Viral Sovereignty and the Political Economy of Pandemics

What Explains How Countries Handle Outbreaks?

Sophal Ear

• Publisher: Routledge
• Year: 2021
• Print ISBN: 9781032133850
• eBook ISBN: 9781000487213
• Edition: 1
• Topic: Politics & International Relations
• Subtopic: Economic Policy
• Index: Politics & International Relations

Over the past few decades a number of emerging infectious diseases (EIDs) have disrupted societies throughout the world, including HIV, Ebola, H5N1 (or ''avian flu'') and SARS, and of course the coronavirus disease (COVID-19) which spread worldwide to become a global pandemic. As well as EIDs, countries and regions also contend with endemic diseases, such as malaria. There are many factors that have contributed to the rise in, and spread of, EIDs and other diseases, including overpopulation, rapid urbanization, environmental degradation, and antibiotic resistance. Political and cultural responses to disease can greatly affect their spread. The global community needs to defend itself against disease threats: one weak link is enough to start a chain reaction that results in a global pandemic such as COVID-19. Some states take a nationalistic approach towards combating disease; however, international cooperation and meaningful ''viral sovereignty''—empowering countries to create effective health institutions and surveillance systems in order to contain disease—must be considered.

This volume, with a focus on Southeast Asia, Africa and North America, considers the intersection between disease, politics, science, and culture in the global battle against pandemics, making use of case studies and interviews to examine the ways in which governments and regions handle outbreaks and pandemics.

1 Cambodia, Indonesia, and the US Naval Area Medical Research Unit 2

DOI: 10.4324/9781003228974-2

The H5N1 strain of fast-mutating, highly pathogenic avian influenza (HPAI) has caused significant concern to the global health community as a pandemic threat.¹ H5N1 is believed to have emerged in 2002. In the previous 45 years, 19 outbreaks of HPAI were identified; each of these outbreaks were suppressed by destroying, or “culling,” infected poultry flocks. H5N1 emerged as a much more threatening strain of the virus, “unprecedented in scale and geographic distribution.” Over the following two years, a handful of Asian countries, including Japan, South Korea, and Malaysia, successfully eradicated H5N1 through aggressive poultry culling, but the virus continued to spread elsewhere. By 2006, scientists were reporting that disease containment efforts of H5N1 had failed. More than 200 million domesticated birds had been killed by the virus or culled to prevent its transmission; moreover, there was a significant increase in H5N1 bird deaths in Cambodia, the People’s Republic of China, Laos, Nigeria, Thailand, and Indonesia.² Due to the failure of containment efforts, H5N1 is currently found in multiple bird species and has spread globally with unprecedented range.

The H5N1 strain of HPAI can spread to human beings who come into close contact with live or dead infected poultry. Although there is currently no evidence of human-to-human transmission, researchers have expressed concern that mutations may allow the H5N1 virus to become more compatible with human transmission. The symptoms of H5N1 include high fever, fatigue, cough, sore throat, and muscle ache. Advanced symptoms include severe respiratory illness and seizure. Human beings infected by H5N1 must seek prompt medical treatment, as the mortality rate of H5N1 in human beings is about 60 percent.³ The first four reported cases of human mortality from H5N1 occurred in China and Viet Nam in 2003. There were 46 cases reported in the following year, including the first to appear in Thailand. By 2005, the number of infections had jumped to 98 cases reported in five countries, and Indonesia and Cambodia appeared on the list of affected nations for the first time, with 20 and four cases, respectively. The following year saw the number of reported human infections climb, encompassing an additional five countries and reaching a high point of 115 cases and 79 deaths before the numbers began to gradually decline through the rest of the decade. H5N1 outbreaks have affected millions of poultry flocks in Asia, Europe, and Africa, and as of January 20, 2020 they had caused 455 human deaths.⁴

This chapter focuses on the response to H5N1 HPAI in Cambodia and Indonesia, and pays particular attention to the role of the United States’ Naval Area Medical Research Unit 2 (NAMRU-2) laboratories in each country. Both local and international attempts to provide appropriate surveillance of the spread of H5N1 in these two countries, as well as the dramatic closure of NAMRU-2 Indonesia following that country’s claim to “viral sovereignty,” failed to adequately monitor and contain H5N1. I draw on extensive interview research with NAMRU-2 personnel and government officials in both Indonesia and Cambodia to determine what went wrong and, given the failure of emerging infectious disease (EID) surveillance, what might have been done differently. This chapter seeks to answer the question of what meaningful viral sovereignty would have looked like in response to H5N1 in Cambodia and Indonesia, as well as how it might have shaped a more effective response to the threat that H5N1 represented to both the national and international communities in the first decade of this century.

By using Cambodia and Indonesia as case studies, and by analyzing the role of the NAMRU–2 in these countries, this chapter finds that the primary constraints to disease surveillance systems in these nation-states stem from the lack of financial resources, the absence of a professional civil service, the prevalence of grand and petty corruption, and the existence of patronage networks.⁵ In order to create effective EID surveillance systems, both the technical and the human aspects of disease surveillance systems must be addressed. National ownership and capacity must be increased, and technology transfer must take place, enabling local actors to take charge of their development and security — thereby replacing Indonesia’s empty and ultimately harmful declaration of viral sovereignty, as well as Cambodia’s damaging decision to exercise what I will call “outbreak declaration sovereignty,” with meaningful viral sovereignty that would benefit both the people of these nations and the international community.

Challenges to EID surveillance in developing countries

Information sharing is vital to effective EID surveillance. As the global health community attempts to revise and strengthen its approach to EID surveillance, the main question I developed from my investigations into various disease surveillance laboratories was how the international community can encourage developing nations to share information regarding infectious disease outbreaks both openly and honestly. The International Health Regulations (IHR) of 2005, a legally binding document of international law, established as their purpose “to prevent, protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade.”⁶ All 194 signatory member countries of the World Health Organization (WHO) agreed to ways in which they should behave when there is an outbreak, including steps they have to take in reporting and sharing viral specimens. Although the IHR is legally binding among nations, there is no enforcement mechanism to hold countries accountable if a country chooses not to abide by the regulations.

The question of the necessary, or ideal, infrastructure needed for effective disease surveillance has been discussed extensively in the context of developing countries. It is widely understood that poor countries usually have to contend with more constraints when attempting to expand disease surveillance programs. A US Government Accountability Office (GAO) report published in 2001 explains that the majority of challenges in disease surveillance stem from financial constraints; a poorer country’s annual per capita expenditure is approximately 3 percent of what most higher-income countries provide. According to WHO,

staff in over 90 percent of developing country laboratories are not familiar with quality assurance principles, and more than 60 percent of laboratory equipment is outdated or not functioning … In addition, poor roads and communications make it difficult for health care workers to alert higher authorities about outbreaks or quickly transport specimens to laboratories. The absence of a clear response discourages lower-level officials from investing effort in surveillance and leads to many cases of disease going unrecorded and unreported. These weaknesses limit the effectiveness of international disease control programs. They also impair routine surveillance for other diseases and efforts to investigate and respond to outbreaks, newly emerging diseases, and growth in antimicrobial resistance.⁷

The most problematic constraints mentioned in the GAO report are the lack of human and material resources, poor infrastructure, inadequate technology, and limited research capabilities. These constraints lead to slow response times, which result in incidents of disease being unrecorded or unreported.

Experts have also considered the role of culture in the effectiveness of disease surveillance systems. The disbursement of resources, the techniques used in diagnostic laboratories, and the development of institutions can all be altered by cultural practices, which can additionally affect response rates and overall efficiency. It is well known that human beings of different ethnic groups, genders, and ages can react differently to pathogens, thereby altering how disease surveillance systems are initially organized. Phua and Lee suggest that health experts should study the “differential short- and long-term impact (if any) of disease outbreaks on different ethnic groups, social classes, occupational groups, males and females, age groups, geographical regions, and so on” to test how emerging diseases can affect certain populations.⁸

While understanding culture prior to development is important, it is also useful to evaluate disease surveillance institutions as they progress. As Ingelhart and Welzel note, socioeconomic modernization can lead to a shift in human development in developing countries. Modernization can lead to self-expression values, which “bring increasing emphasis on the civil and political liberties that constitute democracy,” providing “broader latitude for people to purse freedom of expression and self-realization.” This is not to say that, by modernizing, underdeveloped countries will lose their cultural traditions, but rather that self-expression values will shape institutions as modernization occurs.⁹ Moreover, the quality and effectiveness of governance itself influences EID surveillance in developing countries. It is common for developing countries to struggle to adequately disburse resources domestically. Policymakers and health officials struggle specifically with linking central government spending to rural areas.¹⁰ Finally, because bioterrorism is a concern worldwide, there have been more attempts to make disease surveillance a global effort. Experts suggest that it is not just poor governance, but mismanagement of capabilities within nations that is a problem.¹¹ This can often be seen with technological advancement or discrepancies between nations in regard to disease detection.

Aside from an explicit critique of technical constraints and human resource constraints, the GAO report hints at both economic and political obstacles to effective surveillance. The report never delves, however, into the lack of political will for surveillance due to conflicting priorities—nor does it touch upon cultural constraints that impair effective surveillance. While there is no known source of recent statistics on quality assurance and outdated or malfunctioning equipment in developing country laboratories, the director of laboratory systems development at a major American university notes, “From my own [recent] experiences in countries [of the Southern Caucasus, Central Asia, Southeast Asia, India, and Sub-Saharan Africa], I believe the status has not changed much” since 2001, when the GAO report was filed.¹² Indeed, there are clearly some existing disincentives to detecting emerging (and reemerging) infectious diseases, especially when trade is at stake. Mark Zacher, emeritus professor of political science at the University of British Columbia, argues: “The impact of the early surveillance was also limited because countries often did not report on disease outbreaks for fear of losing commerce. This pattern has held over the course of this century.”¹³

Sociologist Hendri Restuadhi studied, from an anthropological perspective, Indonesia’s Participatory Disease Surveillance and Response (PDSR) program, which was carried out by the Minist...

Table of contents

• Cover
• Endorsements
• Half Title
• Series Page
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Illustrations
• About the author
• Preface
• Acknowledgements
• Introduction
• 1. Cambodia, Indonesia, and the US Naval Area Medical Research Unit 2
• 2. Thailand: a regional leader's challenges with EID surveillance
• 3. Managing artemisinin-resistant malaria in the Greater Mekong Subregion
• 4. The West African Ebola virus epidemic of 2014
• 5. Kenya as an East African Community leader in diagnostics versus research
• 6. Infectious disease surveillance on the US–Mexico border
• 7. Transparency and cooperation in Mexico's swine flu outbreak
• Conclusion
• Bibliography
• Index