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Institute of Medicine (US) Forum on Microbial Threats; Knobler S, Mahmoud A, Lemon S, et al., editors. Learning from SARS: Preparing for the Next Disease Outbreak: Workshop Summary. Washington (DC): National Academies Press (US); 2004.

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Learning from SARS: Preparing for the Next Disease Outbreak: Workshop Summary.

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SARS: POLITICAL PATHOLOGY OF THE FIRST POST-WESTPHALIAN PATHOGEN10

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The World Health Organization (WHO) has asserted that severe acute respiratory syndrome (SARS) was “the first severe infectious disease to emerge in the twenty-first century” and posed “a serious threat to global health security, the livelihood of populations, the functioning of health systems, and the stability and growth of economies” (WHO, 2003a). This paper argues that SARS was also the first post-Westphalian pathogen, and it constructs a political pathology of the outbreak to advance this claim.

In some respects, the SARS outbreak was nothing new. The great cliché of international infectious disease control—germs do not recognize borders—applies to SARS as it applied to earlier outbreaks. SARS joins a long list of infectious diseases that have not recognized borders. For my purposes, what makes SARS interesting is not its germ (SCoV); rather, SARS is important because of the political context in which the germ did not recognize borders. Put another way, I am interested in the borders SARS did not recognize. SARS is the first post-Westphalian pathogen because its nonrecognition of borders transpired in a public health governance environment radically different from what previous border-hopping bugs encountered.

Westphalian and Post-Westphalian Public Health

Of Germs and Borders

Principles for public health governance between countries traditionally derived from the structure for international relations known as the “Westphalian system”: a system composed of principles guided by national sovereignty and nonintervention (Harding and Lim, 1999). “Westphalian public health” refers to public health governance structured by Westphalian principles. “Post-Westphalian public health” describes public health governance that departs from the Westphalian template and responds to increasing forces of globalization that include the interests of both multinational corporations and multilateral organizations. SARS is the first post-Westphalian pathogen because it highlights public health’s transition from a Westphalian to a post-Westphalian governance context.

The concepts that characterize post-Westphalian public health began to appear before SARS, but SARS still represents the first post-Westphalian pathogen for two reasons. First, the SARS outbreak was the first epidemic since HIV/AIDS to pose a truly global threat. Other new and not previously recognized microbes that emerged in the past 20 years had more limited capacity to threaten international public health because of inefficient human-to-human transmission or dependence on food or insects as vectors or on specific geographical conditions (WHO, 2003b). SARS posed a greater threat because of its more efficient person-to- person transmission and its fatality rate—comparable to some of history’s greatest infectious disease foes, smallpox and influenza.

Second, because of the nature of the SARS threat, the epidemic seriously challenged the emerging post-Westphalian governance system. SARS was a global public health emergency (WHO, 2003c), and the sternest measure of governance systems is their performance in times of crisis. The SARS outbreak provided the first opportunity to evaluate how the new governance approach for infectious diseases would fare under serious microbial attack on a global basis.

Westphalian Public Health

The Westphalian system is a system dominated by states (Scholte, 2001). The key principle of the Westphalian structure is sovereignty (Brownlie, 1998; Scholte, 2001). The sovereignty principle spins off corollary principles: (i) the principle of nonintervention (Jackson, 2001); and (ii) rules governing interactions among states arose from the states themselves and were not binding unless states consented to be bound (i.e., international law) (Brownlie, 1998; The SS Lotus, 1927). The combination of sovereignty, nonintervention, and consent-based international law meant that Westphalian governance was horizontal in nature, so that governance (i) involved only states; (ii) primarily addressed the mechanics of state interaction; and (iii) did not penetrate sovereignty to address how a government treated its people or ruled over its territory. The Westphalian system exhibited another characteristic—the great powers dominated Westphalian politics (Bull, 1977).

Infectious disease control became a diplomatic issue in the mid-19th century (Fidler, 1999). The regime that developed for international infectious disease control bore the imprint of all the characteristics of the Westphalian system. The International Health Regulations (IHR) (WHO, 1983), promulgated by WHO, illustrate the essence of Westphalian public health. The regulations are the only set of international legal rules binding on WHO members concerning infectious diseases (WHO, 2002), and they are are classically Westphalian in structure and content.

The IHR’s objective is to ensure maximum security against the international spread of disease with minimal interference with world traffic (WHO, 1983). The regulations seek to achieve maximum security against the international spread of disease by requiring governments to (i) notify WHO of outbreaks of diseases subject to the Regulations; and (ii) maintain certain public health capabilities at ports and airports (WHO, 1983). The regulations seek to achieve minimum interference with world traffic by regulating the trade and travel restrictions WHO members can impose against countries suffering outbreaks of diseases subject to the Regulations (WHO, 1983).

In keeping with Westphalian principles, the regulations are consent-based rules of international law binding on states. The IHR’s disease notification rules mandate that only information from governments can be used in surveillance (WHO, 1983). The regulations respect the principle of nonintervention by addressing only aspects of infectious diseases that relate to the intercourse among states. They do not address aspects of public health that touch on how a government prevents and controls infectious diseases within its sovereign territory. The IHR’s limited governance scope is also clear from the small number of diseases subject to IHR rules—currently only cholera, plague, and yellow fever (WHO, 1983).

As a regime on international infectious disease control, the IHR proved to be a failure. WHO members routinely violated the IHR (e.g., not reporting disease outbreaks and applying excessive trade- and travel-restricting measures to other countries suffering disease outbreaks) (Fidler, 1999), and the IHR was irrelevant as a matter of international law to the emergence of the worst infectious disease epidemic in the 20th century, HIV/AIDS, because HIV/AIDS was not a disease subject to the IHR (Fidler, 1999).

The IHR’s failure combined with other developments in international health policy to suggest that Westphalian public health governance was fundamentally bankrupt. After its creation, WHO began to concentrate less on horizontal public health strategies (such as those in the IHR) in order to focus more on vertical public health strategies that addressed infectious diseases at their sources inside states (e.g., disease eradication campaigns) (Arhin-Tenkorang and Conceico, 2003). Another way to sense this change in policy is to compare the IHR’s horizontal approach and WHO’s Health for All strategy announced at the end of the 1970s, which stressed universal access to primary health care (WHO, 1978). Or, compare the IHR’s state-centric focus and lack of rules regulating domestic public health systems with the emphasis on the right to health proclaimed in the WHO Constitution (WHO, 1994) and implemented through the Health for All strategy.

Post-Westphalian Public Health

The considerable challenges presented by emerging and re-emerging infectious diseases in the 1990s and early 2000s stimulated thinking on strategies different from the IHR’s Westphalian approach. Two key post-Westphalian concepts were “global health governance” (a new kind of political process) (Dodgson et al., 2002) and “global public goods for health” (a new kind of substantive policy goal) (Smith et al., 2003). Global health governance (GHG) includes nonstate actors in the governance process. One of the best examples can be found in the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund, 2003). Its board of directors includes nongovernmental organization representatives as voting members.

Global public goods for health (GPGH) are goods or services, the consumption of which is nonexcludable and nonrival across national boundaries and involving countries and peoples that are in different regional groupings (e.g., North America and sub-Saharan Africa) (Smith et al., 2003). Under the GPGH concept, public health governance should not serve the interests of the great powers, but should produce globally accessible health goods and services. The explosion of so-called public–private partnerships in global public health provide the best illustration of attempts to produce GPGH (e.g., ventures to develop new antimicrobial drugs for malaria and tuberculosis) (Reich, 2002).

The post-Westphalian strategies of GHG and GPGH can be seen in WHO’s attempts to revise the IHR in the latter half of the 1990s and early 2000s. WHO proposed changes to the IHR that would create GHG and produce GPGH and that were, from the perspective of the Westphalian approach, radical. Two critical proposed changes sought to improve global infectious disease surveillance: (i) moving away from disease-specific reporting to notifications of “public health emergencies of international concern”; and (ii) allowing WHO to incorporate nongovernmental sources of information into its surveillance activities (WHO, 2002). Revising the IHR in these ways would: (i) produce GHG by including nonstate actors in the process of global infectious disease surveillance; and (ii) produce the GPGH of better infectious disease surveillance information for use by states and nonstate actors.

The development of GHG and GPGH strategies indicate that post-Westphalian public health governance had started to form in the late 1990s and early 2000s, before SARS emerged. But, prior to SARS, the post-Westphalian strategies, particularly in the context of the Global Fund and HIV/AIDS, were showing signs of severe stress, generating skepticism about the new governance approaches. The IHR revision process was not progressing well and was obscure and ignored in much of the ferment happening in global public health circles in the latter half of the 1990s and early 2000s (Fidler, 2003). If post-Westphalian public health could not handle the strain that existing diseases created, what would happen when the next infectious disease crisis broke in the world?

China, SARS, and Post-Westphalian Public Health

SARS proved to be the next crisis. Instead of failure, the global campaign against SARS achieved a victory that will go down in the annals of public health and international relations history. In SARS, the world confronted a virus never before found in humans that was transmitted from person to person, that had a relatively high fatality rate, and against which public health practitioners had neither adequate diagnostic technologies nor effective treatments or vaccines. The last time the world confronted a virus with this disturbing profile was when HIV emerged in the early 1980s, and HIV triggered one of the worst disease epidemics in human history that is still raging globally. SARS was a crisis of the first order for global public health. Yet, unlike with HIV/AIDS, victory was achieved. How?

China Confronts Public Health’s “New World Order”

We answer this question by focusing on what happened with China’s response to the SARS outbreak. China was the epicenter of the SARS outbreak; thus, it was the governance epicenter. What happened to China during its response to SARS illustrated the power of the GHG and GPGH strategies of post-Westphalian public health. China’s initial responses to SARS followed the Westphalian template because China was under no international legal obligation to report SARS cases to any state or international organization, nor did it have an express duty to cooperate with WHO on the outbreak. China made the mistake, however, of acting Westphalian in a post-Westphalian world. In its confrontation with public health’s “new world order,” China miscalculated and lost.

GHG mechanisms—especially WHO’s access to nongovernmental sources of information for surveillance purposes—trumped Chinese attempts to exercise its sovereignty through control of epidemiological information about SARS. China’s initial handling of SARS demonstrated that it had not grasped the new context for public health governance—epidemiological information about disease does not recognize borders. At the outset of the SARS epidemic, China played the sovereignty card, only to retreat when its sovereignty was seen as a deliberate attempt to hide an outbreak—one that was already indicating serious consequences for the rest of the world.

The need for producing GPGH for the SARS battle—especially accurate surveillance data on the outbreak in China—swept aside China’s narrow construction of its national interest vis-à-vis the outbreak. China behaved as if its national interest in preserving flows of trade and investment into China and the image of the Communist Party could simply ignore the legitimate concerns of other states and nonstate actors, such as multinational corporations. China’s conception of its national interest broke apart in the post-Westphalian public health atmosphere of SARS.

In the SARS outbreak, the world did not witness China enjoying the Westphalian privileges normally accorded powerful countries, but rather saw post-Westphalian public health governance humble a rising great power in the international system for disease control.

Beyond China: SARS and Post-Westphalian Public Health

The SARS outbreak contains other interesting features that support the emergence of post-Westphalian public health governance. The most amazing involved WHO’s issuance of geographically specific travel advisories that recommended that people not travel to locations experiencing local chains of SARS transmission (e.g., Guangdong Province, Beijing, Toronto). These travel advisories were revolutionary developments in international policy on infectious diseases because, in issuing the alerts, WHO exercised independent power over its member states without express authority in international law to do so. The approval by WHO member states at the May 2003 World Health Assembly meeting of these radical acts (WHO, 2003a) confirms the existence of an entirely new governance context for infectious disease control.

Other aspects of the outbreak’s handling also illustrated the power and promise of GPGH, including the unprecedented nature of the global collaborative efforts to create, analyze, and disseminate information on (1) the SARS virus; (2) clinical management of SARS cases; and (3) public health strategies for breaking the chain of transmission. The SARS outbreak was also post-Westphalian in how it elevated public health as a matter of national political priority in many countries (National Intelligence Council, 2003) and reinforced the linkage between infectious disease control and international human rights through the widespread use of quarantine and isolation (McNeil, 2003).

SARS and the Vulnerabilities of Post-Westphalian Public Health

The political pathology of SARS also reveals vulnerabilities that post-Westphalian public health governance faces in light of the SARS outbreak. SARS was a victory for post-Westphalian public health, but serious problems continue to exist, including the presence of public health infrastructures in China and many other countries that remain inadequately prepared for severe infectious disease threats. Repeated warnings that SARS may return in the winter months of 2003– 2004 stress the necessity of sustaining the kind of national and international commitment witnessed during the SARS outbreak, but whether sufficient political, financial, and public health commitment will be forthcoming remains unclear.

Conclusion

The political pathology of SARS constructed in the paper suggests that governance innovations used to move public health into a post-Westphalian context contributed to the successful global response to a severe infectious disease threat. The global containment of SARS represents a historic triumph that will enter the annals of history as one of the most significant achievements in global infectious disease control since the eradication of smallpox.

Commenting on SARS, WHO’s executive director for communicable diseases, Dr. David Heymann, argued that “[i]n the 21st century there is a new way of working”(Heymann, 2003). Against the global health emergency of SARS, the “new way of working” proved effective, which constitutes a victory for the emerging framework of post-Westphalian public health.

Although victory should be savored, everyone should remember that germs do not recognize victories or defeats. The challenge for post-Westphalian public health is to create the conditions necessary for the governance innovations successfully deployed in the SARS outbreak to be refined, improved, expanded, and sustained to meet the ongoing threat that pathogenic microbes present. The germs will keep coming. The great task for the global community that answered the initial challenge from SARS is to ensure that the “new way of working” continues to work far into the 21st century.

Footnotes

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This document summarizes Fidler DP. 2003. SARS: Political pathology of the first post-Westphalian pathogen, Journal of Law, Medicine & Ethics. This article served as the basis for Fidler DP. 2004. SARS, Governance, and the Globalization of Disease, London: Palgrave Macmillan.

Copyright © 2004, National Academy of Sciences.
Bookshelf ID: NBK92470

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