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Article

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.

Article

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.

Article

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.

Article

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.