Mark W. Zacher
Centre of International Relations, University of British Columbia;
and Comparative Program for Health and Society, Munk Centre for International Studies, University of Toronto, 2003-2004

Prepared for the External Advisory Committee on Smart Regulation,
Privy Council Office

November 2003

Abstract

The major purposes of this paper are to trace the development and success of international health governance in controlling the international spread of infectious diseases, to analyze the factors that have influenced the character and success of the governing arrangements, and to draw out some general lessons with regard to future deliberations for international collaboration in many issue areas. (See Appendix II for a list of the general lessons.)  Another objective of the paper is to establish that international governance encompasses a variety of strategies or policy instruments and that states usually adopt certain strategies and not others in managing particular international problems. Policy analysts some times associate governance with regulation, but regulation is often not an appropriate strategy.

International health governance centered on the use of state surveillance and hard regulation (legally binding rules) for most of the 20^th century. These strategies were, in fact, rather unsuccessful although the failures in influencing the international spread of infectious diseases were due largely to the increasing ability of the developed countries to manage the spread of infectious diseases on their own. Since the 1990s important changes have occurred in the pattern of new and old infectious diseases, and these changes and other factors have led to the utilization of surveillance by nongovernmental networks, soft regulation (or recommendatory guidelines), and increased financial and technical assistance to developing states.

Introduction

The central purposes of this paper are to explore trends in international collaboration to control the spread of infectious diseases and to probe lessons for international governance that can be drawn from the international health programs. International collaboration in this health area has not been as strong as it has been in other issue areas, but it still offers valuable insights with regard to international governance of many international problems.

When students of international collaboration address their subject matter, they sometimes confine their analysis to the development of international regulations that prescribe and proscribe behavioral standards. There are, in fact, a number of strategies of collaboration that states adopt in controlling the spread of infectious diseases, and they tend always to include three main strategies and two variants of each of the three. They are:

Surveillance (or knowledge gathering)

• State-based
• Multi-actor (including non-governmental organizations and usually states)

Regulation

• Hard (legally binding rules)
• Soft (recommendatory guidelines)

Financial and technical assistance

• Emergency response
• Capacity-building: long term assistance in building capabilities

The study will dwell on the circumstances under which particular strategies are beneficial or non-beneficial. Usually international collaboration to manage a particular international problem employs a number of strategies. That is to say, states generally employ hybrid strategic approaches. The mix that states choose is generally based on changing patterns of vulnerabilities and investment opportunities.

To be repetitive, international collaboration or governance generally concerns the selection of multiple strategies, and hard regulation is only one of those strategies. In fact, hard regulation is often not an appropriate strategy and is used very little or not at all.

Historical Overview

From Great Expectations to Very Modest Accomplishments, 1900-1980

The origins of modern collaboration to control the spread of infectious diseases are a series of eleven conferences that took place in the last half of the 19^th century. They were spurred by six epidemics of cholera that spread from South Asia throughout the world from the 1820s through the rest of the 19^th century as well as periodic epidemics of other diseases such as yellow fever. The major axis of conflict at these conferences was between Britain and other western European countries that feared that quarantine measures could impede the flow of international commerce and the majority of states largely from the eastern Mediterranean and the Middle East that feared the introduction of diseases and the imposition of embargoes on their goods and citizens if their countries experienced disease outbreaks. The industrialized countries feared the introduction of diseases to an extent, but even prior to the remarkable progress in epidemiology starting in the 1880s they tended to put commercial interests before health interests.

Several conferences in the 1890s achieved some accords on rules that port authorities should follow in controlling diseases, but it was not until the acceptance of the International Sanitary Regulations of 1903 that a major accord  was concluded. It was initially limited to controlling cholera, plague and yellow fever, but typhus, relapsing fever and smallpox were added for periods between the 1920s and the 1970s. The key strategies that were adopted were: (1) an obligation of states to report on disease outbreaks to the International Organization of Public Hygiene and (2) rights and obligations of national health authorities (largely in ports) in controlling the spread of diseases. An important obligation of port and airport authorities was not to adopt stricter measures than those specified in the Regulations. (The International Sanitary Regulations were retitled the International Health Regulations (or IHRs) in 1969, and it is by this title that we will refer to them over their entire life.)

This combination of obligatory state reporting and hard regulation concerning the obligations of health authorities in ports and airports was not successful for a number of reasons. At a general level it papered over some serious differences in policy objectives of most developed and developing states that led to serious violations of the rules. First, the developing countries (especially from the eastern Mediterranean region and the Middle East) refused to respect the obligation to report disease outbreaks since they feared justifiably that that other countries would refuse the entry of their goods and citizens. Second, the developing countries often refused to accept the stricture that they should not apply regulations that were stronger than those set forth in the IHRs. The reason was that they did not have the domestic health systems that could control the spread of diseases, and they wanted maximum freedom to control disease outbreaks even if they slowed the movement of international commerce. Third, the industrialized countries increasingly realized over the 20^th century that their medical systems (in particular their hospitals and pharmaseuticals) were able to cure the diseases that were contracted by their citizens. In other words, they were not as vulnerable to the introduction of diseases from foreign countries as they initially feared. Because of this realization they did not press for compliance with the legal rules. They also did not devote large financial resources to the elimination of diseases in the developing world on the grounds that this would reduce the spread of diseases to other countries. What modest resources they did devote to improvement of health conditions in the developing world were largely motivated by the expected improvement in economic development that would spill over into improved international trade and investment relations.

Optimism concerning a dramatic reduction of infectious diseases grew gradually over the 20^th century in the developed world and reached its apogee in the 1960s and 1970s. If there was one development that both represented and promoted the increased optimism, it was the elimination of smallpox in 1977. People expected that an elimination of a host of other infectious diseases would follow.

In the post-World War II decades the International Health Regulations were revised periodically although this basically ended after the 1960s. The changes that were made to the IHRs tended to be minor and maintained a reliance on states' obligation to report outbreaks, a variety of obligations and rights of port/airport authorities with regard to three diseases (cholera, plague and yellow fever), and states' obligation not to impose more stringent measures than those listed in the IHRs (generally referred to as "excessive measures"). In fact, a reading of the minutes of the WHO committee charged with promoting the control of infectious diseases indicates that the developed countries were obsessed by the excessive measures problem which can be viewed as the facilitation-of-international-commerce issue. Their concern was dominantly the avoidance of obstacles to shipping and air transport—and secondarily the creation of impediments to the entry of infectious diseases. (Appendix I; Goodman 1971; Howard-Jones 1975; Fidler 1999, ch. 2-3; Carvalho and Zacher 2002)

New Challenges and Innovative Responses, 1981-Present

The new era in the international control of infectious diseases can be viewed as having started in 1981 when HIV/AIDS was first identified. The rest of the 1980s witnessed outbreaks of a small number of new or emerging diseases and an increase in some traditional diseases such as malaria and TB, but it was not really until the 1990s that there was a marked increase in new diseases and a surge in some traditional diseases. Africa was particularly seriously hit by both emerging and re-emerging diseases. Various studies identified the emergence of around 30 new diseases from the late 1970s through the 1990s. The ones that particularly scared people were the hemmoraghic fevers such as Ebola since they could be transmitted between people and could kill a significant number quickly. In 2002-2003 the world was, of course, hit by SARS that spread quickly from Guangdong Province in China throughout Asia, Canada and other areas of the world. The airplane became its vector as it was spread by international travelers.

One point is interesting about people's understanding of the threat from these new diseases, and it is that epidemiologists had been worried for some time about the emergence of drug resistant strains of existing diseases, the resistance of diseases-carrying insects to pesticides, and the periodic occurrence of very lethal strains of influenza. They consequently used the opportunity of the emergence of new diseases to stress what had been their general concerns about the future impacts of infectious diseases. Unlike many media commentators they had not been lulled to sleep by the reduction in infectious diseases in recent decades. (Institute of Medicine 1992; Garrett 1995; Brower and Chalk 2003; Fidler 2003, ch. 5; Institute of Medicine 2003, ch. 2-3)

One of the most dramatic strategic changes in the international management of infectious diseases occurred with regard to surveillance of disease outbreaks. Up to the mid-1990s states were obligated to report outbreaks of three epidemic diseases, and the WHO could only report outbreaks in its Weekly Epidemiological Report and in its Outbreak Page on the internet if it had received official notification from a member state. As noted previously, states seldom reported such outbreaks. In the early 1990s a significant number of non-governmental actors became very active in reporting outbreaks because of failures of the WHO system. Probably the most important reporting organization is the International Society for Infectious Diseases which sponsors a surveillance network called ProMed-mail which was created in 1994. (http://www.promedmail.org) It receives reports of outbreaks from about three thousand medical officials throughout the world and it disseminates the information to around thirty thousand health professionals. Medicins sans frontieres (MSF) has its own reporting system, and according to health professionals CNN has a very valuable health reporting program. In addition, Canada has created its own surveillance body—the Global Public Health Information Network or GPHIN. It sifts through over a hundred news websites and sends the information on disease outbreaks to WHO and any organization that pays for a subscription.

Because of the surfeit of information that WHO now receives from non-governmental sources, it created a Rumour Outbreak Page on the internet in 1997 that includes information from a variety of non-official sources. It then created in 2000 the Global Outbreak and Alert Response Network (GOARN) which draws on information from more than seventy various sources apart from states. It is a true "network of networks." (http://www.who.int/csr/outbreaknetwork/) WHO member states now tolerate such WHO reporting from non-official sources because they know that disease outbreaks in their countries will be reported to the world by these sources regardless of their objections. That is to say, non-governmental reporting networks have made accurate WHO reporting possible because the WHO system basically replicates what the NGOs produce. In the language that has been used here for classifying strategic forms of international collaboration, state reporting has been effectively replaced by multi-actor surveillance.

Since the 1980s hard regulations, or legally binding behavioural standards, have been ignored as much as they were ignored in the past. Little attention has been attached to the very detailed International Health Regulations. This is in part due to the fact the regulations solely cover cholera, plague and yellow fever, but it is also due to the fact the developed and developing countries differ on the value of the rules. In particular, the developed want all countries to commit themselves not to impose "excessive measures", and the developing do not accept such a commitment since their medical systems do not provide enough protection from transnational diseases. The basic norm concerning excessive measures may be retained in the new International Health Regulations which will probably accepted in 2005, but the IHRs are likely to continue to be considered as recommendatory guidelines more than they are considered to be legally binding rules.

While hard regulation has continued to be viewed as rather irrelevant to controlling the international spread of infectious diseases, soft regulation has been increasingly used. It particularly takes the form of WHO bodies (more often than not groups of medical experts) recommending particular guidelines for controlling the transmission of diseases or for treating people who have particular diseases. Standing groups of experts who provide advice on particular diseases or groups of diseases have existed for a long time, but they have proliferated. Also, expert groups on particular outbreaks (e.g., Ebola in the Congo) are more common significantly because WHO is sending emergency response teams into areas where such outbreaks occur. These teams generally provide recommendations to local medical staff concerning the handling of the outbreaks. A manifestation of this development is the creation of the Global Outbreak and Alert Response Network in 2000 which combines surveillance and emergency response. (Fidler 1999, ch. 2-3; Zacher 1999; Fidler 2003, ch. 4 and 8; Institute of Medicine 2003, ch. 4)

An interesting case of the use of soft regulations in a variety of ways is the SARS crisis of 2003. First, a group of clinicians, which was rather open-ended in membership, was established to develop recommendations on preventing the spread of the diseases and curing patients with it. The several hundred clinicians were linked by internet communications, and despite a large number of participants the group operated well. Second, WHO sent small groups of experts (largely from the industrialized states) into China to study local outbreaks and make recommendations for the management of the disease. They as well as outside observers soon discovered that the Chinese authorities were not providing accurate information, and the WHO then took a very stern approach in telling the Chinese authorities that they must provide the world with detailed and truthful pictures of what was going on. Third, a committee of about eight experts on infectious diseases was formed at WHO headquarters to formulate guidelines for the political and legal management of SARS although it also got into recommending clinical procedures that originally came from the large group of clinicians that were participating in the WHO network. The WHO committee, whose meetings were some times attended by Director General Brundtland, was the source of perhaps the most controversial policy guidelines that emanated from the WHO, and that was travel advisories. These advisories at times noted that it was fine to travel to travel to certain places, but at certain times they recommended that people only fly to several areas of China (including Hong Kong and Taiwan) and Toronto for essential purposes. The advisories, of course, had very serious economic implications for the areas in question. It is remarkable that they were accepted as well as they were in that victim states suffered major economic losses. The victim states never challenged the legitimacy of the travel advisories; they merely questioned some of the criteria and whether their local circumstances met certain criteria. The authority that was bestowed on a committee of international organization bureaucrats at the WHO is truly unusual in the history of the development of international organizations. (Fidler 2003, ch. 5-8)

The heart of the recent expansion of WHO recommendatory guidelines is that they have been much more specific to particular outbreaks than was the case in the past. The case-specific approach has made it much easier to secure political support by member states, and it has meant that the recommendations are much more likely to be relevant to local situations.

A major change in international health governance that has occurred since the 1990s relates to cooperation in providing financial and technical assistance to reduce the incidence of infectious diseases and to improve health standards more generally. One form of cooperation that relates clearly to the international spread of infectious diseases has been the launching of emergency medical teams from a variety of countries to control disease outbreaks. WHO coordinates such multinational teams in many disease outbreaks, but some times individual states do it at the request of the infected country. The importance of WHO sponsorship in a good number of cases was highlighted by the outbreak of plague in India in 1994 where foreign medical specialists were quite simply not allowed in the country without participation in a WHO consortium of experts. Also, the same was evidently the case with regard to the WHO groups that went into China at the time of the SARS outbreak in 2003. Chinese authorities were very sensitive with regard to incursions foreign groups into their territory and their making judgments as to what should have been done or what should be done, but it would have been much more offensive if the groups had not be under a global UN agency. (Fidler 2003, ch. 6-7)

While it is clear that the emergency response teams have been directed at stemming the international spread of epidemic diseases, it is not as clear that internationally financed health projects have been directed mainly at problems of international spread. They have, in fact, been directed more toward improving economic conditions; but this is not to say that a desire to stem the spread of infectious diseases in the world was a subsidiary concern. Prior to the 1990s most international health assistance was bilateral although some modest amounts were given by the donor states to international collaborative efforts—sometimes within the WHO. The cooperative endeavours tended to be in the realm of coordination of national programs rather than true amalgamated efforts among countries. What really began to change things in the 1990s was an increasing recognition that poor health conditions were one of the most serious drags on economic development in developing countries. There are two studies that had made impacts on thinking along these lines. The first was the World Bank's Investing in Health published in 1993, and the other was a 2001 WHO study written by the Commission on Economics and Health (including Jeffrey Sachs and other economists) entitled Macroeconomics and Health. Suddenly in the 1990s the World Bank became the largest funder of health projects in the Third World after not having funded any projects in this area prior to the 1980s. The significance of the new World Bank role was not just that it gave larger sums for the improvement of health systems but that it established a framework for looking at international health assistance that had a strong influence on bilateral assistance programs. Not everyone was happy with the World Bank approach, but there is no doubt that the World Bank approach did promote collaboration and coordination. (Also, WHO 1996; Institute of Medicine 2003, ch. 4)

Lessons for International Governance

The history of the development of international health governance is rich in insights with regard to the factors that influence international collaboration. The following discussion provides commentaries on forms of collaboration, the factors that shape them, and some lessons that can be drawn from past experiences. There are also short discussions of cooperation in other issue areas that relate to experiences in international health collaboration.

The influence of professional networks

There is a growing recognition of the importance of non-governmental organizations—including networks of professionals in global politics. They are viewed as increasingly important because they exert political pressure on governments and because governments and important private actors defer to their expertise in certain circumstances. There are few areas where these observations are more appropriate than they are in international health politics.

With regard to surveillance of infectious disease outbreaks the non-governmental networks are now clearly more important than states. Networks such as Pro-Med-mail and media firms such as CNN have strong intelligence gathering systems largely because of the communications possibilities that they possess in the era of the internet and satellite communications. States are now very transparent with regard to a host of activities because of modern communications. The veil of sovereignty is now very permeable.

In the case of regulation there has been a dramatic movement away from hard regulation and toward soft regulations or recommendatory guidelines, and this has been facilitated by the growth of professional networks. These networks on their own sometimes offer recommendations for the management of particular problems, and in other cases they are mobilized by WHO or other international organizations. In the SARS crisis the professional networks, which were often organized through WHO, were crucial in developing guidelines on research and treatment. This trend is likely to become stronger in the future.

Lessons for policy makers: Government officials should realize that NGOs will be central participants in international decision-making in many issue areas and that they are often better at doing certain things than intergovernmental organizations (e.g. surveillance). This means that it is important that governments maintain good relations with these organizations, and that they encourage their own nationals to participate in the NGOs. Their own nationals can sometimes be valuable intermediaries with the NGOs.

Impact of scientific and technological progress

Students of international collaboration often associate progress in science and technology with growing interdependence and demands for international collaboration. This is often the case. Certainly technological change has created greater opportunities for mutually beneficial trade in goods and services, and a growth in scientific and technological knowledge has also facilitated a greater understanding of international environmental damages and possible solutions to their control. From these understandings have come some very important international regimes on matters such as ship-generated marine pollution, dumping at sea, the shipment of hazardous chemicals and wastes, and depletion of the ozone layer. At the same time scientific and technological progress have also provided states at times with understandings that allowed them to reduce international independencies and hence the need for international regimes. Scientific and technological change is in a sense a double-edged sword in that that it can cause greater interdependence and collaboration, on the one hand, and a reduction in both interdependence and demands for cooperation, on the other

A classic case of the use of science to reduce international interdependence is the advancement of medical science. While it has provided states with the opportunity to understand what has to be done to cure people with certain diseases or even to prevent them from contracting these diseases, it has also led to medical advances that made states less vulnerable to the international spread of diseases. Public health systems greatly reduced the likelihood of contracting diseases. And if the citizens of particular countries contracted diseases, modern hospitals and medicines often made it possible to cure them. In other words, the same surge of scientific and technological progress that caused the international spread of diseases also gave states the power to control it.

Lessons for policy makers: Before states cooperate to control the negative externalities of modern scientific and technological changes, they should ask whether there are ways that they can individually control their negative effects. Canada, like many countries, has rationally invested in strong public health and health care systems that greatly reduce their vulnerability of the international transmission of infectious diseases. There are many other issue areas where Canada can protect itself from trans-border damages through its own initiatives.

Facilitation of commerce

A central objective of many international regimes is the facilitation of international commerce. For example, it has been central to the acceptance of regimes such as those covering shipping, air transport, telecommunications, and postal services. International commercial interests quite simply refuse to accept serious impediments to the flow of goods and services—unless they are closely connected to international terms of competition. (Zacher with Sutton 1996)

A concern to reduce impediments to the flow of commerce has certainly been central to the support for the International Health Regulations by the developed countries over the past century. This may change with the approval of new International Health Regulations around 2005 because fears of interruption of commerce are not as strong as they used to be and since fears of the spread of infectious diseases are stronger. It, however, needs to be reiterated that when international collaboration can facilitate the flow of commerce without having serious impacts of states' competitive advantage in certain industries, the prospects of stronger international governance are very good. This concern still promotes the stricture that national health authorities should not impose regulations in excess of those recommended for particular disease outbreaks.

Lessons for policy makers: In judging the desirability of particular international regulations states should realize that there is generally very strong support for rules that facilitate the flow of commerce. Conflicting interests may exist, but they are generally overridden by concerns of preventing interruptions in the flow of goods and services.

The Mixing of Collaboration Strategies

It is wrong to equate international collaboration or governance with a particular form or strategy of collaboration such as hard regulation (or legally binding rules). Each is appropriate to particular circumstances. In other terms, one particular approach or combination thereof is appropriate for different conditions. This study has identified three general strategies and two sub-categories of each of these, but it is possible to increase that number. The strategies and sub-categories that are chosen are, needless to say, influenced by the nature of the questions that one is interested in posing.

The conditions required for different strategies vary in terms of their stringency, but certain strategies are not better or worse in any absolute sense because they have more stringent requirements. What is key is the appropriateness of particular strategies or combinations thereof for certain circumstances. In fact, states generally support a number of strategies in seeking to manage particular international problems. The practical course is generally the adoption of diverse and often mutually supporting strategies of collaboration.

Lessons for policy makers: It is almost always desirable for states to adopt a number of strategies of collaboration in seeking to manage international interdependencies. They are often mutually supportive in achieving states' policy objectives. On the other hand, certain collaboration strategies are generally inappropriate in managing particular problems.

Surveillance: State and Multi-Actor

Surveillance is a crucial strategy in many international regimes because it provides information that is important to the selection of other collaborative strategies and to the obtaining of information on states' and nongovernmental actors' compliance with commitments. As is clear from studies of arms control accords, it is foolish to depend on states' reporting on their own compliance because they will sometimes violate their obligations if they can get away with it. Arms control accords are much more feasible when other states or NGOs can monitor compliance with the agreements. One thing that was crucial in the case of arms control accords was the emergence of satellite surveillance technologies that made it possible for parties to the agreements to monitor each other's behavior. In other words, transparency promoted acceptance and compliance.

State surveillance is generally only becomes feasible if states have technological means to penetrate other states' veil of sovereignty or if there are nongovernmental organizations that can monitor what states or private actors are doing. That is to say, states can only be relied on to report on what transpires within their boundaries if other actors can provide the information in any case. In many issue areas, it is increasingly difficult for states to stonewall the international community because of the plethora of nongovernmental reporting networks and the availability of revolutionary information technologies.

The history of reporting networks for monitoring disease outbreaks reinforces the points made above. The obligation of states to report disease outbreaks in the International Health Regulations was generally ignored from the early years of the 20^th century through the mid-1990s. States, particularly those in the developing world, did not want to face embargoes on the movement of their goods and citizens by reporting disease outbreaks to the world, and they therefore refused to comply. In the case of the cholera and the plague outbreaks in Peru and India in 1991 and 1994 the latter two countries lost respectively about $.7 billion and $1.7 billion because of trade and tourist embargoes following the publicizing of the outbreaks. By the early 1990s the media were already very effective disseminators of information on outbreaks. (Zacher 1999; Fidler 1999, 105)

As noted above, the real revolution in reporting by nongovernmental actors did not occur until the mid-1990s as a result of the impact of the internet and the growth of networks of health care professionals throughout the world. Key networks were ProMed-mail and GPHIN, but there were a good number of others as well (e.g., media networks such as CNN). What has developed is "a network of networks" in the form of WHO's Global Outbreak and Alert Response Network. The WHO GOARN suddenly emerged as quite good sources of epidemiological intelligence, but it was only because of the growth of the nongovernmental reporting systems. The most notable feature of contemporary disease surveillance is the centrality of nongovernmental intelligence networks.

Lessons for policy makers: The effectiveness of many forms of international collaboration requires surveillance systems that do not need the active cooperation of governments. Networks of NGOs and professionals in particular fields are often the best institutions for securing transparency.

Regulation: Hard and Soft

In an era when international organizations increasingly produce a wide variety of guidelines or non-binding codes, it is no wonder that there is considerable discussion of the appropriateness of hard and soft regulation. Hard regulation is generally seen as desirable where strong consensuses on policy preferences exist among most states, and when enforcement is needed to realize important policy objectives. It also tends to be appropriate when states can anticipate certain particular contingencies and have clear ideas as to what should be done in those circumstances. Recommendatory guidelines are preferable when there are significant divergences in views among states and when changing circumstances make it difficult to predict contingencies.

In the sphere of infectious disease control in the early 20^th century states adopted traditional hard regulation or legally binding treaty law because that was the approach to managing international economic and social interdependencies with which they were familiar. (Fidler 2003) As time passed and the rules were frequently disobeyed, states did not reject the strategy of hard regulation because they felt that a retreat to recommendatory standards would reduce compliance. By far the most important stricture for the developed countries was the injunction that states should not require standards in excess of those set forth in the IHRs (Appendix I). This basically meant that states should give precedence or at least a very high status to the facilitation of international commerce. The fact that the rules relating to cholera, plague and yellow fever (and for short periods typhus, relapsing fever and small pox) were seldom relevant was not so important. What was important was that states did everything possible to avoid interruptions with international shipping and air transport. It is possible that the legally binding injunction against "excessive measures" has promoted states' concern for the flow of international commerce and that a case exists for its continuation in a revised IHRs. However it is questionable whether this strategy should be pursued since it denigrates the status of international treaty law. The revised IHRs are not likely to have very detailed regulations for particular disease outbreaks—but rather very general provisions for the treatment of ships, planes and infected individuals in ports and airports; and in these circumstances a general non-binding recommendation against delaying international carriers and travelers is probably the best route to take.

Given the diversity of policy priorities among states and the difficulty of predicting medical contingencies it is best to rely on recommendatory guidelines (often geared to existing crises) for controlling the spread of infectious diseases. The WHO is very useful in bringing experts together and developing policy guidelines. The guidelines are seldom of great value to the advanced industrialized countries, but they are often very useful for developing countries that do not have highly developed medical infrastructures. Guidelines for managing long-term disease problems such as malaria, TB and HIV/AIDS are certainly very helpful for some countries, but even more important may be guidelines in crisis situations such as the outbreak of Ebola in African countries or the outbreak of SARS in a variety of countries.

The types of valuable recommendatory guidelines that can be utilized in crisis situations are clearly seen in the SARS crisis. The WHO facilitated the linking together of 11 laboratories that developed guidelines for research cooperation. In the end two of its members produced analyses of the nature of the SARS virus. The WHO also linked together several hundred clinicians and WHO officials who shared information of their experiences with SARS and helped to develop recommended guidelines for the prevention of the disease and the treatment of patients. The committee of WHO officials concerned with the SARS outbreak prescribed a variety of public health measures to control the disease, and they included most notably recommendations to governments on reporting SARS cases to the public and on curtailing travel to SARS infected areas ("travel advisories"). The autonomy of the committee of WHO officials was in retrospect remarkable given the major repercussions of its recommendations, and they were probably only accepted because of the medical expertise that the WHO had brought together and the volume of reporting on the SARS crisis by the media. (Fidler 2003, ch. 5-6)

Lessons for policy makers: When there are significant policy differences among states and significant difficulties in predicting future developments in a particular issue area, it is best to rely on recommendatory guidelines rather than legally binding treaty law. The use of treaty law in such circumstances undermines its status in international relations, and it also discourages the kinds of general and flexible prescriptions and proscriptions that are most useful in issues such as the spread of infectious diseases. In fact, guidelines geared to particular crises are often the most useful.

Financial and Technical Assistance: Emergency and Structural

One of the most striking developments in international governance in a wide range of issue areas is attempts to influence relations among states through restructuring their internal social, economic, political and legal characteristics. Intergovernmental organizations still try to influence interstate relations by regulating trans-border relations, but they increasingly pursue an indirect route for altering international relations by focusing on internal characteristics. In the international trade field states are less concerned with regulating tariffs and are more concerned with restructuring industry subsidies, intellectual property rules, and many rules pertaining to the investment activities of domestic and foreign-owned firms. Needless to say, the manaagement of international monetary relations is concerned centrally with macro-economic strategies and hence the restructuring of the domestic economy. One need only think about the International Monetary Fund's emergency loans to countries that allow them to stave off short-term economic collapse or the long-term structural adjustment loans that entail the reform of a host of domestic economic policies that influence their international economic relations. In the international security realm a major concern today is promoting democratic institutions within countries. The democratic peace literature that reaches back to the 19^th century has had a major influence on the security policies of Western states. These short commentaries on collaboration trends in different international issue areas are basically to establish that the wall of sovereignty is an increasingly porous wall because of our recognition that the international characteristics of states shape the quality of their relations with the world. Increasingly it is very difficult to draw a clear line between international and national politics because they influence each other so intensely.

In the case of controlling the spread of infectious diseases, states (generally through the WHO) have increasingly sponsored emergency assistance to control disease outbreaks. It is only by assisting states to manage the incidence and spread of diseases at the national level that states have been able to stem their spread across interstate boundaries. Good examples were the WHO responses to the outbreaks of cholera in Peru in 1991, Ebola in the Congo in 1995, and SARS in a variety of countries in 2003. The SARS case represented the precise type of case that countries have feared—where a very virulent disease spreads to a number of regions of the world very quickly. The amazing thing was that it did not spread to more areas of the world. The fact that it did not is attributable significantly to the WHO-coordinated interventions in prescribing appropriate medical responses.

International assistance to promote better health conditions has existed over the past century although major collaborative programs are relatively new. In the early decades of the 20^th century the United States directed some modest health assistance to Latin America through the Pan-American Sanitary Bureau, and modest sums were directed to various areas through the League of Nations Health Organization in the 1920s and 1930s. Then after World War II some very small sums were directed to developing countries through the World Health Organization. The developed countries quite simply did not have a great deal of trust in the WHO when it came to dispensing public health assistance.

A major change occurred in health assistance starting in the 1990s. An interesting aspect of this change is that it was not rooted in fears of the spread of diseases as a result of outbreaks of emerging and re-emerging diseases. Rather, it flowed from an increasing recognition of the impact of improved health standards on the economic development of developing states. One can see this in the assistance programs and reports of the World Bank and to a much lesser extent regional development banks such as the Inter-American Development Bank. Until the 1980s the World Bank did not provide any loans or grants for health purposes, and then in the 1990s it became the largest single supplier of international health assistance. Its report Investing in Health published in 1993 not only guided World Bank assistance programs but also had a major impact on bilateral assistance programs such that the developed world was working to a significant degree within a general strategic framework. Another major report that justified health assistance as a major contributor to economic development was Macroeconomics and Health which was written by a group of economists and was published by WHO in 2001. The key point to be made here is that what drove major donor states and intergovernmental organizations to offer larger sums of assistance for public health was the link to economic development. In a sense, reducing the spread of infectious diseases was a bi-product of assistance to further economic development.

Lessons for policy makers: International collaboration to influence interstate relations increasingly concerns states attempts to alter the internal characteristics of states. This can involve the acceptance of common regulatory frameworks, but it can often involve the transfer of financial and technical resources to deal with short-term crises and long-term projects of capacity building. Donor states should be sensitive to autonomy concerns of recipient states, but at the same time they should realize that the restructuring of domestic societies is a major aspect of contemporary international relations.

Conclusion: Conditions Encouraging Canada's Utilization of the Multilateralist Options

The preceding section of the paper focused on lessons that all states might learn with regard to different modes of international governance. This concluding section delves into the conditions that lead states, and particularly Canada, to opt for multilateral collaboration in tackling international problems. The reality is that modern states have become increasingly enmeshed in networks of international collaborative arrangements since the middle of the 19^th century. The first reasons for forgoing unilateralist approaches deal with the pattern of interests and policy preferences among states as well as important non-governmental actors. In the case of Canada it always needs to be reevaluating whether it would benefit from different governance strategies since the conditions surrounding different problems are always changing. For example, its interests in international health collaboration evolved markedly in the last two decades. Precisely how important the changes have been was only really evident with the SARS outbreak.

In reflecting on the utility of multilateralist approaches it is also important that Canada constantly monitor the interests and policies of other countries and particularly major powers and major groups of countries. Support for multilateralist approaches can be foolhardy if there is little chance of broad backing for a particular governance strategy. In past eras of international relations non-governmental organizations (NGOs) – especially public interest NGOs – did not play prominent roles in international politics, but this is not the case today in many international issue areas. They are major sources of knowledge on many issues, and they have leverage in a host of domestic political contexts and hence international negotiations. Health is a major issue for a good number of development and humanitarian NGOs, and in addition there are very important networks of medical professionals who communicate regularly. As can be seen in the SARS crisis, they have important impacts on the ways in which the WHO and individual states approached the problem. To leave out the various roles of NGOs in modern international relations is to exclude a major dimension of the modern transnational world.

While it is crucial to understand Canada's and other countries changing policy interests in international governance in many areas, it is also very important to analyze whether there are important conditions that facilitate or undermine the feasibility of collaborative arrangements. One condition relates to whether knowledge is sufficiently advanced in a particular international issue area to allow governments and NGOs to evaluate what the costs and benefits will be with regard to different strategic options.

A related condition that facilitates collaboration is the existence of formal and informal networks of experts who meet regularly and review the state of knowledge and disseminate to other. Today meetings of these expert networks are often convened by international institutions such as the WHO. One thing that emerged from the SARS crisis was many people's appreciation that the WHO had a more important role in global health issues than most people thought because it brought together groups of experts quite regularly. The impacts of the groups dealing with both the containment of SARS and the development of new scientific understandings of its characteristics had huge impacts over the first half of 2003 when the crisis raged.

Not only does Canada need to grasp the importance of these networks in areas such as global health politics, but it is important that it promote participation of Canadians in these networks. They can provide the government with a better understanding of developments in an international issue area and can often prod other states and NGOs in directions that would be favorable to Canada. The world is increasingly one of intensifying interdependencies and constant diplomatic interactions among states and NGOs as to how they can be governed. The world is becoming highly multilateralized, and this basic long-term trend is unlikely to be reversed

Appendix I :

Summary of main provisions of the International Health Regulations (1969; last revised 1983)

State rights to apply more stringent and different standards

Health administrations should not prescribe measures more stringent than those set down in the IHR. These regulations are "maximum measures." (art. 23)

Health administrations can apply measures beyond those specified in the regulations to ships that carry migrants, nomads, seasonal workers or persons taking part in periodic mass congregations. (art. 84)

Two or more states with special interests can conclude special treaties or arrangements. (art. 85)

State reporting to WHO

Health administrations should send information on cases of cholera, plague and yellow fever to WHO within 24 hours of their detection and information on their development during the outbreak. (arts. 3, 5-7, 9)

Health administrations should send information to WHO on the existence of the three diseases in non-human sources (e.g., insects). (art. 4)

Health administrations should send information on measures they apply to travellers from infected areas, disease control policies, and vaccination requirements to WHO. (art. 8)

Health administrations should send WHO a list of ports where deratting certificates are issued. (art. 20)

WHO rights and obligations

WHO should disseminate to all member states information on outbreaks of the three diseases (cholera, plague, yellow fever) that it receives from member states. (art. 11)

WHO should investigate serious international health threats posed by outbreaks of the three diseases with the approval of the state. (art. 11)

WHO at the request of a state can certify that an airport fulfills the requirements of a sanitary airport and the requirements of airports in yellow fever-infected areas. (art. 21)

Treatment of ships at sea

Health administrations should not stop and apply health measures to a ship that is passing through its territorial sea. (art. 32)

Health administrations can only do one thing with regard to ships passing through a canal or water way, and that is to put a health official on board. (art. 33)

Treatment of ships, aircraft and travelers in ports and airports

Health administrations should apply prescribed measures in the IHRs so as not to harm the health of travelers or the structure ships or aircraft. (art. 25)

Health administrations should explain to officers of a ship or aircraft the measures that have been applied to it. (art. 26)

Health administrations can have travelers that are under surveillance on ships or aircraft examined by medical authorities, but the travelers should be allowed to move freely. If travelers go to another jurisdiction, the travelers should inform the local authority. (art. 27)

Health administrations, except in the case of an emergency, are not allowed to prevent ships or aircraft from discharging passengers or cargo on the basis of a disease outbreak that is not covered by the IHRs. (art. 28)

Health administrations are allowed to take measures to prevent ships from discharging contaminated wastes into the waters of a port. (art. 29)

Health administrations should take measures to prevent the departure of an infected traveler from a port, airport, or frontier post. When the traveler is on an international voyage, a health authority may allow the person to proceed and then should inform the health authority in the person's next port of call. The health administrations can also require a valid vaccination certificate from a departing traveler, and can subject the traveler to a medical exam. (art. 30)

Health administrations should assure that no material that might cause an epidemic is thrown from an aircraft. (art. 31)

Health administrations are allowed to take only one action with regard to healthy ships, and that is to conduct medical exams of passengers. (art. 34)

Health administration should, whenever possible, give ships and aircraft permission to disembark passengers by radio communication. (art. 35)

Health administrations can subject any carrier or passengers on these carriers that are on an international voyage to a medical exam. (art. 36)

Health administrations can remove an infected individual from any kind of carrier and then isolate the person. (art. 38)

Health administrations can place under surveillance any individual who is on an international voyage and is coming from an infected area on any type of carrier. (art. 39)

Health administrations should not repeat a medical examination of a person that was applied at the last port or airport where it called unless there are strong medical reasons for doing so. (art. 40)

Health administrations should not prevent a ship or aircraft from calling at a port unless the health officials judge that the ship or aircraft does not possess the health facilities that it requires. (art. 41)

Health administrations should allow a ship or aircraft unwilling to submit to the regulations to leave a port, but they should not allow it to enter another port or airport within its national territory. (art. 44)

Cargo on a ship or aircraft should only be inspected when it is coming from an infected area. Only live animals can be detailed in a port or airport. (art. 46)

Health administrations should not require that ships or aircraft submit bills of health that provide reports of inspections in previous ports. (art. 76)

Health administrations should require that a ship at its first port of call provide a Maritime Declaration of Health (compiled by its own officers) that provides information on the health of the passengers--unless it is not demanded by the port authorities. (art. 77)

Health administrations can require that aircraft provide the Health Part of the Aircraft General Declaration at the first airport where it lands—but do not need to require it. (art. 78)

Health administrations should require that aircraft and ships leaving an area where there are mosquito-borne diseases (including malaria) be disinsected. (art. 83)

Health administrations can disinsect aircraft and ships arriving in an area where mosquito-borne diseases could develop. (art. 83)

Plague: health administrations in any ports, airports or frontier offices should not require a plague vaccination for entry into their territory. (art. 51)

Plague: health administrations in ports and airports should take measures to prevent the spread of plague by rodents. (art. 52)

Plague: health administrations should assure that all ships are free of rodents or are periodically deratted. Deratting certifications should be issued along the lines of the model provided. A port authority can require that a ship is deratted if it does not provide a deratting certificate. (art. 53)

Plague: if rodents are suspected to be on board ships or aircraft, health administrations can require that they be disinsected and deratted. (art. 54)

Plague: before allowing departure of ships and aircraft from an area where there is pulmonary plague, health administrations should assure that every suspect is placed in isolation for six days. (art. 55)

Plague: health administrations can require that an infected or suspected ship, aircraft or other carrier is disinfected, disinsected, deratted, and put under surveillance for six days. If there is pulmonary plague or rodent plague on board, these actions must be performed. (arts. 57)

Plague: if a ship or aircraft comes from an infected area, health administrations can place anyone that is infected under surveillance and can require the killing of rodents and disinsecting. (art. 59)

Cholera: if there is a case on board a ship, aircraft or other carrier, health administrations can put suspected people under surveillance, remove any substance suspected of contamination, and disinfect the water tanks. (art. 62)

Cholera: health administrations should not examine foodstuffs carried as cargo on a ship, aircraft for other carrier  unless it is in the port of destination. (art. 63)

Yellow fever: health administrations should not allow a ship or aircraft to enter ports or airports where mosquitoes are present if the ship or aircraft is infected with yellow fever. (art. 44)

Yellow fever: vaccination can be required of travelers leaving an infected area on an international voyage on any carrier. (art. 66)

Plague: if rodents are suspected to be on board ships or aircraft, health administrations can require that they be disinsected and deratted. (art. 54)

Yellow fever: health administrations should assure that everyone working in a port or airport possesses a yellow fever vaccination certificate. Every aircraft leaving an infected area should be disinfected. Ships and aircraft leaving areas where mosquitoes that carry yellow fever exist and going to areas where they do not exist should be disinfected. (art. 67)

Yellow fever: health administrations can require that a passenger coming from an infected area by ship or aircraft is isolated until he or she gets a valid vaccination certificate. (art. 68)

Provision facilties and conditions in ports

Health administrations should provide disease-free water and facilities to remove waste mater dangerous to health, and they should provide medical facilities in some ports. (art. 14, 15)

Health administrations should take all practical measures to keep ports free of rodents, and some ports should have facilities to issue deratting certificates. (arts. 16, 17)

Health administrations should designate some airports as sanitary airports where there are: an organized medical service; facilities for disinfection, disinsecting, and controlling rodents; a bacteriological laboratory; and facilities for yellow fever vaccinations. (art. 18)

Health administrations should assure that ports and airports are kept free of mosquito vectors. (art. 19)

Inland frontier posts and transportation facilities

Health administrations should provide, wherever needed, facilities required to comply with IHR rules at frontier posts, railway lines, roads, and inland waterways. (art. 22)

Source: "International Health Regulations, 1969," In International Health Regulations, 3^rd ed. (Geneva: WHO, 1983).

Appendix II

List of Recommendations

1. Government officials should realize that NGOs will be central participants in international decision-making in many issue areas and that they are often better at doing certain things than intergovernmental organizations (e.g., surveillance). This means that it is important that governments maintain open and competitive relations with these organizations, and that they encourage their own nationals to participate in the NGOs. Their own nationals can sometimes be valuable intermediaries with the NGOs.
2. Before states cooperate to control the negative externalities of modern scientific and technological changes, they should ask whether there are ways that they can individually control their negative effects. Canada, like many countries, has rationally invested in strong public health and health care systems that greatly reduce their vulnerability of the international transmission of infectious diseases. There are many other issue areas where Canada can protect itself from trans-border damages through its own initiatives.
3. In judging the desirability of particular international regulations states should realize that there is generally very strong support for rules that facilitate the flow of commerce. Conflicting interests may exist, but they are generally overridden by concerns of preventing interruptions in the flow of goods and service
4. It is almost always desirable for states to adopt a number of strategies of collaboration in seeking to manage international interdependencies. They are often mutually supportive in achieving states' policy objectives. On the other hand, certain collaborative strategies are generally inappropriate in managing particular problems.
5. The effectiveness of many forms of international collaboration requires surveillance systems that do not need the active cooperation of governments. Networks of NGOs and professionals in particular fields are often the best institutions for securing transparency.
6. When there are significant policy differences among states and significant difficulties in predicting future developments in a particular issue area, it is best to rely on recommendatory guidelines rather than legally binding treaty law. The use of treaty law in such circumstances undermines its status in international relations, and it also discourages the kinds of general and flexible prescriptions and proscriptions that are most useful in issues such as the spread of infectious diseases. In fact, guidelines geared to particular crises are often the most useful.
7. International collaboration to influence interstate relations increasingly concerns states attempts to alter the internal characteristics of states. This can involve the acceptance of common regulatory frameworks, but it can often involve the transfer of financial and technical resources to deal with short-term crises and long-term projects of capacity building. Donor states should be sensitive to autonomy concerns of recipient states, but at the same time they should realize that the restructuring of domestic societies is a major aspect of contemporary international relations.

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