Governing Global Health: whose diseases become global diseases?

I. Introduction

In mid March 2003 the small bush airport of Maun, Botswana, the entrance to the magnificent Okawango Delta, transformed overnight from a calm African airstrip into a possible entry point for a major health threat. Airport staff in masks handed health warnings of a novel and unknown disease called Severe Acute Respiratory Syndrome (SARS) to passengers wearing khaki adventure clothing. Ministry of Health officials questioned incoming passengers predominantly from Europe and Northern America, about their latest travels and in return received anxious and concerned inquiries from leaving passengers ready to board their flights back home. A feeling of vulnerability lay heavily in the air.

Meanwhile, on the other side of town, in the local hospital Batswana children, women and men stood patiently in a long line, under the scorching sun to await their routine medical checkups. Every person in this line had tested positive for the Human Immunodeficiency Virus (HIV), and many are also latent or open carriers of the bacterium Mycobacterium tuberculosis (TB). No questions were asked here; overworked doctors and nurses were too busy providing basic support to the never-ending line of patients. The feeling here could be best described as accepting ones fate to die, with little hope to become eligible for a place on the antiretroviral therapy (ARV) program initiated by the government, which had commenced a year earlier.^[1]

What remained was the perception that something profoundly different happened in the same place, at the same time. But what was it?

Only three months later on July 5th, 2003 the World Health Organisation (WHO) issued a statement declaring the SARS threat contained as ‘the human chains of SARS virus transmission appear to have been broken everywhere in the world’. Yet, warned that ‘SARS will continue to menace the global public health system’ and further concluded that the disease ‘pushed even the most advanced public health systems to the breaking point’ .^{[2] [3]} By the end of the same year the organization issued a summary of the probable SARS cases that had occurred globally and estimated the number of infections at 8096 of which 774 were fatal.^[4] Thus amounting to an approximately one in ten chance to die of the disease.^[5]

HIV and TB on the other hand remain far from contained, but have since then increased in global prevalence, especially in developing countries and in particular in Sub-Saharan Africa.^[6] Moreover, as Mills and Shillcutt, observe ‘benefits of research mean that tools and approaches’ are available ‘to address [these] communicable diseases’ to either cure or prolong life considerably and reverse their spread all together.^[7] Yet, the number of people living with HIV globally has been estimated to total 38.6 million in 2006, with 4.1 million new infections and 2.8 million deaths in 2005.^[8] And further, despite the fact that TB is curable 5000 people die of the disease every day totaling to almost two million deaths per year and more than nine million new infections.^[9]

In light of the above introductory observations and empirical facts, this paper will investigate two specific issues in the realm of global health governance. Due to the confines of this paper, and in appropriate response to the research question, this paper focuses on two selective diseases. HIV/AIDS and SARS will act as examples to illustrate how different diseases become global or not. Firstly, it will shed light on the question of how these communicable diseases become ‘global’. Here, the question is broken down into the aspects of physical and ideational ‘becoming’ of those diseases. Secondly, it will scrutinize the aforementioned perception that the SARS epidemic may be constructed as more global than HIV/AIDS. This component of the paper will in particular examine if this construction is based on an inherent interest of powerful actors in the global health realm (i.e. States, Multi National Corporations (MNCs) to make some diseases more global than others. And if so, why?

II. Conceptualizing global communicable diseases and its governance

Before proceeding with the analysis of whose diseases become global, the key concepts and terms of this paper need to be grounded in a set of working definitions. The following paragraphs will therefore set out to define the interrelated and/or overlapping notions of globalization and health, as well as a global health governance approach. At the same time, it will justify the usage of a particular conceptual lens through which the analysis will be guided and [re]viewed.

First, globalization is as Kelley Lee broadly sets out to define a ‘set of processes that are changing the nature of how humans interact across three types of boundary’s - spatial, temporal and cognitive.’^[10] Her definition resonates with, while not directly referring to, the findings of the seminal work of John Ruggie on the ‘unbundling of territoriality’.^[11] Ruggie persuasively argues, that the emerging post-modern ‘spatial extension’ and implosion reconfigures and questions our understanding of the assumption that territorial states are the center of gravity around which socio-political authority itself revolves.^[12] James Rosenau confirms this view by coining these dynamics fragmegration, however,^[13] rightly points out that scholars ‘differ over the degree’ of weakening statehood. From this perspective health implications are wide-ranging, for instance, people not only move with or without passports but also as carriers of communicable diseases in a world of intercontinental air travel and ‘boat people’. At the same time reports of disease outbreaks travel instantaneous through the global village of cyberspace and are able to overtake spreading diseases with ease on the data highway.^[14] Here, concurrently temporal boundaries change as the speed and velocity of human interaction accelerates human social activity.^[15] Further, as Kelly notes, ‘[n]ational aggregates obscure the fact’ that different parts of the population ‘depending on their location in the emerging global order’ will have particular health requirements and are actually more likely to be ‘more akin with people’ in other states.^[16]

In addition, the transforming ‘social episteme’^[17] or cognitive flux in a globalizing world has great impact on how we view the world, fellow humans and ourselves within and amongst those respectively. Once again, the health effects are diverse. Increasing knowledge and awareness of global health threats and implications, even if they do not affect the individual per se, emphasizes ‘the importance of health as a universal value’ or global public good^[18]. Especially as widening and increasing ‘inequalities scar the world’s health landscape’.^[19] While at the same time ‘greater sharing of knowledge and technology across countries’ hold the possibility of greater health benefits, therefore offering important gateways to achieve this universal value.^[20]

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^[1] Ministry of Finance and Development Planning - Botswana, ‘National Development Plan 9 - 2003/04-2008/09’, (Gaborone: Government Printers, 2003), page 322 Note: These observations have been made by the author while employed as Development Worker/Regional Coordinator at the Young Women’s Christians Organisation North West (YWCA N.W) as part of Skillshare International during his placement from 2002 until 2004 in Maun, Botswana. Note: HIV/AIDS has hit Botswana hard, it is estimated that 37.4% of the population are infected with the disease in The National AIDS Coordinating Agency (NACA), ‘Botswana 2003 Second Generation HIV/AIDS Surveillance’, page 2 accessed online 24th of September 2006 http://www.naca.gov.bw/documents/Flyer_ENGLISH_A4.pdf

^[2] World Health Organisation, ‘SARS outbreak contained worldwide’, Press Release 56, 2003, accessed online on the 18th of September 2006 at http://www.who.int/mediacentre/news/releases/2003/pr56/en/

^[3] World Health Organisation, ‘SARS outbreak contained worldwide’, Press Release 56, 2003

^[4] World Health Organisation, ‘ Summary of probable SARS cases with onset of illness from 1 November 2002 to 31 July 2003 ’, accessed online 12th of September 2006 at http://www.who.int/csr/sars/country/table2004_04_21/en/index.html

^[5] World Health Organisation, ‘ Summary of probable SARS cases with onset of illness from 1 November 2002 to 31 July 2003 ’

^[6] UNAIDS, ‘Global facts and figures 2006’, accessed online on the 17th of September 2006 at http://www.who.int/hiv/mediacentre/200605-FS_globalfactsfigures_en.pdf

^[7] Anne Mills, Sam Shillcutt, ‘Communicable Diseases’, in Bjorn Lomborg (ed.) ‘Global Crises, Global Solutions [Copenhagen Consensus 2004], (Cambridge: Cambridge University Press, 2004), page 62 Note: Life expectancy ofpeople living with HIV/AIDS with the latest antiretroviral therapy is estimated to prolong life to at least 10 years from the onset of infection. For instance, the US celebrity and former Basketball player Magic Johnson, having all the resources for the best treatment available to him, has been diagnosed in 1990. See CCTV, ‘The beginning of the end of HIV’ accessed online on the 11th of September 2006 at http://www.cctv.com/program/natureandscience/20060919/100237.shtml

^[8] UNAIDS, ‘Global facts and figures 2006’

^[9] World Health Organisation, ‘2006 Tuberculosis Facts’, accessed online on the 11th of September 2006 at http://www.who.int/tb/publications/2006/tb_factsheet_2006_1_en.pdf

^[10] Kelley Lee, ‘Health Impacts of Globalisation - Towards Global Governance’, (New York: Palgrave Macmillian, 2002) page 4

^[11] John Gerard Ruggie, ‘Territoriality and Beyond: Problematizing Modernity in International Relations’, International Organization, Vol. 47, No.1, 1993,pp. 139-174

^[12] John Gerard Ruggie, ‘Territoriality and Beyond: Problematizing Modernity in International Relations’, page 148 Note: Ruggie abstracts this argument from an analysis of differentiating pre-modern systems of rule, such as nomadic tribes or medieval systems.

^[13] James Rosenau, ‘Governance in a new global order’ in David Held and Anthony McGrew (eds) Governing globalisation: power, authority and globalgovernance (Oxford: Polity, 2002), page 73 Note: Fragmegration understood both as Neologism and hybrid of fragmentation and integration.

^[14] The term was first coined in Lewis Wyndham, ‘America and cosmic man’, (London, Brussels: Nicholson and Watson, 1948)

^[15] William Scheuerman, ‘Globalization’, The Stanford Encyclopedia of Philosophy (Fall 2002 Edition), Edward N. Zalta (ed.), accessed online on the 16th of September 2006 at <http://plato.stanford.edu/archives/fall2002/entries/globalization/>.

^[16] Kelley Lee, ‘Health Impacts of Globalisation - Towards Global Governance’, page 6

^[17] John Gerard Ruggie, ‘Territoriality and Beyond: Problematizing Modernity in International Relations’, page 157

^[18] Richard L. Guerrant, Bronwyn L. Blackwood, ‘Threats to Global Health and Survival: The Growing Crises of Tropical Infectious Diseases - our “Unfinished Agenda”, ClinicalInfectious Diseases, Vol. 28, pp 966-986, 1999, page 966

^[19] Lee Jong-wook, ‘Global improvements and WHO: shaping the future’, The Lancet, Vol. 362, No. 9401, pp 2083-2088, 2003, page 2084

^[20] Kelley Lee, ‘Health Impacts of Globalisation - Towards Global Governance’, page 7