Monday, June 05, 2006

WHO, part III: the world changes

[This is the third of several posts (part I, part II) giving some background to the place of WHO in the international system. I am trying to explain some things about WHO behavior and positions I think might be useful to interpreting their actions and statements. It is not meant as a defense of either.]

The idea that states were the only legitimate actors was the essence of the system WHO was born into, guiding and constraining its activities for the first 50 years or so. It derived from the Peace of Westphalia, 1648 (seep part I):
The Westphalian moment in the seventeenth century represented the effective abandonment of the legitimacy of transnational, non-state actors, such as the Catholic Church, that had played governance roles in earlier times. The Peace of Westphalia stripped governance of international relaitons bare of such actors and grounded governance in the interactions of sovereign states. (David Fidler, SARS, Governance and the Globalization of Disease, p. 50)
In part II we saw how this was reflected in the International Health Regulations that governed WHO's activities in infectious disease, establishing the state as the only legitimate source of epidemiological information and the only actor that could authorize its dissemination. The idea of the IHR was to reduce the possibility that one state would needlessly harm another by the unilateral application of quarantine or product boycott for reasons of infectious disease. The IHR were international health treaty counterparts to the kind of standardization that was done in many places in the twentieth century to standardize regulations, screw sizes and many other things to lubricate the wheels of commerce, travel and trade.

Despite the state-centered basis, non-state actors like multinational corporations (MNCs) and non-governmental organizations (NGOs) were not absent from the WHO world. WHO had both formal and informal systems of relationships with them to allow cooperation and consultation in matters of health. The difference was that the MNCs and NGOs were not part of the WHO governance scheme. Only states were.

But NGOs and MNCs were neither inert nor passive and their power and influence grew in the last third of the twentieth century. An international campaign against infant formula in the developing world had significant success in altering marketing practices of MNCs and national maternal and child health agencies. The field of actors was being enlarged beyond the states, affecting intergovernmental agencies like WHO indirectly through effects on MNCs and governments. MNCs in turn also were players with national governments and sometimes NGOs. The stage was becoming more crowded.

At the same time a new kind of actor was coming into being, the "public-private partnership." A recent example is the Bill and Melinda Gates Foundation's Global Alliance for Vaccines and Immunization, directed at working with WHO and other intergovernmental agencies like the World Bank, governments, NGOs and pharmaceutical companies to provide vaccines for the world's children. This is about as un-Westphalian an endeavor as one can imagine. These partnerships are not treaty agreements between sovereign states but agreements between a wide range of actors that include WHO, sovereign states, NGOs, MNCs and others. Nor is it the only such example. There are many others, including the ambitious voluntary bird flu fund established in January.

Thus while the IHR remained stuck in a Westphalian world, the international system had changed radically. On paper, international health might be populated solely by state actors, in reality that world was gone. Whether it was NGOs, corporations, public-private partnerships or the new sub-cultures growing up through the internet, the prohibitions and constraints that kept WHO confined to horizontal relationships between state actors had broken down and numerous new actors were busily engaged in influencing, intervening, opposing or supporting what was going on inside state borders.

There is more to it. A fundamental change was occurring in how we looked at the world, perhaps best symbolized by the iconic blue marble view of the earth from space. The right to participate in international health governance was no longer seen as the sole right of nation states, whose existence is not visible in this view. Nor is it presumed that the Great Powers should be either the sole producers or sole consumers of products meant to enhance the health of the globe. The Westphalian standard of "the national interest" was no longer the obvious touchstone of all global health decisions.

Fidler discusses how the new view influenced such establishment sources as the 2001 action agenda of the Commission on Macroeconomics and Health on a matter which concerns us here, so I'll end this post with it:
The Commission's action agenda included the recommendation that the supply of global public goods, such as international disease surveillance, be bolstered through additional financing of relevant international organizations, including WHO. The Commission captured why [the idea of global public health good] differs from the policy objectives targeted in Westphalian governance when it observed that global public goods "are public goods that are underprovided by local and national governments, since the benefits accrue beyond a country's borders." (Fidler, p. 60).
In part IV, we'll discuss how WHO responded -- and failed to respond -- to the new reality and the growing threat of emerging and re-emerging infectious diseases.