March 30, 2020 update: As the coronavirus pandemic spread around the globe, USIP published a new Q&A with Dr. William Long, author of "Pandemics and Peace." The 2011 Q&A is below.

"Pandemics and Peace" author William Long discusses his recent book on public health cooperation in zones of conflict.

What is the correlation between pandemics and peace?

The spread of naturally occurring or man-made biological threats—such as Avian flu, Swine flu, Severe Accute Respitory Syndrome (SARs)—present a grave security and humanitarian threat regionally and globally. Global economic and political stability could fall victim to a pandemic. As health provision has become a primary public good and part of the social contract between a people and its government, accelerating transnational flows, particularly of pathogens, can stress and could overwhelm a government’s capacity to meet this essential function. Weak states could fail economically or politically, thereby creating regional instability and a breeding ground for terrorism or human rights violations.

Although the peril is great, so too is the promise of building cooperation through regional disease surveillance, detection, and response. Here is the positive potential of globalization: it can facilitate the rapid responses to health challenges by quickly mobilizing health professionals, medicines, and supplies, and by deploying information technology for disease surveillance and sharing best health practices across nations.

While largely unnoticed, countries with a history of conflict are cooperating across borders in the Middle East, the Mekong Delta, and parts of Africa in infectious disease detection, control, and response.  Can these instances of health cooperation be the leading edge of peace among traditional enemies?  Before we can answer that question in a meaningful way, we have to understand why and how this form of cooperation is possible.  These are the questions that animate the book.   Armed with a better understanding of interstate cooperation and transnational governance in health, practitioners and policymakers can better promote positive and peaceful relations, even among adversaries, in health and other areas of shared concern.

What are some examples of international health cooperation?

Health has the power to convene actors in a common purpose, to signal the possibility of rapprochement between long-standing adversaries, and to serve as a positive dimension of larger interstate dynamic. Recent exchanges between North and South Korea on maternal and child care, between North Korea and American nongovernmental organizations on drug-resistant tuberculosis diagnosis, between Turkey and Armenia on avian influenza, and between the EU and Libya on infectious disease control, are but a few of the intriguing examples of the role of health initiatives as an icebreaker in traditionally hostile relations.

This book uses three unlikely cases—infectious disease surveillance in the Mekong Basin, the Middle East, and East Africa—to explore international cooperation. More specifically, the book develops an empirically grounded theoretical explanation that illustrates exactly how interests, institutions, and ideas together enable international cooperation. This explanation helps clarify the potential and the problems of fostering transnational cooperation in international affairs in this and, potentially, a host of other important areas, such as counterterrorism, environmental challenges, resource management, human rights protection, and economic assistance.

What are the three I’s of international cooperation?

The explanation for cooperation lies in three, interrelated processes involving interests, institutions and identity:

1. securing shared interests in an important transnational public good (in this case health);
2. creating and maintaining institutional arrangements that are appropriately inclusive, practical, equitable, and efficacious, and;
3. redefining identities so as to include formerly excluded actors in one’s salient in-group affiliation and developing trust among members of the new inclusive group.

States participate in transnational initiatives to obtain interests they could not otherwise secure, and it is the overlapping of interests among states and nonstate actors that can be seen as the central or necessary condition for transnational cooperative efforts.  The pursuit or interests serves cooperation in these cases for three reasons. First, it is in the clear self-interest of each member to control trans-boundary communicable diseases. Second, infectious disease control is a common good that creates a consumption externality, that is, preventing or treating an infectious disease not only benefits oneself, but also benefits others by reducing their risk of infection, and vice-versa. Finally, because the consequences of failing to cooperate are apparent and dire, shared vulnerability helps compel cooperation to meet a problem that requires joint action.

Interests alone are not the whole story; the right institutional membership is critical to securing a potential common good, even one as critical as infectious disease control. Effective collaborative problem solving depends on a congruence between those actors affected by a problem and those actors capable of effecting a solution. You need all and only the right actors at the table.

Finally, there is more to cooperation than a confluence of interest among relevant actors: there is also the steady construction by political elites and professionals of a transnational political community, a group that shares a common identity across political boundaries. Such a community can develop when actors who share a common social characteristic, a common relationship, a common experience, and a positive interdependence define themselves as a unique group. As the new group is defined to include previously foreign actors and conceptual separations are diminished, trust is promoted, and collective action problems become more tractable. If successful, the process is marked by a cognitive and affective shift, in terms of loyalty and trust, to encompass the new, larger community.

Creating a new inclusive group identification and a trusted network of cooperation is possible in international relations, but difficult and arduous. The steps that encourage de-categorization and re-categorization to include those previously characterized as other include contact, identifying and accentuating common characteristics, practicing problem solving and positive interdependence, and producing practical results that create value that rewards each participant’s efforts. These steps can create a new, shared identity, engender trust, and enhance cooperation.

What is transnational governance and what role does it play in international health cooperation?

Transnational governance refers to those institutional arrangements beyond the nation-state in which private actors, usually as international nongovernmental organizations (INGOs) and transnational corporations (TNCs), participate in mixed public-private policy networks. The purpose of these hybrid entities is to directly provide common goods and collectively solve problems by setting and implementing rules, and providing services.

Transnational public-private networks are organized around functional issues at various geographical levels and in varying configurations to address a host of governance problems in public health, biodiversity protection, climate change, economic regulation, humanitarian aid, security, and more. Such partnerships in health have expanded rapidly in the past two decades in various states, including infectious disease control.

The networked cooperation studied in the book provides a basis for systematic comparison of the process of transnational governance. The actors involved in the three disease surveillance networks studied here include states, international organizations, national and international nongovernmental organizations, and other important private actors with considerable resources such as corporations and philanthropies. The volume provides a framework for thinking about the structure and function of successful transnational public-private networks. It describes how these public private entities operate and distills what factors make them effective in securing transnational public goods and legitimate to domestic and international constituencies.

What does the United States stand to gain from investing in more global health diplomacy?

The United States, as a leader in both medical and information technology, is well situated to strengthen public health systems abroad and indirectly support regional health cooperation as a peaceful and positive dimension of its global health diplomacy and as a frontline defense of its own population from the threat of infectious diseases, outbreaks of which typically begin in the developing world. Beyond terrorism, disease surveillance and response provides the United States an opportunity to address a critical national and transnational problem. Indeed, because it is largely apolitical and nonreligious, combating pandemics, more than counterterrorism, may offer a basis on which to build better bilateral relations and lay a foundation for regional cooperation. The U.S. government could, by helping prevent the political and social discord and the personal suffering wrought by pandemic disease, win the good will of both foreign governments and peoples.

How does the volume assess the U.S. global health policy?

There is little wrong and much right about U.S. programs in support of improving foreign capacity in infectious disease surveillance and response. The problem is that they do not go far enough. The failure to adequately engage the threat of infectious disease outbreaks at the source and to seize the potential opportunity for enduring international collaborations in public health is both a security lapse and a foregone opportunity for the effective exercise of American influence.

This shortcoming reflects generic problems in U.S, global health policies, including several tendencies of American global health policy:

• to fund treatment for a few diseases rather than strengthen public health systems generally to enable them to respond to existing and emerging challenges;
• to focus overwhelmingly on treating the problem of infectious disease spread only after it has reached U.S. shores;
• to deploy funding in response to the current interests of the donor community and to focus on near-term impact rather than concentrate on recipient needs and sustainable, long-run effects; and
• to support related programs in various agencies without a formal mechanism for interagency coordination and collaboration.

What recommendations do you offer for improving American global health policy?

This study recommends a significant increase in the size of U.S. programs devoted to infectious disease control. In the context of overall U.S. global health expenditures, even an increased expenditure on foreign capacity for infectious disease control would be only a small fraction of America’s international public health budget but deliver significant security and diplomatic returns on the investment. It bears watching to see if President Obama’s new Global Health Initiative (GHI) translates into greater, more comprehensive, and better coordinated support for strengthening infectious disease control systems abroad as a first line of defense for America’s security and welfare and as a meaningful demonstration of America’s commitment to improving the health and well-being of people everywhere.

The study recommends greater interagency coordination. There is currently no overarching coordinating mechanism across the major agencies; no plan for creating an integrated, interagency structure; and until the GHI, no government-wide plan for meeting global health challenges. Further, each of the major agencies involved in shaping global health policy has its own mechanism for coordination. Harmonization in this area should not mean that U.S. policy has a single voice, only that it works in concert.