thus far run in three phases. Previous evaluations of APSED and more generally of IHR implementation emphasize that “two-thirds of states have failed to meet the IHR core capacities” and find APSED to bring about “only thin, mainly instrumental and rhetorical, cooperation that drives only minimal institutional and behavioral change at the regional or domestic level” (pp. 9, 6). In contrast, Davies finds that “the narrative of compliance failure risks downplaying what has been achieved in a short time and the very real evidence that the IHR have exerted considerable ‘compliance pull’ across a sizable majority of states” and argues “whatever their limitations, regional political institutions continue to play a vital role in bridging the gap between the global and the local, between the ambitions of WHO headquarters and the realities on the ground in Southeast Asia” (pp. 41, 158). The book makes its case over six chapters, beginning with the development of the IHR and the political context in Southeast Asia in chapters 1 and 2. Chapter 3 provides a careful dissection of the political pressures enacted by disease outbreaks in Southeast Asia, giving rise to a normative shift toward an understanding of health security threats as collective threats. Against this backdrop, chapter 4 traces the emergence of APSED as a regional “middle path” toward implementation, which is then backed up in chapter 5 with a detailed comparative appraisal of disease outbreak reporting behavior of ASEAN member states. Chapter 6 then discusses the likely reasons for statistical anomalies and contradictions arising from the reporting statistics, finding that in the end “capacity assessments ... are all political statements about the efficiency and stability of the [state’s] regime” (p. 157).
The strength of this book is its close attention to detail, especially in its meticulous and contextualized discussions of reporting behavior and core capacity fulfillment statistics over time. These empirics form a solid basis for Davies’s findings, which skillfully pick apart the above-mentioned statistical value of two-thirds of states not meeting IHR core capacities. Her account carefully differentiates between changes across the eight different capacities and compares states’ performance with their overall reporting behavior, finding “a strong trend toward more open and prompt communication of disease outbreaks and enhanced freedom to report” (p. 115). The influence of APSED, the WHO, and other dedicated organizations via processes of international standard setting here emerges as a pivotal factor for improving surveillance and reporting of designated international public health threats and also of endemic disease outbreaks. This process, however, is not working in the same way in every context. Throughout, Davies balances her assessment with discussions of “a small number of states [that] have remained consistent in the inconsistent practice of detection and verification” (p. 158). She also points out that the “outstanding problem is that endemic diseases without regional or WHO-level attention continue to go undetected” (p. 137). Overall, her findings somewhat lessen worries about the creation of compliance “silos,” through which international priorities deviate funds and operational capacity from other potentially more significant public health issues (p. 160).
Davies builds her argument with great clarity and focus—which, however, at times comes at the expense of taking a wider view of APSED’s and Southeast Asia’s track records in comparison with the experiences of other regions regarding IHR implementation. For example, the book briefly mentions criticism engendered by the WHO’s failure to deal effectively with the Ebola outbreak in West Africa in 2014, thus illuminating the WHO’s emphasis on regional reporting and its pitfalls. Comparative insights such as these could have been introduced more frequently throughout in order to give the reader a deeper understanding of the central argument’s wider implications. This could have contextualized important concluding statements, which, for example, find that “disease surveillance emerged as a priority for Southeast Asia even prior to the IHR revisions, perhaps explaining in part why the region accepted the IHR revisions” (p. 142). Statements such as this raise the question of how much Southeast Asia’s experience differs from other regions and whether this particular experience can be replicated in other regions. A comparative angle is covered more thoroughly in Davies’s co-authored work with Adam Kamradt-Scott and Simon Rushton, Disease Diplomacy: International Norms and Global Health Security (2015), but would have added a further valuable dimension to the discussion in the present book.
The wider implications of the book’s core argument could have also been foregrounded more throughout, as this is essentially a book about some of the central questions for global health security today. Presenting the book’s remit as exclusively focused on the politics of disease outbreaks in Southeast Asia slightly undersells the potential impact. The book directly contributes to discussions of whether the securitization of health issues is advisable, about the conflict between appraisals of the influence of hard power and soft power in international relations, and about the role of human rights standards for and within global health instruments. It also engages with theoretical debates on the relationship between health and governance by discussing the correlation between “health spending, regime type, and political stability,” and shows that no definite correlation can be established (p. 47). Further critical global health issues, such as the use of metrics, also feed into the discussion, as statistics are then used to diminish the impact of grand numbers often used for the promotion of global health programs and priorities. All these different aspects together make this book a compelling showcase for why the study of global health matters and illustrates what a closer look at health governance can add to the understanding of diplomacy.
. The study referenced by Davies is Suerie Moon, et al., “Will Ebola Change the Game? Ten Essential Reforms before the Next Pandemic. The Report of the Harvard-LSHTM Independent Panel on the Global Response to Ebola,” The Lancet 386, no. 10009 (2015): 2204–21.
Eva Hilberg is a postdoctoral fellow at the Federmann School of Public Policy and Government, Hebrew University of Jerusalem, and an honorary research fellow at the School of Global Studies, University of Sussex, UK. Her work traces the politics of knowledge circulating in the global bioeconomy and analyzes the inscription of new priorities into the global health agenda, such as in the field of global mental health. Her PhD focused on the normalization of biomedical knowledge by means of intellectual property rights and the exclusion of patients from this field of politics (“Promoting Health or Securing the Market? The Right to Health and Intellectual Property between Radical Contestation and Accommodation,” in Third World Quarterly [May 2015]).
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