Global Governance and Health. International Responses to SARS and Ebola and the Influence of Framing and Politicisation

Table of Contents

List of Tables and Figures

List of Abbreviations

1. Introduction

2. Global Governance and Health
The Politics of Crisis, the Public Sphere and Accountability Ties
Pandemics and Framing: A Matter of Medicine or Security?

3. Methods

4. Pandemic Crises Revisited
The 2003 SARS Outbreak
The 2014 Ebola Outbreak

5. Conclusion and Discussion

References Cited

TABLES AND FIGURES

1. Competing for Access to State Decision-Making

2. Factors Involved in the (Re-)Emergence of Infectious Diseases

3. Chronology of Frames during the Outbreak of Severe Acute Respiratory Syndrome (SARS)

4. Chronology of Frames during the Outbreak of Ebola Virus Disease (EVD)

5. Total Cases of Ebola, April 2014 – April 2015

6. Total Monthly Cases of Ebola, March 2014 – April 2015

ABBREVIATIONS

Abbildung in dieser Leseprobe nicht enthalten

1. Introduction

The world is rife with potential sources of insecurity. Nowhere is this more evident than in global politics where decisions and prioritisation affect millions. Over the past decades a number of epidemic outbreaks have especially occupied public and scholarly attention, and heightened anxiety about infectious diseases in a world of open borders. It does not necessarily have to be a killer virus bringing humanity to the brink of extinction, but the threats posed by disease are very real and highly unpredictable. Accordingly one would think the shadow of the future—scenarios of aggressive viruses, common invisible enemies—has a unifying impact on global health governance. When SARS broke out in China in February 2003 and quickly spread, it did indeed trigger an unprecedented collective response by the international community and was contained within 8 months by July of the same year (WHO 2003a; Mackenzie & Merianos 2013). It is striking by contrast that the Ebola outbreak in West Africa in March 2014 has not been halted to date. Although both outbreaks similarly qualified as pre-pandemic under the World Health Organisation’s six-phased pandemic alert, the response to Ebola has been slow and inconsistent (WHO 2009; Farrar & Piot 2014). Whereas SARS remained limited to around 700 deaths, Ebola had already killed more than 1,400 people by the time that the WHO first acknowledged the epidemic (WHO 2014a,b). Presently the disease has been ravaging West Africa for over a year with a current death toll of 10,823 (WHO 2015a). Why is it that the international community reacted so rapidly and efficiently in one case but seemed ill-prepared, even unwilling, in the other one?

In this context much has been written about WHO deficiencies, particularly concerning lacking resources, political coordination and effective bureaucracy problems (Godlee 1994; Ruger & Yach 2008; Garrett & Pang 2012; Clift 2013). While these can effectively explain response vacuums, they cannot convincingly account for variation in WHO responsiveness. There is, however, another factor that has been often overlooked, namely the impact of framing. Especially in light of uncertainty related to pandemic crises, the public sphere and its expectations become a point of reference in the sense-making phase of crisis management. The threat level of a local outbreak—whether it will turn into a full-fledged pandemic for instance—can hardly be predicted. Unfolding crises nonetheless demand action as the world turns to policymakers for guidance, and hence confront policymakers with the dilemma of the uncertainty paradox: the need for certainty where there is uncertainty. This paper argues that, in the absence of scientific consensus, it is precisely this uncertainty paradox that opens the floodgates to politicisation of pandemic crises, and renders decision-makers highly susceptible to public influence and social conventions (Boin 2005a; Paul & Sherrill 2015). In the first month of its outbreak Ebola was referred to as both an “unprecedented[...]epidemic” (MSF 2014a) and “relatively small still” (Samb 2014). Likewise SARS was played down by Chinese authorities at first, while the WHO declared it a global threat (WHO 2003b; Tai & Sun 2007).

This paper consequently sets out to investigate how politicisation and framing affected the international responses to SARS and Ebola. It especially looks at the triangular relationship between policymakers, the public sphere and accountability in the face of uncertainty of pandemic crisis. The paper first provides a brief overview of global health governance and the ‘trilemma’ it poses, namely ill-defined problems, polycentrism and capacity asymmetries. It then proceeds to highlight how policymakers engage in framing in order to cope with uncertainty of international crises. A particular emphasis lies on the role of communication and accountability pressures between policymakers and the public sphere. The third section takes a closer look at the specificities of global health and pandemic governance, and attempts to underline the challenges of crisis management in this regard. It moreover elaborates on the frames of ‘securitisation of medicine’ and the ‘medicalisation of insecurity’. Both are the most relevant and common frames in pandemic crises as they provide a sense of certainty by categorising epidemic outbreaks and prescribing a particular course of action. However, they foster very different responses. While securitisation acknowledges the crisis as significant threat and prioritises imminent—often military—responses, medicalisation often presents the situation as less urgent but rather as a problem that can be overcome by medicine. The paper further considers the frames of economics, human rights and development that have been identified as relevant in the wider field of global health governance. Fourth, it briefly defines its methodological approach with regards to the aforementioned theoretical framework and the analysis that follows. Fifth, the previously outlined frames are carefully identified and evaluated in the case studies of the 2003 SARS epidemic and the 2014 Ebola outbreak. Through the assessment of their role in the sense-making phase of the evolving epidemic, and through situating them into the larger process of international crisis management, the paper attempts to determine how frame competition impacted the collective response in both cases. Finally, the paper summarises its main findings in a critical discussion.

In order to fully understand governance processes in global health crisis management it must be assessed whose priorities and security are addressed by international collective action, and how uncertainty, public crisis communication and the sense-making phase shape responses. This paper holds that international responses to such transnational crises crucially depend on competing frames and whether the ‘winning’ frame(s) recognise the crisis as an immediate threat. It moreover asserts that these political frames in turn depend on both the outcome of the contest between domestic and international public pressures (expectations of the public sphere), and the influence of ‘politics of accountability’ as exercised by policymakers and non-state actors.

This can be argued to be particularly the case for pandemic crises that confront governance structures with a high degree of risk and uncertainty, and thereby make crisis management wide open to politicisation. Global health governance has not traditionally been linked to framing. On the contrary, the role of social conventions and politicisation processes has been underestimated in their impact on policy outcomes that are largely regarded as rational medical or security decisions. This paper argues that both the uncertainty paradox inherent to pandemic crises and the governance trilemma associated with global health leave the international management of pandemic crises highly vulnerable to the influence of the public sphere. The cases of Ebola and SARS confirm such a hypothesis. The rapid containment of SARS can be attributed to public pressure in reaction to a multiplication of crisis-affirmative securitisation frames and subsequent out-voicing of accounts that downplayed the outbreak. Similarly, Ebola illustrates the impact of the public sphere, as most political frames initially signalled control and little cause for concern. Political framing, however, significantly changed once domestic constituencies and the media became aware of the epidemic. This paper argues that the co-occurrence of public demand for action and changes in political representations of the outbreaks constitutes evidence for a correlation that goes beyond mere timely coincidence.

2. Global Governance and Health

The changing nature of crises and governance in the 21st century has been acknowledged by a large variety of scholars (Rosenau 1992; Held et al. 1999; Linnerooth-Bayer et al. 2001; Wolf 2002). Globalisation has confronted traditionally state-centric diplomacy with the challenge of adapting to an increasing number of non-state threats such as global warming or infectious diseases as well as to the press-ahead by non-traditional actors like NGOs (Acuto 2011). Crisis diplomacy and management of international crises have therefore increasingly become embedded in the broader network of global governance and collective decision-making (Kahler & Lake 2003; Krasner 2004; Boin 2005a; Dingwerth & Pattberg 2006). Global governance describes ‘a horizontally organised structure of functional self-regulation encompassing state and non-state actors bringing about collectively binding decisions without superior authority’ (Rosenau 1992; Wolf 2002). Its key features are interdependence and a societal element in global politics that has commonly been absent from the study of international relations (Barnett & Sikkink 2008).

While traditional state-centric hierarchies may have been largely dissolved, global governance still depends on the system of international resources and laws created by policymakers in the past and thereby continues to be influenced by governments at its core (Keohane & Nye 2000; Krasner 2004; Hagendijk & Irwin 2006). Nevertheless there is a reciprocal element to this ‘patterned social interaction’ between governments and other actors (Kahler & Lake 2003). This paper thus adopts the understanding of global governance as a ‘set of authority relationships’ with policymakers at the heart of realising global governance outcomes, shifting between principal and agent amidst dynamic societal actor networks (ibid:7-8). Such a definition best captures the social dynamic of global governance processes and the accountability ties between different actors, mainly policymakers and the public sphere. Consequently, the socio-normative dimensions significantly influence international political outcomes, and make it indispensable to assess collective action and coordination problems in addition to the traditional focus on power struggles (Barnett & Sikkink 2008).

This is of particular interest for global health, as one would expect issues that fall into this category to be predominantly scientific, and the required responses hence clearly a matter of medicine. Global health governance however includes anything but well-defined problems (Huynen et al. 2005; Ney 2012). National public health problems no longer exclusively remain within the territorial borders and control of single governments, as changes in socio-economic, ecological, political and institutional factors have altered the contextual determinants of human health everywhere (Huynen et al. 2005). The transboundary, interconnected nature of health threats as well as their spill-over effects beyond health and medicine, make health governance a particularly intricate affair (McInnes & Lee 2006).

There are, however, three main characteristics that complicate global health governance, namely ‘messy’ or ‘wicked’ problems, extensive polycentrism and significant asymmetries (Ney 2012; Frenk et al. 2014). First, health comprises a large variety of ill-defined problems, as it is composed of highly complex components and thereby difficult to define (Ney 2012; Topper & Lagadec 2013). Global health governance is however not limited to disentangling the determinants and dependents of health, and understanding their causal relationship, it must moreover identify the correct problems to respond to (Hodge 2013). Although there are easily-definable problems as well, the risk of prioritising the wrong problems is quite real in the realm of global health and could have disastrous consequences (Mitroff et al. 2004; Frenk et al. 2014). This challenge is however made more difficult, as public health issues expand beyond medicine and science. Global health possesses various social dimensions owing to interdependence with state structures, stability and economics amongst others (McInnes & Lee 2006; Ney 2012; Frenk et al. 2014).

Second, the polycentric nature of global health governance causes further complexity, and thus impedes effective identification of priorities and crisis management. Global health governance—as it is today—largely consists of complex polycentrism, which often takes the form of “unstructured[...,]unregulated pluralism” (Ney 2012:245-255). There are currently a multitude of actors, policies, and measures in the field of global public health, and at the same time a striking lack of transparency and coordination (Buse & Harmer 2007; Sridhar & Woods 2013). Although some may highlight the advantages of a multi-level approach to messy multi-level problems as they exist in health (Hooghe & Marks 2003; Enderlein et al. 2010; Varone et al. 2013), the systemic complexity and ‘open-source anarchy’ often in fact hamper policy coordination and concerted action (Ney 2012). The result is sub-optimal to poor governance at best, humanitarian disaster and prolonged health crises at worst (Buse & Harmer 2007; Fidler 2010; Frenk & Moon 2013; Ulbert 2013). Polycentrism certainly does not always produce only negative externalities, but it has to be noted that it quite frequently adds to the ‘messiness’ of health issues and their regulation.

Third and finally, considerable resource, information and power asymmetries confront policymakers with difficulties. With regards to resources, Frenk et al. (2014) argue that there exists a governance paradox in global health. Whereas problems and disease are largely seen as originating from the Global South, resources and medicines to tackle these health issues are mostly produced and stocked in the Global North. There consequently is an “interconnectedness[...]in[...]causes and effects[...], and interdependence in[...response] capacity” (ibid:95-96). Likewise the ill-defined nature of international health problems and the polycentrism of global health governance foster an asymmetry in information. This can be closely related to the possession of capacity and resources, as the latter facilitate obtaining information. However, some also argue that it is primarily the level of complexity in global health governance that makes information harder to acquire and thereby favours those actors best connected and at the heart of global networks (Fidler 2010; Sridhar & Woods 2013; Frenk et al. 2014). This leads to the third type of asymmetry, namely varying power between actors in global health. There is a growing consensus amongst scholars that Western and developed countries have largely dominated the agenda of global health (McInnes & Lee 2006). The lack of funding for tropical diseases, amongst other examples, demonstrates that the issues highest on the agenda are not necessarily the issues most pressing for the global greater good and the world majority, but rather illustrate that weaker actors and the international community depend on those with the largest capacity and therefore power (McInnes & Lee 2006; Hanhimaki 2008; Cunliffe 2009). It would be wrong however to limit dependency chains to states. This paper thus asserts that the uneven distribution of responsibility and power in global health can likewise be found in sub- and transnational authority relationships.

Global health governance consequently is a highly complex and uncertain affair. The trilemma of messy problems, polycentrism and capacity asymmetries leaves significant room for interpretation, and thereby opens the floodgates to intense bargaining over governance outcomes as well as to social and political influence on policy responses and collective action. In the next section this paper elaborates on its argument that there is a threefold political response to this trilemma and the challenges it presents international crisis management with. First, it asserts that framing is a reaction to the uncertainty of ill-defined problems and an attempt to somehow make sense of them. Second, it argues that the emphasis on social conventions and the public sphere is a means to manage the seemingly chaotic polycentrism. Third, the paper claims that the focus on accountability, namely politicians’ responsibility for society and key principles, is a response to existing asymmetries that allows decision-makers to balance conflicting capacity demands.

The Politics of Crisis, the Public Sphere and Accountability Ties

Global governance itself constitutes a complex object of study. It is, however, further complicated by risks and uncertainty of international crises. Faced with some form of perceived threat, uncertainty and urgency—all of transnational scale—policymakers must manage unfolding crises rapidly and effectively (Rosenthal et al. 1989; Boin 2005b). The first part of the process is the sense-making phase: the situational assessment of the risks that are inherent to transnational crises (Boin 2005a; Alemanno 2011). However, policymakers are presented with a dilemma since neither risks themselves nor their spill-over effects can be accurately predicted but may have systemic impacts (Linnerooth-Bayer et al. 2001; Boin 2005b; Van Asselt et al. 2010). This is particularly relevant in the realm of health where science is expected to have all the answers, but cannot possibly provide certainty where there is none. This ‘uncertainty paradox’ places crisis decision-making somewhere in the grey area between social construction and rational classification of threats, and arguably blurs the lines between sense-making and meaning-making (Van Asselt & Vos 2006).

Action in view of uncertainty thereby leads to ambiguity (Van Asselt & Renn 2011). In the absence of clear facts “[a]ctors[...]respond to risks according to their own risk constructs and images, yielding several meaningful and legitimate interpretations of risk assessment outcomes” (Keeney 2004). The core features of international crises and their demand for collective responses via the global governance framework thus open the floodgates to politicisation and framing. The different crisis phases are accordingly not as clear-cut. In fact this paper argues that meaning-making—in the form of political frames—may increase in relative importance when sense-making cannot provide a basis for decision-making.

In the absence of clear scientific risk assessment, effective and timely crisis recognition and response depend on the interpretation of signals by those situated at the core of decision-making, namely policymakers (Boin 2005a). Only if there is an official decision to recognise a crisis as such on a global level, collective action can take place and response capacities can be developed to successfully overcome the crisis. Much overlooked in the crisis management literature, societal and network dynamics can have significant effects on this recognition process and thereby on global governance outcomes and collective responses (Van Asselt & Renn 2011). Not only are policymakers faced with uncertainty highly susceptible to base their actions on ‘logic of appropriateness’¹, that is, on social norms and foreign policy principles, they are moreover influenced by competing frames and the public sphere (March & Olsen 1995:30-31; Koenig-Archibugi 2010; Van Asselt & Renn 2011). The public sphere, as illustrated in figure 1, impacts political decision-making in two main ways: indirectly via social conventions, and directly via active framing and promotion of certain policy options (Kratochwil 1989; Wendt 2001; Nelson & Katzenstein 2014).

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Just like global governance, international crisis management then can be understood as a ‘set of authority relationships’ in which expectations create pressure (cf. Kahler & Lake 2003). Different actors from both the core of decision-making and the public sphere consequently compete over the governance outcome (Boin 2005c). As science and rational situational assessment cannot provide a satisfactory basis for crisis management decisions, states are faced with contending pressures from multiple stakeholders, and must balance their obligations between the domestic-international dichotomy (Barnett & Sikkink 2008; Van Asselt & Renn 2011:435).

The key to understanding global crisis management therefore are ‘politics of accountability’: the relationship between policymakers and the public sphere on domestic and international levels (Drabek 1994:32; Boin 2005c; Grant & Keohane 2005). Governments must accordingly not only address the evolving transboundary crisis, they must respond to public expectations to which they are linked through accountability ties that may be understood as institutionalised public pressure (see figure 1). Policymakers are formally linked to the domestic and international public sphere through democratic and legal structures. Hence, in the sense- and decision-making phase of pandemic crises they must not only interpret uncertainty, they must take into account their ties to the networks and public spheres that empower them to govern (Hooghe & Marks 2008). In this context meaningful communication presents an effective means for policymakers to manage expectations and maintain a domestic and international ‘permissive consensus’ over the appropriateness of their policy choices (Boin 2005c:92; Van Asselt & Renn 2011:440). The vague, convertible nature of frames helps political actors to do exactly that, signalling responsiveness to societal expectations in their crisis management, and thus balance competing domestic and international pressures. Framing consequently provides a way to avoid public questioning of the accountability and appropriateness of political responses. It is in the best interest of policymakers to pre-empt intensifying pressures from a public sphere that is dissatisfied with the political response, since this could pose a ‘constraining dissensus’ to their authority and political standing (Drabek 1994; Boin & ’t Hart 2003; Hooghe & Marks 2008). Framing is however not limited to policymakers but is conducted by a large range of actors (see figure 1) in the rivalry for favoured governance outcomes.

In sum, when studying transnational crisis management the public sphere cannot be separated from decision-making processes as policymakers are embedded in social conventions and networks and increasingly rely on them in the absence of certainty. The public sphere furthermore provides a shadow of the future that holds policymakers accountable and leads them to consider future consequences when making policy choices. Public diplomacy and international crisis management are therefore closely related, since collective responses to complex crises are essentially influenced by framing and politicisation triggered by the underlying accountability ties between policymakers and the public sphere. Framing, the public sphere and accountability ties can thus be seen as responses to the trilemma of global health governance that is essentially inherent to pandemic crises as well.

Pandemics and Framing: A Matter of Medicine or Security?

Pandemic crises bring together the complex environments of global governance and crisis management, and thereby constitute an extraordinary challenge. Emerging and re-emerging infectious diseases (ERIDs) and related outbreaks have been carefully monitored internationally since the early twentieth century (Zacher & Keefe 2008:33-40). While epidemics refer to regional outbreaks larger than anticipated, pandemics are generalised epidemics that affect several regions and populations (Barreto et al. 2006:193). Despite significant recent improvements in international surveillance systems and the current WHO Global Outbreak Alert and Response Network with its six-phased pandemic approach, definitions remain elusive and thus affects outbreak classification (Heymann & Rodier 2001). Monitoring ERIDs however extends beyond the medical challenge of monitoring pathogens and predicting mutations in order to prevent pandemics. Figure 2 illustrates further factors than can contribute to the (re-) emergence of infectious diseases and add to the ‘ill-defined’ character of the crisis. Aggravating the governance trilemma further, limited resources and capacity force policymakers to prioritise and focus coordinated efforts on certain targets (Lai 2012). The identification of root causes and the ‘correct’ problems however presents a complex challenge in itself.

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Unfolding pandemic crises can therefore only be fully understood as “multiple subjective ‘sense making processes’” (Topper & Lagadec 2013:13). Global health crises are wide open to framing and what Ney (2012) calls ‘patterns of exclusion and out-voicing’ as certain narratives outcompete others. This is particularly relevant as different narratives set different priorities or governance outcomes, and second, trigger different responses, that is, means to realise the governance outcome. In the realm of ERIDs it is the ‘outbreak narrative’ for selected infectious diseases that has largely dominated global governance (McInnes & Lee 2006; Scoones & Forster 2008). Although framing plays a major part in enhancing response and governance capacities it has been largely understudied in the realm of global health (McInnes et al. 2012).

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¹ ‘logic of appropriateness’ : “[...]actors following internalized prescriptions of what is socially defined as normal, true, right or good[...]” (March & Olsen 2008:690). In contrast to ‘logic of consequentiality’ : actors orienting their behaviour to expected consequences, results and effectiveness (ibid:701)