Containing Contagion: The Politics of Disease Outbreaks in Southeast Asia. Sara E. Davies. Johns Hopkins University Press, Baltimore, USA, 2019, pp. xii + 212. ISBN 978‐1‐421‐42739‐3 (pbk).
The story of global health politics is to a large extent, a story of events, both actual and potential—of outbreaks, epidemics and pandemics that have happened, are happening or which might happen—but also of non‐events—the outbreak that didn't occur or the epidemic or pandemic that was contained or failed to spark, or the endemic that doesn't get framed as an emergency or a security issue.
As the world struggles to cope and come to terms with COVID‐19, it is worth recalling that scientists and officials have long warned of the danger of this kind of event: an outbreak that becomes a pandemic, causing widespread death and illness, overwhelming health systems and disrupting social, economic and political life worldwide. The risk of such pandemics has increased as the world has become more populous, more urbanized and more mobile and as humans (some more than others) exact ever‐increasing ecological harm and encroach on new ecological terrains. Global health leaders and activists have been warning since the 1990s that wealthier populations and states should not imagine themselves to be immune to the risks this generates.
Since the 1990s, the dream has been of a global system that, if it cannot prevent outbreaks, can detect and contain them before they become pandemics, a dream that has often been harnessed to the idea of security. Emerging infectious diseases came to be framed as a security issue in the national security strategies of powerful states and the concept of global health security began to appear in World Health Organization (WHO) policy frameworks. Before COVID‐19, a succession of outbreaks, epidemic and pandemics—highly pathogenic avian influenza (HPAI) in 1997; SARS in 2002–03; HPAI again from 2005; H1N1 influenza in 2009–10; MERS from 2012; Ebola 2014–15; Zika in 2015–16—had driven this agenda, each new event triggering new disputes and revealing both progress made and continued problems with preparedness, detection, reporting and response.
A crucial development was the adoption by WHO member states of revised International Health Regulations (IHRs) in 2005. The new IHRs were premised on the need to manage not just specific, identified diseases, but a generic kind of event that they formulated explicitly for the first time: the public health emergency of international concern. Member states committed to work cooperatively to detect and report public health events of possible international concern, and to develop their capacity to do so. The adoption of the IHRs constituted something of an event in its own right, crystallizing, albeit partially and ambiguously, new norms and rationalities of global health politics.
Sara Davies’ excellent book explores how this idea of health security was absorbed, reformulated and worked out in Southeast Asia in the years leading up to and following the adoption of the new IHRs. It makes a significant contribution to the literature on the politics of global health security by re‐examining existing critiques and exploring the track record of IHR implementation via sustained, in‐depth research in and on a particular region. Marshalling an impressive body of fieldwork and policy analysis, the book offers not only a rigorous examination of how policy has been implemented and evaluated and of policy outcomes, but detailed insight into the multiscalar practices, decisions and dilemmas of scientists and officials working on public health in the region and beyond. It provides a fascinating account of the politics of global health in practice, of how regions matter, of how progress happens and how it often turns out to be both double‐edged and fragile.
As Davies observes, many questions remained about implementation and compliance following the adoption of the new IHRs. Disputes over the sharing of virus samples during the second major outbreak of H5N1, self‐interested behaviour by states during H1N1 and belated international action on the 2014 Ebola outbreak had also borne out critical arguments that the theory and practice of health security referred primarily to the security of global north states from threats emerging in the global south. The literature examining the IHRs tended to stress their weaknesses and failures.
Containing Contagion offers significant qualifications to, as well as partial confirmation of, these critiques. As Davies argues, states in Southeast Asia made progress in building IHR‐related capacity and in outbreak reporting in the five years after 2005 that should not be overlooked. But as the book also shows, the IHRs were able to exert ‘compliance pull’ because they could be integrated into ideas that the region had already embraced, arising out of the experience of previous events. As Davies suggests:
[t]he shared experiences of the Nipah, SARS, and then H5N1 outbreaks in quick succession, and especially the political, economic, and social upheavals that these outbreaks risked creating, dispelled the notion that traditional approaches to security, suffused with sovereignty and non‐interference, would be sufficient (p. 162).
This common experience of successive epidemic events generated a sense of ‘common threat’ as well as ‘a shared regional purpose and responsibility to contain it’ (p. 164). Regional institutions and imaginaries were crucial: progress was facilitated by the support of ASEAN and other interlocking organizations and initiatives, but also by donors, who, for a time, trusted regional initiatives. This created a supportive environment for concrete, joint activities; as Davies reports:
From the exchange of staff to the regular program of workshops and conferences, compliance pull is achieved through informal processes, where pilot study results, budgetary obstacles, and ministerial dilemmas are shared over lunches, dinners and small breakout sessions. Information and expectations, progress, and challenges is shared through frequent face‐to‐face dialogue and direct interaction between officials (p. 8).
Central to this relational process was a sense of confidence and trust, which enabled policymakers, officials and staff to share otherwise sensitive information and issues offline, without fear of attracting censure and shame. Davies shows how the first phase of the Asia Pacific Strategy on Emerging Diseases built on existing norms of ‘quiet diplomacy’ (p. 164), created a safe space to discuss potentially sensitive matters and helped to embed detection and response ‘in local capacity, local needs, and local politics’ (p. 163). While the book presents evidence that implementation of IHR‐related programmes did orient disease detection and reporting activity towards outbreaks of likely international concern at the expense of reporting diseases posing greater immediate threats to health, it also traces how regional actors sought to use the focus on potential epidemics to highlight endemic diseases, including dengue and tuberculosis, while occasionally (and with tacit approval) using funds allocated for ‘vertical’, disease‐specific programmes (for example on influenza) in a way that supported broader, ‘horizontal’ capacity.
As the book also shows, while official reporting of outbreaks increased significantly, progress was uneven across states, with gaps in detection, reporting and confirmation continuing to exist. While official reporting increased, there also remained significant disincentives to the kinds of informal reporting WHO had sought to elicit as a way of getting around the reluctance of local and state actors to acknowledge potentially concerning events; while going public is often valorized in liberal imaginaries, it remains risky if it makes power holders look bad and Davies’ account illuminates the pressures faced by people working in the region tellingly and carefully. All interviewees are quoted anonymously and the key arguments and critiques of the book are made in a scrupulous manner.
As Davies tracks, in a valuable conclusion that brings things closer to the present, the failed initial responses to Ebola and concern that progress on developing IHR core capacities had slowed led to WHO and donors launching a new round of health security programmes, in which national technical capacity has been emphasized over regional political cooperation. However, while these programmes ‘go out of their way to be nonhegemonic … [they] have a distinct North‐South character inconsistent with the regional approach adopted by Southeast Asia’ (p. 171); at this point the book offers its most trenchant commentary and reconnects with broader critiques of the global health security agenda.
How, then, might Containing Contagion help us think about the current pandemic? An obvious point is that while COVID‐19 was not contained close to source, the countries that had been most affected by SARS and H5N1 mounted some of the most effective early responses. The book's insights into cooperative regional forms of health diplomacy and practice are also relevant in terms of the wider crisis of liberalism and the rise of populism and authoritarian nationalism, and the crises of trust and competence that accompany them. As COVID‐19 continues to fuel and be fuelled by conspiracism, denial and xenophobic politics, Containing Contagion offers a highly instructive account of painstaking efforts to develop knowledge, trust and cooperation across borders.