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Infectious Disease as a Foreign Policy Threat  

Rebecca Katz, Erin Sorrell, and Claire Standley

The last 30 years have seen the global consequences of newly emerging and re-emerging infectious diseases, starting with the international spread of HIV/AIDS, the emergence of Ebola and other hemorrhagic fevers, SARS, MERS, novel influenza viruses, and most recently, the global spread of Zika. The impact of tuberculosis, malaria, and neglected tropical diseases on society are now better understood, including how these diseases influence the social, economic, and political environment in a nation. Despite international treaties and norms, the specter of intentional use of infectious disease remains present, particularly as technological barriers to access are reduced. The reality is that infectious diseases not only impact population health, but also have clear consequences for international security and foreign policy. Foreign policy has been used to coordinate response to infectious disease events and to advance population health around the world. Conversely, collaboration on infectious disease prevention, preparedness, and response has been used strategically by nations to advance diplomacy and improve foreign relations. Both approaches have become integral to foreign policy, and this chapter provides examples to elucidate how health and foreign policy have become intertwined and used with different levels of effectiveness by governments around the world. As the scope of this topic is extensive, this article primarily draws from U.S. examples for brevity’s sake, while acknowledging the truly global nature of the dynamic between infectious diseases and foreign policy, and noting that the interplay between them will vary between countries and regions. In 2014, U.S. President Barak Obama called upon global partners to, “change our mindsets and start thinking about biological threats as the security threats that they are—in addition to being humanitarian threats and economic threats. We have to bring the same level of commitment and focus to these challenges as we do when meeting around more traditional security issues”. With world leaders increasingly identifying disease as threats to security and economic stability, we are observing infectious diseases—like no other time in history—becoming an integral component of foreign policy.


Coming Out and Political Attitudes Among Sexual Minorities  

Douglas Page

A nascent body of research is growing on the issue of disclosing one’s sexuality, also termed “coming out,” and the implications for attitudes, behavior, and health. This research engages (a) the political attitudes of those reporting their sexual identity, and (b) the social conditions that lead people to express different forms of sexual identity. Four main findings help to characterize the relationship between coming out and political attitudes among sexual minorities. First, people who come out tend to be socially liberal, but the reasons behind this pattern remain unclear. Second, tolerant social conditions correlate with coming out; expressions of tolerant attitudes; and political engagement on behalf of lesbian, gay, and bisexual rights. Third, the reverse holds as well: Intolerant, homophobic social conditions correlate with the concealment of one’s homosexuality and the expression of homophobic attitudes. Fourth, homophobic social conditions also may lead to worse mental health outcomes, which in turn reduce political efficacy and participation. However, the causal relationships between social conditions, coming out, political outcomes, and health outcomes elude existing research. Future research can unpack these relationships and include more cases outside Western Europe and North America, where most research on this topic is conducted.


HIV/AIDS Politics and Policy in Sub-Saharan Africa  

Catherine van de Ruit

Sub-Saharan Africa has the world largest proportion of adults and children living with AIDS. To mitigate the multiple consequences of the epidemic, novel forms of governance arose as international organizations usurped the roles traditionally played by states; new funding streams emerged that led to asymmetries in biomedical resource allocation; and diverse partnerships among international agencies, nation-states, and local and international nongovernmental organizations emerged. Global health actors attempted to define AIDS policy and programming as an apolitical biomedical intervention. However, political dynamics were evident in the negotiations between international donors and African state bureaucracies in setting AIDS policy agendas and the contestations between African and international social movements and global health agencies over AIDS treatment drug prices and access to treatment interventions across the continent. During the first two decades of the African AIDS epidemic (1980–2005) the dominant approach to AIDS disease mitigation was the focus on AIDS prevention, and across sub-Saharan Africa standardized prevention interventions were introduced. These interventions were founded upon limited evidence and ultimately these programs failed to stem rates of new HIV infections. Social movements comprising coalitions of local and international activists and scientists brought extensive pressure on global health institutions and nation-states to reform their approach to AIDS and introduce antiretroviral therapy. Yet the path toward universal provision of antiretroviral treatment has been slow and politically contentious. By the second decade of the 21st century, antiretroviral therapy interventions together with AIDS prevention became the dominant policy approach. The introduction of these initiatives led to a significant decline in AIDS-related mortality and slowed rates of transmission. However, health disparities in treatment access remain, highlighting ongoing shortcomings in the political strategies of global health agencies and the public health bureaucracies of African states.


The Evolution of Transgender Policies in the United States  

Emilia Lombardi

In the United States, increasing numbers of transgender people are coming forward and working to change legislation to better protect their lives and identities. These changes have come over a long period of time with the work of transgender people and allies. Societal acceptance and support for transgender people has evolved, first in the provision of medical resources allowing for physical changes, and later in legislation supporting and protecting people’s ability to publicly and legally express their gender. However, these changes have not been always been to benefit transgender people as others sought to control and limit people’s ability to express nonnormative genders. Policy changes occur in reaction to transgender people, but at the same time, transgender people have been working to allow themselves the freedom to express their genders freely. Major changes first began when scientists and medical professionals became interested in medical technologies such as hormones and its affects on people’s bodies. It was these discoveries that also interested people who felt dysphoric about their gender expression and saw these procedures as being able to reduce their pain and improve their lives. The movement to utilize surgical techniques soon followed. As more people sought these services, medical professionals developed guidelines to identify those who would benefit from the procedures and how to utilize these technologies safely to help people transition from one gender to another. As more people were able to transition, policies arose to prevent or limit people’s ability to express their identity, but transgender people and allies also organized to counter this movement and propose policies that are more supportive and protective for them.


HIV Law and Policy in the United States: A Tipping Point  

Scott Skinner-Thompson

The fight to effectively treat and stop the spread of the human immunodeficiency virus (HIV) has made meaningful progress both in the United States and globally. But within the United States that progress has been uneven across various demographic groups and geographic areas, and has plateaued. While scientific advances have led to the development of medicine capable of both treating and preventing HIV, law and policy dictate who will have ready access to these medicines and other prevention techniques, and who will not. Law and policy also play a crucial role in determining whether HIV will be stigmatized, discouraging people from being tested and treated, or will be identified for what it is—a preventable and treatable disease. To make further progress against HIV, the United States must address healthcare disparities, end the criminalization of HIV, and devote additional resources toward combatting HIV stigma and discrimination.


Key Actors in the Management of Crises: International and Regional Organizations  

Eva-Karin Gardell and Bertjan Verbeek

In crisis-ridden times, when events like the COVID-19 pandemic, acts of terrorism, and climate change-induced crises are making constant headlines, states, businesses, and individuals alike look to international organizations (IOs) to help them weather the storm. How can the role of IOs be better understood in the context of crisis and crisis management? For a start, it requires a distinction between objective and subjective crisis perspectives in studying IOs. From an objective perspective, IOs are examined as unitary actors that have the aim of contributing to the stability of the international political system. On the other hand, in a subjectivistic approach, IOs’ actual crisis management is the focus. In this perspective, the emphasis is on an IO’s internal life, that is, its perceptions, bureau politics, and decision-making. In the exploration of these issues, IOs can no longer by studied as entities but have to be unwrapped into small groups and individuals, such as members of secretariats or member state’s top politicians. As borne out by theories developed by scholars of crisis management and foreign-policy analysis, centralization and cognitive bias are of special interest in the study of IOs. IOs’ crisis management has four crisis phases and tasks: sense-making, decision-making, meaning-making, and crisis termination. Finally, crises may prove a threat to, or an opportunity for, IOs. Transnational crises may usher in IOs’ foundation and flourishing, or they may contribute to IOs’ demise.


Prisons in Africa  

Jeremy Sarkin

African prisons are some of the least-studied penal institutions anywhere in the world. This is not true everywhere on the continent, as prisons in some countries such as South Africa are adequately studied and have been the subject of commissions of inquiry stretching back to colonial times. It is also difficult to generalize about Africa. For example, there are massive disparities between north Africa and sub-Saharan Africa. Usually, not much information beyond generalities exists for many of them across the African continent. As a result, many negative perceptions endure that are not reflective of the different systems and the different countries in the region. The focus of the research has often been on specific themes and certain countries only and has generally focused on problems. There is, however, a need to portray a more realistic situation in prisons in all fifty-four countries more accurately, without generalizing, and to provide more solution-orientated research to a variety of issues. This can be partly achieved by comparative investigation. While the conditions in many African prisons are harsh and difficult for inmates, comparatively speaking, prisons in Africa are not the worst in the world. However, they are generally overcrowded, and there is much violence. Issues generally concerning health, food, sanitation, amenities, and other matters remain generally problematic. However, much data is missing from a range of countries. More research is needed to gather more data and to interrogate the diverse prisons in the different countries. There is a need for more holistic research that understands prisons not as isolated institutions but as part of criminal justice systems. There is a need to understand how methods of policing, the conduct of prosecutions, and court processes all have an impact upon conditions within the prisons of a particular country.


Injustice and Inequalities in Health  

Gopal Sreenivasan

Serious inequalities in health abound the world over. For example, there are marked differences in average life expectancy both between and within countries. Individual life expectancy varies by more than 30 years between the highest national average and the lowest. Even worldwide, average life expectancy lags more than 10 years below the highest national average. Within single countries, inequalities in life expectancy between the top and bottom groups of men, for example, have been recorded at 7 years in England and Wales and at almost 15 years in the United States, albeit using rather differently constituted groups. Intuitively, these inequalities in health will strike many observers as unjust. But why are they unjust, if they are? Are inequalities in health unjust per se? If not, what makes some inequalities in health unjust, but not others? According to an influential analysis, inequalities in health are unjust when they are avoidable, unnecessary, and unfair. Thus, if an inequality in health is inevitable, it is not unjust. Following this analysis means that answering these questions requires a combination of empirical and normative understanding. On the empirical side, some understanding of the socially controllable causes of health is required. On the normative side, various dimensions of fairness have to be understood. In addition, some appreciation of the interaction between these two sides is needed.. Each side of the question is fairly complicated. With respect to the requirements of fairness, three subsidiary controversies can be distinguished. To begin with, should a general principle of equality be applied directly to the case of health? An alternative approach traces the injustice of avoidable inequalities in health to the independent injustice of their social causes instead. Next, should inequalities be defined across social groups (such as class or race within countries or, indeed, countries themselves)? If so, which groups? An alternative is to define inequalities across individuals. Finally, should equality be defined in comparative terms (as is traditional)? An alternative is to define the requirements of fairness non-comparatively (as a matter of “priority” to the worst off). Even if a given inequality in health is avoidable, some resolution of all three controversies is needed to decide whether that inequality is unfair.


The Decision to Vote or to Abstain  

Elisabeth Gidengil

Why voters turn out on Election Day has eluded a straightforward explanation. Rational choice theorists have proposed a parsimonious model, but its logical implication is that hardly anyone would vote since their one vote is unlikely to determine the election outcome. Attempts to save the rational choice model incorporate factors like the expressive benefits of voting, yet these modifications seem to be at odds with core assumptions of rational choice theory. Still, some people do weigh the expected costs and benefits of voting and take account of the closeness of the election when deciding whether or not to vote. Many more, though, vote out of a sense of civic duty. In contrast to the calculus of voting model, the civic voluntarism model focuses on the role of resources, political engagement, and to a lesser extent, recruitment in encouraging people to vote. It pays particular attention to the sources of these factors and traces complex paths among them. There are many other theories of why people vote in elections. Intergenerational transmission and education play central roles in the civic voluntarism models. Studies that link official voting records with census data provide persuasive evidence of the influence of parental turnout. Education is one of the best individual-level predictors of voter turnout, but critics charge that it is simply a proxy for pre-adult experiences within the home. Studies using equally sophisticated designs that mimic the logic of controlled experiments have reached contradictory conclusions about the association between education and turnout. Some of the most innovative work on voter turnout is exploring the role of genetic influences and personality traits, both of which have an element of heritability. This work is in its infancy, but it is likely that many genes shape the predisposition to vote and that they interact in complex ways with environmental influences. Few clear patterns have emerged in the association between personality and turnout. Finally, scholars are beginning to recognize the importance of exploring the connection between health and turnout.


Taxation and Spending in Latin America  

David Doyle

The battle over state redistribution, and the means to pay for welfare transfers, lies at the heart of contemporary political economy. This has been one of the central plinths of political science research on the advanced industrial democracies, and we now have a good understanding of the dynamics of spending and taxation in these countries, rooted in the power of the left and labor movements, together with the embedded liberal compromise. These explanations, however, struggle to explain tax and spending outcomes across Latin America. This is largely because the pressures of globalization, rather than embedded liberalism, drive efficiency concerns in Latin America; across the region, the left often behaves in unanticipated ways, and redistribution comes in many forms. These effects are compounded by the power of business interests across the region and the heterogeneity of voter preferences when it comes to spending and taxation. More research is needed on both the macro and micro level dynamics of taxation and social spending in Latin America.


Pandemic Preparedness and Responses to the 2009 H1N1 Influenza: Crisis Management and Public Policy Insights  

Erik Baekkeskov

From the 1990s and onward, governments and global health actors have dedicated resources and policy attention to threats from emerging infectious diseases, particularly those with pandemic (i.e., global epidemic) potential. Between April 2009 and August 2010, the world experienced the first pandemic in this new era of global preparedness, the 2009 H1N1 influenza pandemic. In line with expectations generated during preparedness efforts in the preceding years, the 2009 H1N1 outbreak consisted of the rapid spread of a novel influenza virus. At the urging of the World Health Organization (WHO) in the years prior to 2009, governments had written pandemic plans for what to do if a pandemic influenza occurred. Some had also taken costly steps to improve response capacity by stockpiling antiviral drugs developed against influenza viruses, pre-purchasing vaccines (which, in turn, led pharmaceutical companies to develop pandemic influenza vaccine models and production capacity), asking domestic healthcare institutions and other organizations to write their own specific pandemic plans, and running live exercises based on constructed scenarios. Aside from departments and agencies of national governments, these preparations involved international organizations, private companies, local governments, hospitals, and healthcare professionals. How can social science scholarship make use of policies and actions related to pandemic preparedness and response, and 2009 H1N1 responses in particular, to generate new insights? The existing literatures on pandemic preparedness and responses to the 2009 H1N1 pandemic illustrate that sites of similarity and difference in pandemic preparedness and response offer opportunities for practical guidance and theory development about crisis management and public policy, as well as policy learning between jurisdictions. Because many jurisdictions and governmental actors were involved, pandemic preparations during the early 2000s and responses to the 2009 H1N1 influenza pandemic offer rich grounds for comparative social science as well as transboundary crisis management research. This includes opportunities to identify whether and how crises involve unique or relatively ordinary political dynamics. It also involves unusual opportunities for learning between jurisdictions that dealt with related issues. Government preparations and responses were often informed by biomedical experts and officials who were networked with each other, as well as by international public health organizations, such as WHO. Yet the loci of preparedness and response were national governments, and implementation relied on local hospitals and healthcare professionals. Hence, the intense period of pandemic preparedness and response between about 2000 and 2010 pitted the isomorphic forces of uniform biology and international collaboration against the differentiating forces of human societies. Social scientific accounts of biosecuritization have charted the emerging awareness of new and untreatable infectious diseases and the pandemic preparedness efforts that followed. First, since about 1990, public health scholars and agencies have been increasingly concerned with general biosecurity linked to numerous disease threats, both natural and man-made. This informed a turn from public health science and policy practice that relied on actuarial statistics about existing diseases to use of scenarios and simulations with projected (or imagined) threats. Second, new disease-fighting prospects presented opportunities for entrepreneurial political and public administrative bodies to “securitize” infectious disease threats in the late 1990s and early 2000s, implying greater empowerment of some agencies and groups within policy systems. Finally, influenza gained a particularly prominent role as a “natural” biosecurity threat as major powers dedicated significant resources to managing the risks of bioterror after September 2001. In subsequent pandemic preparedness efforts, potentially very deadly and contagious influenza became the world community’s primary focus. In turn, the 2009 H1N1 influenza pandemic occurred in the wake of this historic surge in global and national pandemic and, more broadly, biosecurity preparedness efforts. The pandemic led to responses from almost every government in the world throughout 2009 and into 2010, as well as international organizations for public health and medicines. In the wake of the pandemic, formal and scholarly reviews of “lessons learned” sought to inform and influence next steps in pandemic preparedness using the rich panoply of 2009 H1N1 response successes and failures. These generally show that many of the problems often identified in crisis response were repeated in pandemic response. But they also suggest that the rich and varied pandemic experiences offer potential to spread good crisis management practice between jurisdictions, rather than just between events within one jurisdiction. Finally, the 2009 H1N1 pandemic experience allowed careful and in-depth studies of policymaking dynamics relevant to political science, public policy, and public administration theory. Interest-based politics (“politics as usual”) offers partial explanations of the 2009 H1N1 responses, as it does for many public policies. However, the studies of 2009 H1N1 response-making reveal that science and scientific advice (“unusual” politics because scientists are often sidelined in day-to-day policymaking) strongly shaped 2009 H1N1 responses in some contexts. Hence, some of the pandemic response experiences offer insights that are otherwise hard to empirically verify into how sciences (or scientific advisors and networks) become powerful and use power when they have it. As mentioned, the numerous national pandemic response processes during 2009 generated sharply differing pandemic responses. Notably, this was true even among relatively similar countries (e.g., EU member states) and, indeed, subnational regions (e.g., U.S. states). It was also true even when policymaking was dominated by epidemiological and medical experts (e.g., countries in Northwestern Europe). The studies show that global and national scientific leaders, and the pandemic response guidance or policies they made, relied mostly on pre-pandemic established ideas and practices (national ideational trajectories, or paradigms) in their pandemic response decisions. While data about 2009 H1N1 were generated and shared internationally, and government agencies and experts in numerous settings engaged in intense deliberation and sensemaking about 2009 H1N1, such emerging information and knowledge only affected global and national responses slowly (if ever), and, at most, as course alterations.


Ambivalent Humanitarian Crises and Complex Emergencies  

Dennis Dijkzeul and Diana Griesinger

The term “humanitarian crisis” combines two words of controversial meaning and definitions that are often used in very different situations. For example, there is no official definition of “humanitarian crisis” in international humanitarian law. Although some academic disciplines have developed ways of collecting and analyzing data on (potential) crises, all of them have difficulties understanding, defining, and even identifying humanitarian crises. Following an overview of the use of the compound noun “humanitarian crisis,” three perspectives from respectively the disciplines International Humanitarian Law, Public Health, and Humanitarian Studies are discussed in order to explore their different but partly overlapping approaches to (incompletely) defining, representing, and negotiating humanitarian crises. These disciplinary perspectives often paint an incomplete and technocratic picture of crises that is rarely contextualized and, thus, fails to reflect adequately the political causes of crises and the roles of local actors. They center more on defining humanitarian action than on humanitarian crises. They also show four different types of humanitarian action, namely radical, traditional Dunantist, multimandate, and resilience humanitarianism. These humanitarianisms have different strengths and weaknesses in different types of crisis, but none comprehensively and successfully defines humanitarian crises. Finally, a multiperspective and power-sensitive definition of crises, and a more fine-grained language for comprehending the diversity of crises will do more justice to the complexity and longevity of crises and the persons who are surviving—or attempting to survive—them.


Antimicrobial Resistance as a Global Health Crisis  

Erik Baekkeskov, Olivier Rubin, Louise Munkholm, and Wesal Zaman

Antimicrobial resistance (AMR) is a global health crisis estimated to be responsible for 700,000 yearly deaths worldwide. Since the World Health Assembly adopted a Global Action Plan on AMR in 2015, national governments in more than 120 countries have developed national action plans. Notwithstanding this progress, AMR still has limited political commitment, and existing global efforts may be too slow to counter its rise. The article presents five characteristics of the global AMR health crisis that complicate the translation from global attention to effective global initiatives. AMR is (a) a transboundary crisis that suffers from collective action problems, (b) a super wicked and creeping crisis, (c) the product of trying to solve other global threats, (d) suffering from lack of advocacy, and (e) producing distributional and ethical dilemmas. Applying these five different crisis lenses, the article reviews central global initiatives, including the Global Action Plan on AMR and the recommendations of the Interagency Coordination Group on AMR. It argues that the five crisis lenses offer useful entry points for social science analyses that further nuance the existing global governance debate of AMR as a global health crisis.