Exploring collective health security in a new age of pandemics. A review of Sara E. Davies’ Containing Contagion.

Abstract

Containing Contagion: The Politics of Disease Outbreaks in Southeast Asia. Sara E. Davies. Johns Hopkins University Press, Baltimore, USA, 2019, pp. xii + 212. ISBN 978-1-421-42739-3 (pbk). It is impossible to read Sara E. Davies' Containing Contagion in 2020 without evaluating its arguments in light of the dramatic rise of COVID-19 in the year since its publication. Given these developments, the book stands as an invaluable resource for anyone seeking to understand ‘how we got here’, in terms of the range of state responses to the current pandemic and beyond. Containing Contagion opens with rich insights into the historical and political processes that brought about the multiple phases of increased international collaboration that have shaped contemporary international health norms. Where the book's most significant value lies, however, is in its firmly-rooted, empirical exploration of how certain factors work for and against the successful real-world diffusion of these norms. This exploration takes place in Southeast Asia, a region where the uptake of collective health security measures is increasingly important, and one that is well-known for resistance to external adjudication on matters such as human rights. Davies' distinctive approach to assessing collective health security performance in Southeast Asia places more emphasis on values, networks and the normative capacity of health securitization instruments, than on questions of differentials in technical capacities, political systems or public resource mobilization (though she does also account for these). In doing so, she provides a framework through which challenges as well as opportunities can be identified and extrapolated to other regions. For Davies, ‘the Southeast Asian experience provides important insight on how to begin collective realization of a duty to report outbreak events’ (p. 3). The book is divided into six interrelated areas of inquiry, which are briefly explored here. In Chapter One, Davies provides a historical account of the negotiation and adoption in 2005 of the revised International Health Regulations (IHR), described as ‘a significant diplomatic coup for the WHO’ (p. 16). For newcomers to international public health politics, the chapter also provides a helpful introduction to previous iterations of the IHR and the developments that led to its 2005 revision and re-adoption. This background orients the reader to this instrument's significance, especially in its potential to dramatically reshape global responses to infectious disease outbreaks. The chapter then explores dominant narratives that have emerged since 2005 that have sought to evaluate the practical implementation of the new IHR. These include concerns about the decentralized structure of the World Health Organization (WHO) itself, which can be seen to inhibit country accountability in relation to the IHR core capacities. Compounding this is the fact that the regulations are non-binding, and so are not rigidly complied with, monitored or evaluated in the same way that a treaty would be, such as via treaty body review and civil society shadow reports. Relatedly, there is no funding mechanism that supports low- and middle-income countries to fully implement its requirements. This leaves it ‘largely up to states individually to secure the investment needed to achieve the IHR core capacities’ (p. 33). While setting out these critiques, particularly as they intensified following the 2009 swine flu and 2014 Ebola outbreaks, Davies cautions that such narratives of compliance failure can risk ‘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’ (p. 41). This sets up her own line of enquiry, along the following lines: In a region where consistent relevant gains have been made since 2005, what role has the adoption of the revised IHR played in realizing these? This is treated less as a question of benchmarks, and more as one of internalization. Such internalization, or norm diffusion, is particularly remarkable in the case of ASEAN, a region where member states are particularly committed to the principle of non-interference regarding domestic affairs. In Chapter Two, Davies walks the reader through the political context of Southeast Asia in relation to the management of infectious disease outbreaks. By highlighting regional specificities, she helps the reader to better understand the complex and changing conditions that can affect national IHR compliance—conditions which Davies is careful to point out are as political as they are technical or financial. This examination explores the region's underlying challenges, including health inequality, governance-related issues and a longstanding resistance to international norms. In Chapter Three, the book examines the real-world experiences of ASEAN in the mid-2000s as a region increasingly confronted with infectious disease outbreaks. SARS, followed soon after by H5N1, created a ‘compulsion to cooperate’ (p. 83). Crucially, these outbreak events were accompanied by the securitization of health and infectious disease discourse. Davies argues that by creating ‘an environment where ASEAN states recognized the threat as shared and understood that collective action was needed’, an observable normative shift took place (p. 83). Further, the emergence of health securitization discourses appears to have complemented rather than run counter to the region's principle of non-interference, as security threats became appreciated as collective threats to regional security. Chapter Four details the creation of the unique regional implementation program developed to pursue IHR compliance in Southeast Asia: the Asia Pacific Strategy for Emerging Diseases (APSED). Of particular importance was APSED's emphasis on the need to implement the IHR not only nationally but regionally. Such a focus on the regional dimension stood at odds with the approach taken by WHO headquarters, where emphasis was placed firmly on national-level and international-level responsibility. In Chapter Five, Davies impressively surveys surveillance reports relating to the ASEAN states from 1996 to 2010, thereby tracking the changing performance in disease surveillance and response during this period. We see here how the reporting practice of disease outbreak events—even among the most recalcitrant of ASEAN states—changed under the normative influence of the APSED framework. The analysis also reveals the significance of differentiation between states' reporting practices. This differentiation is examined in detail in the final chapter (Chapter Six). Davies shows that ‘the trend toward enhanced detection and reporting is at most risk in two areas: follow-up verification of initial disease outbreak reports and confronting the political situations that affect state capacity to detect and respond’ (p. 116). Despite these challenges, and differences in terms of individual state capacities, her overall argument is that Southeast Asia as a whole exhibited stronger compliance with the IHR reporting requirements, with increased formal reporting widely evident. The media reported this as a monumental failure on behalf of the WHO, and a thousand articles bloomed examining where the WHO had gone wrong. In addition to the debate about the WHO's response were questions about the efficacy of the IHR revisions in shaping state behaviour in response to public health emergencies (p. 30). This quote could potentially be repeated verbatim in 2020, in relation to COVID-19. For instance, Lee (2020) writes of an ‘unprecedented pandemic and [a] splintered global response’, and calls for a new instrument altogether to overcome fragmentation. Ferhani and Rushton (2020: 460) write that bordering practices during the COVID-19 pandemic ‘have highlighted some major limitations in the way the IHR (and the WHO) conceptualize the functioning and location of national borders’. For Stuckelberger and Urbina (2020: 113), COVID-19 is a ‘game changer’ and calls for ‘a revision of IHR as well as a more biological, clinical and community-centered preparedness strategy’. Time will tell whether, like Containing Contagion, a regionally-specific, ASEAN-wide analysis would look more favourably on the practical implementation of containment measures during COVID-19. An additional area of exploration for future research could be to draw links between the securitization of health discourse, (which Davies demonstrates was a framing strategy utilized by, among others, APSED and WHO to encourage compliance with IHR measures), and the wave of human rights violations committed by states in the wake of COVID-19. Such crackdowns, under the guise of ‘defending’ against the ‘threat’ of COVID are an increasingly documented phenomenon among hybrid regimes in particular, including those within ASEAN (Grundy-Warr & Lin, 2020: 499). Leaders of hybrid regimes, while not invoking the IHR itself (which implores countries to uphold human rights principles), have consistently applied heavily securitized language to justify drastic and arguably disproportionate measures taken to ‘combat’ COVID-19. Such measures include militarized lockdown zones, arrests and arbitrary detention of activists and opposition figures, increased surveillance, and the introduction of vague and far-reaching emergency laws (Seewald, 2020; Spadaro, 2020). Much has been written on how the securitization of aid discourse of the mid-2000s provided a normative vehicle for leaders to justify repression, and the deleterious effect this has had on political space for civil society (Fowler, 2008). Perhaps we are likewise now witnessing the flow-on effects of a deliberate institutional strategy to securitize public health discourse in hybrid regimes in order to encourage norm diffusion. Containing Contagion is truly a book that will only increase in significance and relevance in the coming years, providing as it does an essential foundation on IHR internalization and reporting compliance. It will act as a springboard for much future research into pressing issues of increasing global significance for us all.