The Ethics of Public Health, Volumes I and II

Michael Freeman

• Publisher: Routledge
• Year: 2018
• eBook ISBN: 9781351890502
• Topic: Law
• Subtopic: Sociology
• Index: Law

With a number of public health panics emerging in the past few years, most recently the panic over 'swine flu' in 2009, the publication of this two volume collection is extremely timely. These two volumes cover the complete range of issues relating to the ethics of public health. Topics include the relationship with bioethics, questions of governance, public health and human rights, surveillance and privacy, prevention and its limits, confinement and liberty, as well as detailed case studies of previous and continuing crises relating to HIV and AIDS, SARS, bioterrorism, climate change, avian flu and tobacco control. There are sections also on genetic health, public health and equity, and public health and the developing world. The two volumes include nearly 75 articles by leading thinkers, and are accompanied by Michael Freeman's detailed introduction and full bibliography.

Part I
The SARS Crisis

[1]
SARS: Political Pathology of the First Post-Westphalian Pathogen

David P. Fidler

In March 2003, the world discovered, again, that humanity's battle with infectious diseases continues. The twenty-first century began with infectious diseases, especially HIV/AIDS, being discussed as threats to human rights,¹ economic development,² and national security.³ Bioterrorism in the United States in October 2001 increased concerns about pathogenic microbes. The global outbreak of severe acute respiratory syndrome (SARS) in the spring of 2003 kept the global infectious disease challenge at the forefront of world news for weeks. At its May 2003 annual meeting, the World Health Organization (WHO) asserted that SARS is "the first severe infectious disease to emerge in the twenty-first century" and "poses a serious threat to global health security, the livelihood of populations, the functioning of health systems, and the stability and growth of economies."⁴

As an emerging threat, SARS presents novel problems for public health. SARS challenges scientists to develop diagnostics, treatments, and a vaccine for a virus—the SARS-associated coronavirus (SARS-CoV)—not previously identified in humans. Clinicians struggled to diagnose and treat those infected with the SARS-CoV, SARS forced public health officials to respond to the international spread of a new pathogen amplified by globalization. SARS reintroduced societies to long-dormant, large-scale isolation and quarantine practices, raising questions about balancing public health and individual rights.

With SARS, so much has happened and, at the time of writing, so little time has passed, that attempting a comprehensive analysis of SARS as an emerging public health issue would be misguided. My objective is to probe the political pathology of SARS as the first post-Westphalian pathogen, As WHO stated, SARS is the first severe infectious disease to emerge in the twenty-first century; but SARS is also noteworthy because it is the first pathogen to emerge into a political and governance environment that differs from what existed at the time of earlier outbreaks.

This article examines governance issues that SARS raises for public health in its post-Westphalian context. As explored below, the term "Vfestphalian" refers to the governance framework that defined international public health activities from the mid-nineteenth century. In the 1990s and early 2000s, literature on globalization's impact on public health described shifts away from Westphalian public health toward new approaches, strategies, and attitudes. Although post-Westphalian public health began to emerge before the SARS outbreak, SARS represents the first pathogen to emerge into this new political and governance context. As such, SARS presents an opportunity to examine the political pathology of a post-Westphalian pathogen. This examination evaluates the strengths and weaknesses of post-Westphalian public health in light of the "challenges SARS generated. Not surprisingly, the political pathology of SARS contains good and bad news for public health governance.

My analysis proceeds in three parts. First, I explain "Westphalian" and "post-Westphalian" public health to elucidate how the structure and dynamics of international relations shape public health governance. Second, I examine the political pathology of SARS as a post-Westphalian pathogen. Central to this analysis will be China because the Chinese response to SARS provides insights into why public health has entered a post-Westphalian context. Third, I look at vulnerabilities and problems post-Westphalian public health may face in light of the SARS outbreak. The shift from Westphalian to post-Westphalian public health confirmed by SARS is not without sobering elements that require the attention of public health governance.

WESTPHALIAN AND POST-WESTPHALIAN PUBLIC HEALTH

Of germs and borders

In many respects, what transpired in the SARS outbreak happened frequently in the past—a new pathogenic microbe emerges in humans; spreads through international trade and travel; causes economic, political, and social disruption; and reveals weaknesses in public health systems. The great cliche of infectious disease control—germs do not recognize borders—applies to SARS as it previously applied to earlier outbreaks.

These observations raise the question whether the SARS outbreak really represents something new for public health. Analysis of emerging and re-emerging infectious diseases (EIDs) in the 1990s and early 2000s stressed that the world had not conquered infectious diseases and that microbes were increasingly formidable foes.⁵ The global devastation wrought by HIV/AIDS had, by the turn of the century, reached horrifying proportions, making this disease one of the worst in history.⁶ SARS joins, thus, a long list of germs that have not recognized borders,

For my purposes, what makes SARS interesting is not its germ; rather, SARS is important because of the context in which SARS-CoV did not recognize borders. Put another way, I am interested in the borders—the political and governance structure—that SARS did not recognize, SARS is the first post-Westphalian pathogen because its nonrecognition of borders transpired in a public health governance environment different from what previous border-hopping bugs encountered. So much attention has been placed on the novelty of the SARS germ that we may not fully appreciate the novelty of the borders SARS ignored.

To advance my argument, I distinguish between "Westphalian" and "post-Westphalian" public health, Like all social endeavors, public health governance reflects larger political structures and forces, which shape how societies pursue public health. For example, in the United States, federalism structures public health governance in a particular way.⁷ Federalism constructs political borders between federal and state governments. Germs no more recognize these borders than they recognize international borders. Federalism does not, however, disappear as an influence on public health governance simply because germs do not recognize the boundaries it creates.

The same dynamic holds true at the international level—germs do not recognize boundaries between countries-, but those boundaries nevertheless structure the political response to infectious disease threats. As explained below, principles for public health governance between countries traditionally derived from the structure for international relations established in 1648 at the Peace of Westphalia. "Westphalian public health" refers, therefore, to public health governance as structured by Westphalian principles. "Post-Westphalian public health" describes public health governance that departs from the Westphalian template. SARS is the first post-Westphalian pathogen because it highlights public health's transition from a Westphalian to a post-Westphalian context.

Before I distinguish Westphalian and post-Westphalian public health, I should acknowledge that the distinctions between them are not, in reality, as crisp as my analysis may project. Concepts that characterize post-Westphalian public health appeared before SARS emerged and have been applied to address existing pathogens. In addition, responses to other recently emerged microbes utilized tools that characterize post-Westphalian public health governance.

Nevertheless, SARS represents the first post-Westphalian pathogen for two reasons. First, the SARS outbreak is the first infectious disease epidemic since HIV/AIDS to pose a tally global threat. Other microbes that emerged in the last thirty years have had limited capacity to threaten international public health because of inefficient human-to-human transmission (such as the avian influenza, Nipah, Hendra, and Hanta viruses), dependence on food or insects as vectors (examples include Escherichia coli 0157:H7, variant Creutzfeldt-Jakob disease, West Nile and Rift Valley fevers), or specific geographical locations (e.g., Neisseria meningitidis W135, Ebola, Marburg, and Crimean-Congo hemorrhagic fevers).⁸ SARS posed a greater threat because of its more efficient person-to-person respiratory transmission and its fatality rate.

Second, because of the nature of the SARS threat, the epidemic severely challenged the emerging post-Westphalian governance system. SARS was a global public health emergency,⁹ and the sternest measure of governance systems is their performance in times of crisis. The SARS outbreak provided the first opportunity to evaluate how the new governance approach for infectious diseases would fare under serious microbial attack.

WESTPHALIAN PUBLIC HEALTH

Westphalian international politics

International relations scholars identify the Peace of Westphalia in 1648 as a landmark moment because it ended the Thirty Years' War and established a political structure for international politics that has endured for over three centuries.¹⁰ Independent, territorial states interacting in a condition of anarchy characterize the Westphalian system.¹¹ States dominate the Westphalian structure and determine the nature of the anarchy in which they interact.¹² In the Westphalian system, anarchy means the absence of a common, supreme authority.¹³ Political authority is fragmented among states in the Westphalian structure.

This fragmentation created the need for principles to guide anarchical interaction. The key principle of the Westphalian structure is sovereignty—the state reigns supreme over its territory and people.¹⁴ Sovereignty then generates derivative governance principles. First, because sovereignty means supreme power, the Westphalian system frowned upon one state intervening in the domestic affairs of other states.¹⁵ The principle of non-intervention excluded, thus, a great deal of sovereign behavior from diplomacy. Second, sovereignty meant that rules to govern interaction arose from the states themselves because no supreme, central law-making body existed. In the Westphalian order, a state was free to exercise its sovereignty as it saw fit unless that state had consented to a rule of international law that regulated its behavior.¹⁶

The combination of sovereignty, non-intervention, and consent-based international law meant that governance in the Westphalian system was horizontal in nature, meaning that (1) only states were involved in governance; (2) governance primarily addressed the mechanics of state interaction (e.g., diplomacy, war, and trade); and (3) governance did not penetrate sovereignty to address how a government treated its people or ailed over its territory. The Westphalian structure exhibited another characteristic— the great powers determined how the system functioned.¹⁷ Great-power management of international relations occurred through warfare and the balance of power.¹⁸ The great powers' role in the Westphalian structure also came to reflect political and cultural prejudices as European power expanded and brought non-European peoples into the Westphalian system.¹⁹

Like any brief description of complex reality, this overview of the Westphalian structure is simplistic. Nevertheless, it captures basic features of the international governance structure into which public health emerged as an issue in the mid-nineteenth century and under which Westphalian public health governance evolved in subsequent decades.

Westphalian public health

The Westphalian structure for internation...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• Acknowledgements
• Series Preface
• Introduction
• PART I THE SARS CRISIS
• PART II HIV AND AIDS
• PART III BIOTERRORISM
• PART IV AVIAN FLU
• PART V CLIMATE CHANGE
• PART VI TOBACCO CONTROL
• PART VII VACCINATION
• PART VIII PUBLIC HEALTH AND GENETIC HEALTH
• PART IX PUBLIC HEALTH AND EQUITY
• PART X PUBLIC HEALTH AND THE DEVELOPING WORLD
• Index