David P. Fidler, SARS, Governance and the Globalization of Disease
1With memories of the 2003 SARS outbreak still fresh, this study focuses on the governance system that made it possible to control the epidemic in a record time. As Fidler finished his manuscript in August 2003, barely two months after World Health Organisation (WHO) lifted its global alert. SARS may return, the author warns, but he hopes that his book will be helpful regardless.
2Undeniably, the fight against SARS was a success. Less than four months after WHO issued its first global alert, control was in sight as transmission had been interrupted everywhere. Fidler’s narrative takes us through the sequence of events that caused an unknown disease to spread globally from a single floor of the Metropole Hotel in Hong Kong. The alert immediately launched by the WHO, the travel advisories and containment measures put in place, the scientific race to identify the causative agent and the global efforts to roll back SARS are now history.
3The author’s main argument is that this success highlights a change of paradigm. We have moved, he writes, from a Westphalian to a post-Westphalian health governance system. The former was minimally intrusive. In the wake of early nineteenth century cholera epidemics, major powers were primarily anxious to minimise disorderly quarantine measures, which disrupted trade. At the first international health conference convened in 1851, the points of agreement were limited to the notification and control of three diseases : cholera, yellow fever and plague. These so-called “Asiatic” diseases were brought to Europe from Asia by way of maritime trade. In contrast, malaria was never included in the agenda of nineteenth century international health conferences. The reason is that malaria was endemic in parts of Europe, and that any regulation affecting the sovereignty of a European state was at the time out of the question.
4Today’s efforts to contain these and other infectious diseases face similar obstacles. Governments sign up to international health treaties, but routinely flout them. How global, or post-Westphalian, is the governance system that addresses cross-border public health issues ? What has changed, according to Fidler, is that information flows freely across borders and governments no longer have the exclusive right to report outbreaks, as Non Governmental Organisations (NGOs) are also empowered to do so.
5However, in the case of SARS, the recently established global alert and response network of the WHO was far from seamless, instant or ubiquitous. True, collaborative efforts proceeded well and fast, after the alarm bell rang. But before that, SARS most likely roamed around Southern China for several months. We may never know for sure what happened exactly, as sensitive information does not freely flow out of, or within, China. In addition, both local and foreign NGOs face restrictions, as the Chinese government views them with suspicion. China initially failed to acknowledge the problem, until a retired Army doctor pushed the government to face up to its responsibilities.
6Fidler’s chapter on China misses the complexities of the Hong Kong and Taiwan issues. Here is a major power that deeply antagonised the public opinion of its prized Hong Kong SAR and struggled hard to keep all Taiwanese health officials out of the containment loop. Including these perspectives would obviously have weakened the author’s point on the irrelevance of borders, be they internal, to global health governance.
7Equally arguable is the author’s view that an “unchained” WHO suddenly found itself in a position to dictate terms to governments, be they the most powerful. His claim that the US, though not enthusiastic, could not resist WHO’s zeal, is not credible. That the US administration would have felt shy of flexing its muscles here, had it disagreed with WHO’s approach, is a perplexing claim. As the Bush administration was preparing to invade Iraq, the US was presumably keen to avoid getting embroiled in yet another controversy. But it remains to be seen whether WHO will have a free hand in dealing with future outbreaks.
- 1 Richard D. Smith & al. (eds.), Global public goods for health : Health economic and public health p (...)
8Fidler insists that the control of SARS was a global good. Nobody would dispute that. Obviously, everyone felt threatened by a disease that struck all, rich and poor, North and South, East and West in a record time. But what exactly constitutes a global public good for health ? According to the author, it is one that benefits more than one region or continent. Surprisingly, Fidler nevertheless mentions that, although it affects hundreds of millions of people in Africa and Asia and kills over one million each year, malaria fails to qualify as a global disease as cross-border transmission is low1. This leaves us wondering whether a disaster has to threaten rich people seriously, if it wants to be recognised as global. Should a narrow view of what constitutes a global good for health prevail, the new governance paradigm would be bad news for millions of people affected by malaria, sleeping sickness, leishmaniasis and other neglected diseases in low-income countries.
9Beyond SARS, this book raises important questions. How best should the world prepare to respond to the deadly outbreaks WHO warns us will inevitably happen ? One need not necessarily share Professor Fidler’s optimism or his enthusiasm for a post-Westphalian Utopia. But his book is enjoyable, well-written and thought-provoking.
Alain Guilloux, « David P. Fidler, SARS, Governance and the Globalization of Disease », China perspectives [Online], 63 | january - february 2006, Online since 20 December 2006, connection on 21 May 2013. URL : http://chinaperspectives.revues.org/591Top of page
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