In Global Health Governance in International Society, Jeremy Youde reflects on the challenges facing global health governance and the future of international society. While this is a theoretically engaging and empirically informed study, Ioannis Papagaryfallou questions the solidarist approach of the English School of international theory within the text.
Global Health Governance in International Society. Jeremy Youde. Oxford University Press. 2018.
Global Health has emerged as a new interdisciplinary field of inquiry. As an indication of the pronounced role of the international in contemporary society and politics, Global Health promises to bring together the best that Health and International Relations (IR) have to offer. Jeremy Youde is far from a newcomer to the field: he has been studying the challenges of global health for more than a decade, and he is the current Chair of the Global Health Section of the International Studies Association (ISA). His engagement with global health governance has produced distinguished results, which in his latest book he uses to make some more general observations about the future of international society.
Despite the fact that Global Health Governance in International Society is theoretically engaging and empirically informed, Youde’s identification with the solidarist wing of the English School of international theory accounts for a rather one-sided approach to an exciting field. Taking the arguments of English School pluralists regarding the hegemonic aspirations of Western powers in the aftermath of the Cold War more seriously would have enabled the author to depict with greater clarity the tensions, dilemmas and contradictions within existing forms of global health governance, and to delineate an alternative future. Such dilemmas include the choice between limiting global health governance to the containment of epidemics or addressing more deep-seated health problems globally. More fundamentally, they concern the prospects of fighting disease in a world characterised by widening inequalities between and within nations.
Global Health Governance in International Society uses as its point of departure international society’s failure to respond effectively to the Ebola outbreak in West Africa. This failure did not obfuscate, but rather made more evident the need to address health on a global scale. The first two chapters of the book provide an overview of the English School of international theory, and the way in which it conceptualises international society and its institutions. The third chapter provides an illuminating account of the evolution of global health governance from the nineteenth century onwards. This account is supplemented by the presentation of today’s global health actors and a critical evaluation of their relationships and interactions. Chapter Five shows where the lion’s share of today’s development assistance for health goes, and how the importance of non-communicable diseases, such as cancer, is downplayed in favour of confronting epidemics. The last two chapters on Ebola and China’s insider/outsider status in international society touch on some of the thorniest questions confronting global health governance today.
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The 2014-16 Ebola outbreak in West Africa is justifiably described by most students of global health governance as a turning point in the development of effective mechanisms and institutions. Youde echoes these criticisms, and discusses how NGOs such as Doctors Without Borders carried a disproportionate weight in the fight against an epidemic that threatened both particular states and the international community as such. The calls for the reform of the World Health Organisation (WHO) in the aftermath of the Ebola crisis are debated in Chapter Six, which argues that mainstream critiques do not go far enough in addressing the problem of the relationship between state and non-state actors in global health governance.
China’s ambivalence towards existing forms of global health governance is analysed in the last chapter of the book, which explores how the country’s attachment to sovereignty has historically influenced its health diplomacy and more general attitude towards multilateral international institutions. The book’s proposal to engage China in global health governance and encourage its wholehearted incorporation into international society is commendable, but it is somewhat at odds with the writer’s reservations towards sovereignty and ideological support for a number of ideas that may be universally applicable but are not necessarily universally shared.
Like other English School solidarists, Youde understands the end of the Cold War as a positive historical development which opens the way for the emergence of a global humanitarian conscience materialised in attempts to eradicate poverty, fight disease and even protect human rights through military means. Where Youde differs from other English School theorists is in assuming the existence of a primary institution of moral obligation and responsibility within international society, and in presenting global health governance as a secondary institution which realises this moral obligation.
Although reminiscent of the Marxist base/superstructure model, the book’s delineation of the relationship between primary and secondary institutions in international society is theoretically problematic for a number of reasons. First of all, English School thinkers have justifiably limited the application of the term ‘institution’ to phenomena that possess a certain materiality. Although profound disagreements exist between pluralists and solidarists regarding which are the key institutions of international society, purely ideational or emotional phenomena have not so far been described as institutions and with good reason. Independent of whether the balance of power, the global market or environmental stewardship are seen as institutions of international society, an institution must be somehow independent of the observer and not constitute an expression of the observer’s mind-set or moral sensibilities.
More importantly, the book misses the point that, from an English School perspective, secondary institutions – such as the United Nations, the European Union and the World Bank – do not constitute an extension or a reflection of the primary institutions of international society. Primary and secondary institutions lead different lives, perform different functions and come into existence in different ways and for different reasons. Having said that, Youde certainly has a point in arguing that the English School should engage more seriously with secondary institutions in international society: as the book goes on to explain, such institutions are not mere instrumentalities and can play a significant role in shaping the identities and influencing the behaviour of actors. Emphasising the importance of those institutions is important to the book’s overall argument that the progress of global health governance in recent decades means that we now live in a more enlightened world where states frequently display other-regarding behaviour.
The analysis of the multiform challenges facing global health governance in the fourth chapter is well-informed, but the facts do not corroborate the book’s underlying philosophy of history. With regard to the WHO, Youde emphasises the privileged position it occupies in global health governance today, but he also mentions a variety of problems regarding its routes of funding and relationship with non-state actors. The World Bank’s economic dominance and neoliberal ideological commitments come justifiably under scrutiny because of its limited interest in the human rights of the poor. The role of prominent individuals, such as Bono and Jeffrey Sachs, is correctly problematised, and the logic of the Public-Private Partnerships dissected and critically analysed. Despite accepting the heterogeneous nature of global health governance, the book tends to see its failures as transitory and in principle correctible.
Engaging more systematically with the arguments of English School pluralists, such as James Mayall and Robert Jackson, would have enabled a soberer evaluation of the future of international society and its institutions. As Edward Keene has shown in Beyond the Anarchical Society, by pursuing the contradictory goals of toleration and the promotion of ‘civilisation’ within the same social and geographical space, modern international society gives rise to dilemmas that are unlikely to disappear anytime soon. Global health governance should start from the recognition of those dilemmas and not from the elusive search for a common good which could obscure different understandings of health and ways to promote it in a diverse world.
Ioannis Papagaryfallou has completed successfully his PhD at the LSE Department of International Relations, and he is currently working as a research assistant at the research centre LSE Health. He is a member of the English School and Global Health Studies Sections of the International Studies Association (ISA).
Note: This review gives the views of the author, and not the position of the LSE Review of Books blog, or of the London School of Economics.