Simon Rushton

Global health security: the wider lessons from the west African Ebola virus disease epidemic

Summary The Ebola virus disease outbreak in West Africa was unprecedented in both its scale and impact. Out of this human calamity has come renewed attention to global health security—its definition, meaning, and the practical implications for programmes and policy. For example, how does a government begin to strengthen its core public health capacities, as demanded by the International Health Regulations? What counts as a global health security concern? In the context of the governance of global health, including WHO reform, it will be important to distil lessons learned from the Ebola outbreak. The Lancet invited a group of respected global health practitioners to reflect on these lessons, to explore the idea of global health security, and to offer suggestions for next steps. Their contributions describe some of the major threats to individual and collective human health, as well as the values and recommendations that should be considered to counteract such threats in the future. Many different perspectives are proposed. Their common goal is a more sustainable and resilient society for human health and wellbeing.

HIV/AIDS and securitization theory

This article uses an analysis of the securitization of HIV/AIDS as a basis for proposing three contributions to securitization theory. Beginning with an examination of some of the key debates which have taken place between the Copenhagen School and its critics, the article goes on to argue that the process of securitizing HIV/AIDS was in fact significantly more complex than has been generally recognized and, crucially, that a more nuanced reading of this case highlights a number of issues that are not well captured by the existing securitization theory literature. The first is that securitization can be a multi-level process, with distinct securitizing actors and audiences at each level. The second is that securitization can best be understood as a continuum rather than a binary condition, and that different members of an audience may place an issue at varying points along this spectrum. The third contribution we seek to make is an intervention in the debate over the role of empirical evidence in securitization, suggesting that claims about ‘empirical reality’ form a crucial part of securitizing speech acts, but that where doubts subsequently arise over the evidence for this ‘reality’, securitization can be undermined, a dynamic that we show in practice in the HIV/AIDS case.

Frames, Paradigms and Power: Global Health Policy-Making under Neoliberalism

The study of global health governance has developed rapidly over recent years. That literature has identified a range of factors which help explain the “failure” of global health governance, but it has largely neglected the global public policy processes which perpetuate that failure. In this paper we argue that there is such a thing as “global health policy” and set out a new framework for analyzing the processes through which it is made, highlighting the mixture of power and ideas, agency and structure, which impact upon the policy cycle. The framework rests upon four pillars: framing; paradigms; power; and the “deep core” of neoliberalism. Through integrating insights from a range of literatures, in particular from the global health governance and public policy analysis fields, we seek to enrich the conceptual basis of current work on global health governance.

Framing global health: The governance challenge

Abstract With the emergence of global health comes governance challenges which are equally global in nature. This article identifies some of the initial limitations in analyses of global health governance (GHG) before discussing the focus of this special supplement: the framing of global health issues and the manner in which this impacts upon GHG. Whilst not denying the importance of material factors (such as resources and institutional competencies), the article identifies how issues can be framed in different ways, thereby creating particular pathways of response which in turn affect the potential for and nature of GHG. It also identifies and discusses the key frames operating in global health: evidence-based medicine, human rights, security, economics and development.

The UK, health and peace-building: the mysterious disappearance of Health as a Bridge for Peace

Abstract The problem of how to build peace in post-conflict societies continues to loom large for governments and development agencies worldwide. This article examines the involvement of the UK development community in the creation of the World Health Organizations ‘Health as a Bridge for Peace’ (HBP) programme. It argues that the new development policy context brought in by the United Kingdom Labour administration in 1997 appeared to provide fertile ground for health-sector initiatives such as these to become an important part of the UKs peace-building strategy, but that HBP in fact failed to take root. The role of individuals, the changing departmental focus of the Department for International Development (DFID), its relationship with WHO, and the absence of persuasive evidence for the efficacy of HBP are highlighted as being crucial in explaining the policys mysterious disappearance.

New life in old frames: HIV, development and the 'AIDS plus MDGs' approach

Abstract There have been recent indications that the primacy of AIDS among global health issues may be under threat. In this article we examine one response to have emerged from the AIDS policy community as a result of this perceived threat: the ‘AIDS plus Millennium Development Goals (MDGs)’ approach, which argues that the AIDS response (the focus of MDG6) is essential to achieving the other MDG targets by 2015, stressing the two-way relationship between AIDS and other development issues. By framing AIDS in this way, the AIDS plus MDGs approach draws on an established narrative of a ‘virtuous circle’ between health and development, but at the same time makes some important concessions to critics of the AIDS response. This article – the first critical academic analysis of the AIDS plus MDGs approach – uses this case to illuminate aspects of the utilisation of framing in global health, shedding light both on the extent to which new framings draw upon established ‘common sense’ narratives as well as the ways in which framers must adapt to the changing material and ideational context in which they operate.

Private actors in global health governance

The landscape of global health governance has undergone a radical transformation. Perhaps the most striking change has been the rise of private actors and their incorporation into what was previously a publicly dominated governance system. Their rise to prominence in global health has brought many benefits, not least in the vast resources that they have harnessed for addressing key global health problems. Yet they have attracted criticism as well as praise. The fact that there have often been heated debates surrounding the roles of global health partnerships (GHPs) and philanthropic foundations is testament to the simple fact that something fundamental has taken place in the field of global health. In a relatively short period of time, beginning in the mid-1990s, these actors have revolutionised the health governance architecture to an extent that the wider international system has not witnessed since the creation of the modern multilateral system, in the aftermath of the Second World War. In contrast to those earlier seismic shifts in international governance, the entrance of private actors in global health governance has not been the result of a carefully planned process. There has been no equivalent of the San Francisco or Bretton Woods Conferences. Rather, the change in global health governance has been a gradual and often ad hoc process. There are no clear lines of authority, either politically or legally. Mandates often overlap and compete. Traditional governance actors, from states to the World Health Organization (WHO), have been forced to adapt to this new reality.

The transformation of global health governance

The authors examine how health governance is being transformed amid globalization, characterized by the emergence of new actors and institutions, and the interplay of competing ideas about global health. They explore how this has affected the governance of specific health issues and how it relates to global governance more broadly.

The global debate over HIV-related travel restrictions: framing and policy change

Abstract In 2010, the US repealed Section 212(a) of the Immigration and Nationality Act, which stated that a non-citizen determined to have a ‘communicable disease of public health significance’, is not admissible into the country without a waiver. This included HIV+ non-citizens. In the same year, several other countries, including China and South Korea, removed similar restrictions. This paper examines the global debate over HIV-related travel restrictions that has been ongoing since the mid-1980s and attempts to account for these recent policy changes. Entry restrictions have almost always been justified as necessary in two ways: to protect public health from the supposed threat posed by the entry of people living with HIV, and to limit the costs HIV+ migrants impose on domestic health systems. Opponents of these restrictions have consistently sought to challenge the evidence underpinning these claims and also to re-frame the issue in rights terms. However, in this paper I argue that this re-framing was not in itself sufficient to bring about policy change. Contributing to the literature on norm building and transnational advocacy both within and beyond global health, this article argues that some other crucial factors also have to be taken into account, including the changing political context (both domestic and international) and the network building strategies employed by opponents of the restrictions from 2008 onwards.

Health and Peacebuilding: Resuscitating the Failed State in Sierra Leone

In recent years it has increasingly been claimed that health-sector initiatives have the potential to make a meaningful contribution to post-conflict peacebuilding. This article examines two types of such claims - that health can act as a ‘bridge for peace’, and that health-sector reconstruction can assist in rebuilding the social contract and reestablishing the legitimacy of the government - and how they played out in the case of Sierra Leone. In this case there was an opportunity for health-sector assistance to go beyond mere humanitarian relief and for it to play an active role in promoting peace and stability. It is argued that the best chance of success may lie in a successful blending of Health as a Bridge for Peace-type approaches and ‘top-down’ government-centred interventions as the country moves from the immediate post-war relief phase to the longer-term process of securing future peace and stability.