key: cord- -bvalr bl authors: nomura, shuhei; sakamoto, haruka; sugai, maaya kita; nakamura, haruyo; maruyama-sakurai, keiko; lee, sangnim; ishizuka, aya; shibuya, kenji title: tracking japan’s development assistance for health, – date: - - journal: global health doi: . /s - - - sha: doc_id: cord_uid: bvalr bl background: development assistance for health (dah) is one of the most important means for japan to promote diplomacy with developing countries and contribute to the international community. this study, for the first time, estimated the gross disbursement of japan’s dah from to and clarified its flows, including source, aid type, channel, target region, and target health focus area. methods: data on japan tracker, the first data platform of japan’s dah, were used. the dah definition was based on the organisation for economic co-operation and development’s (oecd) sector classification. regarding core funding to non-health-specific multilateral agencies, we estimated dah and its flows based on the oecd methodology for calculating imputed multilateral official development assistance (oda). results: japan’s dah was estimated at . ( ), . ( ), . ( ), . ( ), and . million usd ( ) in constant prices of . multilateral agencies received the largest dah share of . – . % in these periods, followed by bilateral grants ( . – . %) and bilateral loans ( . – . %). ministry of foreign affairs (mofa) was the largest contributors to the dah ( . – . %), followed by ministry of finance (mof) ( . – . %). japan’s dah was most heavily distributed in the african region with . – . % share. the channel through which the most dah went was global fund to fight aids, tuberculosis, and malaria ( . – . %). between and , approximately % was allocated to primary health care and the rest to health system strengthening. conclusions: with many major high-level health related meetings ahead, coming years will play a powerful opportunity to reevaluate dah and shape the future of dah for japan. we hope that the results of this study will enhance the social debate for and contribute to the implementation of japan’s dah with a more efficient and effective strategy. universal health coverage (uhc) is the cornerstone of sustainable and inclusive growth. the promotion of uhc to ensure that all people receive quality health services they need without financial hardship contributes to the development of human resources and security [ ] . at the joint session of finance and health ministers of the group of (g ) held in osaka, japan in june , the "g shared understanding on the importance of uhc financing in developing countries" was confirmed, and agreement was reached to accelerate our global efforts to promote uhc through fair, equitable and preferential use of domestic resources and further invest in primary health care (phc) services [ ] . furthermore, at the seventh tokyo international conference on african development (ticad vii) held in yokohama, japan in august , the yokohama declaration was adopted to promote a robust and sustainable society for human security in africa region, including the achievement of the sustainable development goals (sdgs) and african union (au) agenda as well as uhc [ ] . prioritizing domestic resources and promoting private investment in africa were also agreed as priority areas [ ] . for many donors, development assistance for health (dah) is one of the most important tools for promoting diplomacy and international cooperation with developing countries. for japan, in , the ministry of foreign affairs (mofa) issued the global health diplomacy strategy, officially positioning health as a pillar of government foreign diplomacy [ , ] . as one of the concrete measures, the strategy aims to ensure human security by promoting uhc in developing countries using dah [ ] . human security, as an universal definition, "protects the vital core of all human lives in ways that enhance human freedoms and human fulfillment" [ ] . through its contribution to health, the dah helps build the human capital necessary for economic development [ ] , resulting in greater self-reliance of recipient countries [ ] . also, in an increasingly interconnected world, epidemics, antimicrobial resistance (amr), and other health threats are easily spread, and efforts to prevent or suppress these threats in one country often benefit neighboring and distant countries [ ] . the dah therefore can provide a way for donors and recipient countries to benefit and share global prosperity [ ] . importantly, dah functions as a support for issues that cannot be adequately addressed with domestic and private funds to achieve sdgs, including the sdg target . on uhc. in addition, there is an increasing need to act as a catalyst to strengthen capacity to mobilize and properly manage and disburse domestic and private funds [ ] . dah must also adapt to the growing health effects of climate change, conflict, and refugees/migrants crisis, and global political trends that emphasize national interests [ ] . in early , japanese former foreign minister mr. taro kono (until september ) stated that there was no guarantee that official development assistance (oda) would increase in the future because of japan's fiscal deficit [ ] . as stated in the government official documents and by mr. kono himself, there is a need for more efficient and effective implementation of oda/dah and greater transparency and accountability because oda/ dah is funded by taxes [ , ] . in japan, decision-making and implementation of oda is led by mofa based on the development cooperation charter, reflecting the wishes of other ministries and agencies, such as the ministry of finance (mof) and japan international cooperation agency (jica: an implementation agency that coordinates bilateral oda). in , the oda charter was created by the cabinet office with asia as a priority region, indicating the basic principles of supporting the economic growth and social development of developing countries through oda [ ] . in , it was revised for the second time since the revision in , and the name was changed to "development cooperation charter" [ ] . the core of this revised, new charter is a deep commitment to a proactive contribution to peace standing on the concept of human security [ ] . it also added measures that have not been considered within the framework of oda, such as strengthening cooperation with private sectors; and clarified that oda for military operations must be limited to non-military purposes, such as disaster relief. it puts emphasis not only on the interests of developing countries, but also on securing 'national interests', indicating japan's willingness to actively engage in international cooperation that would contribute to japan's security and economic growth. in the same year, mofa also published the "basic design for peace and health (global health cooperation)" as a guideline for global health policy under the new charter. in this guideline, they put three areas as their priority: promotion of resilient global health governance able to respond to public health crises and natural disasters based on the concept of human security, including the realization of uhc; utilization of japanese expertise, experience, medical products and technologies; and tailored support in response to diversification of regional needs [ ] . in practice, however, due to its complex and fragmented administrative procedures and structures, the actual overall picture and flow of dah has been unclear to date, and strategic decision-making and implementation across ministries and agencies are not sufficient. for example, there is no shared priority among ministries on their own commitments and no inter-ministry collaboration in the budget acquisition process [ ] . jica and other relevant organizations and domestic stakeholders also have their own policies, limiting strategic policy coordination with the government [ ] . here, we present, for the first time, an overview of japan's dah, by examining the tracking of dah using data on japan tracker, the first data platform of japan's dah that the authors were in charge of [ ] . the results of this study will contribute to an effective and strategic dah decision-making and implementation across/within ministries and agencies. data on oda projects from to administered by mofa were used. this data includes, for each project and year, gross disbursements of oda, source (contributing ministry/agency), aid type (bilateral grant, including technical assistance; bilateral loan; earmarked funding to multilaterals [that is also called as 'bi-multi' and was reported as bilateral oda]; and core funding to multilateral agencies [i.e. assessed contributions and non-earmarked funding]), target country/region, and target health focus area. health focus area was based on purpose codes (also known as creditor reporting system [crs] codes) for sector classification defined by organisation for economic co-operation and development's (oecd) development assistance committee (dac) [ ] . purpose codes used for dah were (health) and (population policies/ programs and reproductive health) based on the previous studies, including the five-digit purpose codes [ ] [ ] [ ] . [ ] . regarding core funding to non-health-specific multilateral agencies (e.g., world bank), where it was not possible to directly identify dah out of the oda and its flows to target country/region and health focus area, they were estimated based on the oecd methodology for calculating imputed multilateral oda as follows [ ] . step : based on reports from multilateral agencies to the oecd [ ] , oda flows to the health sector of each agency (i.e., dah) were calculated as a percentage of total oda disbursements (α: health sector share of the agency's total oda). step : based on this report [ ] , each agency's dah flows to each target country/region and each health focus area were calculated (β: target country/region-specific share of the agency's dah, and γ: health focus area-specific share of the agency's dah). step : multiplying α, β, and γ obtained for each multilateral agency by the total oda from japan, we estimated flows of japan's dah through the agency. for example, the mof's multilateral dah through the world bank was estimated by multiplying the total oda from the mof to the world bank by α. in addition, mof's dah through the world bank to a particular target country/region and health focus area was estimated as total oda × α × β and total oda × α × γ, respectively. primary health care and health system strengthening in the spirit of both alma-ata and astana, a wellfunctioning phc system is regarded as the foundation for countries that successfully finance and provide quality health services to their entire population; this is essential to achieve uhc [ , ] . although the current crs system does not facilitate standardized measurement of dah for phc, shaw et al. ( ) attempted to define dah on 'phc delivery' versus on 'health system strengthening (hss)' in support of phc delivery, using crs purpose code data, and our study followed their definition and methodology and estimated how much japan's dah was invested in phc and hss [ ] . in short, as in the previous study, our working definition of phc focused only on inputs that are under the control of the health system itself, so intersectoral interventions (e.g., safe water, sanitation, and hygiene) were not considered. our scope of phc therefore included treatment of diseases and injuries, including the provision of essential medicines; reproductive health; prevention, detection and treatment of hiv/aids, tuberculosis and malaria; public health measures, preventive health care, promotion and education of healthy behavior, good nutrition, and immunization. in this study, we referred to dha for such scope as being most relevant to 'phc delivery'. meanwhile, in order for phc to function properly, system-wide investments are necessary: for example, effective priority setting system; sound management, administrative, financial, and technical capacities; adequate human resources and institution capacity; up-to-date health information systems for monitoring and evaluation of policies and programs; and appropriate regulatory, governance, finance, and accountability mechanisms. in this study, we referred to dah for such investment as being most relevant to 'hss' in support of phc delivery, as in the previous study [ ] . our working definition of hss is therefore much narrower than the extensive discussion of hss often found in the literature, where most public expenditures aimed at improving health care can be interpreted as hss. a discussion of their detailed definition and justification can be found in previous studies [ ] . a list of corresponding crs purpose codes for phc and hss can be found in the resulting table of this study. table . except for in , dah contributed to multilateral agencies had the largest share of about % among all aid types. the share of bilateral (grants) was about % and that of bilateral (loans) was about % in the periods. mofa accounted for majority of the dah contribution ( . %, ), with mof ( . %, ) and ministry of health, labour and welfare (mhlw) ( . %, ) following in that order. japan's dah was most heavily distributed in the african region, with a range of . - . % share between and , followed by south and central asia ( . - . %). figure shows japan's dah by aid type and target region. in bilateral (grants) and multilateral, japan's dah was allocated the most to africa. as for bilateral (loans), the dominant focus was on south and central asia, with the exception of . exact values for fig. table . in japan's dah, health policy and administrative management, medical services, infectious disease control, and sexually transmitted disease (std) control including hiv/aids were the priority areas, which occupied a share over about % every year. however, by aid type the trend was different (fig. ). infectious disease control had largest shares in bilateral (loans) except for - , while std control including hiv/aids had the largest share in multilateral. for bilateral (grants), on the other hand, japanese funds also focused around basic health infrastructure and health policy and administrative management. basic nutrition demonstrated a steep decline in its share in - among the bilateral grants. it was . % in , but fell to . % in . exact values for fig. can be found in supplementary table . to quantify levels and trends in dah to phc and hss, the five-digit purpose codes were grouped into two broad clusters (phc and hss). as reported in fig. with exact values presented in supplementary this study provided, for the first time, an estimated gross disbursement of japan's dah and its flows. japan's dah was found to be approximately million usd in . the main source of dah was mofa. according to the oecd statistics, japan's gross disbursements of oda in amounted to . billion usd [ ] , which means that the share of dah in oda was about . %. in accordance with the oda charter, japan has traditionally placed asia, which has a close relationship with japan, as a priority region [ ] . meanwhile, we revealed that approximately half of japan's bilateral and multilateral dah were allocated to the african region in the study periods (fig. ) . this finding may reflect japan's recent efforts to strengthen its diplomatic relations with african countries through various efforts including ticad as well as agenda and sdgs. for example, japan hosted ticad vi in kenya in and launched the "uhc in africa: framework for action" in partnership with the world bank, who, the global fund, and the african development bank [ ] . this is a roadmap for african countries to accelerate progress towards uhc and to monitor and assess their progress. in the same year, japan hosted the ise-shima group of seven (g ) summit, which was held in the aftermath of the ebola crisis in western africa, providing an important opportunity for japan to advance global health governance issues [ ] . in addition, in may , jica signed, for the first time, an oda loan agreement of up to . million usd (at current price in ) with the government of the federal republic of nigeria for the polio eradication project [ ] . this project aimed to contribute to the early eradication of polio in nigeria by ensuring smooth vaccination of children under five years of age throughout the country through the procurement of polio vaccines. oda loans to africa in in fig. refer to this project. this study examined the distribution of earmarked funding (bi-multi) and core funding to multilateral agencies for dah in - . bi-multi funding is a resource to multilateral agencies over which the donor retains some degree of control on decisions regarding disposal of the funds. such flows may be earmarked for a specific country, project, region, sector or theme. it is aid for bilateral functions channelled through on the other hand, core funding to multilateral agencies are used for a variety of purposes, some of which are channeled to global functions (e.g., provision of global public goods, management of cross-border externalities, and fostering of leadership and stewardship). schäferhoff et al. ( ) estimated the total share of core funding going to global functions by agencies, as follows: who %, unaids %, unfpa %, unicef %, world bank (international development association) %, global fund %, and gavi % [ ] . in japan, core funding accounted for the majority of the dah channeled through multilateral agencies, except for those through unicef and unfpa. in particular, japan's core funding to who, which primarily focuses on global functions, has ranked nd in the world after the united states [ ] . it may be said that japan's global functions in relation to the global trends is relatively high. this finding may be consistent with the direction of the basic design for peace and health, which emphasizes the strengthening of global functions based on the concept of human security. for example, at the ise-shima g summit, japan emphasized the promotion of aid for global functions both in the g ise-shima leaders' declaration and g ise-shima vision for global health [ , ] . while the effective dah allocation has long been discussed, it might be guided by a number of factors, including historical and traditional diplomatic relations, geographic proximity, strategic reciprocity, and trade-related considerations, particularly in bilateral aid; and not necessarily aligned with disease priorities for health aid in recipient countries and cost-effectiveness of interventions [ ] . globally, however, dah growth has been stagnant over the past years and limited financial resources are a universal constraint [ ] ; japan is not exception. it is, therefore, an urgent policy issue to implement dah strategies wisely, efficiently and effectively, while ensuring transparency. both in the global health diplomacy strategy and the basic design for peace and health, protecting human security has been a core concept of japanese foreign policy [ , ] . human security is at a convergence that combines the competing policy issues that could threaten vital core of all human lives, including infectious disease epidemics (as exemplified by the recent ebola outbreak [ ] or pandemic influenza) as well as refugee and migration crises and climate change. human security approach thus enriches the synergy between measures to address these issues. for example, among the nearly one million rohingyas, an islamic minority group, living in a refugee camp in bangladesh, there is a growing concern about a serious infectious disease epidemic, including measles, cholera, and typhoid [ ] . also, as global warming progresses, the distribution of vectors such as mosquitoes that transmit japanese encephalitis, dengue fever, malaria, and yellow fever, may expand [ , ] . human security approach will also contribute to the achievement of sdgs as well as au agenda by building a healthy, sustainable, and stable society. an important issue in the dah strategy for donors is therefore to consider how donors should fund their human security efforts from a limited oda budget, and in particular what is the optimal role of dah in this context. for example, japan is one of the founding partners of the global fund and a major donor who contributed . - . % of dah to the global fund in - . since its establishment in , an accumulated . billion usd has been contributed from japan [ ] . at the meeting of the sustainable development goals promotion headquarters on june , prime minister shinzo abe announced japan's new pledge of million usd to the global fund's sixth replenishment [ ] . infectious disease control is an important dah strategy of japan, which covered . - . % of japan's dah shares overall between and , and was mostly channeled through the global fund. in the context of human security approach to climate change and refugees and migrants crisis, further scale-up of dah investments in effective infectious disease control is expected. note that human security approach in this context means supporting people-centered, comprehensive, context-specific, and prevention-oriented responses that strengthen the protection and empowerment of all people, adopting partnerships across sectors, developing context-sensitive solutions, and supporting the realization of a world without fear, want, and dignity [ ] . caution is needed that while human security as a rationale for linking foreign policy and health introduces significant political power, sufficient attention must be paid to the possibility that national security interests may be skewed towards health and humanitarian issues [ ] . it should also be noted that treating global health issues as national security threats, rather than universal issues to be concerned with the humanity, may cause an excessive concern surrounding diseases surveillance and a divide between affected countries and non-affected countries. in the past, for example, securitization was misused as a rationale for implementing hiv-based travel, migration, and immigration control policies and laws prohibiting the entry of people living with hiv [ ] . the results also showed that between and , approximately % of dah were allocated to phc, and remaining % to hss. although there are no established norms or benchmarks on the balance between phc and hss allocations in dah, the high level task force on innovative international financing for health systems (hltf) proposed that approximately - % of the additional resources would be required for hss-that are broadly consistent with the above definitions-in order to achieve the millennium development goals (mdgs) for low-income countries [ ] . in terms of the mdgs, therefore, the balance between phc and hss in japan's dah could be roughly reasonable. however, in today's era of sdgs, the growing emphasis on social determinants of health makes it even more crucial that dah strengthens health system, including institutional capacity (effectiveness of surveillance systems and laboratory networks, etc.), administrative and financial systems, and human resources development [ ] . donor-recipient countries face the challenges posed by health transition, i.e., a double burden of morbidity, mortality, and associated health care costs from increasing non-communicable diseases (ncds) and continuing high communicable diseases [ ] . phc has played a successful role in the delivery of prevention and care interventions for communicable diseases, such as malaria, tuberculosis, and hiv/aids. however, it is imperative to expand the delivery of phc in countries undergoing health transition in terms of health promotion and disease prevention and treatment in response to ncds [ ] . with limited resources, several studies suggested the need to take a diagonal approach of hss to address ncds, rather than disease-specific, vertical programs [ , ] . hss has the potential to improve the delivery of phc in a cost-effective manner by dealing with the wide range of health problems encountered in health transition. hss are emerging important focus of some multilateral agencies, such as the world bank and the global fund (japan's major dah channels), as well as the gavi, the vaccine alliance. there is an increasing debate as to why donor countries, including japan, should invest more in ncds [ ] . a study demonstrated that recently only % or less of japan's dah went to ncds [ ] , whereas ncds accounted for - % of total disease burden in lowand lower-middle-income countries (lmics) [ ] . however, this does not imply that funds for infectious disease control should be used to scale-up to confront ncds through hss. between and , . - . % of japan's dah went to infectious diseases control including hiv/aids, which has aligned with disease burden in lmics to some extent (or lower), where infectious disease accounted for about - % of the total disease burden in lmics [ ] . importantly, japan's dah allocation should take full account of the health transition of dah-recipient countries and make the burden of disease an important criterion for prioritizing resource allocation [ ] . in the future, it will become increasingly important to promote prevention as well as treatment by focusing on hss in recipient countries. more effective health spending is needed in developing countries, and they should use all available resources. recognizing this need, sdg aims to strengthen domestic resource mobilization and improve domestic fiscal capacity for tax and other revenue collection [ ] . in addition, under the addis ababa action agenda, countries pledged to achieve the sdgs, largely using domestic resources [ ] . these are also recognized as common understanding to achieve uhc at the joint session of finance and health ministers at the osaka g summit this year as well as at tivad vii [ , ] . on the other hand, a recent study estimated that achieving uhc would require an increase in annual per capita health spending of more than usd by in lmics [ ] . more spending may be needed, especially as the country develops economically and prices rise. this figure is much larger than dah alone can cover. while taking into account the country's own priorities, it is the most important strategic challenge for donors to consider how dah can support the use and mobilization of domestic resources and how it can intervene in ways that reduce investment risks for the private sector [ ] . for multilateral aid, the global financing facility (gff) and global action plan for healthy lives and well-being for all is a new approach that leverages domestic resources as well as ongoing funding from private and public sources. japan is one of the donor countries of gff as of may . the first commitment, a pledge of million usd, to the gff by the government of japan was announced at the uhc forum [ ] . in addition, donors should be aware of the potential for the implementation of dah to impair the ability of dah-recipient countries to properly plan health budget disbursements, and should seek ways to avoid it. a study by the world bank and other institutions found that the costs of using parallel systems of dah and domestic resources were more than four times higher than relying solely on national financial systems and skills transfer [ ] . also, there is an evidence of negative correlation between dah and domestic resources; dah may constrain the domestic health budget and cause its significant portion substituted out of the health sector [ , ] . decision-making and implementation of dah should consider how financial flows in dah-recipient countries interact with each other. while oda system is well-known, many complexities are involved in its use. this study made use of dah on gross disbursements rather than commitments as disbursements are actual distributions of committed aid funds, while the commitments are amount the donor agreed to make available to. in some cases, disbursements could be more volatile than commitments, conditional on specific country events (e.g., political instability), and absorptive capacity during any one year [ ] . as noted in the previous study [ ] , it is difficult to draw a strong conclusion about the share of phc and hss for several reasons. first, there is a lack of global agreement on measurable indications for phc and hss. it also includes the lack of normative descriptions of the share of dah by donors for phc and hss. the method developed in the previous study (and used in this study) can be reproduced using oecd/crs data and may serve as a useful method to track future donor resources allocated to phc/hss. our estimates of dah are not necessarily comparable to those of the institute for health metrics and evaluation (ihme) at the university of washington, which also provides an alternative source of data on dah [ ] . ihme uses rather complicated mathematical procedures to classify aid based on a 'word search' of project/program content, rather than the long-established coding procedures followed by donors for the oecd/crs data base. ihme estimates tend to be relatively large in value than our estimates based on the oecd coding procedures. for example, in japan, a dah of was estimated to be million usd in this study, while ihme estimates was million usd (at constant price in ) [ ] . this may be because the ihme's estimation method using word search allows some consideration even in areas, such as 'agriculture' (crs code ), 'water and sanitation' ( ), and 'education' ( ) that the oecd coding procedures based on the crs code does not consider as 'health' ( + ). in addition, in the oecd coding, there are focus areas in the field of health, while ihme classifies health into focus areas. ihme also provides very important data, although the methods of estimation and classification are different. however, this study adopted the oecd coding procedures, whose categorization is more familiar and straightforward for policy makers and government officials in japan to understand. this study used only data from japan over a five-year period, and therefore does not provide long-term trends of dah or comparisons with other countries, or any consideration from the perspective of japan's relative position in global health diplomacy. this is our next research scope. with many major high-level health related meetings ahead, coming years will play a powerful role in reevaluating dah and shaping the future of dah for the world and japan. we hope that the results of this study, which provide an overview of dah in japan, will enhance the social debate for and contribute to the implementation of japan's dah in a more efficient and effective strategy. additional file : figure s . developing assistance for health channeled through multilateral agencies unicef: united nations children's fund; undp: united nations development programme; afdb: african development bank; asdb: asian development bank; iadb: inter-american development bank; global fund: the global fund to fight aids, tuberculosis and malaria; gavi: gavi, the vaccine alliance who: world health organization; unaids: joint united nations programme on hiv/aids; unfpa: united nations population fund; unicef: united nations children's fund; undp: united nations development programme; afdb: african development bank; asdb: asian development bank; iadb: inter-american development bank; global fund: the global fund to fight aids, tuberculosis and malaria; gavi: gavi, the vaccine alliance; jica: japan international cooperation agency. other un agencies include food and agriculture organization (fao), united nations relief and works agency for palestine refugees in the near east (unrwa), world food programme (wfp), etc. ngos include international planned parenthood federation, etc. others include global environment facility (gef), etc. table s . developing assistance for health channeled through multilateral agencies usd in million, %): (a) bilateral (loans), (b) bilateral (grants), (c) multilateral, (d) total. std: sexually transmitted disease. crs purpose code: basic health care = ; basic health infrastructure = ; basic nutrition = ; health education = ; health personnel development = malaria control = ; tuberculosis control = ; std control including hiv/aids = ; health policy and administrative management = ; medical education/training = usd in million, %): (a) bilateral (loans), (b) bilateral (grants), (c) multilateral, (d) total. phc: public health care; hss: health system strengthening. phc definition # = basic health care and infrastructure (crs purpose codes: , , , , ); phc definition # = reproductive health care and family planning ( , ); phc definition # = infectious disease control, including malaria and tuberculosis broader phc definition = definition # + # + # + # ; hss definition # = health policy, administration & management ( ); hss definition # = medical services hss definition # = population policy & administration abbreviations amr: antimicrobial resistance; au: african union; crs: creditor reporting system; dac: development assistance committee; dah: development assistance for health tuberculosis and malaria; hss: health system strengthening; ihme: institute for health metrics and evaluation; jica: japan international cooperation agency; lmics: low-and lower-middle-income countries; maff: ministry of agriculture, forestry and fisheries; meti: ministry of economy, trade and industry; mhlw: ministry of health, labour and welfare; mof: ministry of finance; mofa: ministry of foreign affairs; ncds: non-communicable diseases; oda: official development assistance sustainable development goals; std: sexually transmitted disease ticad: tokyo international conference on african development uhc: universal health coverage; who: world health organization references human security and universal health insurance tokyo: ministry of foreign affairs ministry of foreign affairs. yokohama declaration -advancing africa's development through people, technology and innovation. tokyo: ministry of foreign affairs japan's strategy for global health diplomacy: why it matters japan's 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adopted by the general assembly on beating the drum in lower-income countries. oslo: global financing facility government of japan to invest us$ million in global financing facility to accelerate progress on universal health coverage understanding the costs and benefits of unharmonized and unaligned fm arrangements: pfm in health sector public financing of health in developing countries: a cross-national systematic analysis measuring the displacement and replacement of government health expenditure a review of health resource tracking in developing countries publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we would like to express our gratitude to the staff of each ministry and agency who contributed to the data provision and coordination for the data analysis of japan tracker that the authors were in charge of. our estimates of dah were partially reported at japan tracker on august (https://japantracker.org/en/). japan tracker is the first data platform in japan to visualize the flows of japan's dah, launched in november under the industryacademia-government collaboration and support by the bill & melinda gates foundation. not applicable. all authors conceived of and designed the study and take responsibility for the integrity of the obtained data and accuracy of the data analysis. sn, hs, ms, hn, ks, sl, and ks acquired the data. sn and hs analyzed and interpreted the data. sn drafted the article. all authors made critical revisions to the manuscript for essential intellectual content and gave their final approval. this work was primarily funded by the bill & melinda gates foundation. the funders of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. the views expressed in this paper are solely those of the authors. all data generated or analysed during this study are included in this published article and its supplementary information files.ethics approval and consent to participate not applicable. the authors declare that they have no competing interests. key: cord- -s iavz u authors: ali, harris; dumbuya, barlu; hynie, michaela; idahosa, pablo; keil, roger; perkins, patricia title: the social and political dimensions of the ebola response: global inequality, climate change, and infectious disease date: - - journal: climate change and health doi: . / - - - - _ sha: doc_id: cord_uid: s iavz u the ebola crisis has highlighted public-health vulnerabilities in liberia, sierra leone, and guinea—countries ravaged by extreme poverty, deforestation and mining-related disruption of livelihoods and ecosystems, and bloody civil wars in the cases of liberia and sierra leone. ebola’s emergence and impact are grounded in the legacy of colonialism and its creation of enduring inequalities within african nations and globally, via neoliberalism and the washington consensus. recent experiences with new and emerging diseases such as sars and various strains of hn influenzas have demonstrated the effectiveness of a coordinated local and global public health and education-oriented response to contain epidemics. to what extent is international assistance to fight ebola strengthening local public health and medical capacity in a sustainable way, so that other emerging disease threats, which are accelerating with climate change, may be met successfully? this chapter considers the wide-ranging socio-political, medical, legal and environmental factors that have contributed to the rapid spread of ebola, with particular emphasis on the politics of the global and public health response and the role of gender, social inequality, colonialism and racism as they relate to the mobilization and establishment of the public health infrastructure required to combat ebola and other emerging diseases in times of climate change. poor nutrition, eroding infrastructure, and ebola transmission rates. section "stigmatization and the local and global response to ebola", discusses the role of stigmatization in the political and global aid response to ebola. section "community engagement and the ebola response", examines the long-term impact of global health assistance on sustainable community-based health services. the conclusion builds on this background to consider ebola's lessons in relation to future and emergent health risks in times of climate change. ebola's emergence is grounded in the legacy of colonialism and its contribution to enduring inequalities within african nations and globally. the contemporary expression of this history is seen in the "washington consensus," the international aid industry and the underfunding and decentralization of service delivery, through privatization, reduced public expenditures, and lack of access to health care for the most vulnerable. developmentalism still informs and has implications for the effectiveness of current public health responses. the racist discourse of the diseased, incapable african, requiring outsiders to swoop in to save the day, can only be superseded through sincere and authentic participatory approaches-real collaboration between global institutions such as the world health organization (who) and local public health and government officials. the whole world bears the responsibility for the ebola crisis. as noted by the people's health movement, "the epidemic, in all probability, will run its course and die down after leaving a trail of death and destruction (not) because we as a global community would have done very much right, but because of the nature of the virus itself. the moot question is, will we have learnt anything? or will it be back to business as usual?" (phm : ) . market demand from consumers in the global north fuels the resource exploitation that produces the conditions in which the ebola epidemic emerged, and other diseases are sure to follow. ebola has its origin in "the unchecked exploitation of natural resources by international timber and mining companies," as the observer ( ) noted in early october based on a who report on the disease. as long as ebola erupted sporadically in small villages along the global resource economies' path, as it did beginning in the s, the outbreaks flared up and went away as quickly as the global corporations leave their tailings ponds behind. the situation is different now. the virus found its way along the human food chain towards the exploding centres of a rapidly urbanizing africa. it reached large cities with their huge inequities, overcrowding, and underdeveloped sanitation and public health systems, and only extreme measures fuelled by moral panic have thus far (and perhaps temporarily) prevented its global spread in the same way sars expanded across the globe in . the unspoken divisions in how these measures play out reveal deep injustices at the global level. for example, in the early days of the ebola crisis, some criticized the unavailability of vaccines to help the sick, despite the fact that several vaccines had been in development for many years in the global north (stanford ) . it was also pointed out that a large pool of exposed but disease-resistant people, such as those now living in ebola-ravaged areas of west africa, would facilitate the development of a serum-based vaccine. even if a vaccine is developed and tested, will it ever be widely available and accessible to all those who need it, in africa and globally? will this become yet another source of profits for big pharma? as has often been noted, there are "tensions inherent in the socioeconomic construct that is today's pharmaceutical industry [which on one hand seeks to protect] the health of the public, but on the other it seeks to maximize profit" (cohen et al. : ) . there may, then, be an understandable concern that seeking a cure or antidote for ebola might become either an opportunity for the pharmaceutical industry to use africa as a laboratory (see chippaux ) , or as another source of profits for the pharmaceutical industry, rather than promoting the enhancement of well-being. or, as david healy has said more dramatically, "an incentive to chase blockbuster profits-doing so regardless of patient welfare" (healy : ) . the who, hit hard by un retrenchment related to the global financial downturn, cut its budget and downscaled its activities rather than insisting on adequate support and new funding approaches, which left the who woefully unprepared to help guinea, liberia and sierra leone mount a speedy and effective ebola response in early (phm ; lee ; harman ; kay and williams ). this put organizations like medecins san frontières (msf), missionaries, and cuban doctors in the position of heroic first responders in very difficult circumstances. points out ibrahim abdullah, who teaches at the university of sierra leone (the oldest university in west africa) in freetown, the epicenter of the epidemic, "this is the neo-liberal scourge: if you privatize health care in the context of mass poverty, you get the ebola epidemic. if, however, you put people at the centre of development by modernizing health and education, you can prevent ebola. ebola is about governance and modernity" (personal communication ). this crisis is neoliberal precisely because each of the three hardest-hit countries (liberia, sierra leone and guinea), in addition to suffering civil wars and large-scale human displacement over the past decade, were also encouraged to privatize health care and introduce-fee-for-service systems that crumbled amidst poverty-a recipe for the ebola disaster (phm ) . this impoverishment has also opened up the same countries for land-grabs, mining exploitation, rapacious foreign direct investment, agro-forestry, habitat destruction, and human displacement which destroys social resilience, endangers public health, and makes quarantine and disease-control systems nearly impossible to manage. the only way to combat these trends is for african states to be encouraged and supported in the harder part of development: building health care and education systems that are public and sustainable. the ebola crisis reveals, thus, both shorter term and longer term issues of development, which represent the deeper crisis affecting not only the three main ebola-affected countries but global distribution in general. the west africa of the ebola epidemic is one of the fastest urbanizing regions on the planet (diallo and dilorenzo ; salaam-blyther ). perhaps the most dynamic social process in africa is its rapid urbanization (including peri-and suburbanization). the ravaging of the countryside by resource companies and the expansion of the urban fabric into regional hinterlands demonstrate the interface between humans and infectious disease. this is, of course, not just an african story. a planetary process of urbanization is underway across vast networks of infrastructure lines, resource supply chains and human travel (brenner ) . as much of this urbanization leads to massive peripheral settlement in existing and new urban centres, often in contiguity with previously mostly undisturbed natural landscapes, we can speak of "suburban constellations" at the heart of the process (keil ; bloch ; mabin ; leahy ) . a new landscape of risk emerges (bloch et al. ) . in mining towns, sometimes physically remote and isolated but connected through global metabolisms and labour markets, we can speak of a "feral" form of suburbanization that confronts human and non-human nature in direct encounter (shields ) . by , it is expected that urbanized land on the planet will cover . million square kilometres which is twice as much as in . this massive urbanization is unequally distributed across the globe, with china and africa absorbing the lion's share of global urbanization during the next generation. we can expect significant consequences for climate change, biodiversity, etc. (seto et al. ; oxfam ) . in this context, ebola, once thought of as being an isolated problem in remote rural areas, has become an urban disease affecting cities and their peripheries, where its spread tends to be rapid and seemingly random due to massive human interaction and often dense and unhygienic living conditions. in the past, disease outbreaks were associated with squalid and unhygienic urban conditions and the immobility of affected communities (keil ) . the new bundled problematique of urbanization, density, and migration has often been the source of huge moral panic (wald : - ) . emerging forms of urbanization lack the infrastructure necessary to support communities in a health emergency. places like kroo bay in freetown, described by a journalist as "a labyrinth of shacks and muddy pathways perched at the edge of a large rubbish dump stretching out into the atlantic ocean", caused concern amongst health care professionals. one was quoted as saying that "these places are always prone to outbreaks" (trenchard : n.p.) . but now the attention is on the (transnational) network of extended urbanization as "the virus is travelling effortlessly across borders by plane, car and foot, shifting from forests to cities and springing up in clusters far from any previously known infections. border closures, flight bans and mass quarantines have been ineffective" (diallo and dilorenzo : n.p.; see also salaam-blyther ; keil ) . standard textbooks on globalization and health tend to overlook the urban dimension and lean towards seeing urban political pathologies in the framework of the nation state system (cockerham and cockerham ; price-smith ). with the sars crisis of , the world was made aware of the importance of cities in the governance of global health crises (ali and keil ) . but this also meant moving from public health governance in and by cities to global public health governance in urban society-a different challenge altogether. the ebola crisis points further in this direction: public health institutions and procedures in cities are absolutely critical (and they often failed in the cases of sars as well as ebola). the time has come for a systemic and networked view of governance (and not just health governance) across the global urban expanse, the entire field of extended urbanization. global institutions, in their imperfection, have begun to act. urban public health systems could be a prime target of international aid to stave off the ebola threat while creating the conditions for future epidemic prevention. the who made a courageous step in to strengthen the roles of cities in improving public health and in the fight against emerging infectious diseases (who ). while ebola proved to be resistant to many conventional containment measures, the strengthening of urban public health institutions in the overall architecture of global health governance and responses is certainly a path that must be pursued in future outbreaks of this and other infectious diseases as cities grow faster and in different patterns than in the past. the impoverished public health sector and desperate state of critical infrastructure in guinea, liberia, mali and sierra leone-barely functioning hospitals, inaccessible and inadequate care with few medical staff, intermittent electricity, underdeveloped transportation networks and non-existent communication networks-are markers of the extent to which the ebola outbreak was able to spread and impact the region (who ; oladele et al. ) . lack of surveillance, monitoring, andlaboratory facilities delayed early ebola diagnoses until march . the region's history, beset by political and social unrest and internal strife, adds to the complexity. both liberia and sierra leone experienced over a decade long civil conflict that decimated their already weak public health infrastructure. health care expenditures in these countries are heavily dependent on foreign aid, tied to commitments that often prohibit investments in public infrastructure (undp ) (table . ). furthermore, countries with a health care workforce below who's recommended critical threshold of professionals (physicians, nurses and midwives) per , people have a lower resilience for diseases and epidemics (afri-dev.info ; who a) (table . ). it is no surprise that the ebola response was weak and characterized by what msf ( ) cites as huge gaps "in medical care, training of health staff, infection control, contact tracing, epidemiological surveillance, alert and referral systems, community mobilization and education"-important components of a comprehensive ebola preparedness and response plan as outlined by the who. mistrust, miscommunication, and rumours fuelled community resistance and avoidance that interfered with public health measures in the region (fofana ) . unlike nigeria and mali, sierra leone, liberia and guinea's outbreak started in rural areas with porous geopolitical borders, plus woefully inadequate and inaccessible public health care, forcing people to seek alternative affordable and accessible traditional medicine (who ). nigeria and mali had successful outcomes for several reasons. first, as the epidemic was in its fourth month, they had enough time to draw up ebola preparedness and response plans. second, both countries repurposed existing infrastructure for ebola: nigeria used its polio facility as an ebola response centre and mali equipped an existing laboratory for ebola testing (who b (who , c (who , . third, the index case arrived in urban cities, where medical care was available (nigeria's by air to lagos city and mali's via road to bamako), allowing for quick diagnosis and activation of monitoring and contact tracing. the region's colonial history depicts an exploitative and extractive relationship with the global north since the s, plus a history of disease importation to the region, and is the backdrop that sheds light on the level of mistrust of national and international agencies that partly shaped public response to the ebola outbreak. for example, in august , the spanish influenza arrived on the shores of sierra leone aboard a british naval vessel (rashid ; olaniyan ) . rural areasthe disease epicenter-are underserved. post independence, national governments perpetuate this exploitative legacy. in sierra leone, rural agriculture and minerals account for a high percentage of national gdp, yet rural areas have not had proportional investment in basic infrastructure like health, water and sanitation and transportation networks (bti ) . it is increasingly evident that climate change is adversely affecting human health. the health burden of climate change also includes the emergence and source: afri-dev.info ( ), dumont and zurn ( ) increased incidence of infectious and water borne diseases. the current ebola outbreak was a chance encounter between a -year old child and a fruit bat, the reservoir for the virus (baize et al. ; saéz et al. ; who ) . some studies cite climate variability as the cause for fruit bats to migrate long distances and reside near cities and towns (frumkin et al. ; pinzon et al. ). an action aid ( ) study on the increasing flood frequency in six african cities reports that "climate change is altering rainfall patterns and tending to increase storm frequency and intensity". in sierra leone, recent extreme weather observed includes heavy rains that cause flash floods, mass land movement, injuries and fatalities, and infrastructure damage ( women accounted for roughly - % of deaths in the ebola epidemic (wolfe ). ebola's gendered impacts-including greater fatality rates for pregnant women, higher risks for caregivers who are often women, and dangers from sexual violence due to ebola-related economic collapse (thomas )-have implications for social resilience, survival of caregivers and mothers, economic in sierra leone, june to august is called "the hungry season," when heavy rains make it hard to harvest and obtain food decline and subsequent recovery in disease-affected areas, and the strength of public health systems (perkins ) . when economic and ecological pressures, exacerbated by climate change, bring people and animals into closer contact while uprooting communities, depleting health care systems, undermining social resilience, and degrading infrastructure, this becomes a "perfect storm" for the emergence and spread of infectious disease. disease ecology reminds us that the transmission dynamics of infectious disease spread involves a complex interplay between natural ecosystems, human economic activity and cultural belief systems (mayer ). an oft-neglected consideration of the disease ecology is the role that stigmatization may play in disease transmission dynamics. stigma is a common aspect of all cultural systems and quite often used in the service of social control (goffman ) . as such, despite the reality of the lethality of ebola, the challenges that stigmatization poses for the effectiveness of outbreak response should not be trivialized. patients may conceal the fact that they are infected, for various reasons related to stigmatization. for instance, one liberian physician observed that "some patients don't tell the truth. they come to you with a different story, like 'abdominal pain'. it's because of the stigma of ebola. they think they won't be treated and they'll be sent away" (york c ). stigmatization in the ebola outbreak situation is not limited to patients. health care workers, for example, were evicted from their homes by landlords out of fear (york b) . furthermore, mobs in rural villages attacked journalists and health care workers (including those engaged in educational efforts but especially those responsible for removing the deceased). similar to the situation with hiv/aids (lewis ) , orphans whose parents had succumbed to ebola also became stigmatized during the earlier stages of the outbreaks. given that unicef found that as of february , there existed , orphans in the ebola-affected west african countries (un newscentre ), the potential for a tragic problem has loomed. however, a unicef official remarked on a positive note that: there were fears that stigma around ebola would isolate the orphaned children, which would mean there would be thousands of abandoned children, but that has, luckily, not materialized. (un newscentre : n.p.). unicef programs provided cash support, material assistance, psycho-social support, and implemented programs to refer families for food assistance. this collectively helped to mitigate the effects of stigmatization and led to % of the orphaned children being reunified with their extended families (ibid.). combatting stigma in populations where half the population is illiterate poses challenging problems. programs that have successfully addressed such challenges may however be found. in monrovia, billboards and posters visible on every major street helped to raise awareness, while thousands of "social mobilizers", consisting of health workers, teachers, religious leaders and youth activists, were recruited in ebola-affected areas to spread the message about the disease (york b) . unicef produced videos and catchy songs with the same intent (ibid.). public health responders from outside west africa were themselves hampered by stigmatization. this is an especially important issue in light of the observation by the who director-general that the ebola outbreak response urgently required outside assistance (weintraub ) . western hospitals were reluctant to allow medical staff to go to west africa, or take in ebola-infected patients, due to worries of being labelled as the "ebola hospital" in their community, or because of concerns that taking such actions would cause anxiety amongst in-house hospital staff (york a) . at another level, stigmatization may be understood as coming from the conflation of race with disease. this association may be bolstered by the term "ebola" itself. according to one linguist, "ebola" connotes to american listeners the very idea of africa because of its sound similarities to 'ebonics' or 'ebony' in the american vernacular (troutman ) . these types of stigmatization have deep structural origins that can be traced to the legacies of imperialism and colonialism in which "tropicality" is associated with disease (bankoff ) . in this type of colonialist discourse, "other" parts of the world are depicted as dangerous, particularly those with "warm climates" from where "new and emerging diseases" are seen to emanate in the twenty-first century (ibid). the effects of such neocolonial influences are seen, for example, in the way in which medical research in the global north has benefited from blood, parasites, and viruses collected from the people of the global south. the patented vaccines developed from such materials benefit those in the global north (and especially the private pharmaceutical companies). as noted by fearnley ( ) , such biomedical gains did little to help build public health capacity and infrastructure within west africa. dealing with such enduring forms of stigmatization is vexing because of the structural dimensions involved in the geopolitics of dependency and global north-south relations. one way forward, however, may be seen in the recent efforts of the african union to establish an ebola solidarity fund and an african centre for disease control by mid- (anders ) . this initiative may have the potential to serve as an impetus to organize and institutionalize efforts against the types of stigmatization that ensue from structural dependency and power differentials embedded in neocolonialism. while ebola may be lethal for those contracting the disease, many, especially the medical practitioners involved in fighting ebola (see gbakima et al. ) , as well as a number of mainstream journalists, have pointed to the media sensationalism surrounding the disease. as such it has been noted that there is a "tendency (in) the international media to attract viewers (which) has led some careless journalists to focus almost exclusively on the fear-invoking mode of death from the disease" such as the garish images of victims "coughing up blood" (wallace ) . such foci are often fed by stereotypes about africa, which are also linked to the oft-depicted image of africa as a site of primitivism and catastrophe, the sources of which lie in colonial discourses of backwardness, exoticism and savagery. thus, while it may be that having a fear of ebola is a somewhat understandable response and not in itself a colonial attitude, the colonial legacy nevertheless exerts a tacit and often unrecognized influence on the fear. specifically, it may "fan the flames of fear" or to put it in more technical terms, the colonial legacy may contribute to the phenomenon known as the "social amplification of risk", whereby peoples' perceptions of risk are unreasonably intensified (kasperson et al. ). one criticism of the international ebola response has been the failure of some international agencies to partner effectively with local government agencies, ngos, and community organizations to respond appropriately and effectively to the epidemic, and to build capacity for the future (gundan ; kaba jones and norman ). the need to engage communities in successful health initiatives is well-established (israel et al. ) and yet this seems to have been lost in the urgency of the international response. international initiatives responding to the ebola epidemic focused on immediate treatment responses, the development and delivery of vaccines, security and containment, and large initiatives like building hospitals. for example, canada's contribution to the ebola campaign was the provision of protective gear, setting up mobile labs, and the delivery of an experimental vaccine (public health agency of canada ). at best, these responses have been slow, expensive, difficult to coordinate, and unsustainable (gundan ). at their worst, the responses met resistance by local populations, and were slow to adapt to the local contexts, thus rendering such responses ineffective and inefficient, and in the end, leaving the communities vulnerable to the next health crises. the importance of acknowledging and respecting concerns and practices of local communities and their socio-political context has been identified as a major issue in implementing health policies and practices (nichter ) . in reviewing the trajectory of the response to the ebola outbreak, petherick ( ) noted the general lack of trust between medical teams and local communities. this lack of trust contributed to community responses ranging from hiding ebola cases from health workers, to attacking health workers and health facilities, driven by the belief that medical staff were spreading the infection, rather than trying to contain it. mitman ( ) argues that the colonial history between africa and europe is one underlying source of this mistrust, a history that began with slave traders and missionaries and continues with the current european exploitation of resources and labour and western military involvement in a range of conflicts. in the early to mid s, american medical researchers followed this path of exploitation, extracting blood, tissue and, ultimately, knowledge, on expeditions to africa, with some amount of coercion and without benefit or explanation to local populations (karamouzian and hategekimana ) . this history of violence, invasion and exploitation has not been forgotten and could only have been reinforced by the presence of western military personnel supporting biohazard-suited health workers (bayntun et al. ) . community based health initiatives are rapid and culturally appropriate responses from agencies trusted by the communities, and as such are more likely to be successful (teutsch and fielding ) . effective and innovative grassroots community led responses began immediately in ebola-affected areas across west africa and have been successful (kaba jones and norman ) . moreover, strengthening these local community organizations can also be part of a strategy to build primary health care in general (anders ) . however, obtaining international support for grassroots initiatives is challenging. most international funding is directed to eu or us organizations, which may have local initiatives and a history of working successfully in the area, but little funding is generally directed to local grassroots organizations or to the development of sustainable health infrastructure (gundan ). the ebola epidemic rose rapidly in countries experiencing severe poverty, with a recent history of political unrest and conflict, and with very poor health care systems and infrastructure. prevention of future epidemics requires development of strong social, political and health infrastructure (kaba jones and norman ). the challenge is that international responses often do little to produce sustainable development. in an interview with journalist flavie halais, development expert ian smillie noted that canada's interventions in sierra leone would have no lasting impact on the health care system (halais ) , and thus make no contribution towards the prevention of future epidemics. representatives of the uk department for international development (dfid) now claim that they should have focused on prevention and social mobilization earlier, and funneled more funding to local grassroots organizations to do so effectively (j oźwiak ). in the same article, however, the author noted that dfid's funding policies made it difficult to fund local agencies, and that they report no plans to shift funding policies, reflecting the disconnect between evidence based practices in population health, and the politics of international aid funding. ebola is a well-studied disease, not an unknown one like sars was when it first appeared in , with a fatality rate of %. ebola's genomes have been sequenced and patented, and supportive health care can reduce its fatality rate to about %, according to health researcher laurie garrett (cbc ) . but as former who staffer akong charles ndika notes, the desperate state of most african health-care systems enables the threat posed by ebola outbreaks to be maintained, and these inequities "will continue in [the] future to manufacture new and re-emerging epidemics like ebola . . . with frightening impact on a global scale" (ndika : n.p.) . moral panic is not helpful. health-care workers need the training and equipment to protect themselves, and basic health education for the general public is crucial to counter stigma, fear, ignorance, and superstition. participatory education and logistics are the main challenges, not just to build hospitals and public health interventions, but also to support food security, infrastructure and governance systems, especially at local levels across the global south. this is a huge and pressing endeavour which only the who can coordinate, working closely with local institutions. so the who must be supported-not just in words but with significant financial and material resources-in order to meet the immediate challenges of new disease outbreaks and also to build the longer-term capacity of local public health agencies so that local units can function effectively and sustainably, since future outbreaks are inevitable in today's globalized world. this applies not only to the need to increase the supply of material resources needed for the emergency response, but also the training of local staff so that they can thwart the threat themselves. broad public participation in governance of the entire health care system is also necessary, both locally and globally, so that education and democracy go hand in hand with the development of strong health care systems. urban public health systems should become a prime focus of who and international support. analysis of the social and economic roots of the ebola epidemic demonstrates that the crisis was grounded in global income inequality and the same impoverishment that had opened up countries for land grabbing, rapacious foreign direct investment and agro-forestry, the displacement of more and more people, the destruction of natural habitats and the erosion of the capacity for social resilience. these conditions will continue to produce outbreaks of emergent diseases in times of climate change, and unless they are addressed, these outbreaks will continue to facilitate ongoing global health threats. political and physical environments. this includes work on culture, migration and health inequities; climate change adaptation; and social integration of refugees. pablo idahosa (ph.d. political economy, university of toronto) is a professor in the department of social science at york university, where he directs the african studies program, and teaches development studies. he has written on development ethics, the politics of ethnicity, and national development. he is author of the populist dimension of african political thought, co-editor of the somali diaspora, and co-editor of development's displacements. among his ongoing research interests are the relationships between development and cultural production in africa, and the politics of disease in africa. he has served on the executive of the international development ethics association. he is completing a book on social welfare in africa. roger keil (dr. phil political science, goethe university, frankfurt) is york research chair in global sub/urban studies in the faculty of environmental studies at york university in toronto. a former director of york university's city institute, he researches global suburbanization, urban political ecology, cities and infectious disease, and regional governance and is principal investigator of a major collaborative research initiative on "global suburbanisms: governance, land and infrastructure in the st century" ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . he is the editor of suburban constellations (jovis ) and co-editor (with pierre hamel) of suburban governance: a global view (utp ) . patricia e. perkins (ph.d. economics, university of toronto) is a professor in the faculty of environmental studies, york university, toronto, where she teaches and advises students in the areas of ecological economics, community economic development, and critical interdisciplinary research design. her research focuses on feminist ecological economics, climate justice, and participatory governance. she has directed international research projects on community-based environmental and watershed education in brazil and canada and on climate justice and equity in watershed management with partners in mozambique, south africa and kenya, and is the editor of water and climate change in africa: challenges and community initiatives in durban, maputo and nairobi. unjust waters: climate change, flooding and the protection of poor urban communities: experiences from six african cities african factsheet on ebola challenges, health workforce and human resources for health shortages emerging diseases in the global city. blackwell, oxford anders m ( ) ebola responders tap past survivors. youth in community-based strategy emergence of zaire ebola virus disease in guinea rendering the world unsafe: 'vulnerability' as western discourse ebola crisis: beliefs and behaviours warrant urgent attention suburban governance: a global view suburbs at risk. in: keil r (ed) suburban constellations: governance, land and infrastructure in the st century sierra leone country report. bertelsmann stiftung's transformation index (bti) csi ebola: tracking the outbreak's origins. quirks and quarks ebola making a comeback in places it was contained. the toronto star immigrant health workers in oecd countries in the broader context of highly skilled migration. international migration outlook the disease that emerged. limn issue number , ebola's ecologies sierra leone ebola patient, recovered from family, dies in ambulance. reuters climate change: the public health response the truth about ebola: the real way to control ebola is to stop the fear and misunderstanding englewood cliffs gundan f ( ) liberia: how africa and africans are responding to the ebola crisis money (not) well spent? concerns raised over canada's response to ebola. devex global health governance: crisis, institutions and political economy review of community-based research: assessing partnership approaches to improve public health dfid has learned 'a lot' in ebola response. devex fighting ebola from the grassroots ebola treatment and prevention are not the only battles: understanding ebola-related fear and stigma the social amplification of risk: a conceptual framework introduction: the international political economy of global health governance transnational urban political ecology: health, environment and infrastructure in the unbounded city suburban constellations: governance, land and infrastructure in the st century the handbook of mobilities. routledge climate change and transdisciplinary science: problematizing the integration imperative corrupt global food system, farmland is the new gold. inter press service the world health organization (who) race against time: searching for hope in aids-ravaged africa suburbanisms in africa? in: keil r (ed) suburban constellations: governance, land and infrastructure in the st century geography, ecology and emerging infectious diseases ebola in a stew of fear triangulation and integration: processes, claims and implications ebola crisis update-sept th ebola: recovery of americans sharpens divisions in global health global health: why cultural perceptions, social representations and biopolitics matter an assessment of the emergency response among health workers involved in the cholera outbreak in northern nigeria africa: varied colonial legacies another inconvenient truth: how biofuel policies are deepening poverty and accelerating climate change climate justice and gender justice: building women's political agency in times of climate change. paper presented at the international association for feminist economics (iaffe) conference, accra ebola in west africa: learning the lessons ebola epidemic exposes the pathology of the global economic and political system trigger events: enviroclimatic coupling of ebola hemorrhagic fever outbreaks contagion and chaos: disease, ecology and national security in the era of globalization. mit, cambridge public health agency of canada ( ) speaking notes for the honorable rona ambrose, minister of health: the government's response to the ebola outbreak epidemics and resistance in colonial sierra leone during the first world war taking complexity seriously: policy analysis, triangulation and sustainable development the ebola outbreak: international and u.s. responses. congressional research service global forecasts of urban expansion to and direct impacts on biodiversity and carbon pools feral suburbs: cultural topologies of social reproduction, fort mcmurray, canada ebola vaccine story shows folly of free-market drugs rediscovering the core of public health ebola's gender bias sierra leone capital now in grip of ebola. aljazeera race and disease: should we change the name of ebola? aid sustainability and equity: a better future for all west african communities receiving ebola's orphans with open arms contagious: cultures, carriers, and the outbreak narrative ebola's exaggerated fear being fed by stigma and stereotypes as ebola's spread continues, warnings of an inadequate global response cities and public health crisis cholera in sierra leone: the case study of an outbreak: world health organization atlas of african health statistics : health situation analysis of african region ebola virus disease outbreak response plan in west africa nigeria is now free of ebola virus transmission. world health organization updates one year into the ebola epidemic: a deadly, tenacious and unforgiving virus. world health organization updates why are so many women dying from ebola? foreign policy only a few aid agencies willing to help fight ebola in africa. the globe and mail fear and education play crucial role in ebola crisis. the globe and mail u.s. troops arrive in west africa to help fight ebola outbreak. the globe and mail his research focuses on the analyses of 'disaster incubation': how normally unnoticed social and ecological processes converge to create a disaster, including disease outbreaks. he is currently studying the social and political implications of oil sands extraction, with a special focus on the state surveillance and monitoring of environmental activists in canada barlu dumbuya is a graduate student in the disaster and emergency management program with a concentration in environmental issues, technology and disaster management at york university. she is interested in social vulnerability, community resilience and capacity building in developing countries she conducts collaborative research with students, communities and organizations, both locally and internationally, on the relationship between different kinds of social connections (interpersonal relationships, social networks) and resilience in situations of social conflict and displacement key: cord- - cjlolp authors: cotton‐barratt, owen; daniel, max; sandberg, anders title: defence in depth against human extinction: prevention, response, resilience, and why they all matter date: - - journal: glob policy doi: . / - . sha: doc_id: cord_uid: cjlolp we look at classifying extinction risks in three different ways, which affect how we can intervene to reduce risk. first, how does it start causing damage? second, how does it reach the scale of a global catastrophe? third, how does it reach everyone? in all of these three phases there is a defence layer that blocks most risks: first, we can prevent catastrophes from occurring. second, we can respond to catastrophes before they reach a global scale. third, humanity is resilient against extinction even in the face of global catastrophes. the largest probability of extinction is posed when all of these defences are weak, that is, by risks we are unlikely to prevent, unlikely to successfully respond to, and unlikely to be resilient against. we find that it’s usually best to invest significantly into strengthening all three defence layers. we also suggest ways to do so tailored to the classes of risk we identify. lastly, we discuss the importance of underlying risk factors – events or structural conditions that may weaken the defence layers even without posing a risk of immediate extinction themselves. • future research should identify synergies between reducing extinction and other risks. for example, research on climate change adaptation and mitigation should assess how we can best preserve our ability to prevent, respond to, and be resilient against extinction risks. our framework for discussing extinction risks human extinction would be a tragedy. for many moral views it would be far worse than merely the deaths entailed, because it would curtail our potential by wiping out all future generations and all value they could have produced (bostrom, ; parfit, ; rees, rees, , . human extinction is also possible, even this century. both the total risk of extinction by and the probabilities of specific potential causes have been estimated using a variety of methods including trend extrapolation, mathematical modelling, and expert elicitation; see rowe and beard ( ) for a review, as well as tonn and stiefel ( ) for methodological recommendations. for example, pamlin and armstrong ( ) give probabilities between . % and % for different scenarios that could eventually cause irreversible civilisational collapse. to guide research and policymaking in these areas, it may be important to understand what kind of processes could lead to our premature extinction. people have considered and studied possibilities such as asteroid impacts (matheny, ) , nuclear war (turco et al., ) , and engineered pandemics (millett and snyder-beattie, ) . in this article we will consider three different ways of classifying such risks. the motivating question behind the classifications we present is 'how might this affect policy towards these risks? ' we proceed by identifying three phases in an extinction process at which people may intervene. for each phase, we ask how people could stop the process, because the different failure modes may be best addressed in different ways. for this reason we do not try to classify risks by the kind of natural process they represent, or which life support system they undermine (unlike e.g. avin et al., ) . an event causing human extinction would be unprecedented, so is likely to have some feature or combination of features that is without precedent in human history. now, we see events with some unprecedented property all of the timewhether they are natural, accidental, or deliberateand many of these will be bad for people. however, a large majority of those pose essentially zero risk of causing our extinction. why is it that some damaging processes pose risks of extinction, but many do not? by understanding the key differences we may be better placed to identify new risks and to form risk management strategies that attack their causes as well as other factors behind their destructive potential. we suggest that much of the difference can usefully be explained by three broad defence layers ( figure ): . first layer: prevention. processesnatural or humanwhich help people are liable to be recognised and scaled up (barring defeaters such as coordination problems). in contrast processes which harm people tend to be avoided and dissuaded. in order to be bad for significant numbers of people, a process must either require minimal assistance from people, or otherwise bypass this avoidance mechanism. . second layer: response. if a process is recognised to be causing great harm (and perhaps pose a risk of extinction), people may cooperate to reduce or mitigate its impact. in order to cause large global damage, it must impede this response, or have enough momentum that there is nothing people can do. . third layer: resilience. people are scattered widely over the planet. some are isolated from external contact for months at a time, or have several years' worth of stored food. even if a process manages to kill most of humanity, a surviving few might be able to rebuild. in order to cause human extinction, a catastrophe must kill everybody, or prevent a long-term recovery. the boundaries between these different types of risk-reducing activity aren't crisp, and one activity may help at multiple stages. but it seems that often activities will help primarily at one stage. we characterise prevention as reducing the likelihood that catastrophe strikes at all; it is necessarily done in advance. we characterise response as reducing the likelihood that a catastrophe becomes a severe global catastrophe (at the level which might threaten the future of civilisation). this includes reducing the impact of the catastrophe after it is causing obvious and significant damage, but the response layer might also be bolstered by mitigation work which is done in advance. finally, we characterise resilience as reducing the likelihood that a severe global catastrophe eventually causes human extinction. successfully avoiding extinction could happen at each of these defence layers. in the rest of the article we explore two consequences of this. first, we can classify damaging processes by the way in which we could stop them at the defence layers. in section , we'll look at a classification of risks by their origin: understanding different ways in which we could succeed at the prevention layer. in section , we'll look at the features which may allow us to block them at the response layer. in section , we'll classify risks by the way in which we could stop them from finishing everybody. we conclude each section by policy implications. each risk will thus belong to three classesone per defence layer. for example, consider a terrorist group releasing an engineered virus that grows into a pandemic and eventually kills everyone. in our classification, we'll call this prospect a malicious risk with respect to its origin; a cascading risk with respect to its scaling mechanism of becoming a global catastrophe; and a vector risk in the last phase we've called endgame. we'll present more examples at the end of section and in table . second, we present implications of our framework distinguishing three layers. in section , we discuss how to allocate resources between the three defence layers, concluding that in most cases all of prevention, response, and resilience should receive substantial funding and attention. in section , we highlight that risk management, in addition to monitoring specific hazards, must protect its defence layers by fostering favourable structural conditions such as good global governance. avin et al. ( ) have recently presented a classification of risks to the lives of a significant proportion of the human population. they classify such risks based on 'critical systems affected, global spread mechanism, and prevention and mitigation failure'. our framework differs from theirs in two major ways. first, with extinction risks we focus on a more narrow type of risk. this allows us, in section , to discuss what might stop global catastrophes from causing extinction, a question specific to extinction risks. second, even where the classifications cover the same temporal phase of a global catastrophe, they are motivated by different questions. avin et al. attempt a comprehensive survey of the natural, technological, and social systems that may be affected by a disaster, for example listing critical systems in their second section. by contrast, we ask why a risk might break through a defence layer, and look for answers that abstract away from the specific system affected. for instance, in section , we'll distinguish between unforeseen, expected but unintended, and intended harms. we believe the two classifications complement each other well. avin and colleagues' ( ) discussion of prevention and response failures is congenial to our section on underlying risk factors. their extensive catalogues of critical systems, spread mechanisms and prevention failures highlight the wide range of relevant scientific disciplines and stakeholders, and can help identify fault points relevant to particularly many risks. conversely, we hope that our coarser typology can guide the search for additional critical systems and spread mechanisms. we believe that our classification also usefully highlights different ways of protecting the same systems. for example, the risks from natural and engineered pandemics might best be reduced by different policy levers even if both affected the same critical systems and spread by the same mechanisms. lastly, our classification can help identify risk management strategies that would reduce whole clusters of risks. for example, restricting access to dangerous information may prevent many risks from malicious groups, irrespective of the critical system that would be targeted. our classification also overlaps with the one by liu et al. ( ) , for example when they distinguish intended from other vulnerabilities or emphasise the importance of resilience. while the classifications otherwise differ, we believe ours contributes to their goal to dig 'beyond hazards' and surface a variety of intervention points. both the risks discussed by avin et al. ( ) and extinction risks by definition involve risks of a massive loss of lives. this sets them apart from other risks where the adverse outcome would also have global scale but could be limited to less severe damage such as economic losses. such risks are being studied by a growing literature on 'global systemic risk' (centeno et al., ) . rather than reviewing that literature here, we'll point out throughout the article where we believe it contains useful lessons for the study of extinction risks. finally, it's worth keeping in mind that extinction is not the only outcome that would permanently curtail humanity's potential; see bostrom ( ) for other ways in which this could happen. a classification of these other existential risks is beyond the scope of this article, as is a more comprehensive survey of the large literature on global risks (e.g. baum and barrett, ; baum and handoh, ; bostrom and cirkovi c ; posner, ) . avoiding catastrophe altogether is the most desirable outcome. the origin of a risk determines how it passes through the prevention layer, and hence the kind of steps society can take to strengthen prevention ( figure ). the simplest explanation for a risk to bypass our background prevention of harm-creating activities is if the origin is outside of human control: a natural risk. examples include a large enough asteroid striking the earth, or a naturally occurring but particularly deadly pandemic. we sometimes can take steps to avoid natural risks. for example, we may be able to develop methods for deflecting asteroids. preventing natural risks generally requires proactive understanding and perhaps detection, for instance scanning for asteroids on earth-intersecting orbits. such risks share important properties with anthropogenic risks, as any explanation for how they might materialise must include an explanation of why the human-controlled prevention layer failed. all non-natural risks are in some sense anthropogenic, but we can classify them further. some may have a localised origin, needing relatively small numbers of people to trigger them. others require large-scale and widespread activity. in each case there are at least a couple of ways that it could get through the prevention layer. note that there is a spectrum in terms of the number of people who are needed to produce different risks, so the division between 'few people' and 'many people' is not crisp. we might think of the boundary as being around one hundred thousand or one million people, and things close to this boundary will have properties of both classes. however, it appears to us that for many of the plausible risks the number required is either much smaller (e.g., an individual or a cohesive group of people such as a company or military unit) or much larger than this (e.g., the population of a major power or even the whole world), so the qualitative distinction between 'few people' and 'many people' (and the different implications of these for responding) seems to us a useful one. also potentially relevant are the knowledge and intentions of the people conducting the risky activity. they may anthropogenic risks from small groups the case of a risk where relatively few people are involved in triggering and they are unaware of the potential harm is an unseen risk. this is likely to involve a new kind of activity; it is most plausible with the development of unprecedented technologies (gpp, ) , such as perhaps advanced artificial intelligence (bostrom, ) , nanotechnology (auplat, (auplat, , umbrello and baum, ) , or high-energy physics experiments (ord et al., ) . the case of a localised unintentional trigger which was foreseen as a possibility (and the dynamics somewhat understood) is an accident risk. this could include a nuclear war starting because of a fault in a system or human error, or the escape of an engineered pathogen from an experiment despite safety precautions. if the harm was known and intended, we have a malicious risk. this is a scenario where a small group of people wants to do widespread damage; see torres ( torres ( , b for a typology and examples. malicious risks tend to be extreme forms of terrorism, where there is a threat which could cause global damage. turning to scenarios where many people are involved, we ask why so many would pursue an activity which causes global damage. perhaps they do not know about the damage. this is a latent risk. for them to remain ignorant for long enough, it is likely that the damage is caused in an indirect or delayed manner. we have seen latent risks realised before, but not ones that threatened extinction. for example, asbestos was used in a widespread manner before it was realised that it caused health problems. and it was many decades after we scaled up the burning of fossil fuels that we realised this contributed to climate change. if our climate turns out to be more sensitive than expected (nordhaus, ; wagner and weitzman, ; weitzman, ) , and continued fossil fuel use triggers a truly catastrophic shift in climate, then this could be a latent risk today. in some cases people may be aware of the damage and engage in the activity anyway. this failure to internalise negative externalities is typified by 'tragedy of the commons' scenarios, so we can call this a commons risk. for example, failure to act together to tackle global warming may be a commons risk (but lack of understanding of the dynamics causes a blur with latent risk). in general, commons risks require some coordination failure. they are therefore more likely if features of the risk inhibit coordination; see for example barrett ( ) and sandler ( ) for a game-theoretic analysis of such features. finally, there are cases where a large number of people engage in an activity to cause deliberate harm: conflict risk. this could include wars and genocides. wars share some features with commons risk: there are solutions which are better for everybody but are not reached. in most conflicts, actors are intentionally causing harm, but only as an instrumental goal. in the above we classify risks according to who creates the risk and their state of knowledge. we have done this because if we want to prevent risk it will often be most effective to go to the source. but we could also ask who is in a position to take actions to avoid the risk. in many cases those creating it have most leverage, but in principle almost any actor could take steps to reduce the occurrence rate. if risk prevention is underprovided, this is likely to be a tragedy of the commons scenario, and share characteristics with commons risk. from a moral and legal standpoint intentionality often matters. the possibility of being found culpable is an important incentive for avoiding risk-causing activities and part of risk management in most societies. if creating or hiding potential catastrophic risks is made more blameworthy, prevention will likely be more effective. unfortunately it also often motivates concealment that can create or aggravate risk; see chernov and sornette ( ) for case studies of how this misincentive can weaken prevention and response. this shows the importance of making accountability effectively enforceable. • to be able to prevent natural risks, we need research aimed at identifying potential hazards, understanding their dynamics, and eventually develop ways to reduce their rate of occurrence. • to avoid unseen and latent risks, we can promote norms such as appropriate risk management principles at institutions that engage in plausibly risky activities; note that there is an extensive literature on rivalling risk management principles (e.g. foster et al., ; o'riordan and cameron, ; sandin, ; sunstein, ; wiener, ) , especially in the face of catastrophic risks (baum, ; bostrom, ; buchholz and schymura, ; sunstein, sunstein, , tonn, ; tonn and stiefel, )advocating for any particular principle is beyond the scope of this article. see also jebari ( ) for a discussion of how heuristics from engineering safety may help prevent unseen, latent, and accident risks. regular horizon scanning may identify previously unknown risks, enabling us to develop targeted prevention measures. organisations must be set up in such a way that warnings of newly discovered risks reach decision-makers (see clarke and eddy, , for case studies where this failed). • accidents may be prevented by general safety norms that also help reduce unseen risk. in addition, building on our understanding of specific accident scenarios, we can design failsafe systems or follow operational routines that minimise accident risk. in some cases, we may want to eschew an accident-prone technology altogether in favour of safer alternatives. accident prevention may benefit from research on high reliability organisations (roberts and bea, ) and lessons learnt from historical accidents. where effective prevention measures have been identified, it may be beneficial to codify them through norms and law at the national and international levels. alternatively, if we can internalise the expected damages of accidents through mechanisms such as insurance, we can leverage market incentives. • solving the coordination problems at the heart of commons and conflict risks is sometimes possible by fostering national or international cooperation, be it through building dedicated institutions or through establishing beneficial customs. one idea is to give a stronger political voice to future generations (jones et al., ; tonn, tonn, , . • lastly, we can prevent malicious risks by combating extremism. technical (trask, ) as well as institutional (lewis, ) innovations may help with governance challenges in this area, a survey of which is beyond the scope of this article. • note that our classification by origin is aimed at identifying policies that wouldif successfully implementedreduce a broad class of risks. developing policy solutions is, however, just one step toward effective prevention. we must then also actually implement themwhich may not happen due to, for example, free-riding incentives. our classification does not speak to this implementation step. avin et al. ( ) congenially address just this challenge in their classification of prevention and mitigation failures. classification by scaling mechanism: types of response failure for a catastrophe to become a global catastrophe, it must eventually have large effects despite our response aimed at stopping it. to understand how this can happen, it's useful to look at the time when we could first react. effects must then either already be large or scale up by a large factor afterwards ( figure ). if the initial effects are large, we will simply say that the risk is large. if not, we can look at the scaling process. if massive scaling happens in a small number of steps, we say there is leverage in play. if scaling in all steps is moderate, there must be quite a lot of such stepsin this case we say that the risk is cascading. paradigm examples of catastrophes of an immediately global scale are large sudden-onset natural disasters such as asteroid strikes. since we cannot respond to them at a smaller-scale stage, mitigation measures we can take in advance (part of the second defence layer as they would reduce damage after it has started) and the other defence layers of prevention and resilience are particularly important to reduce such risks. prevention and mitigation may benefit from detecting a threatsay, an asteroidearly, but in our classification this is different from responding after there has been some actual small-scale damage. leverage points for rapid one-step scaling can be located in natural systems, for example if the extinction of a key species caused an ecosystem to collapse. however, it seems to us that leverage points are more common in technological or social systems that were designed to concentrate power or control. risks of both natural and anthropogenic origin may interact with such systems. for instance, a tsunami triggered the disaster at the fukushima daiichi nuclear power plant. anthropogenic examples include nuclear war (possible to trigger by a few individuals linked to a larger chain of command and control) or attacks on weak points in key global infrastructure. responding to leverage risks is challenging because there are only few opportunities to intervene. on the other hand, blocking even one step of leveraged growth would be highly impactful. this suggests that response measures may be worthwhile if they can be targeted at the leverage points. with the major exception of escalating conflicts, cascading risks normally cascade in a way which does not rely on humans deciding to further the effects. a typical example is the self-propagating growth of an epidemic. as automation becomes more widespread, there will be larger systems without humans in the loop, and thus perhaps more opportunities for different kinds of cascading risk. since cascading risks are those which have a substantial amount of growing effects after we're able to interact with defence in depth them, it seems likely that they will typically give us more opportunities to respond, and that response will therefore be an important component of risk reduction. for risks which cascade exponentially (such as epidemics), an earlier response may be much more effective than a later one. reducing the rate of propagation is also effective if there exist other interventions that can eventually stop or revert the damage. however, there are a few secondary risk-enabling properties that can weaken the response layer and therefore help damage cascade to a global catastrophe which we could have stopped. for example, a cascading risk may: • impede cooperation: by preventing a coordinated response, the likelihood of a global catastrophe is increased. cooperation is harder when communication is limited, when it is hard to observe defection, or when there is decreased trust. • not obviously present a risk: the longer a cascading risk is under-recognised, the more it can develop before any real response. for example, long-incubation pathogens can spread further before their hazard becomes apparent. • be on extreme timescales: if the risk presents and cascades very fast, there is little opportunity for any response. johnson et al. ( ) analyse such 'ultrafast' events, using rapid changes in stock prices driven by trading algorithms as an example (braun et al., , however find that most of these 'mini flash crashes' are dominated by a single large order rather than being the result of a cascade). note, however, that which timescales count as relevantly 'fast' depends on our response capabilitiestechnological and institutional progress may result in faster-cascading threats but also in opportunities to respond faster. on the other hand people may be bad at addressing problems that won't manifest for generations, as is the case for some impacts of global warming. policy implications for responding to extinction risk • by their nature, we cannot respond to large risks before they become a global catastrophe. of particular importance for such risks are therefore: mitigation that can be done in advance, and the defence layers of prevention and resilience. • leverage risks provide us with the opportunity of a leveraged response: we can identify leverage points in advance and target our responses at them. • while the details of responses to cascading risks must be tailored to each specific case, we can highlight three general recommendations. first, detect damage early, when a catastrophe is still easy to contain. second, reduce the time lag between detection and response, for example, by continuously maintaining response capabilities and having rapidly executable contingency plans in place. third, ensure that planned responses won't be stymied by the cascading process itselffor example, don't store contingency plans for how to respond to a power outage on computers. for a global catastrophe to cause human extinction, it must in the end stop the continued survival of the species. this could be direct: killing everyone; or indirect: removing our ability to continue flourishing over a longer period (figure ). in order to kill everyone, the catastrophe must reach everyone. we can further classify direct risks by how they reach everyone. the simplest way this could happen is if it is everywhere that people are or could plausibly be: a ubiquity risk. if the entire planet is struck by a deadly gamma ray burst, or enough of a deadly toxin is dispersed through the atmosphere, this could plausibly kill everyone. if it doesn't reach everywhere people might be, a direct risk must at least reach everywhere that people in fact are. this might occur when people have carried it along with them: a vector risk. this includes risk from pandemics (if they are sufficiently deadly and have a long enough incubation period that it is spread everywhere) or perhaps risks which are spread by memes (dawkins, ) , or which come from some technological artefacts which we carry everywhere. note that to directly cause extinction, a vector would need to impact hard-to-reach populations including 'disaster shelters, people working on submarines, and isolated peoples' (beckstead, a, p. ) . if not ubiquitous and not carried with the people, we would have to be extraordinarily unlucky for it to reach everyone by chance. setting this aside as too unlikely, we are left with agency risk: deliberate actors trying to reach everybody. the actors could be humans or nonhuman global policy ( ) intelligence (perhaps machine intelligence or even aliens). agency risk probably means someone deliberately trying to ensure nobody survives, which may make it easier to get through the resilience layer by allowing anticipation of and response to possible survival plans. in principle agency risk includes cases where someone is deliberately trying to reach everyone, and only by accident does so in a way that kills them. if the risk threatens extinction without killing everyone, it must reduce our long-term ability to survive as a species. this could include a very broad range of effects, but we can break them up according to the kind of ability it impedes. habitat risks make long-term survival impossible by altering or destroying the environment we live in so that it cannot easily support human life. for example a large enough asteroid impact might throw up dust which could prevent us from growing food for many yearsif this was long enough, it could lead to human extinction. alternatively an environmental change which lowered the average number of viable offspring to below replacement rates could pose a habitat risk. capability risks knock us back in a way that permanently remove an important societal capability, leading in the long run to extinction. one example might be moving to a social structure which precluded the ability to adapt to new circumstances. we are gesturing towards a distinction between habitat risks and capability risks, rather than drawing a sharp line. habitat risks work through damage to an external environment, where capability risks work through damage to more internal social systems (or even biological or psychological factors). capability risks are also even less direct than habitat risks, perhaps taking hundreds or thousands of years to lead to extinction. indeed there is not a clear line between capability risks and events which damage our capabilities but are not extinction risks (cf. section ). nonetheless when considering risks of human extinction it may be important to account for events which could cause the loss of fragile but important capabilities. an important type of capability risk may be civilisational collapse. it is possible that killing enough people and destroying enough infrastructure could lead to a collapse of civilisation without causing immediate extinction. if this happens, it is then plausible that it might never recover, or recover in a less robust form, and be wiped out by some subsequent risk. it is an open and important question how likely this permanent loss of capability is (beckstead, b) . if it is likely, the resilience layer may therefore be particularly important to reinforce, perhaps along the lines proposed by maher and baum ( ) . on the other hand, if even large amounts of destruction have only small effects on the chances of eventual extinction, it becomes more important to focus on risks which can otherwise get past the resilience layer. we finally illustrate our completed classification scheme by applying it to examples, which we summarise in table . throughout the text, we've repeatedly referred to an asteroid strike that might cause extinction due to an ensuing impact winter. we've called this a natural risk regarding its origin; a large risk regarding scale, with no opportunity to intervene between the asteroid impact and its damage affecting the whole globe; and, if we assume that humanity dies out because climatic changes remove the ability to grow crops, a habitat risk in the endgame phase. our next pair of examples illustrates that risks with the same salient central mechanismin this case nuclear warmay well differ during other phases. consider first a nuclear war precipitated by a malfunctioning early warning system that is, a nuclear power launching what turns out to be a first strike because it falsely believed that its nuclear destruction was imminent. suppose further that this causes a nuclear winter, leading to human extinction. this would be an accident that scales via leverage, and finally manifests as a habitat risk. contrast this with the intentional use of nuclear weapons in an escalating conventional war, and assume further that this either doesn't cause a nuclear winter or that some humans are able to survive despite adverse climatic conditions. instead, humanity never recovers from widespread destruction, and is eventually wiped out by some other catastrophe that could have easily been avoided by a technologically advanced civilisation. this second scenario would be a conflict that again scaled via the leverage associated with nuclear weapons, but then finished off humanity by removing a crucial capability rather than via damage to its habitat. we close by applying our classification to a more speculative risk we might face this century. some scholars (e.g. bostrom, ) have warned that progress in artificial intelligence (ai) could at some point allow unforeseen rapid self-improvement in some ai system, perhaps one that uses machine learning and can autonomously acquire additional training data via sensors or simulation. the concern is that this could result in a powerful ai agent that deliberately wipes out humanity to pre-empt interference with its objectives (see omohundro, , for an argument why such preemption might be plausible). to the extent that we currently don't know of any machine learning algorithms that could exhibit such behaviour, this would be an unseen risk; the scaling would be via leverage if we assume a discrete algorithmic improvement as trigger, or alternatively the risk could be rapidly cascading; in the endgame, this scenario would present an agency risk. • to guard against what today would be ubiquity risks, we may in the future be able to establish human settlements on other planets (armstrong and sandberg, ) . • vector risks may not reach people in isolated and self-sufficient communities. establishing disaster shelters may hence be an attractive option. self-sufficient shelters can also reduce habitat risk. jebari ( ) discusses how to maximise the resilience benefits from shelters, while beckstead ( a) has argued that their marginal effect would be limited due to the presence of isolated peoples, submarine crews, and existing shelters. • resilience against vector and agency risks may be increased by late-stage response measures that work even in the event of widespread damage to infrastructure and the breakdown of social structure. an example might be the 'isolated, self-sufficient, and continuously manned underground refuges' suggested by jebari ( , p. ). in this section we will use our guiding idea of three defence layers to present a way of calculating the extinction probability posed by a given risk. we'll draw three high-level conclusions: first, the most severe risks are those which have a high probability of breaking through all three defence layers. second, when allocating resources between the defence layers, rather than comparing absolute changes in these probabilities we should assess how often we can halve the probability of a risk getting through each layer. third, it's best to distribute a sufficiently large budget across all three defence layers. we are interested in the probability p that a given risk r will cause human extinction in a specific timeframe, say by . whichever three classes r belongs to, in order to cause extinction it needs to get past all three defence layers; its associated extinction probability p is therefore equal to the product of three factors: . the probability c for r getting past the first barrier and causing a catastrophe; . the conditional probability g that r gets past the second barrier to cause a global catastrophe, given that it has passed the first barrier; and . the conditional probability e that r gets past the third barrier to cause human extinction, given that it has passed the second barrier. in short: p = cÁgÁe. each of c, g, and e can get extremely small for some risks. but the extinction probability p will be highest when all three terms are non-negligible. hence we get our (somewhat obvious) first conclusion that the most concerning risks are those which can plausibly get past all three defence layers. however, most concerning doesn't necessarily translate into the most valuable to act on. suppose we'd like to invest additional resources into reducing risk r. we could use them to strengthen either of the three defences, which would make it less likely that r passes that defence. we should then compare relative rather than absolute changes to these probabilities, which is our second conclusion. that is, to minimise the extinction probability p we should ask which of c, g, and e we can halve most often. this is because the same relative change of each probability will have the same effect on the extinction probability phalving either of c, g, or e will halve p. by contrast, the effect of the same absolute change will vary depending on the other two probabilities; for instance, reducing c by . reduces p by . ÁgÁe. in particular, a given absolute change will be more valuable if the other two probabilities are large. when one of c, g, or e is close to %, it may be much harder to reduce it to % than it would be to halve a smaller probability. the principle of comparing how often we can halve c, g, and e then implies that we're better off reducing probabilities not close to %. for example, consider a large asteroid striking the earth. we could take steps to avoid it (for example by scanning and deflecting), and we could take steps to increase our resilience (for example by securing food production). but if a large asteroid does cause a catastrophe, it seems very likely to cause a global catastrophe, and it is unclear that there is much to be done in reducing the risk at the scaling stage. in other words, the probability g is close to and prohibitively hard to substantially reduce. we therefore shouldn't invest resources into futile responses, but instead use them to strengthen both prevention and resilience. what if each defence layer has a decent chance of stopping a risk? we'll then be best off by allocating a non-zero chunk of funding to all three of thema strategy of defence in depth, our third conclusion. the reason just is the familiar phenomenon of diminishing marginal returns of resources. it may initially be best to strengthen a particular layerbut once we've taken the low-hanging fruit there, investing in another layer (or in reducing another risk) will become equally cost-effective. of course, our budget might be exhausted earlier. defending in depth therefore tends to be optimal if and only if we can spend relatively much in total. we close by discussing some limitations of our analysis. first, we remain silent on the optimal allocation of resources between different risks (rather than between different layers for a fixed risk or basket of risks); indeed, as we'll argue in section , comprehensively answering the question of how to optimally allocate resources intended for extinction risk reduction requires us to look beyond even the full set of extinction risks. we do hope that our work could prove foundational for further research that investigates both the allocation between risks and between defence layers simultaneously. indeed, it would be straightforward to consider several risks p i = c i Ág i Áe i , i = , . . ., n; assuming specific functional forms for how the probabilities c i , g i , and e i change in response to invested resources could then yield valuable insights. second, we have not considered interactions between different defence layers or different risks (graham et al., ; baum, ; baum and barrett, ; martin and pindyck, ) . these can present both as tradeoffs or synergies. for example, traffic restrictions in response to a pandemic might slow down research on a treatment that would render the disease non-fatal, thus harming the resilience layer; on the other hand, they may inadvertently help with preventing malicious risk or being resilient against agency risk. • the most important extinction risks to act on are those that have a non-negligible chance of breaking through all three defence layersrisks where we have a realistic chance of failing to prevent, a realistic chance of failing to successfully respond to, and a realistic chance of failing to be resilient against. • due to diminishing marginal returns, when budgets are high enough it will often be best to maintain a portfolio of significant investment into each of prevention, response, and resilience. in sections - we have considered ways of classifying threats that may cause human extinction and the pathways through which they may do so. our classification was based on the three defence layers of prevention, response, and resilience. giving centre stage to the defence layers provides the following useful lens for extinction risk management. if our main goal is to reduce the likelihood of extinction, we can equivalently express this by saying that we should aim to strengthen the defence layers. indeed, extinction can only become less likely if at least one particular extinction risk is made less likely; in turn this requires that it has a smaller chance of making it past at least one of the defence layers. this is significant because there is a spectrum of ways to improve our defences depending on how narrowly our measures are tailored to specific risks. at one extreme, we can increase our capacity to prevent, respond to, or be resilient against one risk; for example, we can research methods to deflect asteroids. in between are measures to defend against a particular class of risk, as we've highlighted in our policy recommendations. at the other extreme is the reduction of underlying risk factors that weaken our capacity to defend against many classes of risks. risk factors need not be associated with any potential proximate cause of extinction. for example, consider regional wars; even when they don't escalate to a global catastrophe, they could hinder global cooperation and thus impede many defences. global catastrophes constitute one important type of risk factor. we already discussed the possibility of them making earth uninhabitable or removing a capability that would be crucial for long-term survival. but even if they do neither of these, they can severely damage our defence layers. in particular, getting hit by a global catastrophe followed in short succession by another might be enough to cause extinction when neither alone would have done so. there are significant historic examples of such compound risks below the extinction level. for instance, the deadliest accident in aviation history occurred when two planes collided on an airport runway; this was only possible because a previous terrorist attack on another airport had caused congestion due to rerouted planes, which disabled the prevention measure of using separate routes for taxiing and takeoff (weick, ) . when considering catastrophes we should therefore pay particular attention to negative impacts they may have on the defence layers. our capacity to defend also depends on various structural properties that can change in gradual ways even in the absence of particularly conspicuous events. for example, the resilience layer may be weakened by continuous increases in specialisation and global interdependence. this can be compared with the model of synchronous failure suggested by homer-dixon et al. ( ) . they describe how the slow accumulation of multiple simultaneous stresses makes a system vulnerable to a cascading failure. it is beyond the scope of this article to attempt a complete survey of risk factors; we merely emphasise that they should be considered. we do hope that our classifications in sections - may be helpful in identifying risk factors. for example, thinking about preventing conflict and common risks may point us to global governance, while having identified vector and agency risks may highlight the importance of interdependence (even though, upon further scrutiny, these risk factors turn out to be relevant for many other classes of risk as well). we conclude that the allocation of resources between layers defending against specific risks, which we investigated in section , is not necessarily the most central task of extinction risk management. it is an open and important question whether reducing specific risks, clusters of risks, or underlying risk factors is most effective on the margin. the study and management of extinction risks are challenging for several reasons. cognitive biases make it hard to appreciate the scale and probability of human extinction (wiener, ; yudkowsky, ) . most potential people affected are in future generations, whose interests aren't well represented in our political systems. hazards can arise and scale in many different ways, requiring a variety of disciplines and stakeholders to understand and stop them. and since there is no precedent for human extinction, we struggle with a lack of data. faced with such difficult terrain, we have considered the problem from a reasonably high level of abstraction; we hope thereby to focus attention on the most crucial aspects. if this work is useful, it will be as a foundation for future work or decisions. in some cases our classification might provoke thoughts that are helpful directly for decision-makers that engage with specific risks. however, we anticipate that our work will be most useful in informing the design of systems for analysing and prioritising between several extinction risks, or in informing the direction of future research. data sharing is not applicable to this article as no new data were created or analysed. notes we are particularly indebted to toby ord for several very helpful comments and conversations. we also thank scott janzwood, sebastian farquhar, martina kunz, huw price, se an o h eigeartaigh, shahar avin, the audience at a seminar at cambridge's centre for the study of existential risk (cser), and two anonymous reviewers for helpful comments on earlier drafts of this article. we're also grateful to eva-maria nag for comments on our policy suggestions. the contributions of owen cotton-barratt and anders sandberg to this article are part of a project that has received funding from the european research council (erc) under the european union's horizon research and innovation programme (grant agreement no ). . in the terminology of the united nations office for disaster risk reduction (undrr, ), response denotes the provision of emergency services and public assistance during and immediately after a disaster. in our usage, we include any steps which may prevent a catastrophe scaling to a global catastrophe. this could include work traditionally referred to as mitigation. . the concept of resilience, originally coined in ecology (holling, ) , today is widely used in the analysis of risks of many types (e.g. folke et al., ) . in undrr ( ) terminology, resilience refers to '[t]he ability of a system, community or society exposed to hazards to resist, absorb, accommodate, adapt to, transform and recover from the effects of a hazard in a timely and efficient manner, including through the preservation and restoration of its essential basic structures and functions through risk management.' in this article, we usually use resilience to specifically denote the ability of humanity as a whole to recover from a global catastrophe in a way that enables its long-term survival. this ability may in turn depend on the resilience of many smaller natural, technical, and socio-ecological systems. . strictly knowledge and intentionality are two separate dimensions; however it is essentially impossible to intend the harm without being aware of the possibility, so we treat it as a spectrum with ignorance at one end, intent at the other end, and knowledge without intent in the middle. again, there is some blur between these: there are degrees of awareness about a risk, and an intention of harm may be more or less central to an action. . there are degrees of lack of foresight of the risk. cases where the people performing the activity are substantially unaware of the risks have many of the relevant features of this category, even if they have suspicions about the risks, or other people are aware of the risks. . they may not intend for that damage to cause human extinctionfor the purposes of acting on this classification it's more useful to know whether they were trying to cause harm. . we thank an anonymous reviewer for suggesting the policy responses of avoiding dangerous technologies and mandating insurance. . global coordination more broadly may however be a double edged tool, since increased interdependency if not well managed can also increase the chance of systemic risks (goldin & mariathasan, ) . . we thank an anonymous reviewer for suggesting both the third general recommendation and the example. . what about a risk that directly kills, say, . % of people? technically this poses only an indirect risk, since to cause extinction it needs to remove the capability of the survivors to recover. however, if the proportion threatened is high enough then we can reason that it must also have a way of reaching essentially everyone, so the analysis of direct risks will also be relevant. . some scholars have argued that humanity expanding into space would increase other risks; see for 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affecting judgment of global risks owen cotton-barratt is a mathematician at the future of humanity institute, university of oxford. his research concerns high-stakes decision-making in cases of deep uncertainty, including normative uncertainty, future technological developments, unprecedented accidents, and untested social responses.max daniel is a senior research scholar at the future of humanity institute, university of oxford. his research interests include existential risks, the governance of risks from transformative artificial intelligence, and foundational questions regarding our obligations and abilities to help future generations.anders sandberg is a senior research fellow at the future of humanity institute, university of oxford. his research deals with the management of low-probability high-impact risks, societal and ethical issues surrounding human enhancement, estimating the capabilities of future technologies, and very long-range futures. key: cord- - i bn m authors: nan title: bilateral and multilateral financing of hiv/aids programs: the world bank, the international monetary fund, the global fund, bilateral donors and the private sector date: journal: global lessons from the aids pandemic doi: . / - - - - _ sha: doc_id: cord_uid: i bn m this chapter examines the operations of the world bank (a multilateral development institution), the international monetary fund (a multilateral financial institution) and the global fund to fight aids, tuberculosis and malaria (a multilateral fundraising and financing institution) to fight hiv/aids. we also examine the role of bilateral donors and the private sector in financing the fight against hiv/aids. we examine the relationships among bilateral donors and international organizations, what distinguishes their roles in the global hiv/aids pandemic and the extent to which their activities overlap. in addition, we consider how funding strategies and parameters may affect the effectiveness of aids funding in preventing transmission and providing treatment. the following series of tables ( . - . ) show the funding requirements for hiv/aids and break down those requirements by area in which the funding is needed. table . contrasts the actual funding available and the funding gap. (in chap. , we considered the potential economic impact on recipient countries of while the increase in funding for hiv/aids is a positive development, the multiplicity of donors has created problems regarding overlapping actions and conflicting conditions attached to the aid. in , over one hundred ministers, heads of agencies and other senior officials endorsed the paris declaration on aid effectiveness, an international agreement to increase efforts in harmonization, alignment and managing aid for results with a set of monitorable actions and indicators (oecd ) . also in , the unaids global task team on improving aids coordination among multilateral institutions and international donors (gtt) published a set of recommendations on how countries and multilateral institutions can streamline their aids-related activities. many of these recommendations are aimed at improving the coordination of the aids-related activities of multilateral organizations and minimizing overlap. the recommendations build upon the principles of the "three ones" -the three principles for coordinated response at the country level: ( ) one agreed hiv/aids action framework that provides the basis for coordinating the work of all parties; ( ) one national aids coordinating authority, with a broad based multi-sector mandate; and ( ) one ing to a unaids report, more than % of national aids plans were not serving as the framework for contributions by donors (unaids ) . more than % of national aids plans were not evaluated for cost or provided sufficient clarity on inputs and outputs, with the result that donors preferred to engage more poor alignment of donor strategies with national efforts and poor harmonization among donor procedures for aid management are significant impediments to achieving universal access to treatment for hiv/aids, because of the number and diversity of organizations that have become involved in addressing the pandemic. duplication of work and high transaction costs by individual agencies, together directly with countries (sidibe et al., ) . with the absence of important learning exchanges, economies of scale and synergies, impedes the speed, quantity, and quality of the response to the pandemic (sidibe et al., ) . thus, while pursuing affordable access to medicine and expanding medical services infrastructure are both essential elements for expanding access to treatment, they form a two-legged stool. the harmonization of donor and governance processes represents a key third element in the efforts to expand access to information and treatment. donald kaberuka, president of the african development bank, has noted that in the late s, members of the development assistance committee of the oecd (oecd/dac) accounted for % of total aid to developing countries. twenty years later, aid to developing countries is delivered through more than multilateral agencies, bilateral members of the oecd/dac and at least non-dac governments. as a result, some developing countries have more than active projects and receive more than missions a year, each with its own spectives, more resources, greater innovation and competition, which could reduce costs and improve program delivery. however, this has not been the result thus far (kaberuka ) . figure . shows the sources of the estimated and projected funding for the aids response from to . government ministries, not just the health ministry) (patel ) . however, even where the host government has donor coordination mechanisms in place, coordination is made more difficult when individual donors come with pre-established priorities, without involving host countries in the setting of priorities (dekay ) . one clear example is pepfar. it has established abstinence-only as a priority, and denied funding for needle exchange programs, which are priorities for the us government that do not necessarily coincide with the priorities of host governments (see chap. for details). in addition to the multiplicity of players, donors and host governments with different interests, ideologies, demands and expectations make coordination more difficult for host countries. when donors are driven by their own national ideologies and interests, at the expense of scientifically proven approaches, they undermine coordination and local leadership. moreover, when donors focus on civil society, they may undermine adherence to a national hiv/aids framework (mwale ). there has also been a proliferation of recipients. figure . shows the distribution of entities that participated in the preparation of funding proposals for round four of the global fund. with respect to the lack of donor coordination, some argue that the source of the problem is the host government, which may fear losing control over the agenda to a well-coordinated group of donors, rather than the donors themselves. the center for global development has analyzed the policies and practices of pepfar, the global fund and the world bank's map in mozambique, uganda and zambia, and compared these systems against six key funding practices that can help donors support the national aids response in a manner consistent with the aid effectiveness principles of the paris declaration. these best practices are: donor commitments and disbursements can diverge. table . shows that, in the case of some bilateral donors, commitments have exceeded disbursements, while for (oecd ) . others the reverse is true. in most cases, the actual disbursements lag commitments since its foundation since the end of the world war ii, the world bank has grown in size and importance. in , it provides financial and technical assistance to developing countries through two development institutions owned by member countries -the international bank for reconstruction and development (ibrd) and the international development association (ida). the world bank's current mission is to reduce global poverty and to improve living standards. the ibrd working with the government; building local capacity; keeping funding flexible; ing data. this study made the following recommendations to all three donors to increase the effectiveness of aid: ( ) jointly coordinate and plan activities to support the national aids plan; ( ) assist the host government in tracking total national aids funds; ( ) focus on building and measuring capacity; ( ) develop strategies with host governments and other donors to ensure financial sustainability; and ( ) strengthen financial data collection and disclosure. the study also offered specific recommendations for how each donor can improve its own prorecommendations are addressed further below. focuses on middle income and creditworthy poor countries, while ida focuses on the poorest countries. together they provide low-interest loans, interest-free credit and grants to developing countries for education, health, infrastructure, communications and other development programs. the world bank's traditional loan package integrates loans with analytic and advisory services. the world bank's research program supports studies on a range of development issues (http://web. worldbank.org). the world bank provides loans to national governments to assist in the implementation of national hiv/aids programs. the bank also does research and provides assistance to make national aids programs more effective. the world bank's first hiv/aids-related project was in . between and , the bank the world bank organizes its aids-related activities globally, through its "global hiv/aids program of action" and six regional hiv/aids programs: ( ) sub-saharan africa, ( ) east asia and the pacific, ( ) europe and central asia, ( ) latin america and the caribbean, ( ) middle east and north africa, and ( ) south asia. the purpose of this organizational structure is to have a global focus gram to increase the effectiveness of aid (oomman et al., ) . these specific selecting appropriate recipients; making the money move; and collecting and shar- bilateral and multilateral financing of hiv/aids programs loaned over usd . billion to finance national hiv/aids programs. the world bank's programs seek to focus support where national programs need it the most. the world bank has adopted the "three ones principles", noted above. the world bank monitors and evaluates its programs to ensure hiv/aids programs are context-specific. the world bank also seeks to integrate hiv/aids issues into the broader development planning process. the world bank recognizes the need to make all of the key players part of each national strategy -governments, the private sector, community and civil society organizations, people living with hiv/aids, ngos and international organizations (world bank a). the bank's program of action focuses on five areas: ( ) sustained funding for hiv/aids programs and health systems; ( ) better national hiv/aids planning, focused on high-risk groups and locations; ( ) accelerating implementation of national hiv/aids plans by overcoming administrative constraints that delay the use of new funding; ( ) building country monitoring and evaluation systems and that takes regional differences into account and to define the world bank's role in relation to other multilateral and international actors. the overall goals of these programs are prevention and treatment, taking into account local transmission patterns and sources of infection, in order to avoid a mismatch between funding and sustained funding is crucial. once people with hiv begin taking medication, they be monitored on an ongoing basis. if the underlying funding is not sustained, and more infectious and develop drug-resistant viruses. thus, the suspension of treatment is not only inhumane, but also makes prevention and treatment more difficult. resources are limited and need to be used effectively. targeting tripartite preventiontreatment-human rights strategies at high-risk groups has proved effective in countries like brazil (see chap. ). targeting high-risk groups is a key component of an effective national hiv/aids strategy, particularly when those groups have been marginalized through discrimination. while funding for hiv/aids programs has increased, there remains an "implementation gap" between the available funding and its deployment. this is due to impediments to quick implementation: a lack of skilled personnel; unpredictable or conditional funding; burdensome disbursement and procurement processes; government reluctance to contract out implementation to civil society or the private sector; and multiple systems of management, monitoring and evaluation to meet different donor requirements. to address this problem, the world bank is simplifying its own processes and procedures, strengthening its implementation advisory service and coordinating un, global fund and world bank actions through the global joint problem-solving and implementation support team (gist) (world bank a). the global aids monitoring and evaluation support team (gamet) seeks to build a well-functioning monitoring and evaluation system in each country, to enhance the impact of national programs. gamet provides field support to build country systems and capacity, as well as training and guidelines (world bank a). the world bank's main focus has shifted from getting resources to countries to ensuring that more impact evaluations are done of bank-supported hiv/aids et al., ) . the scope of the world bank's operations is quite wide, covering a wide range of development issues in a large number of countries, in addition to its work related to hiv/aids. projects with an hiv/aids component of more than usd one million, in countries. these projects include health sector support and reform, prevention and control ( http://siteresources.worldbank.org / inthivaids / projects / / gramsupport. programs, human resources development and education and national aids prowas designed to help countries intensify and expand their multi-sector national financing - - .xls) some of these projects are conducted as part of the responses to the hiv epidemic, to dramatically increase access to hiv prevention, in rwanda the world bank used map community grants for hiv initiatives to fund over civil society organizations to provide preventive, medical and support services for people living with hiv. in , rwanda was among the ten countries most severely affected by hiv and had recently emerged from a genocide/war. the usd . million grant became effective on august, and was fully committed and almost fully disbursed by the end of . the world bank board of directors approved additional financing of usd million on sustainability. building, and monitoring and evaluation of programs. just over % paid for hiv/ one part of this project was to help female sex workers to find different sources of income. several factors contributed to the success of this project. first, the project engaged local champions to mobilize people (in this case, the deputy mayor in charge of social welfare on the district hiv/aids commission became personally engaged in designing the program design). second, to break the aids-poverty cycle, poverty mitigation accompanied preventive measures (in this case, new sources of income provided a basis for further, community-based economic development projects). third, the project sought to empower women to benefit the whole family (in this case, empowering them to provide better education and health care for their children). fourth, ongoing support was provided to sustain the success of the project (in this case, to prevent the women returning to prostitution when challenges arise) (world bank ) . however, as we will see in chap. , programs for sex workers that focus on alternative employment have been criticized for contributing to their stigmatization and failing to address the needs of those who continue to earn their income from sex work. another part of the rwanda map project provided orphans and vulnerable children with sewing machines and training as tailors so that they could start a clothes-manufacturing association. this program combined information about hiv and aids, reproductive health and life skills with income generating activities. the children then served as role models and sources of information on hiv and aids for other vulnerable children. the experience with this program suggests three key factors for success. first, establish solidarity among participants, in this case by bringing the children together to find solutions to their problems and design their own interventions. second, enable beneficiaries to be role models for behavioral change. third, address poverty and vulnerability in order to make aids prevention effective (world bank ). in yet another part of the map project, the rwanda national youth council (cnjr) created a voucher system for expanding access to hiv testing for youths aged - (almost % of the population). the rationale behind promoting testing is that enabling people to learn their hiv status is a first critical step in changing behavior. the cnjr trained peer educators in behavioral change communication and reached out to youth through anti-aids clubs and sports and cultural activities. the voucher system enabled youths to go to local health facilities on designated days, minimizing waiting times. the map funding was used to pay for these services. this approach was more cost-effective (usd per person) than using mobile units to reach these youths (usd per person). it also enhanced the returns on global fund investments in facility-based services. in the first months almost , youths were tested. about % tested hiv positive. the three main lessons from the cnjr campaign were ( ) hiv testing is critical to modifying sexual behavior and expanding condom use; ( ) better knowledge leads to greater empathy and solidarity with people living with hiv; and ( ) awareness campaigns foster a culture of responsibility, trust and faithfulness among young couples (world bank ) . the rwandan government developed a treatment plan with the support of the clinton foundation. a user fee policy with a sliding scale results in most rwandans receiving free care because they live below the poverty line. the rwandan government, the world bank, the clinton foundation, the global fund, us centers for disease control and prevention (cdc) and the us government/pepfar worked together to design, implement and monitor the treatment program. different sites were funded by different donors (the world bank, the global fund and the us government/pepfar). patients receiving treatment increased from patients at seven sites at the end of to roughly , patients at sites national procurement system, the world bank and the global fund finance generic drugs and the us government/pepfar pays for brand name drugs. the clinton foundation has helped to lower the prices paid for drugs and diagnostics. pepfar funded the "tracnet" system, which uses mobile phones to transmit information. it tracks the number of patients on treatment and the drugs dispensed nation-wide, to manage the treatment program and supplies efficiently and to avoid drug shortages that would lead to interruptions in treatment. interruptions in treatment could diminish the effectiveness of treatment by creating resistance to the drugs being used and raise costs by requiring the use of other drugs and medical treatments. performance-based contracting and bonuses for health care staff expanded key hiv services rapidly in a relatively short time (for example, the number of hiv tests performed by staff) (world bank ). the world bank has also addressed the hiv/aids epidemic in central america on a regional basis. four of the six countries in latin america with the highest hiv prevalence are in central america. two central american countries have prevalence rates above %, which is a key threshold for an hiv epidemic to run out of control unless prevention efforts are improved among high-risk groups, such as commercial sex workers, men who have sex with men and prisoners (see chap. ). the adult hiv prevalence rates are as follows (in alphabetical order): costa rica ( . %); el salvador ( . %); honduras ( . %); guatemala ( %); nicaragua ( . %) and panama ( . %). by , the adult hiv prevalence rate may reach % in the region. hiv transmission in central america is primarily associated with heterosexual sex (with the exception of costa rica), as in africa and the caribbean (world bank ) . the world bank has developed a model to help governments to allocate resources efficiently to prevent the maximum number of new infections (world bank ) . in central america, the world bank also studied the extent of discrimination and stigmatization and identified areas where changes in general legislation or hiv/aids laws are necessary (world bank ). economist jagdish bhagwati has taken the world bank to task for not having a sufficiently narrow focus. in particular, he has opined that the world does not need a global think tank staffed by , people and that the world bank should not be involved in intellectual programs for countries, like india, that have sufficient resources to handle their own affairs. thus, in his view, the world bank should be cut to staff to focus on a good intellectual program for countries that need it (bbc news a). easterly ( ) has accused the world bank of wasting resources on inefficient bureaucracies and for having a late response to the hiv/aids epidemic (it had only implemented one project by and only completed ten by ). in a comparative study of us and world bank funding for hiv/aids between and , smith ( ) found that, although there is a positive correlation between the incidence of hiv/aids and poverty and the likelihood of receiving aid from the world bank, the us government is more responsive to the incidence of hiv/aids and poverty with its foreign aid donations. moreover, the world bank allocates more money to countries with political systems that are less likely to use the funds for public goods like education, treatment and health care, and does not do as well as the united states in targeting aid to countries most in need of funding (smith ). it is difficult to assess the success of the world bank's hiv/aids programs, since they are ongoing, diverse and numerous. however, the world bank's current programs have incorporated several features that suggest that they will be effective: following "the three ones", ongoing support, monitoring and evaluation of programs for effectiveness, sharing information regarding the factors that contribute to the success of individual projects and working with other multilateral and bilateral donors to reduce overlap. the world bank has undertaken or commissioned three reviews of its hiv/aids work (world bank a). the "interim review of the multi-country hiv/aids program for africa", was done in early . this review listed the following key barriers and challenges: ( ) many national hiv/aids plans are not strategic, and are poorly prioritized; ( ) prevention, care and treatment efforts are too small, and coverage is too low; ( ) management and implementation constraints hamper action; ( ) health systems are weak and overwhelmed, particularly with efforts to expand access to treatment; ( ) the effort to expand antiretroviral (arv) treatment raises difficult issues of equity, sustainability and adherence; ( ) prevention remains inadequate, regardless of the stage of the epidemic in a given country; ( ) stigma and discrimination, denial and silence persist, to the point that some people would rather die than let others know they are hiv positive; and ( ) donors sometimes create additional problems for countries, for example in tanzania, where program managers spend more time meeting the needs of visiting donors than implementing the programs. the world bank's operations evaluation department (oed) has assessed the development effectiveness of the world bank's country-level hiv/aids assisimpact of the aids epidemic) (world bank b). the oed's assessment found more focused and cost-effective way. it has helped raise political commitment, create or strengthen aids institutions, enlist ngos, and prioritize activities. the oed's assessment also found that political commitment and capacity had been overestimated and needs continuous assessment. moreover, failure to reach people with the highest risk behaviors likely had reduced the efficiency and impact of assistance. the effectiveness of the national response had been hampered by weak monitoring and evaluation and the failure to ensure that country-based research as a result of its assessment, the oed made several recommendations for the future work of the world bank in the hiv/aids epidemic. first, it should help governments use human and financial resources more efficiently and effectively. second, the world bank should help governments to be more strategic and selective, and to prioritize activities that will have the greatest impact. third, it should work to strengthen national institutions for managing and implementing the long-run response, particularly in the health sector. fourth, it needs to improve the local evidence base for decision-making and create incentives to ensure that program bilateral and multilateral financing of hiv/aids programs tance (defined as policy dialogue, analytical work and lending to reduce the scope or that the world bank's assistance has induced governments to act earlier or in a is focused on priorities areas. decisions are guided by relevant local evidence and rigorous analytical work. wilson has concluded that the world bank's map programs must place far greater emphasis on improved surveillance, research and analysis in order to design more intelligent maps that take into account prevalence and transmission patterns, the distinction between generalized and concentrated epidemics, the effect of stigma and community values on treatment programs and the role of political leadership in national aids strategies. the money must follow the epidemic by focusing primarily on normative and behavioral change in the general population in generalized epidemics and on high coverage of vulnerable groups in concentrated epidemics. in generalized epidemics, emphasis must shift from knowledge and awareness to normative change. in more concentrated epidemics, the world bank needs greater focus on groups and areas where transmission is occurring (wilson ) . a survey revealed that more than a third of patients on hiv medication in sub-saharan africa die or discontinue their treatment within years of starting; only . % of all patients were still receiving medication. the study found that many were too late taking up arv drugs and died within a few months of commencing treatment. for some it was impractical to travel to distant clinics. the researchers also found evidence that, in cases where patients had to pay for arvs, some stopped treatment. some people also suffered from stigma: in some workplaces, people are not able to carry their arvs and take their arvs freely at workplaces. retention rates between individual arv programs varied widely across africa. one program in south africa retained as many as % of their patients after years while another in uganda retained only % of patients after the same period of time (bbc news b). the world bank was a member of the gtt. the agreements reached by the gtt, including the division of labor, are reflected in the world bank's program of action (world bank a). however, as noted above, more work is needed to resolve the problems created by the proliferation of donors. in its study of funding practices, the center for global development made the following recommendations to the world bank regarding map: ( ) focus resources on building government capacity; ( ) become a knowledge bank, with a focus on prevention; ( ) make the transition to the use of existing government systems; ( ) increase individual disbursement amounts; and ( ) publicly dis- dominique strauss-kahn, who became the director general of the imf on november , has noted the need for the imf to adapt to a new global economic order (to better reflect the rise of emerging market economies and the interests of less developed ones, plus the need to better regulate globalization) and to downsize or die. in strauss-kahn's view, the imf needs to reach out to other multilateral organizations, in particular the world bank. the imf also needs to mend fences in a meaningful way with regions of the world that felt hard done by during close data (oomman et al., ) . the imf is an international organization that was established to promote international monetary cooperation, exchange stability and orderly exchange arrangements; to foster economic growth and high levels of employment; and to provide temporary financial assistance to countries to help ease balance of payments adjustment. it has member countries. the imf is to be guided in all its policies and decisions by the purposes set forth in article i of the articles of agreement of the international monetary fund. article i sets out these purposes as follows: . to promote international monetary cooperation through a permanent institution which provides the machinery for consultation and collaboration on international monetary problems. . to facilitate the expansion and balanced growth of international trade, and to contribute thereby to the promotion and maintenance of high levels of employment and real income and to the development of the productive resources of all members as primary objectives of economic policy. . to promote exchange stability, to maintain orderly exchange arrangements among members, and to avoid competitive exchange depreciation. . to assist in the establishment of a multilateral system of payments in respect of current transactions between members and in the elimination of foreign exchange restrictions which hamper the growth of world trade. the fund temporarily available to them under adequate safeguards, thus providing them with opportunity to correct maladjustments in their balance of payments without resorting to measures destructive of national or international prosperity. . in accordance with the above, to shorten the duration and lessen the degree of disequilibrium in the international balances of payments of members. since inception the imf's purposes have remained the same, but its operations have developed over time, particularly with respect to surveillance of public expenditure management systems, financial assistance and technical assistance. the imf focuses on three kinds of operations. first, surveillance operations moni- the imf also provides emergency assistance to support recovery from natural dis- the imf can allocate additional spending to hiv/aids as part of national poverty-reduction strategies. the imf also provides advice to countries on the macroeconomic impact of hiv/aids and how to manage inflows of foreign aid. reduction strategy papers, which provide the operational basis for imf and world bank loans to low-income countries and fo r debt relief under the heavily indebted poor countries (hipc) initiative (imf ) . unlike development banks, the imf does not lend for specific projects. thus, unlike the world bank and the global fund, the imf does not have projects specifically aimed at hiv/aids. rather, hiv/aids issues are addressed as part of the imf's general operations. the research of the imf on hiv/aids has been focused primarily on its macroeconomic impact. with respect to hiv/aids, imf (and world bank) policies have been criticized for not considering the impact of structural adjustment requirements (austerity making debt repayment a higher priority than health care, thereby undermining the ability of national governments to finance health care. peter lurie et al. ( ) argued that export-oriented, structural-adjustment policies were undermining hiv/aids control by contributing to social changes that favor the spread of hiv in the developing world, through increased mobility, migration, urbanization and dislocation of family units. tor economic and financial developments and provide policy advice, aimed especially at crisis prevention. second, the imf also lends to countries with balance of payments difficulties, to provide temporary financing and to support policies aimed aimed at poverty reduction. third, the imf provides countries with technical assis-at correcting the underlying problems. loans to low-income countries are also tance and training. the imf also conducts economic research and gathers statistics shocks facility. non-concessional loans are subject to the imf' s market-related related to these three types of operations. an imf loan usually stipulates the specific policies and measures a country has to implement to resolve its balance interest rate, which is revised weekly to take account of changes in short-term in-of payments problem. low-income countries may borrow at a concessional interest rate through the poverty reduction and growth facility and the exogenous country-level hiv prevention and treatment programs form part of many poverty asters and conflicts, in some cases at concessional interest rates (http://www.imf.org). terest rates in major international money markets. large loans carry a surcharge. measures) on the spread of hiv/aids. the imf has also been criticized for hanlon ( ) noted that the imf required the mozambican government and other african governments to reduce spending in the s without decreasing repayments of its debts, thereby contributing to cuts in spending on health services that increased corruption in hospitals. the international community later recognized that much of africa's debt could not be paid and agreed to cancel some debts. this led to the hipc initiative in . however, hanlon reported that with the hipc mozambique would still be paying back usd million a year, because the world bank and imf agreed to cancel only the part of the debt that mozambique was not paying. the hipc only canceled the uncollectable debt. thus, mozambique was paying usd , per day in debt service, but only usd , per day for its entire health service. in , african ministers of finance, planning and economic development warned that the enhanced hipc initiative was not delivering long-term debt sustainability. they recommended that the imf impose fewer structural conditions and provide for outcomes-based conditions where appropriate. the ministers also urged the imf and world bank, bilateral partners and the african development bank to avoid "cross-conditionalities" that impede access to resources. they recommended that to provide greater fiscal flexibility, the imf should also analyze the linkages, trade-offs and policy choices required to attain the millennium development goals (which include addressing the hiv/aids pandemic). they also proposed that evaluating exogenous shocks should be a standard feature of imf discussions with member states, and that access to loans should be extended to countries suffering from exceptional exogenous shocks such as the onslaught of imf and world bank to consider revising the eligibility criteria for assistance to middle-income countries affected by the aids epidemic, and to find ways of ensuring that countries could expand expenditure on health and social welfare without violating conditions that impose limits on public spending (eca ) . the imf restricted aid to mozambique's budget in order to control inflation and required donors' aid to fund more projects outside the state budget, contrary to the policy of many donors (hanlon ) . the imf resident representative mozambique argued that it was difficult for the government to be certain about the level of donor payments in the medium term, and it might not be prudent to make medium term expenditure commitments (such as the hiring of health personnel) given the uncertainty about whether the money would still be available over the next budget cycle. the imf representative recognized the need to improve the design of the imf fiscal target taking into account that donor aid has increasingly moved away from lending to support capital investment projects, and toward direct budget support for hiring personnel and purchasing medicine (perone ) . this story highlights the ongoing importance of policy coordination on the ground between the imf, donors and national governments and the need for sustainable funding from donors. the global fund was created to raise and disburse additional private and public sector funds for the fight against aids, tuberculosis and malaria. as of october , the global fund had committed usd . billion in countries. it provides around two thirds of all international financing for tuberculosis and malaria and close to a quarter of the global resources for aids. as we saw in chap. , malaria prevention is a cost-effective means to prevent hiv/aids in areas with high malaria prevalence, because of the impact of life-expectancy on incentives to change sexual behavior to reduce the risk of hiv/aids. the prevalence of hiv/aids also has a direct impact on the spread of extensively drug-resistant tuberculosis (xdr-tb). people living with aids are especially susceptible to xdr-tb because of their depressed immune systems, increasing the risk that xdr-tb will spread rapidly in sub-saharan africa (picard ). in turn, an xdr-tb epidemic could reduce life expectancy, thereby hampering hiv/aids prevention. thus, it is important to attack all three diseases together. there are two key differences between the global fund and the world bank. first, the global fund is a hands-off operation that focuses on financing rather than implementation, whereas the world bank is very involved in the implementation of its programs. second, the global fund has a much narrower scope of operations with respect to the issues that it tackles, being restricted to aids, tuberculosis and malaria. the world bank has a much broader development agenda, albeit one that incorporates health care in general, and hiv/aids in particular, into its development programs. section ii of the framework document of the global fund sets out its purpose in the following terms: the purpose of the fund is to attract, manage and disburse additional sustainable and significant contribution to the reduction of infections, illness and death, thereby mitigating the impact caused by hiv/aids, section ii of the framework document clarifies that the fund's mandate is to finance prevention, treatment, care and support in an integrated and balanced way, not to implement such programs. the framework document provides further that the global fund "should make use of existing international mechanisms and health plans". in making its funding decisions, the global fund is to focus on best . the global fund: a fundraising and financing institution ). resources through a new public-private partnership that will make a reduction as part of the millennium development goals (global fund tuberculosis and malaria in countries in need, and contributing to poverty expansion of government/private/ngo partnerships. the global fund is required to support programs that reflect "national ownership", by focusing upon the technical quality of proposals, while leaving the design of programs and priorities to partners within recipient countries. "country coordinating mechanisms" (ccms) are country-level partnerships that develop and submit grant proposals to the global fund based on priority needs at the national level. after grant approval, they oversee progress during implementation. ccms include representatives from the public and private sectors, including governments, multilateral or bilateral agencies, non-governmental organizations, academic institutions, private businesses and people living with the diseases. the proposals that are supported by the global fund must be consistent with international law and agreements, respecting intellectual property rights laws, such as trips. at the same time, the programs should encourage efforts to make quality drugs and products available at the lowest possible prices and give priority to the most affected countries and communities, and to those countries most at risk. the framework document provides specifically for programs that aim to eliminate the stigmatization of and discrimination against those infected and affected by hiv/aids, especially for women, children and vulnerable groups. the framework document requires the global fund to use, wherever possible, existing monitoring and evaluation mechanisms. monitoring at the country level is country-driven, but also linked to the fund's monitoring and evaluation system at a global level. grantees need to be: ( ) accountable to donors for the use of funds and achievement of results; ( ) responsive to developing countries; and ( ) responsive to the needs of those infected and directly affected by the three diseases. the framework document contemplates the following options for who oversees the process of monitoring both global and local program progress on behalf of the global fund board: global fund secretariat; ad hoc monitoring and evaluation working group; the world bank's operations evaluation department; a un agency; existing mechanisms (unaids, stop tb, roll back malaria); an independent monitoring and evaluation oversight committee appointed by the global fund board; or a third party (for example, an accounting firm or university). the world bank serves as the trustee for the global fund. the trustee has primary responsibility for financial accountability, including: ( ) collection, investment, and management of funds; ( ) disbursement of funds to national-level entities, on the instruction of the global fund board; ( ) reporting to stakeholders on the financial management of the fund and the allocation of fund resources; and ( ) independent audits. local funding agents are organizations (mainly multinational audit firms) that the global fund contracts to provide the secretariat with the information used to practices and performance, linking resources to the achievement of clear, measurable and sustainable results. another focus is on the creation, development and report on the capacity of the agencies that implement funded programs and on program results and make recommendations regarding future funding. the outfor global fund offices in the relevant countries, thereby enabling the global fund to have a leaner administration and to set up more rapidly in a country (euro the framework document requires the highest priority to be given to proposals from countries and regions with the greatest need, based on the highest burden of disease and the least financial resources. these are identified as including sub-saharan africa, currently the region most affected, as well as some countries within the caribbean, asia-pacific, latin america and central and eastern europe. the criteria for identifying these proposals include: ( ) disease burden for hiv, tb and/or malaria; ( ) poverty indicators, such as per capita gnp and the un human such as recent disease trends, size of population at risk, prevalence of risk factors, extent of cross-border and internal migration, conflict, or natural disaster; ( ) political commitment, as indicated by contribution to the financing of the proposal, public spending on health, existence of supportive national policies or the presence of a national counterpart in the proposal; ( ) existence of a country coordination mechanism, which consists of an inclusive collaborative partnership, with all relevant partners engaged in planning, decision-making and implementation. the framework document requires the global fund to provide grants to public, private and non-governmental programs for the prevention, treatment, care and support of the infected and directly affected, which may include: increased access to health services; provision of critical health products (for example, bed nets; condoms; antiretroviral, anti-tb and anti-malarial drugs; treatment for sexually transmitted infections; laboratory supplies and materials; and diagnostic kits); training of personnel and community health workers; behavioral change and outreach; and community-based programs, including care for the sick and orphans. technical review panels, made up of independent, impartial teams of experts appointed by the global fund board, review grant proposals, based on criteria set by the board, and make recommendations to the board for final decision. the global fund's technical evaluation reference group (an independent advisory body) was charged with overseeing a five-year evaluation on the operations of the global fund, during - . the first area of evaluation is "organizational efficiency", which analyzes whether the global fund is efficient and effective in fulfilling its core principles, including acting as a financial instrument rather than implementation agency and furthering country ownership. the second area of evaluation is "partnership environment", which considers how effective a striking feature of the global fund's very user-friendly web site is the global fund evaluation library (http://www.theglobalfund.org/en/links_resources/ brary/). this web page makes both internal and external evaluations of the global fund readily available and has the stated aim of improving the global fund's delivery of key services for hiv/aids, tuberculosis and malaria by stimulating open debate and evaluation of the fund. this novel method of inviting and inciting critical evaluations, in order to improve performance, stands in contrast to the world bank and imf approaches to external criticism. the global fund has been criticized for funding drugs without strengthening the underlying health systems. in response, the global fund opened the possibility of funding health system improvements, but this was not used often and rarely covered staff remuneration. the world bank has proposed leaving the strengthening of health systems up to the world bank, in order to avoid overlap. however, the world bank itself has been criticized for poor performance in supporting and reinforcing public health services, particularly given its role, together with the international monetary fund, in maintaining limits on public health expenditures and wages. the global fund, with its narrow funding mandate, has also been criticized for not placing more conditions on the use of the resources provided and for giving into technical advisors from the world bank and bilateral donors who oppose the exceptional nature of aids (philips ) . and efficient the global fund partnership system is in supporting hiv, malaria and tb programs at the global and country level. the third area of evaluation is "health impact", which studies the global fund's contribution to reducing the burden of the three diseases. fig. . global fund, sector of recipients ( ) ( ) ( ) ( ) ( ) ( ) the global fund evaluates program performance after years. the center for global development analyzed data on of the first global fund grants evaluated in . due to the subjective nature of the evaluation process, this analysis should be seen as an analysis of evaluation scores rather than of the actual performance of the programs. moreover, the results were not intended to be used to influence the distribution of funding, but rather to allocate resources for oversight and risk management. the programs that scored lowest had government agencies as principal recipients, had a large amount of funding, were focused on malaria, had weak initial proposals or were evaluated by the accounting firm kpmg. countries with a high number of doctors per head, high measles immunization rates, few health-sector donors and high disease-prevalence rates had higher evaluation scores. poor countries, those with small government budget deficits and those that have or have had socialist governments also received higher scores. programs in which a government was the principal recipient received significantly lower scores than those with civil society, private sector or multilateral recipients. malaria programs were . % less likely than hiv/aids or tuberculosis programs to receive an a. in addition, evaluation scores were slightly higher in countries with higher prevalence rates for the target disease of the program (radelet countries with stronger health systems and larger numbers of trained health workers were more likely to have successful programs. this suggests that the global fund needs to ensure greater oversight in countries with weaker systems and capacity, and underscores the importance of building strong health systems rather than focusing narrowly on short-term targets. however, evaluation scores were lower in programs where there were many other donors. this may have been due to the greater administrative and management burden placed on recipients when there are multiple donors. alternatively, it may indicate that the incentives for strong performance are weaker when recipients have many funding alternatives the global fund's country coordination mechanism has been criticized for focusing on government actors and not including people with hiv/aids (gonzalves ; mckai ) . faith-based organizations in host countries have also not been included in country coordination mechanisms to the degree that they would like, often due to a lack of information from governments, a lack of access to guidelines for funding proposals and a need for assistance in preparing funding the center for global development convened a high-level independent working group to help the new executive director of the global fund define the major tasks that require attention, and provided specific recommendations for action. the working group consisted of members, including relevant experts in government, civil society organizations, foundations, academia, private sector companies and disease-based partnership initiatives. some of the working group's key recommendations were: ( ) convene a "heads of agencies group" with the director general of the who, the executive director of unaids, and the president of the proposals (lee et al., ) . ( radelet and siddiqi, ) . world bank to jointly tackle key problems in technical assistance, procurement, monitoring, evaluation and other key issues; ( ) work with other agencies to develop an information market for technical assistance, building on existing mechanisms with unaids, the stop tb partnership and roll back malaria; ( ) provide early warning information on country programs to recipients, ccm members, governments, international partners and key ngo groups so that actions can be taken quickly to get programs back on track; ( ) commission a management audit of the secretariat, consider hiring additional portfolio managers and consider shifting from one portfolio manager per country to teams of two or three working across countries; ( ) hire a full-time professional fund raising team, led by a senior professional and comprised of experts with diverse skills to work with traditional, non-traditional and private sector donors; ( ) make the executive director a nonvoting member of the board so that the experiences and insights of the executive director and the secretariat are more fully reflected in board discussions (radelet ) . in its study of funding practices, the center for global development made gaps; ( ) re-examine strategies to build local capacity; ( ) simplify procedures for a external evaluation of the global fund's local funding agent system evaluation found that the system needs: ( ) greater emphasis on health program skills (since few local funding agents have staff with health backgrounds); ( ) to implement a quality assurance system to verify the adequacy of local funding agent methods (for example, with respect to documentation of audits); ( ) to provide more complete capacity assessments of the organizations that implement programs; ( ) to increase the use of in-country partnerships; ( ) to implement a comprehensive performance evaluation system for local funding agents; and ( ) management process (euro health group ). an internal evaluation made similar findings: ( ) that there were gaps in local funding agent documentation that failed to meet professional auditing standards; ( ) adherence to specific auditing standards needed to be integrated as a requirement in the tendering process; ( ) a lack of a consistent management approach; ( ) that the global fund secretariat should introduce a systematic performance evaluation system for local funding agents and a handbook; ( ) that capacity assessment should extend to sub-recipients, not just principal recipients of funding; ( ) the health program skills and experience of local funding agents was inadequate; and ( ) that local funding agents needed to develop partnerships with other health-sector players through networking, to have greater access to health sector intelligence and improve coordination with other players (technical evaluation reference group ). the united states government accountability office (gao) also conducts reviews of the global fund, since the united states contributes funds. in , the gao review of grant disbursements and grant renewal decisions found that good performers; and ( ) publicly disclose data (oomman et al., ) . bilateral and multilateral financing of hiv/aids programs the following recommendations to the global fund: ( ) keep the focus on funding concluded that the system should be maintained, but needs to be improved. the to create an operational manual or handbook to govern the local funding agent bilateral governmental donations are an important source of financing for hiv/aids programs. in , the resources available from all sources totaled usd . billion, out of which g /ec and other donor government commitments for hiv/aids totaled roughly usd . billion. of these donor government commitments, usd . billion were bilateral commitments and usd million were contributions to the global fund. the g /ec commitments were % of the total donor govern-they were well documented and that documentation had improved since . the gao also noted that the global fund has begun developing a risk assessment framework to improve the identification of risks that may affect grant implementation, having found that an earlier risk assessment model was inadequate. however, the gao also found that the lack of a mandatory system of local funding agent performance assessment limits the global fund's ability to determine the quality of local funding agent monitoring and reporting (gao ). as we noted earlier, commitments and disbursements are not the same thing. for example, while the united states accounted for . % of bilateral commit- . and . ). many donors prefer to channel funding through bilateral programs ( % of g / ments). however, preferences vary from one donor country to the next. for example, at on end of the spectrum, the uk made % of its commitments through bilateral ec commitments), rather than the multilateral channel ( % of g /ec commit- channels and % through the global fund. at the other end of the spectrum, italy made % of its commitments through bilateral channels and % through the global fund. canada was in the middle, with % of its commitments through bi- ). engaging the private sector in hiv/aids prevention and treatment is increasingly becoming a major focus for governments, advocates and public health practitioners. the private sector, through domestic firms or the foreign direct investment of multinational firms, is a significant source of financing for the prevention and treatment of hiv/aids. private charitable foundations have also become an important source of funding in the fight against hiv/aids. two issues regarding private sector donors provoke controversy. one is the issue of donations of goods and services in kind by the private sector. critics argue that such donations impede the ability of recipient governments to build their own infrastructure. supporters argue that such donations give a boost to local efforts to build infrastructure, provided they take place in close cooperation with recipient governments. a second issue is donor reliability and sustainability, particularly with respect to donations from the private sector (although this issue is also raised regarding other sources of funding). here, the concern is that host governments will be unwilling to integrate funding for hiv/aids into general revenues that support the overall health infrastructure (for example, salaries for medical personnel) unless there is some assurance that the funding will be ongoing (mckinnell ) . while the participation of the private sector in addressing the hiv/aids pandemic is very important, its efforts need to be coordinated with the other players (governments, donors and ngos) and the roles of the various players need to be well defined. for example, oxfam has criticized developed countries and the world bank for undermining governments' ability to deliver public services by advocating inappropriate private sector projects in health. oxfam acknowledges that the private sector has a role to play, but argues the private sector cannot provide services on the necessary scale, geared to the needs of all citizens (oxfam ) . companies have an incentive to invest in hiv/aids programs due to the impact of the pandemic on enterprise performance. this impact depends on worker attrition due to sickness and death, the corresponding costs to the firm for providing health and sickness benefits, replacement costs to obtain new workers and the . the role of the private sector in funding prevention and treatment lateral channels and % through the global fund (see fig. . ) (kates and lief, same time, the health of a country's population may affect inflows of foreign hiv/aids pandemic thus creates a catch- situation. hiv/aids has clear effects on a company's workforce and its customer base. the literature suggests that skilled workers are most likely to contract the virus, waterhousecoopers survey found that only % of organizations in eastern vention among employees and their families and providing access to treatment. for example, in botswana an early and innovative program by debswana, a diamond mining company that is the country's largest non-government employer, made it the first company to provide free anti-retroviral treatment to employees and their spouses (center for global development ). however, as with multilateral organizations such as the world bank, the imf, the global fund and the un, it is important to have an overarching framework in order to ensure the adoption of best practices by individual firms and to minimize overlap between the private sector and the other players that are involved in addressing the pandemic. in this regard, there have been some important national and global initiatives. an example of a national initiative is the commercial market strategies (cms) project, which was a -year usaid-funded project ( ) ( ) ( ) ( ) ( ) ( ) . cms's aids treatment brochure articulated the business case for providing arvs to employees as part of their health care benefits. the key global initiative is the global business coalition on hiv/aids (gbc), which has members, headquartered in thirty countries, employing over eleven million people in more than countries and is supported almost entirely by its member companies. the gbc and booz allen hamilton conducted a baseline survey and interview program to establish a basis to look at the scope and depth of the response being made by the global business community. the study highlighted variations in business response by region, industry and enterprise scale. the study found that business increasingly sees hiv/aids as a strategic as well as a social responsibility issue, and manages programs and resources based on bottom line impact (gbc and booz, allen, hamilton ) . the data source was the expertise and experiences of gbc member companies across industries that were surveyed in april and companies who participated in a detailed interview program. the baseline showed business response in the form of an index, on a scale of - . the index was calculated from the number of companies active in each of global business hiv/aids categories of best practice aids standard (bpas), each with five levels of action. the impact of hiv/aids on worker productivity (ramachandran et al., ) . at the and that these are extremely difficult to replace. customers, suppliers and inves-direct investment to low-and middle-income countries (alsan et al., ) . the tors in a company are also likely to be affected by hiv/aids, and this effect is expected to increase as the virus spreads (bloom et al., ) . however, a price-on an individual basis, firms can have a tremendous impact in promoting pre-africa had hiv/aids policies in place (pricewaterhousecoopers ). surveyed companies had an average index score of . . this was equivalent to being active in more than of categories with two actions underway in each. the most active % scored . and the least active % scored . . this variation was primarily due to perceived business needs and the length of time the companies had been addressing the hiv/aids issue. of the bpas categories there are two in which the business response was particularly strong -prevention initiaoil) (gbc and booz, allen, hamilton ). were twice as likely to fully subsidize treatment for employees in high prevalence ments, suggesting that program design and follow up could be enhanced. with the survey found that developing and implementing a company hiv/aids pro- the gbc survey had several key findings regarding ways to improve the global business community's response to hiv/aids. first, there is a need to develop strategies to work closely with suppliers and business associates to expand the network of business engagement. second, there is a need to partner with ngos, community, and local government to develop and fund programs and initiatives with greater reach. third, companies should extend confidential testing and treatment programs, including monitoring of testing participation rates, access to viral load tests and, in high prevalence areas, treatment for dependents and post employment. fourth, companies should focus on balanced prevention and treatment programs that target behavior change in conjunction with treatment. fifth, there is a need to increase the role of business in advocacy and to extend programs into emerging markets. in particular, ceos and senior management should provide leadership to dispel myths and stigma, break down workplace barriers and influence community change. in this regard, the gbc study concluded that the private sector can enhance their response to hiv/aids by treating it like any other disease and integrating responses into broader packages supporting health and well-being. employment contracts and health benefits packages should include hiv as a normal component rather than an exception. rather than isolating hiv/aids, interventions should be part of a comprehensive health system for employees and the broader community (gbc and booz, allen, hamilton ) . the gbc study recommends that an hiv/aids response be a core component of an overall business strategy, whether the response takes the form of cause-related marketing, co-investments with governments on hiv programs or comprehensive overall market leader and will also help sustain markets and serve a need in countries like india and china, with rapidly growing young, sexually active middleclass populations (gbc and booz, allen, hamilton ). in addition to direct company participation in prevention and treatment programs, there have been efforts to create market-based incentives for the private sector to donate more funds to combating hiv/aids. the most notable example is product red, an economic initiative designed to deliver a sustainable flow of private sector money to the global fund to fight aids, tuberculosis and malaria. this initiative was announced at the world economic forum annual meeting in by bono and bobby shriver. with product red, the world's leading companies made a commitment to channel a portion of their profits from sales of speciallydesigned products to the global fund to support aids programs for women and children in africa. another market-based initiative for the private sector is "social marketing". population services international (psi), a nonprofit organization based in washingpanies seeking to fight hiv/aids in the workplace. psi, a large aid contractor, uses commercial marketing strategies to promote health products, services and healthy behavior in low-income and vulnerable populations in developing countries. products and services are sold at subsidized prices rather than being provided free of charge. the logic behind social marketing is that charging money will enhance the perceived value of products and services, increase the likelihood needs to be charged for hiv treatment in order for the recipients to see "value" in the drugs has been discredited. arata kochi, the director of the world health organization's malaria program, has concluded that the social marketing approach is not an effective means to expand the use of mosquito nets to prevent malaria. using the social marketing approach, mosquito nets were sold through local shops at subsidized prices, with donors underwriting the losses and paying consultants to come up with brand names and to advertise the nets. the social marketing approach was also used to distribute condoms and oral rehydration salts. however, it was revealed that the united states agency for international development (usaid) was spending % of its malaria budget on consultants and % on goods like nets, drugs and insecticide. experiences in kenya helped to persuade the who to change its policy. a -year study of health districts revealed that a psi social marketing scheme for malaria nets only increased coverage from % of the population to about % between and . in contrast, when the health ministry got a grant from the global fund that allowed it to hand out . million free nets in weeks, coverage rose to %, and distribution became more equitable. under social marketing, the richest of the poor had % coverage, while the poorest of the poor had only %. after the distribution of free nets, they were about equal and deaths of children dropped %. free distribution was also cheaper. with consultant fees, transportation, advertising and shipping, social marketing added about usd to the cost of each net beyond the usd to usd that manufacturers charged. even with payments to volunteers, the added cost of free distribution was only about usd . médecins sans frontières (msf) has criticized donors for proposing to continue having patients make a financial contribution to the cost of arv treatment in populations where incomes are barely adequate for people to feed themselves (médecins sans frontières ) . aids patients need to receive treatment their entire lives without interruption in order to avoid death or creating drug-resistant mutations of hiv. requiring patients (who do not have enough money for food) to pay for treatment reduces the effectiveness of arv treatment, reduces adherence and decreases survival rates. even where arv treatment is free of charge, where countries define aids care narrowly many direct treatment costs must be covered by patients. for example, the high cost of laboratory tests can deter patients from . the role of the private sector in funding prevention and treatment ton, dc., created a comprehensive corporate aids prevention program for comof use, and motivate commercial sector involvement. however, the notion that fee per net (kyama and mcneil, ) . monitoring the effectiveness and side effects of arv treatment. a related problem is the cost of treatment for opportunistic infections (such as pneumonia), which may bankrupt patients before they even start arv treatment. other costs, such as consultation or hospital fees, can also constitute a barrier to treatment for patients in developing countries. as a result, msf has recommended that major international donors such as the global fund, pepfar, and the world bank should require recipients to provide arv treatment and other essential elements of aids care without patient contributions, and to slightly increase funding to include these complementary costs (philips ) . the world bank president, former us trade representative robert zoellick, has called on the bank's member nations to give the private sector a bigger role in development (reuters ) . with respect to the world bank's aids programs, as well as other health-related issues, careful thought will have to be given to the appropriate role for the private sector, particularly the failure of social marketing to achieve adequate and equitable coverage in poor populations. the experience of the private sector thus far indicates that the business response to the aids pandemic needs to be standardized and coordinated with the activities of other players, notably national governments, ngos and multilateral institutions. while some companies limit their response to donations of money, goods and services, others have taken a more proactive approach by implementing prevention and treatment programs for their employees and, in some cases, the dependents of employees. this proactive approach is particularly useful in areas with high prevalence rates and poor public health care infrastructure. global multinational companies are in a position to use their influence with suppliers and other business associates to expand the use of best practices, particularly with respect to prevention and treatment programs. in this regard, the gbc plan to review the state of business and aids annually and to use the results of these assessments to adapt the best practice aids standard is to be commended. the gbc study notes that companies have addressed child labor, wage equity and occupational safety through their supply chains, including distributors, business associates and small and medium enterprises. however, this network of global suppliers has been a weak link in the aids response. if tapped, the reach of employee and community networks could make a tremendous impact in mobilizing communities around hiv prevention and treatment. similarly, enhanced supply chain practices promoting youth education and gender equity can help to address underlying social factors that contribute to the spread of hiv/aids (gbc and booz, allen, hamilton ). the further standardization of best practices would be a useful next step. the international standards organization (iso) certification process that is currently used to improve business processes could serve as a model. the iso has specific standards for the automotive industry and has specific standards for environmental processes. while these standards are voluntary, many multinational companies require their suppliers to be iso-certified. the creation of specific iso standards for hiv/aids policies, or for company health policies more generally, would be a private charitable foundations have become a significant source of funding, research and political leadership in fighting hiv/aids. in this section, we examine the hiv/aids activities of three us foundations: the bill & melinda gates foundation, the kaiser family foundation and the william j. clinton foundation. it is notable that these foundations have largely avoided overlap in the nature of their operations related to hiv/aids, by specializing in addressing different needs. the first two foundations have also collaborated closely. useful vehicle for standardizing best practices and expanding the adoption of best practices to suppliers. as with iso, the standards could be voluntary, but major multinationals could require their suppliers to get certified in order to qualify as suppliers. as of december , the bill & melinda gates foundation had net assets totaling usd billion, which it uses to fund global development and global health initiatives. the mission of the foundation's global health program is to encourage the development of lifesaving medical advances and to help ensure they reach the people who are disproportionately affected. the foundation is guided by the belief that all lives, no matter where they are lived, have equal value. with respect to global health, the foundation focuses its funding in two main areas: ( ) access to existing vaccines, drugs and other tools to fight diseases common in developing countries; and ( ) research to develop health solutions that are effective, affordable and practical. in developing countries, the foundation supports efforts to prevent and treat diseases and conditions that meet three criteria: ( ) they cause widespread illness and death in developing countries; ( ) they represent the greatest inequities in health between developed and developing countries; and ( ) they receive inadequate attention and funding. hiv/aids is one of the foundation's priority diseases. to slow the global spread of hiv, the foundation supports the development of vaccines and other tools and strategies with the potential to prevent tens of millions of infections and deaths. the foundation also funds comprehensive initiatives that include both prevention and treatment (http://www.gatesfoundation. org/globalhealth/). the bill & melinda gates foundation's primary focus with respect to hiv/aids is on prevention. illustrative examples of the programs funded by the foundation are: ( ) avahan (which means call to action in sanskrit), an aids prevention initiative established in india in , to which it has committed usd million; ( ) the global hiv prevention working group, an international panel of experts; and ( ) the global hiv vaccine enterprise. through the avahan program, the foundation is working to expand access to effective prevention in the six states with india's highest infection rates and along the nation's major trucking routes. the working group is an international panel of more than leading public health experts, clinicians, researchers and people affected by hiv/aids. it is coconvened by the henry j. kaiser family foundation and the bill & melinda gates foundation. the global hiv prevention working group has developed reports and other materials about critical hiv prevention issues, such as scaling up the combined use of proven prevention strategies (male circumcision, aids education, condoms, hiv testing and prevention of mother-to-child transmission) in order to cut the number of projected new infections to in half (global hiv prevention working group ). the global hiv vaccine enterprise is an international alliance of independent organizations dedicated to accelerating the development of an hiv/aids vaccine through collaborative research efforts. the bill & melinda gates foundation serves as interim chair and funds vaccine research. in july , the bill & melinda gates foundation funded grants totaling usd million to create an international network of collaborative research consortia focused on accelerating the pace of hiv vaccine development (http://www.gatesfoundation.org). the kaiser family foundation is a non-profit, private operating foundation focusing on the major health care issues facing the united states, but has a growing role in global health. the foundation has an endowment of over half a billion dollars and an operating budget of over usd million per year. unlike grant-making foundations, kaiser develops and runs its own research and communications programs, sometimes in partnership with other non-profit research organizations or major media companies. this foundation focuses on three areas of activity: ( ) producing policy analysis and research; ( ) operating a large-scale health news and information service on the web and a series of specialized websites; and ( ) developing and helping to run large-scale public health information campaigns in the united states and around the world, through direct partnerships with major media companies. the current focus of the latter is on hiv/aids, with an emphasis on reaching young people (http://www.kff.org/about/index .cfm). the william j. clinton foundation is president bill clinton's vehicle for strengthening the capacity of people in the united states and throughout the world to meet the challenges of global interdependence. one of the foundation's main initiatives is focused on hiv/aids. in , the foundation helped to negotiate major price reductions for developing countries for medicines critical to fighting hiv/ aids, in an agreement with pharmaceutical manufacturers (see chap. ). these countries together have % of aids cases in the developing world. the foundation's hiv/aids initiative (chai) has also involved political leadership from president clinton to reduce fear and ignorance of the disease and to discourage discrimination. donations are the primary source of revenue for the foundation, making up usd , , of the usd , , in revenue for (http:// www.clintonfoundation.org). the clinton foundation also funds access to treatment and information. it has committed usd million to fund a -year program to ensure all hiv-positive children in kenya receive treatment. the funds would pay for a public awareness campaign and purchase anti-retroviral drugs to rapidly scale up the number of infected children under treatment from to . half all hiv-positive children in kenya die before their second birthday; % of those die because they are not provided with treatment. anti-retroviral therapy would increase the life expectancy to years. of an estimated , hiv-positive children, , are in need of treatment and only , are on life-saving anti-retroviral therapy. a survey commissioned by the kenyan ministry of medical services showed that % of mothers and caregivers were unaware of the availability of hiv testing for children and that only % had taken their children for hiv testing (ndegwa ) . there is also collaboration among private firms, private foundations and host governments. for example, an innovative model for fighting hiv/aids in africa is being piloted in botswana through a public-private partnership involving the government of botswana, the bill & melinda gates foundation and merck & co., inc. the partnership is intended to help botswana achieve an "aids-free generation by " by expanding prevention, supporting treatment, increasing counseling and testing and empowering communities (center for global development and merck ). the main focus of this chapter has been on multilateral financial institutions. however, it is important to note the role of other financial donors, notably bilateral governmental arrangements. private actors and ngos also make significant contributions to addressing the global aids pandemic. as important as it is to marshal the resources of numerous governmental and non-governmental agencies, the multiplicity of donors involved in the aids epidemic, together with a multiplicity of donor requirements, is a significant issue in seeking to expand prevention and treatment programs. national political leadership is a crucial part of any hiv/aids strategy. in many countries, statements made by politicians who make decisions on resource allocation have been appalling. in south africa, tshabalala-msimang, the health minister, shares south african president mbeki's rejection of the international scientific consensus that aids is caused by the hiv. the health minister has also criticized the use of standard anti-retroviral drugs to treat aids, recommending instead that south africans with aids follow a diet of beetroot, garlic, olive oil and african potato. in a recent south african population survey, a quarter of the population said they didn't believe in a link between hiv and aids (wilson ) . figure . reveals the impact of misinformation on south africans perceptions regarding the sources of hiv transmission. of mozambique's population is hiv positive (bbc news a). these lapses in political leadership highlight the need to incorporate political leadership into aids programs that are funded by multilateral, bilateral and private sector donors. multilateral institutions, such as the world bank, the imf and the global fund, and bilateral donors, including ngos and national governments, need to coordinate and harmonize their policies and financing conditions further in order to reduce were also infected "in order to finish quickly the african people". the catholic assigned to the private sector in delivering aid, in order to avoid the unnecessary diversion of funds away from the core goal of health care. in this regard, the experience to date suggests that social marketing is less effective and less equitable than the free provision of goods and services. particularly in the case of fastmoving infectious diseases, equitable and effective distribution should be paramount, since such diseases are unlikely to respect socio-economic boundaries, as the experience with hiv/aids and malaria has demonstrated. in particular, donors should not impose requirements to use patented medicines in place of cheaper, generic alternatives. the global business community has an important role to play in addressing global diseases. there are several key lessons that arise from the gbc's experience with hiv/aids. first, it is important to integrate health issues into overall business strategy, particularly since it takes about years to fully implement such strategies. second, there is a need to standardize best practices on a more systematic the administrative burden on recipients and in order to avoid imposing conflicting conditions on recipients. donors also need to be careful with respect to the role basis and to create incentives for those best practices to be adopted by suppliers and business partners of global companies. in this regard, the creation of iso standards for company health policies would be extremely useful, particularly for fastmoving global infectious diseases that have the potential to cause widespread economic damage and human suffering, such as avian influenza and sars. the global response to the hiv/aids pandemic has highlighted the need to strengthen health care infrastructure in developing countries. there is a concern that the high profile given to the hiv/aids pandemic may have diverted funds away from other important health issues (england et al., ) . in chap. we concluded that the focus on hiv/aids is justified, but it is important to address the hiv/aids pandemic in a way that strengthens the ability of national governments and multilateral organizations to address health concerns more generally. the following chapter examines the role of global health organizations in the hiv/aids pandemic, with a particular focus on the world health organization, which is the multilateral institution that is charged with addressing global health issues. the effect of population health on foreign direct investment private sector responses to hiv/aids: the case of debswana, botswana's diamond company funding the response to aids: why are donors not working together? are we spending too much on hiv? global fund to fight aids, tuberculosis and malaria: pdf global fund to fight aids, tb and malaria has improved its documenta-d the framework document of the global fund to fight aids bringing hiv prevention to scale: an urgent global priority funding the response to aids: why are donors not working together? pound of flesh: joseph hanlon reports on how local people have wised up to a huge international hoax donor concern over imf cap on aid increases tion of funding decisions but needs standardized oversight expectations and assessments evaluation of the local fund agent system international assistance for hiv/aids in the developing world: taking stock of the g , other donor governments, and the european commission. kaiser family foundation, center for strategic and international studies/unaids, data distribution of nets splits malaria fighters. www. nytimes.com. accessed the new international aid architecture: new players, new challenges strengthening partnerships in hiv monitoring and evaluation: how joint missions build and strengthen partnerships to support the realization of national m&e systems global fund responsiveness to faith-based organizations imf must adapt and downsize or die socioeconomic obstacles to hiv prevention and treatment in developing countries: the roles of the international monetary fund and the world bank funding the response to aids: why are donors not working together? funding the response to aids: why are donors not working together? access to healthcare, mortality and violence in reports funding the response to aids: why are donors not working together? kenya: clinton foundation provides $ m for children living with hiv/aids the paris declaration following the funding for hiv/aids: a comparative analysis of the funding practices of pepfar, the global fund and the world bank map in mozambique, uganda and zambia the public interest: health, education, and water and sanitation for all funding the response to aids: why are donors not working together? a response to joseph hanlon's recent article, donor concern over imf cap on aid increases aids: free access to treatment, a public health necessity or an economic heresy? picard a ( ) quarantine sought for harsh tb strain: variant poses 'extreme risk hiv/aids: what is business doing? a survey of the business community's response to hiv/aids in kenya challenges and opportunities for the new executive director of the global fund: seven essential tasks global fund grant programmes: an analysis of evaluation scores hiv/aids and the private sector in africa: evidence from the investment climate survey data world bank chief calls for new direction for lender summary paper on the evaluation of the studies/specific_evaluations/terg_summary_paper the evolving hiv epidemic: what have we learned since the map began? powerpoint presentation hiv/aids in central america: the epidemic and priorities for its prevention an oed evaluation of the world bank's assistance for hiv our commitment: the world bank's africa region hiv/aids agenda resources/wb_hiv-aids-afa_ - _advance_copy external /default/ wdscontentserver/ wdsp/ib/ / / / _ / aids situation and response to the epidemic key: cord- - glgeft authors: possas, cristina; antunes, adelaide maria de souza; de magalhães, jorge lima; mendes, flavia maria lins; ramos, mateus pinheiro; de simone morais, juliana; homma, akira title: vaccines: biotechnology market, coverage, and regulatory challenges for achieving sustainable development goals date: - - journal: bioeconomy for sustainable development doi: . / - - - - _ sha: doc_id: cord_uid: glgeft this chapter provides an overview, from bioeconomic and global sustainability perspectives, of the main constraints to the current global vaccine innovation system for achieving sustainable development goals – sdgs. biotechnology market trends, gaps in vaccine coverage against emerging and neglected diseases, and patent protection and regulation are discussed. a structured long-term “public-return-driven” innovation model to overcome vaccine market failure is proposed. innovative preventive vaccines against emerging and neglected infectious diseases, such as zika, dengue, chikungunya, influenza, and hiv/aids, are examined here from bioeconomics and global sustainability perspectives, aiming to integrate public health and biotechnology market approaches. novel vaccines with reduced adverse effects can have an enormous impact on life expectancy and on the quality of life of the global population, significantly reducing government, individual, and business costs . nevertheless, there are significant production, technological development, market, coverage, regulatory, and governance constraints to achieving sustainable development goals (sdgs) . in this chapter we examine vaccine biotechnology market and the factors contributing to market failure, discussing policy strategies to optimize science, technology, and innovation (sti) and drastically reduce current constraints to vaccine development (singh et al. a (singh et al. , b, . for achieving sdg, it should be noted that only one of these goals, sdg , refers specifically to vaccines ( .b. ). however, in addition, we have also identified other sdg goals strongly related to vaccines and sdg goals related to vaccine, in a total of vaccine-related goals in sdgs. two of these goals are related to innovation and technological development of vaccines (sdg and sd ). we discuss the main vaccine development challenges for achieving sdg and current technological and regulatory obstacles particularly affecting developing countries. from this perspective, we propose sti governance strategies to overcome these gaps and increase global access to vaccines, focusing on institutional and regulatory perspectives, including intellectual property and ethics. policy recommendations for vaccine funding and incentives for innovation, development, and production are made. finally, we emphasize the enormous potential role that access to innovative vaccines can play on global sustainability (milstien et al. ; possas et al. ) , benefiting particularly the poorest countries in a global context permeated by sharp social inequalities. the global market for human vaccines is projected to reach usd . billion by from . billion in at a cgar of . % (markets and markets ) driven by the growing importance of vaccines in public health, reducing healthcare costs and contributing through prevention of diseases toward a more sustainable healthcare system. drastic changes in the dynamics of the global vaccine market occurred between and , with a sharp growth from usd billion in to usd billion in (access to vaccines index ) and to usd . billion in (markets and markets ) , with sales to high-income countries representing about % of the total value of this market (access to vaccines index ). in fig. . we indicate the evolution of the global human vaccine market from to and the forecast for . recently, other reports have been released anticipating an even more favorable scenario for the global human vaccines market. a recent study estimated that this market would grow from . billion in to . billion by (grand view research ) . these market forecasts also anticipate rising r&d investments in vaccine development projects by the main global players in the vaccine market. table . indicates the top pharmaceutical players according to global revenue share in . pfizer is expected to increase its participation in the market in the next decade due to the success of its pneumococcal vaccine prevnar and increasing investments in vaccine development. other important vaccine players include emergent biosolutions, csl, inovio pharmaceuticals, bavarian nordic, mitsubishi tanabe, serum institute of india pvt. ltd., alk-abelló a/s, altimmune, inc., bharat biotech international, and medimmune. the world vaccine market consists of four segments: gavi (the global alliance for vaccine and immunizations), unicef, paho revolving fund (rf), and rest of the world (row). about of the lowest-income countries in the world rely on gavi for funding of some key vaccines (who ) . unicef supply division (sd) is the procurement agent for most of these countries and for an additional approximately middle-income countries (mics) (totaling about countries). the paho rf provides financial and procurement support to about countries and territories in the americas. the row consists of self-funding and self-procuring countries spanning all income levels and receiving only marginal, mostly indirect, financial, procurement, market shaping, or other related support. these increasing investments in vaccine innovation, development, and production are guided by the growing global need for preventive vaccines and immunotherapy strategies against cancer, zika, hpv, hsv, hiv, and a broad range of infectious diseases that currently burden the healthcare system and societies worldwide (who (who , . this scenario of increasing global demand for vaccines in the next decade is supported by epidemiological indicators: annual burden of new hpv-related cancers worldwide to the tune of , ; rise of zika into a public health emergency with over countries reporting , cumulative confirmed cases of infection between and ; very high prevalence of hsv which infects approximately % of the world population under years of age; continued prevalence of tuberculosis which infects million and takes . million lives each year despite the progress made toward eliminating the disease; and rise in hiv infections worldwide over . million (who ; global industry analysts ). developments in reverse vaccinology and synthetic vaccinology are expected to help increase the rate of successful vaccine design and development (sette and rappuoli ) . emerging countries with mandatory immunization programs represent large markets with enormous potential for future growth and expansion. with large population base and relatively high proportion of young children and teen population, emerging markets including china and india represent the fastest growing markets in asia-pacific, with this region expected to grow at the fastest rate of . % in the next decade. the pharma industry is rapidly becoming a competitive player in the bioeconomy market, a new global paradigm that will introduce novel technologies such as genomics and proteomics across multiple economic sectors and industries. immunome, resulting from advances in sequencing technology and a bioinformatics resource, is also contributing to vaccine innovation and development. these advances in genomics, proteomics, immunome, bioinformatics and new information technologies and their increasing convergence are driving these new market trends. this accelerated innovation scenario is revolutionizing healthcare with new preventive and therapeutic technologies, expected to provide longer, healthier lives to the global population. physicians will eventually be able to predict a person's predisposition to a broad range of diseases and intervene appropriately, insert new genes to replace faulty ones, and tailor therapies to an individual's needs and profile. the immune system is a highly complex system, based on a coordinated expression of a wide array of genes and proteins. one of the major gaps in vaccine innovation, particularly affecting the development of new vaccines against emerging and neglected diseases, is related to the inability of scientists to explain the diversity of individual immune responses and clinical outcomes to the same vaccine and how this diversity relates to innate and acquired immunity. the human immunome, a specific set of genes and molecular structures underlying the response of the immune system to fight disease, is vast and estimated at billion times larger than the human genome project in terms of data output. because of this scale, scientists have never been able to characterize the core parts by which the immune system responds to pathogens and develops a disease. only recently, with the dramatic advances in sequencing technologies and bioinformatics, exponentially extending their informational scale, it became possible for the first time for scientists to uncover the complexity of the human immunome (soto et al. ; briney et al. ) . immunome, a bioinformatics resource, has been conceived for the characterization of the human immune system. it contains information about immunity-related proteins, their domain structure, and the related ontology terms and contains also information about the localization and mechanisms involved in the coding genes. determining the core parts of the immune system in the human immunome could drastically transform how we diagnose, prevent, and treat disease through the identification of new biomarkers while enabling highly targeted, computationally designed vaccines and therapies that reduce time and risk of product development. the immunome program of the human vaccines project is sequencing, in a global collaborative -year effort, receptors from a group of genetically diverse individuals in several continents and determines the structure and function of a key subset of receptors. through an open-source procedure, data will be made available to researchers across the world. in this program, laboratory analyses of biospecimens will be combined with an array of other genetic, lifestyle, and health information provided by volunteers to help researchers to identify individual genetic differences that contribute to diverse immune responses. the initial study will assess immune responses of ten healthy adults (ages - ) to a licensed hepatitis b vaccine (considered an ideal model to study human immunological protection), and it is expected that this study will expand to include several hundred people from neonates to the elderly in middleand low-income countries. the immunome program can thus bring crucial information to the development of more effective vaccines against emerging and neglected infectious diseases. vaccine manufacturers in developing countries, particularly affected by these diseases, should be actively involved in its international scientific and technological collaborations. in the near future, sophisticated technology will allow patients to search and manage their medical records, comparing them to current public health information based on individual genomic profiles. intelligent marketing agents will aggregate patient information from a variety of sources to provide timely and relevant responses. networks of distributed processing systems will offer new insights into data by mining all enterprise and public data sources. and supercomputing platforms and information management will enable the rigorous manipulation of genomic data. advances in remote sensing and artificial intelligence technologies have already created intelligent operating rooms with sensory control mechanisms and devices that transmit health information via telephones and personal digital assistants. the industry can now develop programmable microchips for the subcutaneous delivery of precisely timed doses of drugs and vaccines. interactive chips with built-in sensors may mimic the body's own regulatory ability. as the bioeconomy evolves, the industry faces an unprecedented era of opportunity and challenge. companies recognize that alliances are critical to their future and are now making them a major component of their strategy. virtual research organizations are now conceived searching to provide discovery technologies to scientists in pharmaceutical enterprises; providing them links to gene database, proteomics database, or high-throughput screening capabilities; and enabling fast and efficient access to vaccine and immunotherapy information. the world is facing multiple public health challenges, such as outbreaks of vaccinepreventable diseases, increasing reports of drug-resistant pathogens, climate change, and multiple humanitarian crises. the world health organization (who) included several emerging and neglected diseases among the ten global threats for (who ): influenza, dengue, hiv, and also high-threat pathogens, such as ebola, several other hemorrhagic fevers, zika, nipah, middle east respiratory syndrome coronavirus (mers-cov), and severe acute respiratory syndrome (sars) and disease x, which represents the need to prepare for an unknown pathogen that could cause a serious epidemic. to address these and other threats, started its new -year strategic plan: the th general programme of work. this plan focuses on a triple billion target: ensuring billion more people benefit from access to universal health coverage, billion more people protected from health emergencies, and billion more people in better health and well-being. reaching this goal will require addressing these threats to health from a variety of angles. the world will face another influenza pandemic; the only thing we don't know is when it will hit and how severe it will be. global defenses are only as effective as the weakest link in any country's health emergency preparedness and response system. who is constantly monitoring the circulation of influenza viruses to detect potential pandemic strains: institutions in countries are involved in global surveillance and response. every year, who recommends which strains should be included in the flu vaccine to protect people from seasonal flu. in the event that a new flu strain develops pandemic potential, who has set up a unique partnership with all the major players to ensure effective and equitable access to diagnostics, vaccines, and antivirals (treatments), especially in developing countries, in order to make possible the supply of required vaccines as soon as possible. dengue, a mosquito-borne disease that causes flu-like symptoms and can be lethal and kill up to % of those with severe dengue, has been a growing threat for decades. a high number of cases occur in the rainy seasons of countries such as bangladesh and india. now, its season in these countries is lengthening significantly (in , bangladesh saw the highest number of deaths in almost two decades), and the disease is spreading to less tropical and more temperate countries such as nepal that have not traditionally seen the disease. an estimated % of the world is at risk of dengue fever, and there are around million infections a year. who's dengue control strategy aims to reduce deaths from the disease by % by . hiv infections in sub-saharan africa despite being only % of the population. this year, who will work with countries to support the introduction of self-testing so that more people living with hiv know their status and can receive treatment (or preventive measures in the case of a negative test result). who has included in these ten global threats for diseases and pathogens that have potential to cause a public health emergency but lack effective treatments and vaccines. this list for priority research and development includes ebola, several other hemorrhagic fevers, zika, nipah, middle east respiratory syndrome coronavirus (mers-cov), and severe acute respiratory syndrome (sars) and disease x, which represents the need to prepare for an unknown pathogen that could cause a serious epidemic. international recognition of vaccines' impact and increased global demand for vaccines have stressed the need for global strategies to assure timely provision of lowprice vaccines (meissner ) through policies supporting free and universal access. in this scenario, the decade of vaccines (dov) initiative was launched at the world economic forum in davos in , signed by international agencies, such as the world health organization (who), unicef, the us national institute of allergy and infectious diseases (niaid), and the bill & melinda gates foundation, with the mission: "to extend, by and beyond, the full benefits of immunization to all people, regardless of where they are born, who they are, or where they live." this declaration was supported by a commitment by the bill & melinda gates foundation to donate usd billion to research and development and to delivering vaccines for the poorest countries. the dov initiative gained significant international support and visibility. two years later, after consultations with dov stakeholders, including industry groups, a global vaccine action plan (gvap) was launched by the member states of the th world health assembly in may , aiming to deliver universal access to immunization by . following the collaborative dov strategies, the gvap brought together multiple stakeholders to achieve the ambitious goals of the plan: the leadership of the bill & melinda gates foundation, gavi alliance, unicef, us national institute of allergies and infectious diseases (niaid), and who, mobilizing many partners (governments, health professionals, academia, manufacturers, funding agencies, development partners, civil society, media, and the private sector). if the gvap is translated into action and resources are mobilized, it is expected that between . and . million deaths could be averted by the end of the decade, with gains in billions of dollars in productivity. nevertheless, it is important to note that actions and resources will not be sufficient for the success of gvap if the plan does not conceive a global strategy to support manufacturers in the developing world to overcome the main ipr and regulatory barriers that delay and hinder vaccine development and production. the millennium development goals (mdgs) for - were incorporated by governments worldwide and had a strong global mobilization power on promoting development and social initiatives, engaging national leaders in elaborating and monitoring these goals (un ) . this mobilization was facilitated since the targets were quantifiable and could potentially be attained. although the two healthrelated goals, mdg (reduce under- mortality from to by two-thirds) and mdg (reduce maternal mortality from to by three-quarters), had not been met by and it is estimated by who that . million infants worldwide are still missing out on basic vaccines, significant progress has been made, with child and maternal mortality approximately halved, with significant global progress. in sequence to mdgs, the united nations promoted an in-depth revision of this strategy (un (un , and formulated a new global strategy, sustainable development goals (sdgs) for - with goals, with one of them (sdg ) directly related to health (un ). the target of sdg is to "ensure healthy lives and promote well-being for all at all ages." its sub-targets include ones that could be met: two-thirds less maternal mortality and a third less noncommunicable disease (ncd) mortality. they also include ending preventable newborn and under- deaths and ending hiv/aids, tuberculosis, malaria, and neglected tropical diseases, besides other non-vaccine related sub-targets. in this chapter, we argue that a major component of sdgs is crucial for attaining sdg goals and should not be minimized: innovation and technological development of vaccines. we discuss how this component should be incorporated into monitoring the sub-targets of this goal, and we emphasize the need for a new vaccine innovation model based on an expanded role of the state and incentive mechanisms to pharmaceutical companies and public manufactures to correct the current scenario of "market failure" constraining access to vaccines. it is certainly unacceptable, from ethical and sustainable development perspectives, to simply recognize this "market failure" as a detrimental and inevitable consequence of the rationale of a global market economy. on the contrary, it should be seen as a massive public health failure and a global failure to direct economic development for the benefit of societies (trouiller et al. ). the "valley of death" although vaccine candidates are in the development pipeline for neglected and emerging infectious diseases mainly affecting the poorest countries such as malaria, dengue, hiv, tuberculosis, and pneumonia, only of them have made it through the pipeline recently and are widely used in these countries: a conjugate vaccine for meningitis serogroup a diseases and a vaccine against japanese encephalitis virus (kaslo et al. ; who ) . it has been estimated by these authors that unfortunately much of this promising pipeline could go to waste and fall into the so-called valley of death, failing to move from proof-of-concept to second-phase trial due to lack of market interest in vaccines against these emerging and neglected diseases affecting only the poorest populations in developing countries. no single organization or group is interested in supporting the costly and more complex late-stage clinical trials for neglected diseases that mainly affect the poor nations. this scenario raises great concern for two reasons. first, around % of these vaccine candidates in the development pipeline target the mentioned neglected and emerging infectious diseases, a much higher problem in lower-and middle-income countries (kaslow et al. ). second, this means a significant waste of global resources in a crucial area for sustainable development, considering that these vaccine candidates received billions of dollars for the first phase of vaccine development from prestigious donors, such as the us national institutes of health (nih), the european union, the welcome trust, and the bill and melinda gates foundation. taking a vaccine candidate from a discovery at the laboratory bench to widespread deployment is a complex, lengthy, and expensive endeavor, with many financial, licensing, and regulatory barriers. no organization or group plans to support the emerging and neglected diseases vaccines from the beginning to end. therefore, it could take many decades to incorporate these vaccines into the national immunization programs in these poorest countries (kaslow et al. ) . in table . we provided a selection of promising projects for vaccines for emerging and neglected infectious diseases affecting the poorest developing countries that could significantly impact on achieving sdg targets. science and technology have made enormous progress and are now prepared to provide the innovative-intensive vaccines that the poorest populations in the world urgently need. but innovation and discovery are not the major bottleneck, which reside in technological development, production, and timely provision of vaccines to people (homma et al. ). r&d-based pharmaceutical major industry players are reluctant, due to freemarket rationale, to invest in the development of vaccines to treat the major neglected and emerging diseases affecting mainly the poorest nations, since return on their investments cannot be guaranteed. national and international policies currently support a free-market-based global order, with economic opportunities, rather than global public health needs guiding the direction and rationale of vaccines development. it is certainly unacceptable, from ethical and sustainable development perspectives, to simply recognize this "market failure" as a detrimental and inevitable consequence of the rationale of a global market economy. on the contrary, it should be seen as a massive public health failure and a global failure to direct economic development for the benefit of societies (trouiller et al. ). an urgent redefinition of priorities in vaccine development is needed. this strategy cannot rely only on fragmented contributions of researchers, funding agencies, and the pharmaceutical industry. effective national and international policies need to be urgently conceived to redirect the global economy to address the true public health needs of society (homma et al. ; røttingen et al. ) . "political will," identified as the need for a strong commitment to prioritize health considerations over economic interests, has been frequently emphasized by policy-makers as a major issue to ensure access to vaccines but is not sufficient. it is necessary to go beyond "political will," with a clear goal in mind and a realistic plan to achieve it. from this perspective, it will be necessary to promote effective global implementation of strategies to accelerate innovation, technological development, and production of new vaccines and to ensure timely global access to them. moreover, a global vaccine policy strategy should be conceived to promote the necessary enforcement of regulations and other mechanisms to stimulate vaccine development, production, and global access to these products. novel, creative, and effective strategies involving both the public and the private sector are needed to ensure low-price vaccines, accelerating innovation and technological of vaccines against emerging and neglected diseases. priority action areas should include: . advocating a preventive vaccines r&d agenda . conceiving capacity-building programs adequate to the conditions of developing countries' manufacturers . promoting technology transfer to public and private manufacturers in emerging countries . elaborating an adapted legal and regulatory framework to increase flexibility and "fast-track" procedures . prioritizing funding for vaccine development . securing availability, accessibility, and distribution of these vaccines consensus is building among the main stakeholders in the global vaccine community that the spiraling costs of risks associated with vaccine r&d are detrimental to global access to these products, particularly in the poorest developing countries. most of them agree that these vaccine r&d costs should be instead rewarded by means other than financial returns in the market from charging high product prices. novel mechanisms such as incentives, prizes, and "patent pools" for drugs and vaccine innovation and development have been proposed in the last two decades. there is now vast literature on the subject, claiming for alternative models that should be urgently implemented to meet the increasing global demand for vaccines, particularly in the poorest developing countries. the main question is: how to conceive a feasible long-term mechanism to minimize these risks faced by pharma companies? which global organizations should be responsible for this alternative model? we recommend this new vaccine incentive model should be coordinated by three international organizations: who, gavi, and unicef. these organizations would, in collaboration with the main stakeholders, identify from the list of candidates the priority vaccine candidates, identify the funding mechanisms necessary to these candidates to enter the second-phase clinical trials, and specify which organization, or alliance, would be responsible for these selected vaccine candidates from beginning to end. in this innovative global collaboration strategy, these three leading international organizations should bring together the main players and stakeholders in the vaccine market, with funding agencies such as the bill & melinda gates foundation, nih, welcome trust, and other organizations as path, iavi, and the international vaccine institute in seoul and vaccine manufacturers, in collaboration with other nongovernmental organizations in order to conceive and implement this alternative long-term model for sustainable development and provision of vaccines which are uncertain business products or require a great amount of public funding to go beyond the initial proof-of-concept phase. a novel global priority-setting strategy, driving adequate implementation, will be necessary to assess the vaccine candidates in the pipeline, trying to identify the most favorable candidates which are uncertain business cases that will require significant public funding to move into second-phase clinical trials. funding mechanisms supported by subsidies from governments, such as those of the g countries, and philanthropic organizations, such as the bill & melinda gates foundation, could remedy the market failure threatening vaccine development for lmics. gavi already provides one form of subsidy (gavi a, b). support to develop vaccines or to make them available during epidemics is also provided by public organizations, such as the coalition for epidemic preparedness innovations in oslo and the biomedical advanced research and development authority, part of the us department of health and human services. such schemes need to be expanded and rethought to give vaccine developers more certainty and upfront financial backing (kaddar et al. ) . for instance, gavi could commit to purchasing a vaccine before it has been developed, on the condition that the developers meet certain regulatory milestones. at present, the alliance buys vaccines to distribute to lmics after they have been licensed or recommended by the who for general use (gavi (gavi , b . only with this kind of leadership will the global community secure vaccines for some of the world's most debilitating diseases. there is an urgent need for a paradigm shift in global governance of health innovation systems to achieve sustainable development goals (buse and hawkes ; possas et al. ; seib et al. ; mazzucato ) . "mission-oriented" approaches have been proposed to overcome current constraints in innovation systems (mazzucato and penna ) . recently, in a new report, "the people's prescription: re-imagining health innovation to deliver public value" (mazzucato ) , the authors call for restructuring research and development innovation systems in order to create, rather than extract, value. it also calls for long-term "missionoriented" public investment and a public return on this investment. in this report the authors argue that health innovation is about making new treatments and cures available to the people that need them. profits might be earned but not at the cost of doing what the health system is meant to do: heal. this report is the outcome of result of collaboration between the ucl institute for innovation and public purpose, stopaids, and global justice now and just treatment. the report identifies gaps of the current health innovation system and sets principles for a new model. it proposes concrete policy actions that can be taken in the long term to actively shape and co-create a health system that delivers real public value. the report is structured into two sections. the first is "diagnosis" with chapters on "problems with the current health innovation system" and "principles for a health innovation model that delivers public value." the second section, "remedies," includes chapters on "immediate policy actions: getting better prices today" and "transformative proposals: re-imagining our health innovation system to deliver public value." the report focuses on the unethical and unacceptable current global scenario for health innovation, highly inefficient, with a pharmaceutical industry that makes billions in profits without providing the affordable products that people need. the report examines all those problems, and then it sets out some key principles of how a "healthy" innovation model for health would work, based on an analysis of case studies from different countries and different contexts, looking at where innovation has been done well. in vaccine development, as in drugs development, there is a tremendous waste of resources because public health is not driving the r&d agenda. we have all the money going into proof-of-concept studies instead of developing public accountability. track" the need to provide more flexible and expedite new vaccine products and processes resulting from biotechnology is challenging both developed and developing countries to accelerate the implementation of adequate regulations and intellectual property rights (crager ; possas et al. ) . ipr are granted by the state to individuals, enterprises, or organizations under temporary monopolistic conditions (patents) in order to compensate them for the investments made in their creations/innovations. in industry, a patent is clearly an instrument to guarantee the returns of the investments on r&d through the commercialization of the patented products and through the payment of property rights. patents are viewed as a crucial incentive to innovation. nevertheless, arrow ( ) recognized in his pioneer theory that in spite of its advantages, the patent system creates a suboptimal situation in economic terms: patents create a monopoly that restricts the diffusion and dissemination of innovation. the argument is that this restriction is temporary (after years the patent protection "falls" to public domain) and is compensated by the fact that the knowledge related to the patent is necessarily published in the moment that the patent is granted. nevertheless, several authors have noted the detrimental impacts of the monopoly created by the patent system on health products' innovation, particularly on the development and accessibility to new drugs for neglected and emerging diseases and proposed incentive mechanisms, such as prizes, "patent pools," and awards to compensate this "market failure." although in the vaccine sector many intellectual property and market issues affecting price remain unclear, in the current regulatory scenario, the access to new technologies in multipatented vaccines, such as adjuvants for vaccine compositions, remains a main challenge (possas et al. ) . for vaccine manufacturers in emerging countries, access to patent information on vaccine adjuvants is a crucial issue, detrimental to vaccine development. the incorporation of new adjuvants for vaccines which boost the immune response has become crucial to the development of innovative vaccines, as new antigens, with purer and smaller molecules, may have less then optimal immune responses, necessary to vaccine protection for a lengthy period of time. the malaria vaccine candidate rts provides a good example of the crucial role new adjuvants can play: this vaccine, based on the plasmodium falciparum sporozoite antigen circumsporozoite protein (csp), was successful in providing protection against clinical malaria only when combined with a powerful adjuvant (as or as ). another example are the tests using hybrid flagelins also in malaria vaccines. adjuvants have emerged thus as an alternative route for vaccine development with enormous potential in the global market (mbow et al. ) . the development of new, powerful, and safe adjuvants is therefore a key component of vaccine research. we present in table . some of licensed vaccine adjuvants, with company and class. figure . indicates the countries concentrating patent deposits for adjuvants to vaccine compositions and the diseases related to them (zika, dengue, hiv/aids, influenza), china ( %), the usa ( %), south korea ( %), and the uk ( %), with these three countries accounting for nearly % of all patent deposits. it is also observed that chikungunya had no deposit in the period from to , as indicated the espacenet base. it should be stressed that very few deposits are related to zika and dengue vaccine, only in china and the usa. it also indicates that most of these adjuvant deposits are concentrated in vaccine compositions related to just two diseases, influenza ( %) and hiv/aids ( . %), while zika, followed by dengue, is more neglected. the increasing risk of a pandemic of influenza, rapidly affecting all continents, might explain the concentration of r&d efforts on vaccine compositions and adjuvants for this disease. table . provides an overview of the patent holders of deposits for vaccine adjuvants against zika, dengue, and hiv in the - period, listed by country, number of deposits, and deposits with partnerships and partners. this table indicates that the number of partnerships is very low and should be stimulated. figure . shows the temporal evolution of patent deposits in the period - of the three largest patent depositors of adjuvants and formulation of vaccines with adjuvants for the diseases studied, showing that only in the last decade there has been a greater r&d effort. this figure also indicates the leadership of china and the increasing role played by this country in the development of adjuvants for vaccine compositions. finally, it should be noted that in addition to these intellectual property barriers to access to vaccine formulations and vaccine adjuvants, such as confidentiality and constraints to patent information sharing (possas ; possas et al. ) , other regulatory obstacles remain also a challenge to vaccine development and access to timely immunization: virtual inexistence in many countries, particularly the developing ones, of expedite and "fast-track" review processes (fda ; u.s. dept. of hhs et al. ) for evaluating priority and emergency projects; lack of flexible regulatory procedures for sharing biospecimens and samples; legal constraints in access to biorepositories and to biobank information; and the difficulties in defining the standard of care to be provided during clinical trials. we examined here, from bioeconomics and global sustainability perspectives, the current innovation system for vaccine development, providing considerations on how this system should be better designed and implemented to address sdgs' vaccine coverage targets. public investment plays a crucial role in biomedical r&d worldwide, but research and development activities supported by governments with public resources are in most cases not directed into targets that have the most public health value, such as vaccines. for this reason, there is increasing awareness and concern in the global vaccine community on the fact that public-supported vaccine products should be shared by the public and not just privately appropriated by pharmaceutical companies. this scenario evidences a need for conceiving a new innovation governance paradigm for vaccine development compatible with the market rationale, aiming profitable products with social return: an expanded role of the state, with clear procedures for planning, development, regulation, and forecast; a redefinition of the patterns of relationship between private and public players; and finally, a political agreement between the main players and stakeholders on the more adequate mechanisms to balance the risks and the rewards between those players. moreover, there is a need to conceive a more flexible intellectual property regime for emerging and neglected diseases mainly affecting the poorest populations in developing countries. the monopoly created by patent protection must be compensated by new incentive mechanisms such as awards, prizes, and "patent pools" to accelerate global access to vaccines. it is also crucial to strengthen the local capacity of vaccine r&d institutes and manufacturers in emerging developing countries in order to accelerate the incorporation of new technologies for production of innovative vaccine products. the multinational companies have the intellectual property of these new technologies, such as adjuvants for vaccine compositions, but they do not have sufficient production capacity to meet the global demand for these products, a gap that should be overcome with expanded global collaboration with developing countries' manufacturers. in addition, these players should identify gaps and priorities in infrastructure and capacity building in developing countries' manufacturers in order to facilitate technology transfer agreements with leading pharmaceutical companies and ensure a sustainable long-term supply of vaccines to the poorest populations. finally, clear expedite and "fast-track" regulatory procedures and pathways should be conceived and implemented. in other words, it will be necessary for international organizations and pharmaceutical companies to move from a short-term "shareholder-driven innovation model" to a long-term "public-return-driven innovation model", aiming global sustainability and social welfare for meeting the needs of low-income populations while searching for innovative and profitable vaccine products. access to vaccines index ( ) how vaccines companies are responding to 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cord_uid: u brl bi first, theories of globalisation and their implications for the analysis of health issues are discussed. emphasis is on: ( ) globalisation as embodied, something often overlooked by sociologists working outside of the field of health and ( ) health vulnerabilities that arise from the heightened mobility and connectivities that characterise globalisation, taking migration and health as an illustration. second, differentiation is considered by highlighting disparities in health vulnerability and the capacity of social groups to protect their health. this is illustrated by reference to the securitisation of health and the health consequences of violent conflict and the special vulnerabilities of children and of women. third, the influence of interconnectedness of various national healthcare systems and implications for the delivery of effective healthcare are considered. sociology was born of modernity and the conception of 'society' as a sovereign unit of analysis. since the turn of the present century this has been subject to considerable critical analysis as it has been argued, with increasing force, that the discipline has entered a 'post-societal phase' as a consequence of globalisation, challenging as a consequence sociology's basic units of analysis, namely, the nation-state (burawoy ). urry characterises this as 'a theoretical and empirical whirlpool where most of the tentative certainties that sociology has endeavoured to erect are being washed away ' ( : ) . the effects are several, including the search for new theoretical frameworks and associated conceptual tools which turn from the traditional emphasis on stasis, structure and social order in favour of mobility, contingency and complexity (see e.g. castells ; walby walby , . concurrently, theorists have re-examined the assumptions of modernity, or what it means to be modern, that shaped the discipline. as connell ( : ) expands, 'sociology developed in a specific location: among men of the metropolitan liberal bourgeoisie'. the so-called founding fathers of the nineteenth century, such as durkheim, marx and weber, were concerned principally with the social changes taking place as european societies modernised, processes such as socio-economic restructuring, loss of social cohesion and new forms of social inequality. consequently, the very meaning of modernity itself was eurocentric since the social was conceived as 'an internally coherent, bounded phenomenon that could be understood without any reference to external relations such as the colonial or imperial misadventures that were being undertaken at the time' (bhambra : ) . for example, durkheim's ( durkheim's ( [ ) analysis of the division of labour in society, especially his disquiet about excessive individualism and lack of social cohesion under organic solidarity, was approached overwhelmingly by reference to processes internal to a society. sociologists have questioned the constraints that this presents for an adequate understanding of social life in both the global north and the global south. but as bhambra ( : ) argues, while sociologists are now far more inclined to discuss modernities in the plural, these often refer back to european analysis such that 'the west is understood as the major clearing house of modernity' to the rest of the world, meaning that non-western peoples must now begin to engage their traditions with modernity in different forms of hybrid "modernities"'. as she continues, with globalisation these multiple modernities still tend to be seen as becoming global as they incorporate features of the west to local circumstances. thus, as she puts it, while there is recognition of difference, that difference does not necessarily make a difference to sociological ways of thinking. bhambra ( ) exemplifies this through the analogy of the spokes of a wheel where european modernity of the centre diffuses along the spokes of other parts of the world or countries in relation to their encounters with the west, with very little consideration given to how the spokes may relate to each other. perforce there is a tenacious northernness to sociological theory which can result in the erasure of the experience of peoples outside of the metropole-the majority of the people of world-from the foundations of social thought (connell ). this has sizeable implications for the analysis of society, differentiation and globalisation and health. the connections between 'global' and 'health' are very far from given, rather, as this chapter seeks to show, global health problems and responses are 'enabled, imagined, and performed via particular knowledges, rationalities, technologies, affects, and practices across a variety of sites, spaces, and relations' (brown et al. (brown et al. : . this means it is important not only to consider globalisation's processes and effects but also how they are theorised and the consequences that this might have for our understanding of health and healthcare in different parts of the world. this chapter is organised as follows. part addresses theories of globalisation and their implications for the analysis of health issues. in particular i emphasise that globalisation is embodied, something often overlooked by sociologists working outside of the field of health (turner ) . emphasis is given to the health vulnerabilities that arise from the heightened mobility, and connectivities that characterise globalisation, taking migration and health as an illustration. in part , i turn to consider differentiation by highlighting disparities in health vulnerability and the capacity of social groups to protect their health. this is illustrated first by reference to the securitisation of health and (elbe a) . a focus on the mental and physical health consequences of violent conflict then draws out the special vulnerabilities of children and of women. finally, in part , i reflect on neoliberalism as the dominant politico-economic policy framework driving health system change and on the increasing interconnectedness of various national health systems, and their implications for the delivery of effective healthcare. as turner emphasised over a decade ago, 'we can no longer study the treatment of disease in an exclusively national framework because the character of disease and its treatment are global ' ( : ) . the sociology of health needs to be global in scope and, crucially, the globalisation of health risks and of medical institutions should be added to globalisation theory as 'the first steps toward a globalisation of the body' (turner : ) . while turner underlines that the spread of global health risks and global health institutions can be thought of as a new phase of globalisation, attention in these terms is wanting in most globalisation theories. even so, they can provide a useful lens into the analysis of health in the global context. as already noted, since globalisation is envisaged as a new social order, a substantially new theoretical framework is necessary to analyse what is envisaged as a 'new unbounded social system' (connell : ) . while popular thinking tends to equate globalisation with linear diffusion of western values and ideas to the rest of the world and construe arrested globalisation as resistance to such a trend-such as in the interpretation of the rise of islamic fundamentalism as a direct response to the spread of western political and cultural values into the middle east-most social scientists maintain that globalisation has no one single logic. instead of moving in one direction, they stress that it is multi-dimensional and multi-causal. bauman ( : ) describes globalisation as uncontrolled, operating in what he depicts as a 'vast -foggy and slushy, impassable and untameable -"no man's land"'. similarly for beck ( ) , there is no over-riding logic or driver, such as the economic; rather globalisation is multi-causal and multi-dimensional. consequently it presents as a new form of radically uncertain modernity. according to walby, globalisation is best identified as 'a process of increased density and frequency of international interactions relative to local or national ones ' ( : ) . she argues that this can be grasped most effectively through the lens of complexity theory. this entails a reworking of the concept and theory of society to bring system to the fore but in a substantively different way to erstwhile approaches such as that of parsons ( ) , where social systems were construed as entities made up of parts. by contrast, walby ( ) proposes that sociology should be the study not of parts but of all of society as a set of relations. from this position, she maintains it is possible to 'address multiple regimes of inequality existing within the same territory without assuming that they must neatly map onto each other or be confined to the same borders' (walby : ) . this offers a new vocabulary with which to understand social change; that of co-emergence, non-linear processes and heterogeneity (walby ), which draws attention to features of globalisation such as heightened mobility and new forms of connectivity between people, all of which have health implications. in his theory of the networked society, castells ( ) advances that social structure is always in the making, connecting the local and the global. while mobility is crucial, of equal importance for castells is perpetual connectivity. mobility stratifies through movement and through the lack of it. for some, 'space has lost its constraining quality and is easily traversed in both its "real" and "virtual" renditions' (bauman : ) , increasingly making it possible to move around the world for employment, in search of personal health and well-being and, as discussed in part of the chapter, for healthcare. conversely, there are people, such as refugees, who, for reasons such as civil war and persecution, have no choice but to move and to keep on moving. globalisation also makes visible the world of the 'locally tied' and globally many people are tied to risky communities that are damaging to their physical and mental health. (see chap. .) in collateral damage, bauman argues that 'the inflammable mixture of growing social inequality and the rising volume of human suffering marginalised as "collateral" is one of the most cataclysmic problems of our time' ( ). 'collateral damage' is military in origin and refers to the unplanned effects of armed intrusions. applying it to global societies, bauman conveys how the poor become collateral damage in a profitdriven, consumer-oriented society. although he does not address health and illness, it may be instructive to conceptualise those increasingly vulnerable to health inequity as a form of collateral damage. we turn to look at this now through the example of recent migration and health. the term migrant encompasses multiple forms of mobility. in broad usage, it is often taken to refer to people who move 'voluntarily' to live in another country for a year or more, such as 'economic migrants' and also 'irregular migrants' (those entering a country without required documents). by turn, 'forced migrants' comprises refuges, defined under the united nations (un) refugee convention of as those forced to flee to save their life or preserve their freedom; asylum seekers, or people seeking international protection, awaiting a decision on whether they have refugee status; and internally displaced persons (idps) forced to leave their homes to avoid armed conflict, natural or human-made disasters, or violations of human rights, but who have not crossed an international border. the un convention protects refugees, but asylum seekers and idps have few rights and hence limited protection. the relationship between migration and health is complex for the reason that migrants are a heterogeneous group. nonetheless, it can be useful to draw a general distinction between 'voluntary' and 'forced' migrants. although we need to be wary of overgeneralising, where 'voluntary' movement is concerned, research points to health selection since migrants often are healthier compared to people in their country of origin, yet it is important to recognise that migration itself can carry risks such as those of transit and adjusting to life in a new country. from his in-depth consideration, gatrell ( ) concludes that although migrants tend to be in better health than those left behind as well as than those in the new host population, these relative health advantages attenuate as immigrants adapt their behaviours, particularly their dietary and exercise behaviour, to the norms of the new community. this is borne out by huijts and kraaykamp's ( ) large-scale analysis of immigrant health in europe. based on european social survey data for - , they analysed the health of over , immigrants from different countries who had moved to different european countries. basing self-assessed health on a five point scale (i.e. very bad, bad, fair, good, very good), they analysed foreign born and second generation migrants in europe with a focus on 'origin' and 'destination' effects on health. characteristics of origin were found to have a lasting influence. for example, high levels of political oppression were associated with poorer health in both first and second generation migrants. religion was found also to be influential. notably, first generation immigrants from islamic countries reported better health than those from countries where other religions predominate (all other factors being equal). the authors relate this to socialisation into positive health behaviours such as refraining from alcohol consumption and smoking, although, this did not apply to the second generation, something which they put down to the influence of culture in the destina-tion countries. overall then the health of immigrants shows a strong resemblance to the health of native inhabitants of the country of destination, but there are some lasting effects of origin countries (huijts and kraaykamp ) . the deregulation of wars is one of globalisation's most ominous effects. as discussed further below, most present-day war-like actions are carried out by non-state entities and consequently associated with the erosion of state sovereignty and the burgeoning frontier-land conditions of 'suprastate global space' (bauman : ) . populations who flee conflict in their homelands often find themselves as outcasts in camps where they are neither 'settled nor are they on the move; they are neither sedentary not nomadic', becoming 'undecidables' made flesh (bauman : ) . when analysing forced migration we need to think less in terms of individuals moving in a linear fashion from point a to point b and more of constructed group movement, where the journey from a to b is often protracted and involves periods of stasis in 'transit' locations such as idp and refugee camps, as well as interception stages, such as border controls. such journeys are risk-laden (zwi and alvarez-castillo ) . as gostin and roberts ( : ) relate, 'each stage of the forced migration journey…poses health risks. individuals face armed conflict, famine, or both in their home countries causing physical illness, severe mental distress, and lifelong trauma'. the body of a -year old syrian refugee, aylan al-kurdi, lying on a turkish beach in september is an enduring image of the present european 'migrant crisis'. in alone, people were reported dead or missing in the mediterranean sea as they sought to escape conflict in countries such as syria and afghanistan (unhcr ). other health risks include injury and disability in transit and infectious diseases, such as measles, polio, cholera, tuberculosis, dysentery, and typhoid which can be rife in camps and exacerbated by food insecurity and lack of clean water. a report from unhcr (hassan et al. ) on the mental health and psychosocial well-being of syrians affected by armed conflict draws attention to experiences of violence, exploitation, isolation and losses such as grief for loved ones, homes and possessions. this manifests in helplessness, loss of control and anxiety as well as social withdrawal (especially amongst women and young people), fatigue, sleep problems, loss of appetite, and unexplained physical symp-toms. the authors detail that often suffering is understood as a normal part of life, not in need of medical attention. most arabic and syrian idioms of distress do not separate physical experience and mental symptoms since body and soul are linked in explanations of illness. for example, 'habat qalb or houbout el qalb, literally "falling or crumbling of the heart", corresponds to the somatic reaction of sudden fear', and 'kamatni kalbi "my heart is squeezing"…generally refers to anticipated anxiety and worry' (hassan et al. : ) . the health consequences of forced migration are a powerful illustration of the 'social suffering [that] results from what political, economic, and institutional power does to people, and reciprocally, from how these forms of power themselves influence responses to social problems' (kleinman et al. : ix) . bauman ( ) argues that, from the stance of the more secure in the world, migrants embody ambient fears of precarity and of people whose lives are defined by precariousness and anxiety. the insecure are less able to evade their own vulnerabilities, including fears of loss such as of work, homes and loved ones, that are intensified by their scattered and unpinpointable nature (bauman ) . grove and zwi ( ) draw on 'othering theory' to account for the responses of people in destination countries of the global north to forced migrants. the process of othering marks migrants out as different to 'us' and in the process shores up feelings of normalcy. concurrently migrants are constructed as risky to 'us', as distant and strange others, as needy, as charity cases and as health services queue jumpers who create welfare overload. as grove and zwi ( ) discuss, the language used is that of burden to the neglect of the agency, resilience and skill of many migrants. the health of forced migrants is but one example of the negative health consequences of globalisation. it highlights differential health vulnerabilities and the (in)capacity of groups of people to protect their health, the focus of this section of the chapter. the concept of the 'other', referred to earlier, is a useful frame within which to approach the effects of the securitisation of health in global context. although there is a strong historical connection between health and the security of nations, such as in times of war, the notion of 'health security' is quite recent. the catalyst was the events of / in the year . this occasioned the setting up of the global health security initiative, an international partnership between several countries, including canada, france, germany, italy, japan, mexico, the uk and the us, intended to supplement and strengthen their preparedness to respond to threats to global health, not only in regard to terrorism, but also pandemic infection and bio-chemical warfare. by , 'health security' was high on the global agenda, as reflected in the world health organisation's annual report, a safer future (who ) . the report defines health security as 'the activities required, both proactive and reactive, to minimise vulnerability to acute public health events that endanger the collective health of populations living across geographical regions and international boundaries' (who : ix) . this signifies a two-way relationship between health and security. first, the health of populations is seen increasingly in security terms; that is, there is a felt need to secure population health against threats. concomitantly, the security of nations is viewed in medical terms. in security and global health, elbe ( a) proposes that the medicalisation of security has three dimensions. the first is that national security moves from being only about military capabilities and the hostile intentions of other states to the proliferation of lethal medical problems in the bodies of citizens. an instructive way to consider this, and also to track changes in ways of thinking over recent time, is to consider responses to infectious diseases such as hiv/aids and sars (severe acute respiratory syndrome). the aids epidemic (see also the discussions on aids in chaps. and ), which began over years ago in the s, was perhaps the first time that governments, notably the us as a superpower, began to link pandemics to national security and to worry about the possible effects of illness on us interests abroad (mcinnes and ruston ). several years on in , then us president clinton declared aids a national security threat to the country. first, and perhaps foremost, there was concern with high hiv prevalence in the armed forces in times of war and hence the capacity to protect the nation (elbe a) . with the sars epidemic of , security concerns shifted from armed conflict and the stability of national states to mortality burdens and economic repercussions (elbe a) . sars was traced to guangdong province in china, and thereafter it spread to hong kong, singapore and toronto. by , the who was warning against all but essential travel to these countries. in hong kong, over people were subject to isolation orders. when sars spread to the middle-class private housing complex of amoy gardens in kowloon, the department of health quarantined apartments (although by the time the police arrived most people had already fled). a headline in the singapore straits times of may that year emblazoned that 'sars is like singapore's / '. the security threat attended very much to the economic repercussions. with sars respiratory droplets are produced when an infected person coughs or sneezes; this is largely invisible and unpredictable and hence hard to avoid. during the outbreak people began to keep away from public spaces, to minimise time spent outside home, and to wear face masks. the economic effects were predictable; with the avoidance of travel, retail sales declined and there were less business exhibitions and meetings. it was estimated that the asian region as a whole lost the equivalent of - million us dollars. the canadian government evaluated that three million dollars were lost to the country's economy in the first two weeks alone of the outbreak in toronto (elbe a) . this prompted wider concern that any epidemic outbreak could wreak havoc on the world economy, further boosting the medicalisation of security. the second dimension of the medicalisation of security addressed by elbe ( a) is the expansion of medical power and accompanying influence. at the most general level this is evident in increased involvement of medically trained persons in national security circles, most notably in the us. a key turning point was when then president clinton brought physicians into politics in relation to aids with the objective of using them in helping to defend the us population from disease. of significance here is the shift in emphasis from physicians as not only treating disease in individuals but defending against disease in populations. presently, the us homeland security hosts an office of health affairs which has a division of health threats resilience. the third and final dimension of the medicalisation of security brought to the fore by elbe ( a) is measures to secure, or attempt to secure, population health. the main strategy of governments to protect citizens has been the stockpiling of medical countermeasures to major illness as a readiness or preparedness against future uncertainly highlighted by bauman ( ) as referred to earlier. this is exemplified by the stockpiling by several governments of the global north of the anti-viral tamiflu during the 'swine flu' (h n ) outbreak of . the differential consequences for populations of containment efforts can be illustrated by the race to secure antiviral medications and vaccines in the wake of the possible h ni (avian flu) pandemic in the mid- s. as recounted by elbe ( b) , the majority of cases and of deaths at the time were in indonesia (see also chap. regarding how rural poor women in indonesia are at great risk for maternal mortality, morbidity and infant death). in , the country's government stopped sharing its virus samples to who under the global influenza surveillance network because it discovered that they were being given to western pharmaceutical companies and novel vaccines offered back at unaffordable commercial rates. it is therefore important to underscore that the securitisation of health is practised through, and acts on, the bodies of populations; it is a fundamentally embodied phenomenon involving the surveillance and control of populations, their bodies and their health (see also chap. for a detailed discussion on embodiment). this is now pervasive for the reason that many of the health threats referred to are unpredictable-no one predicted the outbreaks of sars in and ebola virus in - , for example, and it is hard to know where future threats may come from and what they will mean. future health pandemics have rogue status, as depicted in the metaphor of the black swan. initially the notion of black swan was used to refer to unexpected events in financial markets, and then expanded to refer to any surprise event of major proportions. it has been evoked by the us national intelligence council ( : ), which advises that 'no one can predict which pathogen will be the next to start spreading to humans, or when or where such a development will occur. an easily transmissible novel respiratory pathogen that kills or incapacitates more than one percent of its victims is amongst the most disruptive events possible. such an outbreak could result in millions of people suffering or dying in every corner of the world'. uncertainly is associated with both vulnerability and the escalation of agencies of health security. while the securitisation of health might seem to the good for all individuals and all populations, it can also be divisive, highlighting our concern with differentiation. among the questions to be posed are: to what extent is the concern with 'national security' and to what extent with 'human security'? (delaet ) are differential health interests being served? it has been argued (davis ) that the securitisation of infectious disease prioritises the health concerns of western states. in this regard agencies such as who are not neutral actors; diseases come to be identified as a threat when western states feel threatened; after the threats wane so does the support (davis ) . securitisation is then state-centric and shaped by the interests of privileged populations. disease that is seen as containable within national boundaries, such as diarrheal disease and the more hidden burdens such as maternal mortality, infant mortality, hunger and traffic deaths, fails to reach the level of concern that securitised infectious diseases evoke. resources are directed away from public health actors and poverty-related health challenges in ways that do not accurately reflect the global burden of disease (delaet ). based on data reported at the end of , there were extremely violent conflicts going on in the world in (ocha ). as well as deaths, injuries and all the other effects of collective violence, there were . million forcibly displaced persons, including . million refugees, . million asylum seekers and . million idps (ocha ). most contemporary or 'new wars' involve a range of not only state but also nonstate combatants who use violence to pursue exclusionary goals, such as religious, ethnic and economic interests, as exemplified by the civil war in syria. frequently in such contexts, civilian casualty is not a side effect but an aim in itself. to give an illustration, unicef ( ) reports that two million children are living in areas largely cut off from any humanitarian assistance; saw over cases of killing and maiming of children, as well as attacks on schools and hospitals and denial of humanitarian aid to children. when considering the health effects of armed conflict analysts can be inclined to focus on fatalities from direct combat or death from fatal injuries sustained in combat, including the deliberate use of starvation as a direct weapon of war. but, there are other direct effects such as significant physical and mental health problems amongst both the armed forces and targeted and untargeted civilians-such as illness resulting from disabilities (e.g. loss of limbs) and from atrocities of war, such as rape and torture, and sexually transmitted infections. there are also indirect effects of conflict. for example, health facilities, which may not have been of the highest standard even before the onset of conflict, can be destroyed, cutting off access to essential care. moreover, disease spreads in insanitary conditions such as overcrowded refugee camps, and persons living in war-torn environments invariably suffer fear, insecurity and mental trauma (levy and sidel ) . the differentiation of peoples is fundamental here. in frames of war, butler ( ) counsels that wars seek to manage populations by distinguishing lives to be preserved from those that are dispensable. some lives become grievable and others not, since to be grievable a life has to matter rather than to be seen as imminently destructible. violent conflict is then one of the most radical inequalities imaginable as some deaths of some populations or groups are seen as necessary to protect the living of others. as will be discussed later, women and girls, and children in general are often differentially vulnerable. we will now take this further through two case illustrations: the health of former child soldiers and rape of women in war. the term 'former child soldier' refers to children abducted into armies and rebel forces and then returned home. there are an estimated , child soldiers in the world today, of whom, over percent are girls. the participation of children under the age of years in armed conflict is generally prohibited under international law, and the recruitment of children under into conflict is a war crime (amnesty international ). coerced, enticed or abducted, children serve as combatants, porters, spies, human mine detectors and sex slaves. their health and lives are endangered. many are forced to commit atrocities such as killing or maiming a family member in order to break ties with their community and to make it harder for them to return home. a high rate of mental health problems amongst returnees is inevitable, not the least because when they return home they can experience stigma due to perceptions that they are immoral or dangerous. it is unsurprising, therefore, that former child soldiers have high incidences of post-traumatic stress disorder (ptsd), which is associated not only with their experience during war, but its aftermath. betancourt et al. ( ) researched children in sierra leone who were recruited into the national army and civilian defence during the civil war of , most notably the revolutionary united front (ruf), which was responsible for brutal atrocities against civilian populations, including amputations to supress resistance, and large-scale abduction of children. the ruf forced children to commit atrocities including the murder of loved ones. many were subject to repeated rape and forced to take drugs to reduce inhibition against committing violent acts. after the war ended, programs were set up to reintegrate children into their former communities, yet this was very difficult as most faced fear and distrust and girls were seen as sexually promiscuous or defiled. betancourt et al. ( ) studied the role of stigma in mediating children's exposure to war-related events and mental health outcomes. a total of former ruf child soldiers aged between and years were interviewed at the end of the war in and again in with a focus on family and community acceptance and psychological adjustment, especially levels of depression, anxiety and hostility. the researchers found that the large majority of the respondents were involved with the rebels by force with an average age at abduction of years. in all, percent of the girls and percent of the boys reported being a victim of rape; percent of girls and percent of boys had wounded or killed either a loved one or a stranger. levels of depression were high and percent felt local people acted afraid of them, and percent that the local people felt threatend by them. as one child said, 'initially when i arrived [back home], people feared me. some said i was a killer. there were times when i wanted to touch or play with other kids, but their parents will shout at me. i felt bad during those early days' (quoted in betancourt et al. : ) . in conflict zones around the world, military forces use gender-based sexual violence (gbsv) to terrorise, humiliate and demoralise whole communities, including by the spread of a disease such as hiv and of sexually transmitted diseases-a clear illustration of illness as a tactic of war. here the association between the individual and the collective becomes paramount. there has been a tendency to explain rape and sexual violence as random and opportunistic acts of war, that is, outside of the wider structural context of the society concerned. yet gendered structural conditions are crucial. indeed, it is arguably because of the normalisation of women's inequality in a society where gbsv appears logical and instrumental (davis and true ) . though violent conflict and health is not their focus, scheper-hughes and lock's ( ) theorisation of the 'mindful body' is a valuable lens through which to evaluate gbsv. (see chap. for a discussion of 'the mindful body' in the context of embodiment theory.) they draw attention to the individually experienced body-self, and also to the social body and its symbolic and representational uses, and to the body politic, or the regulation and control of bodies, for example in families and in medical systems. research examples illustrate how the individual body, social body and body politics come together to help explain rape and sexual violence in war. in their research on gbsv in south kivu, democratic republic of the congo, kelly and colleagues ( ) found that, absolutely vital though this is, rape goes far beyond individual physical and psychological trauma and becomes a societal phenomenon where isolation and shame often become as important as the attack itself. analysis of focus group data revealed that many interpreted rape as a form of destruction to the community, associated with the spread of disease, the devaluation of women and the breakdown of families. as one respondent put it, 'if you are a girl [who has been raped], your parents will start mistreating you, they can't understand that you have been forced and that it was not your fault. you will never get married. they will throw you away because you are not worth anything; you will lose all value because nobody will marry you' (quoted in kelly et al. : ) . husbands may view their wives as 'contaminated', such as by sexually transmitted infections, and also as morally contaminating since the rape of a wife can result in loss of pride and a feeling of impotence in being unable to provide support (kelly et al. ) . a second illustration of the power of collective structural context on individual experience comes from the serbian occupation of croatia in the early s. olujic ( ) argues that to understand what happens in war we must take account of the pre-war gendered context, especially meanings of female sexuality and the codes of honour and virtue that women represent in the family, alongside the role of men in protecting this honour. as she puts it, 'women's honour reflects that of men's, which, in turn, reflects that of the nation' (olujic : ) . rape can then represent men's inability to protect women, an attack on their honour and a cause of their shame. thereby the individual bodies of women become metaphoric representations of the social body and the injury to their bodies maims the family and the community. based on fieldwork in hospitals in 'post-conflict' erbil, kurdistan, keller ( ) explored women's expression of illness through presenting symptoms such as limb paralysis, convulsions and muteness. in women's own accounts, symptoms such as these were linked to home life, to experiences that were too much to bear and to lack of support. keeler ( ) associated this with the imposition of global neoliberal agendas in the individual and social body: women's trauma narratives become (re)inscribed by their physicians as anti-modern, positioned as belonging to a 'bygone age'. thus 'hysterical women' become a counternarrative to the global prosperity trope and are medically silenced by the 'body politic' to 'expunge non-normative expressions of trauma' (keeler : ) in post-conflict modernity. this occurs by such procedures as 'pain stimulation', including saline injections, the bending back of fingers and the threat of sexual trauma as 'medical treatment'. this illustration directs our attention to the alliances between healthcare and political agendas. in the final part of the chapter, i reflect on the interconnections of healthcare systems and neoliberal political agendas. health systems can be defined as the assemblage of public and private sector institutions and actors concerned with the support of health and the amelioration of illness. even though globally many countries are grappling with common problems, such as increased health needs and demands for healthcare, alongside the rising costs of providing it, there is not one, simple international line of convergence towards a common form of health system. the reason is that health systems are shaped significantly by their centuries-old economic and political regimes. in addi-tion, they take their form from 'national logics', that is, how a society defines and deals with issues of health and illness. equally, cultural factors influence how populations respond to proposed changes to their health system as well as how those external to a country relate to it. even so, without undue risk of overgeneralisation, we can point towards a worldwide drive towards the commercialisation of health systems and, where public provision exists, such as in our case example of the uk, to the rollback of state or public provision in favour of the free market principles. thus, most health systems around the world have or are moving towards a mix of public/private provision. with this point in mind, it has been argued that health services are now as much about investor potential as access to care for patients. tritter and colleagues maintain that health systems are no longer important primarily because they ensure that people gain access to health services when in need and irrespective of their ability to pay, that epidemics are prevented or controlled [...] or that the social determinants of health are addressed as part of public policies. in the emerging context of the reform policies, health systems are important not only as providers of products and services for which people are willing to pay, but also as an investment opportunity within global financial markets. (tritter et al. : ) although they manifest in different ways across health systems, we can point to a set of three shared global influences: neoliberalism (see also the discussions on neoliberalism in chaps. and ) as the dominant politico-economic policy framework driving system change; macroeconomic policies and structural adjustment programmes (saps); and international trade agreements. as addressed elsewhere in this book, neoliberalism can be defined as a project of economic and social change based on the transfer of economic power and control from governments to private markets and the injection of market competition into areas such as education, housing and healthcare which, in many western countries at least, were once part of the welfare state (scott-samuel et al. ) . as discussed in chap. , neoliberalism is usually interpreted as a response to the period of structural crisis of the s when, from mid-decade, countries such as the us and uk witnessed lower rates of financial accumulation and growth, rises in unemployment and rising inflation. neoliberal economic policies encourage financial deregulation and the opening up of trade and investment by resource-rich countries in regions where social conditions afford high returns. up to the late s, the predominant approach to health improvement globally was to strengthen public health systems, especially access to primary health care. this was the position established by the who's influential alma-ata declaration of which brought about access to healthcare as a human right. the world bank (wb), the international monetary fund (imf), the world trade organisation (wto) and other agencies rebuffed this position in the s as they established monetarist policies prioritising the achievement of macroeconomic stability by putting constraints on the growth of money supply and public spending. supranational agencies, such as the imf, wto and the wb, have been key players in the spread of global neoliberalism in the health field. their influence is often indirect comprising the development of trade and investment agreements negotiated at bilateral and multilateral levels and the promotion of market-friendly structures and regulatory reforms. one of the most controversial of wb policies has been the pressure upon countries of the global south to adopt saps. as a condition of receipt of foreign aid and loans, structural adjustments comprise lowering trade barriers, the selling off of state-owned assets and cutting public sector budgets and public sector workforces (rowden ). the stance of the wb is that structural adjustment stabilises economies, promotes investment and generates long-term economic growth. but it has been argued to the contrary that this leads directly to chronic underfunding of local public sector services, collapsing domestic industries in the face of cheaper imports, rural-urban migration, reduced health budgets (and less money for health workers) and the reduction of access to services by local communities. for example, it might be argued that the unpreparedness of liberia, sierra leone and guinea to deal with the ebola virus outbreak of - in west africa was associated with a short-term focus on economic objectives and on profitable sectors, such as minerals (iron ore, gold, bauxite and rubber) at the expense of the public sector. stubbs et al. ( ) explored the effects of imf aid conditionalities on the provision of healthcare in west african countries including the gambia, liberia, nigeria and sierra leonne, between and . the number of conditions put on aid over the period amounted in total to in the region. imf targets, such as budget deficit reduction, were found to crowd out or to reduce the space for investment in the health sector and aid conditions which stipulated staff layoffs or caps on public sector wages limited much-needed staff expansion of doctors and nurses. in other words, conditionalities of aid negatively impacted the provision of healthcare in the countries concerned. the third significant influence on global health systems is international trade agreements, specifically the general agreement on trade in services (gats) and the associated proliferation of bilateral agreements. gats, which came into effect in , was the first set of multilateral rules governing international trade in services, such as education and healthcare, with the object of removing trade barriers. ultimately, since it aims to liberate all services, it is a potential challenge to the sovereignty of national governments over policy-making in relation to public health and the provision of health services. for example, at the time of writing in march , it is not clear whether the transatlantic trade and investment partnership (t-tip) between the eu and the usa, presently in an eighth round of discussions, will exclude the uk nhs (national health service). if it does not then it could give transnational corporations the right to enter the uk market and operate without limits on their activities. for the reasons referred to earlier concerning the different histories and cultural contexts, the organisation of health systems varies considerably in different countries. the us, for example, has always been a privately reimbursed system where citizens pay for care by insurance through employment or out of pocket. by contrast, in the uk health system since the inception of the nhs in most aspects of care have been provided free of charge through taxation. the same broadly applies to the nordic countries, as well as others such as italy. in between this many countries, such as germany, japan, taiwan and france, have social insurance models whereby patients and employers pay into sick funds which contract with a range of health providers. but, to varying degrees and in different ways, almost all are moving towards a blending of public/ private elements. the uk has in many ways been at the fore in this regard, beginning with reforms of the thatcher government in the s. but the approach has been espoused internationally by countries as varied as italy, singapore, india, taiwan, malaysia, the philippines and russia. fundamentally, the intent has been to introduce market mechanisms to control costs. globally, though to varying degrees, healthcare costs have been rising at significant rates. for example, healthcare expenditure as percentage of gdp rose from . percent in / to . percent in in the uk and, for the equivalent period, from . to . percent in the us, and from . to . percent in germany (world bank ). in the uk and most notably england, an internal market was introduced in the early s as a number of gp practices became fundholders who purchased care from hospitals and other providers on behalf of their patients (doh ) . the intention was that this would make them more cost conscious since they would be paying; that is, they would be deterred from referring patients too readily for tests and treatments, and that they would hold care providers, principally hospitals, to account for spending and quality of care for patients (hunter ) . the new labour government of broadly extended this policy, merging general practices into primary care trusts which jointly commissioned services for patients. the late s into the early s saw the further introduction of private providers into the nhs, for example, to run day surgery, pathology and diagnostic services (doh ). in , the new coalition government consolidated this by the setting up of clinical commissioning groups (ccgs) which hold approximately two-thirds of the nhs budget. ccgs currently purchase care on behalf of gps for their patients. moreover, under the new 'any qualified provider' provision, care could be commissioned not only from nhs providers but also from the for-profit and the not-for-profit third sector (charities and social enterprises) (doh ). this overall policy remains in place at the time of writing in with recent concern focusing less visibly on structural reform and more on incapacity to meet demand-for example, in january the british red cross said that the nhs was facing a humanitarian crisis in the face of escalating demand and rising waiting lists for treatment. health, culture and society endorses the enduring conceptual legacies that have shaped and continue to shape our thinking. it seeks to understand not only where we have come from but where we are going to. this has been the focus of the current chapter as we have explored sociology's disquiet with 'society', as its erstwhile unit of analysis. while theorists of globalisation have given relatively little direct attention to matters of health, it has been suggested that the attention to international connections, mobility and new emergent forms of differentiation and inequality can be a useful point of departure for the analysis of health and healthcare. in these terms we have addressed several critical health issues of our time, such as migration and health, the securitisation of health, the health devastation wrought on civilians caught up in violent conflicts around the world, and the commercialisation of health systems. amnesty international globalization: the human consequences collateral damage: social inequalities in a global age why the world fears refugees what is globalisation? cambridge: polity past horrors, present struggles: the role of stigma in the association between war experiences and psychosocial adjustment among former child soldiers in sierra leone rethinking modernity: postcolonialism and the sociological imagination critical interventions in global health: governmentality, risk and assemblage for public sociology fames of war: when is life grievable? london southern theory securitizing infectious disease reframing conflict-related sexual and genderbased violence: bringing gender analysis back in whose interests is the securitisation of health serving? working for patients. london: stationary office the new nhs: modern, dependable. london: stationary office equality and excellence: liberating the nhs. london: stationary office the division of labour in society security and global health haggling over viruses: the downside risks of securitizing infectious disease mobilities and health forced migration: the human face of a health crisis our health and theirs: forced migration, othering, and public health culture, context and the mental health and psychosocial wellbeing of syrians: a review for mental health and psychosocial support staff working with syrians affected by armed conflict immigrants' health in europe: a crossclassified multilevel approach to examine origin country, destination country, and community effects the health debate first do no harm? female hysteria, trauma, and the (bio)logic of violence in iraq if your husband doesn't humiliate you, other people won't': gendered attitudes towards sexual violence in eastern democratic republic of congo social suffering war and public health global trends : alternative worlds. a publication of the national intelligence council ocha (office for the national coordination of humanitarian affairs) embodiment of terror: gendered violence in peacetime and wartime in croatia and bosnia-herzegovina the social system the mindful body: a prolegomenon to future work in medical anthropology the impact of thatcherism on health and well-being in britain the impact of imf conditionality on government health expenditure: a crossnational analysis of west african nations globalisation, markets and healthcare policy the new medical sociology. london: w. w. norton company. unhcr bureau for europe no place for children -the impacts of five years of war on syrian children and their childhoods sociology beyond societies globalization and inequalities: complexity and contested modernities world development indicators: health systems the world health report -a safer future: global public health security in the twenty-first century forced migration, globalisation, and public health; getting the big picture into focus key: cord- -s e bwx authors: pulcini, elena title: spectators and victims: between denial and projection date: - - journal: care of the world doi: . / - - - - _ sha: doc_id: cord_uid: s e bwx this chapter goes into the unproductive metamorphosis of fear, and analyses the defence mechanisms that it generates: namely denial and projection. in the case of global risks, fear provokes self-defensive strategies based on denial (in the face of the nuclear challenge) and self-deception (in the face of global warming); and, in the case of the threat of the other, projective and persecutory strategies based on reactivating the dynamic of the ‘scapegoat’. they are two contrasting but specular responses which, at the emotional level, reflect the divarication between (unlimited) individualism and (endogamous) communitarianism. the first, implosive response converts into an absence of fear, attested to above all by the figure of the global spectator, while the second, explosive response converts into an excess of fear (fear of the other, fear of contamination), fuelled by forms of reinventing community. these responses are defined as irrational since in the first case they inhibit the spectator’s capacity to recognize himself as also a potential victim of the threats, thus preventing his mobilization, and in the second case they give rise to dynamics of demonization-dehumanization of the other, which result in a spiral of violence and impede forms of solidarity. this case a subjective factor comes into play, linked to the capacity and manner of perceiving the threats. it is telling that sociology and psychology converge on the importance of this aspect, underlining the fact that the very characteristics of the risk have a de fi nite in fl uence on the way in which it is perceived. ulrich beck had already stressed the fact that the often invisible nature of the global risks, the unforeseeability of their effects and the only potential character of the damage which they provoke mean that they are removed from our perception and require the intervention of a re fl exive attitude interpreting the new scenarios through a knowledge that is equal to the new challenges. but in reality the problem is more complex still, since rather than an absence, we are faced with processes that distort the perception and assessment of the risk, which affect both the emotional and the cognitive spheres, and above all how they interact together. among the approaches sensitive to this problem, the one which seems to dwell on it most is cognitive psychology. starting from the classic studies by chauncey starr and then fischoff and slovic, and on the basis of the so-called psychometric paradigm, cognitive psychology has built complex cognitive maps aimed at providing as exhaustive a list as possible of the variables that in fl uence the subjective perception of risk. the conclusions that have emerged from this interpretative approach show, for example, that concern in the face of threats (whether they derive from particular activities, substances or technologies) grows in correspondence to certain characteristics, amongst which the involuntary nature of the risks, the impossibility of controlling them, their capacity to cause irreversible damage and their originating from an unknown source. but above all, the results stress the fact that individuals are subject to distorted assessments and judgements in relation to the risks they are exposed to. for example, they tend to overestimate threats publicized by the media even if they are infrequent; to consider dangers dealt with voluntarily as more acceptable compared to those to which we are subjected or which are completely unprecedented or not very familiar; to feel fear in the face of very vivid events ( september ), at the same time being quite incapable of a historical memory that links these same events together. while the merit of this approach is that it accepts and recognizes the presence of the subjective aspect and the uncertainty factor in de fi ning the concept of risk, pointing out the presence of non-rational responses, its limits lie, however, in its still strongly assuming the notion of probability. namely, it ignores what is instead underlined by mary douglas, that is, the social and institutional context and the symbolic-cultural factors that in fl uence the perception of the threats, and reproposes the idea of an essentially individualistic and de-contextualized social actor based on an abstract idea of rationality. finally, what we are most interested in here, in part deriving from the latter aspect, the limit of this approach lies in its failure to account for the why , the deep reasons that pollute a correct perception and assessment of the risks. in this connection, based on the reassessment of the role of emotions that has greatly questioned the hegemonic paradigm of rationality over the last few decades, some authors have underlined that cognitive and emotional factors have to go together in order to recognize the existence of a risk and to weigh up its possible consequences. they have put forward the idea that the information that enters our cognitive system can only have an effective impact on our action if it succeeds in creating images laden with emotion in our psyche. in other words, this means that we can be perfectly aware of particular threats without this involving us emotionally. put differently, only if this converts into the capacity to 'feel', to react emotionally and imagine its possible effects can our knowledge of the risk be effectively said to be knowledge, and therefore produce apt mobilization. now, the problem with regard to global risks seems to be prompted, as günther anders had already perfectly grasped in his diagnosis of fear in the age of technology, by the very imbalance between knowing and feeling. this imbalance is none other than one of the many variants of the psychic split that characterizes the contemporary subject and that anders, as has already been hinted, calls the 'promethean gap'. with this expression, he alludes in general to the detachment between the faculties, fi rst of all between the power to do and the capacity to foresee, which characterizes contemporary homo faber , or rather homo faber who has become homo creator . paradoxically what corresponds to the immense human power to . global risks and absence of fear produce and create permitted by developments in technology is man's inability to imagine its consequences: the faculties have got further and further away from each other so now they can no longer see each other; as they cannot see each other, they no longer come into contact, they no longer do each other harm. in short: man as such no longer exists, there only exists he who acts or produces on one hand, and he who feels on the other; man as producer and man as feeling, and only these specialized fragments of men have a reality. no more are our imagination and our emotions equal to our unlimited power; at this point man's soul is irreparably 'outdated' with respect to what he produces and his colossal performances. in short, no more can we keep up-to-date with our promethean productivity and with the world that we ourselves have built: we are about to build a world that we cannot keep up with, and, in order to "catch" it, demands are made that go way beyond our imagination, our emotions and our responsibility. this 'schizophrenia', which is where the fundamental pathology of our time resides, prompts the paradoxical and ambivalent combination of power and impotence, activity and passivity, knowledge and unawareness that exposes the contemporary prometheus not only to previously inconceivable risks, but, also and above all, to the impossibility to recognize their destructive potential. this pathological drift appears particularly evident in the risk par excellence of the age of technology, which undermines not only the quality of individuals' lives (like in the case of the possible effects of the biotechnologies), but humankind's very survival on the planet: namely, the risk produced by the creation of the nuclear bomb, which we can recognize as the fi rst effectively global challenge. before the horror of hiroshima and the spectre of humankind's self-destruction anders says: we really have gained the omnipotence that we had been yearning for so long, with promethean spirit, albeit in a different form to what we hoped for. given that we possess the strength to prepare each other's end, we are the masters of the apocalypse. we are in fi nity . but the inability of our imagination to be equal to our unlimited power makes the latter mortally dangerous and transforms us into potential victims of what we ourselves have built: we, the men of today, are the fi rst men to dominate the apocalypse, hence we are also the fi rst to be endlessly subject to its threat. we are the fi rst titans, hence we are also the fi rst dwarves or pygmies -or whatever else we care to call ourselves, we beings with our collective deadline -we are no longer mortal as individuals, but as a group; whose existence is exposed to annulment. suf fi ce it to think that it is impossible to see the bomb simply a means; an impossibility generated by the fact that if someone used the bomb… the means would not be extinguished in the purpose, but, on the contrary, the effect of the presumed "means" would put an end to the purpose. and it would not be one effect, but an unforeseeable chain of effects, in which the end of our life would be but one link among the many. the gap between the power to do and the power to foresee, therefore, gives rise to the paradoxical coexistence of omnipotence and vulnerability, which exposes future humankind and the whole of civilization to the risk of extinction, thereby con fi guring the apocalyptic scenario of a 'world without man'. but the problem does not stop here. indeed, if men, even when faced with the loss of foresight and projectuality caused by their own action, were capable of recognizing the reality of the danger, a change of direction could be set in motion to restore their control over their future. or, to put it in terms that allow us to return to our theme, if people felt fear in the face of the spectre of self-destruction and the enormity of the risks ahead, they would probably manage to break that promethean spiral of unlimitedness and restore sense and purpose to their action. furthermore, this is the normative premise at the basis of hans jonas's whole line of argument in favour of an ethics of responsibility. he starts from a similar diagnosis to that of anders on the drifts of technological power and the threats, for the whole living world, produced by a ' fi nally unbound prometheus' to suggest what he de fi nes as a 'heuristics of fear', as the precondition for ethically responsible action. ' […] it is an anticipated distortion of man,' he says, 'that helps us to detect that in the normative conception of man which is to be preserved from that threat […] . we know the thing at stake only when we know that it is at stake .' this means that only the fear of 'losing the world' can push us to responsibly take on the problem of how to preserve it. i shall come back to the nexus between fear and responsibility later on. but the problem, which anders strongly underlines -showing, unlike jonas, its complex anthropological and psychic roots -is that today we are in the presence of the unavailability of fear ; in actual fact it is paradoxically absent, due to the additional and deeper manifestation of the promethean gap which is the imbalance between knowing and feeling . indeed, there is no one who does not know what the bomb is and who does not know its possible, catastrophic consequences, but, anders adds, 'most people indeed only "know" it: in the emptiest of manners'. namely, this this asynchrony, anders points out, is something that pertains to human nature as a matter of fact. in general, in itself this is not bad, since it only shows that feeling is slower to transform. however, so to speak, it degenerates into a pathology when the gap between the faculties becomes too wide, as is happening today. as a consequence, it breaks all bonds and communication between them, and reduces contemporary men to the 'most dissociated, most disproportionate in themselves, most inhuman that have ever existed.' therefore, it is here, in the inadequacy of our emotional resources with respect to our productive power, that the anthropological root of our 'blindness to the apocalypse' lies. and this inadequacy, which is true for all the emotions in general, concerns fear fi rst of all. everyone, in however confused a manner and in spite of the minimization strategies implemented by those who produce it, realize that the bomb is not a pure means whose function ends in the ful fi lment of a purpose, but a monstrous ' unicum ' that, together with our lives and the lives of future generations, can put an end to all purposes tout court . yet, surprisingly, there is no fear : if today we were to seek out fear ( angst ),* real fear in vienna paris, london, new yorkwhere the expression ' age of anxiety ' is very much in use -, the booty would be extremely modest. of course, we would fi nd the word 'fear', in swarms even, in whole reams of publications […] . because today fear has become a commodity; and these days everyone is talking about fear. but those talking out of fear these days are very few. if we are to observe our present-day situation, we could even claim that the more fear becomes the subject of talk in the newspapers and mass media, the more it is withdrawn from emotional perception and is anaesthetized by the reassuring urgency of routine and day-to-day concerns. the anaesthetizing mechanism also works in a directly proportionate manner to the enormity of the risk and the stake at play. while it may be true that at best we ibid., i, . ibid., i, - . ibid., i, - . see ibid., part iv, i, ff. anders underlines its historical roots, such as trust in progress that prevents man from thinking of an 'end', and above all, the con fi guration at the anthropological level of what he de fi nes as the 'medial man', whose passive and conformist action ends up removing his ability to project himself into the future, together with all sense and purpose. see ibid., part , i, ff. ibid., i, ff. * translator's note: anders only uses one term -angst -and does not distinguish between anxiety and fear. since, however, the meaning with which he uses the term angst coincides more with 'fear' in the acceptation put forward by elena pulcini, i have decided to translate it with 'fear' so as to distinguish it from 'anxiety'. ibid., i, . are able to imagine our own death, but not that of tens or thousands of people, and that we may be able to destroy a whole city without batting an eyelid while not managing, however, to imagine the actual, terrible scenario of 'smoke, blood and ruins', it is inevitable that we are totally incapable of perceiving the destruction of all humankind : 'before the thought of the apocalypse, the soul remains inert. the thought remains a word.' even though today the end of humankind has entered the sphere of possibility and even though man himself is responsible for this, the psyche removes the thought of this possibility, thus preventing fear from arising. hence, we are illiterate in fear -'analphabeten der angst' -and 'if one had to seek a motto for our age, the most appropriate thing to call it would be "the era of the inability to feel fear"'. anders's diagnosis concerning the anaesthetizing of fear and the imbalance between knowing and feeling seems to fi nd a perfect correspondence in that distinctive defence mechanism that freud de fi ned as 'denial of reality'. more complex and subtle than repression ( verdrängung ), which indicates the operation with which the subject pushes particular representations linked to an instinct to the unconscious, and which for freud becomes a sort of prototype of defence mechanisms, denial ( verleugnung ) causes the self, despite rationally recognizing a painful and dif fi cult situation, to prevent this reaching the emotional sphere. in other words, while repression is a defence against internal instinctual demands , denial is a defence against the claims of external reality , which is rationally recognized, but not emotionally felt or participated. this converts into that distinctive ambivalence of 'knowing and not-knowing' which, as has recently been ibid., i, - . ibid., i, . in his recent sociological valuation of the concept of 'denial', stanley cohen stresses this ambivalence, pointing this out as the most interesting side of the concept, and above all the most suited to accounting for a series of phenomena that characterize contemporary reality. explicitly drawing from psychoanalysis, whose worth he acknowledges -if nothing else against the reductive simpli fi cations of cognitive psychology -as more than any other approach having grasped the elusive quality of the concept of denial, cohen offers a de fi nition that fi rst of all takes into account the meaning that is more general and common to the various forms: […] people, organizations, governments or whole societies are presented with information that is too disturbing, threatening or anomalous to be fully absorbed or openly acknowledged. the information is therefore somehow repressed, disavowed, pushed aside or reinterpreted. or else the information "registers" well enough, but its implications -cognitive, emotional or moral -are evaded, neutralized or rationalized away.' on the basis of this premise, cohen analyses the many forms of denial. it can occur in good faith or be deliberate and intentional; it changes in relation to the subjects' different positions, that is, whether they are victims, guilty parties or witnesses; it depends on how the object is evaluated, which can be expressed through a simple refusal to acknowledge the facts, through a different interpretation or through a rationalization that aims to prevent its psychological, political and moral implications. but the most disconcerting and problematic form, since it can affect whole cultures -as is the case today -is what makes the subjects of the denial aware and unaware at the same time, that is, placed on the threshold between consciousness and unconsciousness. here they do have access to the reality, but in such a way as to ignore it since it is too frightening or painful, or simply too unpleasant to accept. 'we are vaguely aware,' cohen says, 'of choosing not to look at the facts, but not quite conscious of just what it is we are evading. we know, but at the same time we don't know.' for example, much more than the intentional denial which is often ibid, . anders, die antiquiertheit des menschen , i, - . cohen, states of denial . 'the cognitive revolution of the last thirty years has removed all traces of freudian and other motivational theories. if you distort the external world, this means that your faculties of information processing and rational decision making are faulty.' (ibid., ) . ibid., . ibid., . moreover, this is the core of the freudian concept, which evidently presupposes the idea of splitting the ego ( ichspaltung ): 'freud,' says cohen, 'was fascinated by the idea that awkward facts of life could be handled by simultaneous acceptance and disavowal. they are too threatening to confront, but impossible to ignore. the compromise solution is to deny and acknowledge them at the same time.' (ibid., ) . implemented by political actors and institutional authorities to cover up regrettable facts and unpopular decisions, this is the frame of mind that most interests us and disturbs us because it can explain the widespread and paradoxical indifference with which common people react to situations of suffering, atrocities and violence. tellingly, the focus of cohen's whole and documented analysis seems to be the fi gure of the 'passive bystander' who, when faced with other people's suffering (whether this is experienced in a direct manner like a rape or episode of bullying, or is distant like genocide or torture), defensively withdraws from all involvement, pretending not to see and not to know, inhibiting emotional reactions, minimizing the event's capacity or changing channel if the information is transmitted through mass media images. hence the bystander withdraws from facing up to painful and embarrassing situations and avoids all possible mobilization. therefore, cohen seems, quite rightly, to rediscover denial above all as a reaction of defence in the face of other people's suffering where this assumes such proportions as not to be acceptable by the psyche. as a consequence, he fi nds it to be the root of the emotional indifference that today seems to be permeating contemporary societies. nevertheless, as we have seen, anders's re fl ection allows us to grasp another aspect of denial that sharpens its paradoxical nature, since it concerns the tendency to ignore, wipe out or minimize something that not only concerns other people's destinies, but that threatens our own lives: like in the exemplary case of denying the global challenge par excellence , the nuclear risk. consistent with anders's diagnosis, a few decades ago the psychoanalysis of war had already re fl ected on the radical changes caused by the nuclear threat with respect to the traditional forms of war con fl ict, and hence explained, more or less indirectly, the psychic roots of this speci fi c case of denial. while underlining the abstract or phantasmal nature of the danger at the objective level -due to the invisibility and intangibility of nuclear weapons, the distance of the target, as well as the bureaucratic 'normality' of those who hold the actual decision-making powersome authors have singled out the unprecedented nature of the nuclear con fl ict in its split and autonomization from the individual's instinctual sphere. that is, unlike traditional war, based on mobilizing aggressive instincts, nuclear war (its destructive potential) appears as a mechanical event, or rather, a psychologically unreal event, in which the 'enemy' himself, far from being the object of projective dynamics, becomes an inanimate abstraction with whom all emotional bonds are lost. this sort of 'dehumanization' of war, which affects the relationship with the other and the relationship with oneself to the same extent, thereby producing its 'the grey areas between consciousness and unconsciousness are far more signi fi cant in explaining ordinary public responses to knowledge about atrocities and suffering' (ibid., ). 'devitalization', is at the root, together with the enormity of the risk and the impossibility to 'think the unthinkable', of the denial of the danger, which immunizes individuals from emotional involvement, and, therefore, from true awareness. it is telling that, in addition to denial, martin wangh spoke of a 'narcissistic withdrawal', as he alluded to the entropic and self-defensive strategy of individuals reduced to passive and indifferent 'spectators' of events. individuals who, with respect to events, preclude any form of effective reaction and thus inhibit the insurgence of fear at the outset. i will return to the 'spectator phenomenon' shortly. as i have already hinted, this phenomenon is one of the most disturbing pathologies of contemporary individualism. first, however, it is interesting to dwell on one of the -so to speakmore active variants of denial, which consists not only of withdrawal from a reality that is uncomfortable or painful for the psyche, sheltering in a sort of emotional indifference, but of lying to ourselves in order to believe something that does not respond to our rational evaluations, but to our desires. this is self-deception , a defence mechanism that has tellingly been de fi ned as 'the most extreme form of the paradox of irrationality'. without going into the (at times muddled) analytical controversies relating to a concept that is without doubt slippery and problematic, we can, however, try to sum up the characteristics -shared by many authors -which prove fruitful in further extending the picture relating to the metamorphosis of fear in the global age. self-deception is what pushes individuals to form a belief that contrasts with the information and proof at their disposal, since their desires end up interfering with their vision of reality and cause them to act in a different way from what their rational judgement would suggest. in other words, it consists of believing something because one desires it to be true, hence it converges, despite some differences, with martin wangh speaks of 'dehumanization' and 'devitalization' (meant as the impoverishment of the ability to feel) in 'narcissism in our time: some psychoanalytic re fl ections on its genesis," psychoanalytic quarterly ( ). the allusion is to the text by herman kahn, thinking about the unthinkable (new york: horizon press, ). martin wangh, "the nuclear threat: its impact on psychoanalytic conceptualizations," psychoanalytical inquiry , no. ( ). the expression ( zuschauer-phänomen ) is by martin wangh, "die herrschaft des thanatos," in zur psychoanalyse der nuklearen drohung. vorträge einer tagung der deutchsen gesellschaft für psychotherapie, psychosomatik und tiefenpsychologie , ed. carl nedelmann (göttingen: verlag für medizinische psychologie, ). david pears, "the goals and strategies of self-deception," in the multiple self , ed. elster, ; giovanni jervis, fondamenti di psicologia dinamica (milan: feltrinelli, ) and massimo marraffa, "il problema dell'autoinganno: una guida per il lettore," sistemi intelligenti , no. ( ): - . '[…] self-deception,' davidson says, 'is a problem for philosophical psychology. for in thinking about self-deception, as in thinking about other forms of irrationality, we fi nd ourselves tempted by opposing thoughts.' (donald davidson, "deception and division," in the multiple self , ed. elster, ). ibid., . the dynamic of wishful thinking. like denial, meant in its pure form, so to speak, self-deception implies ichspaltung , no matter what name may be given to what freud identi fi ed as the splitting of the ego. finally, like denial, it is an ambivalent phenomenon since it acts in that threshold between consciousness and unconsciousness which, as cohen stresses in this case too, creates a paradoxical situation of knowing and not-knowing. but while denial appears, as we have seen, effective in explaining the lack of perception and the anaesthetizing of fear in the face of the nuclear threat, selfdeception can prove pertinent in order to understand the complex emotional response that individuals give to the other global risk already brought up above: that is, the twofold environmental risk of global warming and the depletion of the ozone layer, which by no means seems to generate that mobilization of the whole of humankind which it would instead -urgently -require. from this point of view, the recently proposed de fi nition of 'global risks in the making' or 'potentially global' risks, which tends to distinguish them from the global risk par excellence represented by nuclear power, can prove to be extremely useful in explaining the however blurred difference in the subject's reaction and in further enlightening the phenomenology of fear. the inde fi nite nature that without doubt also pertains to the nuclear risk is greatly stressed here, due to the fact that global warming and depletion of the ozone layer have wider margins of uncertainty created by their inertial nature, the impossibility to measure and foresee their future development, and therefore to calculate with certainty, together with their possible effects, the last deadline for possible countermeasures. their ungraspable and invisible nature, further fuelled by the dif fi culty to point the fi nger of blame mean that, in spite of the alarming international reports on the climate and reliable scienti fi c forecasts on the devastating future damage, moreover given increasing mass media coverage, individuals mostly seem in paradoxes of irrationality (in richard a. wollheim and james hopkins, eds., philosophical essays on freud , (cambridge: cambridge university press, )), davidson upholds that in wishful thinking desire produces a belief without providing any proof in its favour, so that in this case the belief is evidently irrational. however, he underlines the differences between self-denial and wishful thinking: unlike the second, the fi rst requires the agent's intervention, that is, the agent has to 'do' something to change his way of seeing things; in the second the belief always takes the direction of positive effect, never of negative, while in the fi rst the thought that it triggers can be painful (see 'deception and division', ff.). in this connection pears speaks of 'functional insulation', "goals and strategies of self-deception", ; davidson speaks of 'boundaries': '[…] i postulate such a boundary somewhere between any (obviously) con fl icting beliefs. such boundaries are not discovered by introspection; they are conceptual aids to the coherent description of genuine irrationalities.' "deception and division", - . on self-denial and splitting of the ego, see herbert fingarette, self-deception (london : henley-routledge, ) . see cohen, states of denial , ff. it is important to point out that the second problem (the one relating to the risk of ozone layer depletion) nevertheless found some solutions as of the montreal protocol in , made possible due to the fact that they did not require costs or relinquishments in terms of economics or lifestyle. d'andrea, "rischi ambientali globali e aporie della modernità". to fail to suitably perceive the phenomenon. instead, it is often shrugged off with detached irony towards the excessive catastrophism, with resigned declarations of impotence, or the expression of enlightened trust in the capacities of technology to repair the situation. in other words, despite being rationally known and recognized, the risk does not produce such emotional involvement as to give rise to effective answers. at most it produces a widespread and generic feeling of anxiety which ends up imploding, sucked in by the much more real worries of everyday life. the causes of this paradoxical situation can be traced fi rst of all to within the same dynamic of fear of which, as i will recall, hobbes's diagnosis had grasped an essential aspect. namely, fear as a necessary and vital passion that allows us to respond to the immediate danger (of death) loses its ef fi cacy when the danger, and the damage it could cause, are shifted to the future, that is, when a time gap inserts itself between the present action (based on destructive passions) and its possible consequences. thus all certainty and inexorability are taken away from the evil, enabling individuals to imagine it as a remote and avoidable possibility, for which it makes no sense to mobilize themselves immediately. in other words, in this case, fear does not manage to overcome the passions of the present. hobbes's intuition is all the more valid in the case of global risks, whose possible damage is even more remote and does not concern current individuals, but future generations. that is, fear does not have the strength to change present action (and therefore the underlying desires and passions) when the damage that this action can cause is not an evil for ourselves but for 'others': anonymous, generic and distant in time. in short, by weakening fear, the future nature of the damage makes it easy for essentially selfpreserving and narcissistic individuals to deceive themselves as to the actual entity of the risk and therefore to minimize or deny the possible consequences. in this case, the aim is not so much for individuals to defend themselves emotionally from events that are too painful to bear (like in the case of nuclear con fl ict), but to carry on with a manner of acting that allows them to legitimize and satisfy their current desires, preserve their lifestyles and not lose consolidated privileges. to once again recall the pathologies of the global self, we could say that the acquisitive voracity of homo creator , orientated towards unlimited growth, combines with the parasitic bent of a consumer individual anchored solely to the present, to prevent access -through the cunning of self-deception -to a correct perception of the catastrophic effects of climate change, global warming, the greenhouse effect and depletion of the ozone layer. this appears all the more paradoxical where these effects start to be dramatically visible: tropicalization of the climate, deserti fi cation, destruction of the ecosystem, lethal viruses and infective diseases are no longer only remote possibilities but the disturbing proof of environmental risks. by now scattered all over the planet, they affect whole geographical areas and populations, damaging the illusion of individuals and states' immunity more and more. indeed, despite not just abstract information and forecasts, but a more and more invasive state of affairs that is starting to concern them at close quarters, guaranteed and supported by the instrumental interests of local politics and the global economy, individuals prefer to deceive themselves in order not to pay the costs of relinquishing their current desires, assets and pleasures; further eased, in this self-defensive operation, by the morally innocent, innocuous and banally everyday nature of the action that produces the risks. moreover, the absence of a 'productive' fear, inhibited by denial and self-deception, is not belied by the cyclical outbursts of panic and collective hysteria in the face of the sudden appearance of threats (as has always been the case, from chernobyl, to sars and bird fl u). on the contrary, the absence and the excess of fear are nothing but two sides of the same coin, the two extreme and 'unproductive' manifestations of what i de fi ned as global fear . both denial and self-deception leave individuals in the passive position of spectators of events. thus they are enclosed in the immunitarian circuit of a self-defensive and self-preserving individualism which anaesthetizes fear and is incapable of converting into effective action, practice or political participation. alongside the two extroverted pathologies, so to speak, of unlimited individualism, represented by the insatiable voracity of the consumer individual and the omnipotence of homo creator , appears a third, paradoxically introverted con fi guration, namely a passive and impotent individual, who helplessly watches the destructive effects of his own action, over which he seems to have lost all capacity for orientation and control. against the loss of objective spaces of protection and security, increasingly eroded by the global diffusion of the risks, he seems to seek shelter, as i have already hinted , in a sort of interior immunity , entrenching himself in the emotional indifference that is just one of the many manifestations of narcissism. in addition, the yearning for immunity becomes more tenacious and obstinate the more it is felt to be ineffective and illusory. thus a new condition is outlined, which to recall the metaphorical fi gures proposed by hans blumenberg in his shipwreck with spectator , is neither the premodern and 'lucretian' condition of the spectator watching the shipwreck from a safe place, sheltered from the danger, nor the modern and 'pascalian' condition of being the actors of our own lives, ' être embarqués ', involved in the things of the world and ready to put ourselves at stake fi rst of all by recognizing the constitutive precariousness of the human condition and accepting the very risk of existence. while modernity had rati fi ed the decline of the spectator fi gure, and enhanced the moments of practice and action, involvement and commitment; and while late modernity had radicalized his condemnation by emphasizing the need to expose oneself to risk and accept the uncertainty and fl uidity of the human condition, the global age seems to be objectively bringing the spectator up-to-date, which nevertheless coincides with a deep and disturbing change with respect to the fi gure of the lucretian wise man. the erosion of boundaries and disappearance of an 'elsewhere'redrawing global space, cancelling out the distinction between inside and out -is turning into the loss of free areas from where the shipwreck can be observed. at this point, due to the end of every real guarantee of immunity, deprived of the possibility of a safe harbour where he can feel sheltered from the world's dangers, the global self withdraws into the only space apparently able to protect him from events and threats that he is not able to deal with: namely, the wholly interior space of an emotional indifference, an anaesthetizing of emotions , generated by implementing sophisticated and for the most part unconscious defence mechanisms. in other words, the spectator fi gure is undergoing a process of interiorization , which replaces the spatial distance from the shipwreck and the contemplative safety of the lucretian subject with the apathetical extraneousness and obstinate blindness of he who refuses to recognize the very risk of the shipwreck, and encloses himself in the entropic space of an inert solitude. moreover, the spectator phenomenon seems to pervade the whole social structure, due to the spectacularization of reality that, as jacques debord had already masterfully diagnosed a few decades ago, deeply upsets the very nature of social relations. by denouncing the erosion of the boundaries between real and virtual and the pervasive power of images (mass media images fi rst of all), and by diagnosing life's 'total colonization' by commodi fi cation processes and the indistinctive overlapping of true and false as the effects of the 'society of the spectacle', debord had indeed grasped the spectator fi gure as the symptom and symbol of a new form of alienation that invades the individual's whole relationship with the world. passiveness and submission to the totalitarianism of images, prioritization of appearance, loss of contact with one's desires and genuine needs, atomism and isolation are among the most evident and disturbing characteristics of the spectator-individual, who thus ends up losing all capacity to be involved and to grasp reality. in short, the emotional indifference in which individuals shelter in order to cancel out the awareness of the risks surrounding them, unconsciously implementing powerful defence mechanisms, seems to be a sort of inevitable outcome of a widespread anthropological condition. or rather, it seems to be the extreme form of a general tendency towards apathy and inertia, produced by a spectacular society that empties reality of its contents and thus deprives individuals of pathos and action. suf fi ce it to think of the de-realizing effects, with respect to the effective drama of events, produced by mass media images (for example the fi rst gulf war), or the narcotizing addiction that they cause to dangers and catastrophes of all kinds (from tsunamis to sars). the images deprive events of the fl esh and blood of the experience and neutralize them in the aseptic and equalizing space of the screen. however, the problem today is no longer the subject's passivization and atomization alone, nor his a-pathetical detachment from reality: aspects which, moreover, sociological re fl ection on narcissism had already underlined some time ago, and to which the most recent and sagacious sociological diagnoses do not fail to draw attention. the problem, as we have seen, regards above all the negation of reality and the possible destructive effects of this denial on the very survival of individuals and the whole of humankind. by withdrawing into the immunitarian space of a selfdefensive apathy, the global spectator performs a dangerously illusory operation which precludes the possibility to perceive and understand what the unprecedented risk of the global age is: namely, that he himself is the potential victim of events from which there is no shelter, or rather, from which there is no other possible shelter than active and universal mobilization. while it may be true that the hallmark of global challenges is that they cross boundaries and no perimeter can be drawn around or circumscribe them, it is also true that everyone, in every corner of the planet, is always potentially exposed to their effects, that everyone is always potentially a victim of a shipwreck which, for the fi rst time, could affect and sweep away humankind and all living beings. by anaesthetizing fear, the denial (and self-deception) strategy paradoxically ends up betraying the very same purpose that it had been implemented for: namely, self-preservation. or rather, in order to pursue an entropic and defensive selfpreservation that preserves them from all emotional and active involvement, not only are individuals undermining the quality of their lives, but the very preservation of humankind and the world. see antonio scurati, televisioni di guerra. il con fl itto del golfo come evento mediatico e il paradosso dello spettatore totale (verona: ombre corte, ), who observes how the increase in media exposure of the war phenomenon corresponds to a lesser ability, on the part of the spectator, to grasp its reality. as a result, on the part of the citizen there is less possibility to decide and act. in other words, the 'total visibility' offered by the television medium corresponds, in an only apparent paradox, to the blindness and impotence of the 'total spectator'. this unwillingly nihilistic outcome could perhaps be interpreted as a radical and extreme manifestation of the immunitarian paradigm recognized as the very emblem of modernity, owing to which the preservation of life is paradoxically turned around into its negation. however, what i would like to stress, to go back to anders's diagnosis, is the fact that -in this case at least -this worrying reversal originates in the pathologies of feeling and the denial of fear, which prevent individuals from recognizing their paradoxical condition of spectators and victims at the same time. denial, however, is just one of the unproductive metamorphoses of fear in the global age, and only one of the strategies that the global individual uses to contrast the anxious perception of new risks. denial sums up the individualistic and implosive response to the inde fi nite and unintentional threats produced by techno-economic globalization. in parallel to this there emerges, as i had mentioned, another defence strategy, which responds to what is perceived as the second, fundamental source of danger, essentially generated by economic-cultural globalization: that is, defence against the other . this strategy is specular to the fi rst since it converts more into an excess rather than an absence of fear, and i have suggested de fi ning it as communitarian and explosive . it is based on reducing insecurity and inde fi niteness through the defence mechanism of projection : namely, the fear is displaced onto indirect and specious objects since these appear easier to de fi ne and identify. many of the ethnoreligious con fl icts that are traversing the planet can at least in part be traced back to this basic defence mechanism which converts inde fi nite anxiety into de fi nite fear. in this case too, we are dealing with a strategy that is anything but new since, as we will see, it results in the classic mechanism of building a 'scapegoat'. however, the novelty lies in the fact that, like in the denial strategy, this strategy seems to be resulting in substantial ineffectiveness . if, as suggested to us by rené girard's enlightening diagnosis, the fundamental goal of creating scapegoats has always been, since the origins of civilization, to keep check on and resolve violence in defence of a given community, today we are instead faced with an escalation in violence which attests to the substantial failure of the scapegoat dynamic. through a fascinating thesis that i can only brie fl y recall here, girard claims that in truth this loss of effectiveness has distant roots, since it coincides with the end of the processes which made violence ritual and sacred, and with the revelation of the see esposito, immunitas . here there is a generic allusion to bauman's 'explosive communities' in liquid modernity . of great use for the issues that follow is the essay by stefano tomelleri, "il capro espiatorio. la rivelazione cristiana e la modernità," studi perugini , no. ( ): - . victimage mechanism brought on by the advent of christianity. in other words, while archaic societies had entrusted the rite of sacri fi cing the scapegoat with the function of providing a remedy to internal violence in order to found and preserve social order and peaceful coexistence among men, the revelation of christ radically damaged this mechanism since, by disclosing the victim's innocence, for the fi rst time it made people aware of the victimizing and persecutory dynamics. by unmasking the nexus between violence and the sacred, the christian message led to the breakdown of the mythical-ritual universe, and placed people before the unavoidable truth of their violence. thus it weakened the possibility of resolving the violence through the sacri fi cial mechanism and opened totally new scenarios, affected by a fundamental ambivalence. on one hand, by depriving men of all external justi fi cation for their violence, the christian revelation of the victim's innocence opened up the possibility of renouncing the scapegoat logic and resolving the problem of the social bond, without any exclusion or sacri fi ce; on the other hand, in the absence of ritual antidotes and their power to create order, it exposed men to the spreading of violence and the persistence -in more ambiguous, disguised and clandestine forms -of the victimage mechanism. that this second scenario is the one which, unfortunately, has ended up prevailing is manifestly undeniable; and, paradoxically, it can be pinpointed as originating above all in modernity. while it may be true that modernity -the time of rights, democracy and equality -seems to offer the possibility of transforming violence into 'soft', peaceful and even emancipatory forms of competition and rivalry, it is also true that, for the same reasons, it can provide a breeding ground which favours the heightening of violence. indeed modernity produces an ampli fi cation of the mimetic dynamic that girard recognized as the constitutive source of violent con fl ictuality among men. as has been underlined, the same equality that, à la tocqueville, can be interpreted as a loss of differences, frees the mimetic desire, which becomes unlimited and inevitably exacerbates rivalry among people. in other words, in a society of equals the desire to be according to the other which pushes the mimetic actor to see the other as model and rival at the same time, triggers a spiral of competitive comparison. even the smallest difference becomes the opportunity for resentment, envy and hate, and can always provide the opportunity for violent clashes. while on one hand democratic indifferentiation and, we could add, narcissistic and postmodern intolerance towards every difference -which tocqueville had prophetically diagnosed -provoke the continuance of rivalry and con fl ict, on the other hand the sacri fi cial dynamic, to which premodern societies had entrusted the function of keeping check on violence, seems to have lost its traditional ef fi cacy due to its irreversible disclosure. this means that modern and contemporary societies are exposed to a radical 'crisis of the sacri fi cial system' which, since it is impossible to fi nd a solution in the scapegoat mechanism, can result in a multiplication of violence and its manifestation in increasingly crude and destructive forms. the loss of the victimage mechanism's ef fi cacy, due to the deritualization process, does not equate to its disappearance, however. on the contrary, girard once again observes that phenomena of 'sacri fi cial substitutions' reappear 'in a shameful, furtive, and clandestine manner' so as to avert moral condemnation (and selfcondemnation). they take on the shape of psychological violence which is easier to conceal, or they re-explode in the exacerbated form of immolating victims to evil ideologies, as was the case of the genocides in the twentieth century. these mechanisms continue in our world usually as only a trace, but occasionally they can also reappear in forms more virulent than ever and on an enormous scale. an example is hitler's systematic destruction of european jews, and we see this also in all the other genocides and near genocides that occurred in the twentieth century. of course the reference to the nazi genocide is not random, but extremely emblematic of the modern and contemporary reappearance of the victimage mechanism in spite of its disclosure. a fi rst formulation of this can be found in the diagnosis of totalitarianism that franz neumann was already suggesting in the s, as he traced its psychic origins back to the transformation of fear into 'persecutory anxiety'. every time, neumann says, over the course of history a particular social group (whether it can be de fi ned on the basis of class, religion or race) feels threatened by objective dangers which, together with material survival, compromise its prestige and identity, the deriving anxiety is displaced onto groups and people, who are given the requirements ad hoc , and the guilt made to converge on them. if we are to take up the freudian distinction between 'realistic anxiety' and 'neurotic anxiety ', neumann shows how fear and uncertainty are transformed into persecutory anxiety through the projective and hence specious creation of an enemy who becomes the subject of hate and aggression. as a result, the masses threatened with disintegration can rediscover their internal cohesion. in the case of nazism and the persecution of the jews, political and ideological manipulation linked up to this social dynamic, took advantage of the mass anxiety and pushed the masses towards 'caesaristic' and regressive identi fi cation with a leader libidinally attributed the task of resolving the anxiety by expelling the evil and its presumed carriers. by recognizing the victimage mechanism as originating in the persecutory transformation of anxiety, neumann allows us to see its emotional roots, which girard evidently considers less essential for his so-to-speak ontological diagnosis of violence. however, at the same time, while neumann particularly stresses the totalitarian outcomes of the scapegoat dynamic, girard underlines its persistence in 'all the phenomena of nonritualized collective transference that we observe or believe we observe around us.' although deritualized -and indeed all the more violent for this precise reason -the victimage mechanism continues to act in the same modern democratic societies in all creeping and disguised phenomena of exclusion and discrimination, or in the cyclical explosions of reciprocal aggression and disdain that are fuelled by identity con fl icts: we easily see now that scapegoats multiply wherever human groups seek to lock themselves into a given identity -communal, local, national, ideological, racial, religious, and so on. evidently, here we are coming back to the topic of identity con fl ict which, as we have seen, is proliferating inside and outside the west, bringing the scapegoat strategy back up-to-date: a strategy which becomes all the more aggressive the more the perception of the threat grows in a global society. by eroding territorial and cultural boundaries, globalization is producing, fi rst of all in western societies, a disturbing proximity of the other. as a result, the other can increasingly be identi fi ed with the simmelian fi gure of the 'stranger within', who challenges the order and cohesion of a given community through a swarming and liminal presence that is felt, as suggested neumann stresses the regressive nature of this identi fi cation mechanism for the very masses who implement it, since it involves alienation and the relinquishment of one's self: 'since the identi fi cation of the masses with the leader is an alienation of the individual member, identi fi cation always constitutes a regression'. ( anxiety and politics , ). 'caesaristic identi fi cations may play a role in history when the situation of masses is objectively endangered, when the masses are incapable of understanding the historical process, and when the anxiety activated by the danger becomes neurotic persecutory (aggressive) anxiety through manipulation.' (ibid . , . it is interesting to see how neumann indeed also alludes to the unconscious nature of the persecutory dynamic: 'hatred, resentment, dread, created by great upheavals, are concentrated on certain persons who are denounced as devilish conspirators. nothing would be more incorrect than to characterize the enemies as scapegoats […] for they appear as genuine enemies whom one must extirpate and not as substitutes whom one only needs to send into the wilderness.' (ibid., ) . girard, i see satan fall like lightning , . ibid., . by mary douglas, as potentially contaminating. coming forth in response to the siege of a hybrid and unstemmable multitude that is penetrating the protected spaces of our identity citadels is the ancestral fear of a 'contamination' endangering the need for 'purity' upon which, douglas says, every culture and civilization builds its reassuring separations and classi fi cations. the other (the stranger, he who is different, the migrant, the illegal immigrant) becomes the target upon whom to displace our fears, upon whom to project a persecutory anxiety that transforms him into the person responsible for the dangers threatening a society that is increasingly deprived of the traditional control structures. hence this enables that blaming process which is indispensable for social cohesion and which, however, the anarchic and anonymous logic of globalization seems to be progressively eroding. but since it is no longer possible to rely on ritual expulsion practices or strategies to con fi ne the other to a spatial and territorial elsewhere clearly divided by a de fi nite boundary that traces the separation between an inside and an outside, the exclusion mechanism becomes interiorized and acts at an eminently symbolic level. the exclusion dynamic, as has been underlined, is shifted into the conscience: 'defence and exclusion, no longer possible towards the outside, will be shifted into the conscience, the imagination, the social mythologies and into the self-evident that these hold up.' thus immunity is ensured through dehumanization processes that transform the stranger within (the metoikos ) into an 'inside being' in such a way that he remains an 'outside being' all the same. all this can take place in the insidious and hidden forms of psychological violence and everyday discrimination towards those who have crossed the territorial boundaries of a state and broken the taboo of distance and separation, therefore representing a constant challenge to consolidated privileges and to the 'purity' of identity. or it can occur through cyclical collective mobilization against the weak and marginalized in the attempt to deal with insecurity by displacing the fear onto problems of personal safety, which politics does not then hesitate to exploit, in selflegitimation, in the name of defending public order. but, as we have already seen, it can also convert into a real and proper 'attack on the minorities', in which it is perhaps legitimate to recognize, as suggested by arjun appadurai, the distinctive form of violence spreading to the global level. when global insecurity is added to the delirious fantasy of national purity which appadurai de fi nes as an 'anxiety of incompleteness', the majorities in every single state whose hegemony is threatened tend to transform into 'predatory identities'. their aim becomes to defend the purity of the ethnos by eliminating the element of disturbance represented by the 'minor differences'. the minorities 'are embarrassments to any state-sponsored image of national purity and state fairness. they are thus scapegoats in the classical sense.' more speci fi cally in the global age they 'are the major site for displacing the anxieties of many states about their own minority or marginality (real or imagined) in a world of a few megastates, of unruly economic fl ows and compromised sovereignties.' from iraq to ex-yugoslavia, from indonesia to chechnya, from palestine to rwanda, to the emblematic case of the clash between hindus and muslims within a modern democracy like india, the victimage mechanism seems to reassert itself with a fresh violence that tellingly -testimony to the obsession with purity at its origin -seems to repeat itself in particular towards the body . indeed, as appadurai underlines by taking on douglas's perspective, the body becomes subject to unheardof violations and atrocities (bodies massacred, decapitated, tortured, raped) in view of punishing the minorities for the fact that they 'blur the boundaries between "us" and "them," here and there, in and out, healthy and unhealthy, loyal and disloyal, needed but unwelcome.' nevertheless, it is precisely this obsessive, punitive and puri fi catory nature that announces the danger that the violence may assume an unstemmable drift. far from producing a stop to the violence, the scapegoat strategy causes its proliferation, through a sort of perverse up-the-ante that seems to bring the brutality of archaic practices, such as sacri fi ce, and of the starkest materiality back inside the abstract and impersonal space of globalization. but that is not all. today the spiral of violence is further fuelled by a new factor that upsets the logic -to date essentially one-way -of the persecutors-victims relationship. what happens, unlike for example the emblematic case of nazism, is that the other tries to overturn his position as victim, and in turn becomes the persecutor, giving rise to a dynamic of hostility and aggression that potentially becomes unlimited owing to its reciprocal and specular nature. suf fi ce it to think of islamic terrorism and the projection it puts upon the west as the image of the other and evil, against which, by fuelling passions of resentment , a compact and endogamous us is condensed together and built. indeed this proves the fact that the scapegoat, as girard warns, is not only necessarily embodied in the weak and oppressed but also in the rich and powerful. hence, in the grip of dehumanization on one hand and demonization on the other, the world becomes a theatre, through the reciprocal invention of an enemy, of an escalation in violence that has much to do with the persecutory metamorphosis of insecurity and anxiety and very little to do with a presumed 'clash of civilizations'. shifted to the inner self, the victimage mechanism continues to act, hidden from view. nonetheless, it ultimately becomes ineffective since it fails in its original purpose to resolve the fear and keep a check on violence. orphaned of ritualization processes and deprived of an 'elsewhere' that permits the other's spatial and territorial exclusion, the construction of the enemy/victim generates forms of identity cohesion that are as aggressive as they are regressive, fuelled by a reciprocal persecutory projection. far from restoring cohesion and security to a given community, the scapegoat dynamic gives rise to endogamous and reciprocally exclusive processes of building an us , whose foremost and manifest effect is to form what i have de fi ned as immunitarian communities : whether they are the 'voluntary ghettoes' and 'communities of fear' that explode cyclically in a west frightened by the siege of the other and anything but free from regressive phenomena, or ethno-religious communities entrenched around the obsession of identity and homogeneity, willing to reactivate atrocious forms of excluding the other, or lastly global communities that come together around the war/terrorism polarization. the metamorphosis of fear in the global age therefore seems to con fi rm, at the emotional level, the pathological split between an unlimited individualism and an endogamous communitarianism , which originates in the implementation of defence mechanisms leading to not only the polarization of an absence and excess of pathos , but also, it needs to be stressed, in their substantial inef fi cacy . on one hand, the denial of fear, we have seen, pushes individuals towards forms of apathy and narcissistic entropy that prevents them from recognizing the new risks produced by global challenges. as a consequence, this produces the individuals' incapacity to perceive their unprecedented condition of spectators and potential victims at the same time, and fuels the illusion of immunity: which means that in the name of entropic self-preservation we end up delivering the whole of humankind to the danger of self-destruction. on the other hand, the persecutory conversion of fear generates perverse and endogamous forms of alliance and solidarity, which thereby result in the reactivation of destructive communities driven by 'primordial loyalties'. this gives rise to the explosive drift of identity con fl icts and to an unlimited escalation of violence at the planetary level. between self-obsession and us-obsession , as the specular polarities of the same immunitarian strategy, we run the risk of not grasping the chance that the global age could actually be capable of offering through the very transformations that it produces and the very challenges that it contains. on one hand, as we will see, the risks that are bearing down on humankind for the fi rst time mean we can think of the latter as a new subject, as a set of individuals linked by their common vulnerability and weakness . therefore, they are able to take care of the world in the sense of the planet, the 'loss' of which would coincide with the disappearance of the only dwelling of living beings that we know of. on the other hand, the multiplication of differences and the slide of the idea of 'other' towards the notion of 'difference', which can neither be assimilated nor expelled into an elsewhere, for the fi rst time makes it possible to rethink the social bond as the solidaristic coexistence of a plurality of individuals, genders, cultures, races, religions, capable of forming a 'world', à la arendt, since they are capable of recognizing not only the necessity but also the potential vitality of reciprocal contamination . these real possibilities are, however, only a chance. insofar as it is a chance, the subjects have the task of knowing how to grasp it. to recall a successful suggestion by andré gorz, we could say that to pro fi t from the chance in the fi rst place means 'to learn to discern the unrealized opportunities which lie dormant in the recesses of the present' ; or, in a word, to lay a wager on the ability to build alternative scenarios and create possibilities that may not yet have been taken up but are still latent. the expression is inspired by georges bataille who, as already remembered above, proposes the idea of chance meant as the 'possibility of openness', see on nietzsche (london: athlone, ), originally published as "sur nietzsche," in oeuvres complètes, vol. (paris: gallimard, ). gorz, reclaiming work , . originally published as des choses cachées depuis la fondation du monde we haven't given up having scapegoats, but our belief in them is percent spoiled. the phenomenon appears so morally base to us, so reprehensible, that when we catch ourselves "letting off steam" against someone innocent, we are ashamed of ourselves originally published as je vois satan tomber comme l'éclaire democratic and authoritarian state neumann says, there must always be a core of truth that makes this choice particularly dangerous: so in the case of the jews, the core of truth is given by their being 'concrete symbols of a so-called parasitical capitalism, through their position in commerce and fi nance on this see part ii purity and danger. an analysis of concepts of pollution and taboo mary douglas underlines that risk itself becomes a resource at the moral and political level and speaks of a 'forensic theory of danger': 'disasters that befoul the air and soil and poison the water are generally turned to political account: someone already unpopular is going to be blamed for it.' ( risk and blame , ) risk and blame appadurai continues, 'are metaphors and reminders of the betrayal of the classical national project. and it is this betrayal -actually rooted in the failure of the nation-state to preserve its promise to be the guarantor of national sovereignty -that underwrites the worldwide impulse to extrude or to eliminate minorities originally published as orrorismo fear of small numbers , chap. again underlines the nexus between the abstract logic of globalization and the brutality of physical violence - ; for an interesting treatment of the topic see stefano tomelleri key: cord- -xedqhl m authors: lister, graham; lee, kelley title: the process and practice of negotiation date: - - journal: global health diplomacy doi: . / - - - - _ sha: doc_id: cord_uid: xedqhl m global health diplomacy has been defined as the art and practice of negotiation in relation to global health issues. this chapter draws on generic concepts of negotiation as a process of diagnosis, formula development, exchange and implementation, reflecting the shared and sometimes contested values, power relationships and interests of the many different actors involved. it sets out a framework for understanding the main phases of global health negotiation process as they arise in many different contexts. the negotiation of global health issues is shown to be a driver of the regimes of global health governance institutions that are shaped by the new trends in global governance described in the previous chapter. the leadership and development of diplomatic negotiations at every level with an increasing range of actors is therefore key to global governance for health. global health diplomacy has been de fi ned as the art and practice of negotiation in relation to global health issues. this chapter draws on generic concepts of negotiation as a process of diagnosis, formula development, exchange and implementation, re fl ecting the shared and sometimes contested values, power relationships and interests of the many different actors involved. it sets out a framework for understanding the main phases of global health negotiation process as they arise in many different contexts. the negotiation of global health issues is shown to be a driver of the regimes of global health governance institutions that are shaped by the new trends in global governance described in the previous chapter. the leadership and development of diplomatic negotiation s at every level with an increasing range of actors is therefore key to global governance for health. negotiation can be de fi ned as a process of exchange between two or more interested parties for the purpose of reaching agreement on issues of mutual concern. zartman and berman ( ) distinguish three main phases leading to agreement: the diagnostic phase, during which the issues are identi fi ed, stakeholders engaged and information is prepared, the formula phase, establishing a shared framework for agreement including the process of exchange and the detailed phase of negotiation and exchange. negotiation is also crucial to the effective implementation of any international agreement, requiring ongoing monitoring and possibly arbitration of disputes by an international body. negotiation can be characterized in terms of the expression of values and power. global health negotiations often invoke shared values and goals, though interpretation and interests may differ. as fisher et al. ( ) note, negotiations based on common principles are fundamentally different to negotiations based on positional power. where values are shared, stakeholders are more likely to seek, as a minimum, to accommodate the speci fi c interpretations and interests of each party. more constructively they may collaborate to fi nd new solutions to mutually recognized problems. where values are not shared, stakeholders are more likely, either to avoid the issues or to seek to develop a position of advantage to advance one interest over another. while in the former case there are great advantages in sharing information and working for a "win-win" integrative solution, in the latter case the sides may understanding the negotiating process from diagnosis of issues and • interests, the establishment of a formula to provide a framework for resolution of con fl icting interests to the detailed process of negotiating exchanges to resolve the issues. the need to de fi ne and frame the issue in a way that can be accepted and • addressed by all parties to negotiations. the importance of engaging relevant stakeholders and aligning their • interests. the key role of information and knowledge in preparing a negotiating • position. the design of the process and formula for the process of detailed • negotiation. insights for the conduct of detailed negotiation and exchange and in par-• ticular the importance of timing. the importance of continuing negotiation in the implementation of inter-• national treaties or agreements. the exercise of • meta leadership in global health negotiations . wish to apply game-theory based strategies that emphasize their position or the extent of the power of one side in relation to the other, it is assumed that one side wins at the expense of the other. the ethical values of health as human rights are generally recognized by all the parties as de fi ned in the constitution of the who and this can provide a basis for the negotiation of outcomes that can be considered "fair" in these terms. but even values such as fairness and rights to health may be interpreted in different ways. moreover, it is also clear that the other interests of the parties, as examples: their trade, economic, and security concerns shape their interpretation of health values. thus while global health negotiations tend to be couched in terms of the expression of shared values and concerns for health, it is also possible to discern the interplay between the speci fi c interests and powers of the parties. global health negotiations can arise in many different ways in relation to threats posed by different diseases and determinants of health or as a consequence of other foreign policy issues such as security and trade. they often involve multiple stakeholders and interests, both because they deal with trans-border issues and because health and its determinants, including globalization, have impacts across all social and economic spheres. the health issues negotiated are often uncertain in their long-term impact and capable of different interpretation, thus an agreed evidence base and effective presentation of information are essential during the negotiation of international agreements and in their implementation. for these reasons the negotiation of global health issues can be protracted and though agreements to joint action on health emergencies are often reached within days, this may re fl ect years of preparation and exchange. where issues arise within other policy spheres the process can sometimes be very protracted but can be hastened by international events as shown by the negotiation of trade related aspects of intellectual property (trips) and access to medicines. world trade organisation negotiations on trips were fi rst concluded as part of the uruguay round of the general agreement on tariffs and trade (gatt) in . this reinforced the protection of intellectual property rights including those applying to pharmaceuticals, for all countries joining the wto. the agreement was negotiated purely as a trade concern without regard to public health consequences. as hiv/aids and other global health issues gained increasing prominence many resource poor countries and international civil society groups found that trips presented a further obstacle to access to affordable medicines. this issue came to the fore when the government of south africa passed the medicines act in . this was intended to enable the sa government to license the production of drugs to treat some of the complications of hiv/ (continued) in global health negotiations the fi rst step is the identi fi cation of issues that are ready or "ripe" for resolution and to frame them in a way that all parties can recognize. this must invoke a common recognition of a problem and the moral and practical case for action. the time when an issue is "ripe" for resolution may depend on box (continued) aids, thus avoiding patent restrictions. an international group of pharmaceutical companies challenged the legality of the act in the pretoria high court. this challenge might have succeeded, but for the intervention of a local civil society group called the treatment action campaign (tac) who alerted the international network of civil society groups in this fi eld and won the right to present their case in court. protests grew around the world and in the face of this the pharmaceutical fi rms withdrew their challenge. as a result the legislation was applied more widely than had originally been intended, particularly in relation to hiv/aids medicines and other countries followed south africa's lead in passing similar measures. the public awareness raised by this case was one of the factors that led to the partial resolution of this issue in the wto resolutions of and (see box ). an illustration of how events can raise awareness of issues and thus facilitate negotiations is provided by lee (forthcoming ) who describes negotiations to revise the international health regulations, initiated by a resolution of the world health assembly (wha) in amid concerns about emerging and re-emerging diseases. while a revision process commenced, progress proved glacial due to the lack of interest and support by key member states. it was not until the outbreak of severe acute respiratory syndrome (sars) in - that suf fi cient political priority was forthcoming. this led to concerted efforts, under the auspices of an intergovernmental working group on the revision of the international health regulations, which reached agreement on the revised ihr ( ) which countries have adopted. factors such as the emergence of research evidence, the response to a crisis or simply as a result of ongoing international discussions. issues for global health negotiations are identi fi ed in many different ways: as a result of the policy leadership role of who, as an outcome of a speci fi c review, or a concern of national governments or groups such as g or the eu. issues may also be raised by civil society groups or as a result of negotiations in spheres not previously associated with health such as the world trade organisation. but it is not a simple matter to introduce a new issue to the crowded agenda of global health diplomacy. moreover the way in which an issue is framed, how it is identi fi ed and the policy context in which it is viewed is crucial to subsequent global health negotiations. as labonté and gagnon ( ) note, global health issues arise in many different policy frames : security, development, global public goods, human rights, trade and ethical/moral reasoning. this question has still not been fully resolved as the declaration was only • implemented in by the wto general council as a temporary waiver of trips rules. as a consequence negotiations on the application of paragraphs - of the doha declaration that permit the compulsory licensing of drugs (circumventing patent rights) in response to threats to public health considered to be a national emergency or other circumstance of extreme urgency must be negotiated on a case-by-case basis in the light of local conditions (see box ). however the issues are identi fi ed, it is important to raise the policy questions in a way that will be recognized by all relevant stakeholders. this does not mean pandering to the lowest common denominator but it does require the legitimate interests of all parties necessary for eventual agreement to be acknowledged. the policy lens or frame applied to the issue may also determine the fora at which the issue will be raised and the way it will be resolved. one dif fi culty faced by many of the government and interstate institutions traditionally engaged in global health diplomacy is that their commitment to existing policy frame s and ongoing international regimes may make it dif fi cult for them to identify and raise new issues. for this reason civil society organizations including advocacy groups and foundations that are less bound by formal roles and positions can sometimes play an important role as in stimulating new thinking to identify and frame issues. a second step during diagnosis can be described as engagement of stakeholders or the alignment of interests . this involves exploring the perspectives and points of agreement and disagreement between all relevant parties. the parties establish their respective negotiating stances build relationships and common understanding between aligned groups and, if they are wise, explore the positions of other parties. in the context of global health negotiations the alignment of interests may include developing a shared position amongst regional or other international groups of states such as the eu, g /g and south-south cooperation. it may also include the alignment of actors at national level to develop national global health strategies. but it is not just states that come together in this way, civil society groups and other actors may also seek to establish shared positions to strengthen their advocacy for action on global health issues. proposals for an international convention on tobacco control were fi rst raised at the ninth world congress on tobacco or health in , which resulted in a proposal to the wha meeting of . following this the who considered various formulae for such a convention, and it was decided to try to produce a framework convention to promote international and national action. this was accepted at the wha meeting of . an international negotiating board (inb) was formed which negotiated the wording of the convention over two years. in the framework convention on tobacco control (fctc) was adopted by the wha, the convention came into effect in after -member states had signed, often following internal dialogue. by , countries had signed, of these including the usa have yet to bring the fctc into national laws by formal rati fi cation. (continued) the interests of stakeholders and consortia de fi ned at this stage should clarify the shared goals that provide the basis for aligning interests. depending upon circumstances it may be that the negotiating strength of a group or consortium is best served by acting together as a negotiating bloc or acting as separate agents with common interests. for example, in certain fora the interests of civil society groups may be most effectively expressed as a single voice, but in other circumstances they may be more effective when supporting a common view from different perspectives. stakeholders may also indicate certain sticking points, for example it may be that some governments would be unable to countenance certain forms of prohibition of tobacco use, or would not accept the political and economic impact of limiting alcohol marketing. this will indicate the points at which these parties would walk away from negotiations, it is therefore important either to fi nd a way round such sticking points or to develop new creative solutions to overcome such barriers. it is important to understand the walk away points for all parties to a negotiation as these de fi ne the negotiating space . while this may seem a long drawn-out process, agreement on the fctc was relatively swift compared to other international agreements and laws. and while the issues were intensively negotiated from to the preparation of the grounds for such an agreement by building national awareness and action was a much longer process. brazil was the second country to introduce graphic warnings on cigarette packs, it has a history of awareness raising and controls on tobacco stretching back to . its programme of public engagement and working with civil society organizations to reduce smoking rates is regarded as exemplary and perhaps for this reason and because of the growing importance of emerging countries such as brazil, russia, india, china and south africa in international fora-and as target markets for tobacco companies, brazil was invited to chair the inb. this is described by lee et al. ( ) as an example of the way brazil has deployed "soft power" in global health. it is a tribute to the diplomatic skills of those who negotiated the fctc that so many countries and organizations from the european union to national patient groups feel that they have played an important role in its formulation. consultations within and between countries ensured a coalition of interests was created capable of withstanding the tobacco companies, who were clearly intent on defending their position. instead of ignoring them who initiated public hearings both at international and regional levels to make the consultation process open to them but also transparent to public opinion. effective information gathering and use is essential for global health negotiations . information will be of greatest value once the concerns of all relevant stakeholders are identi fi ed as it is then possible to gather information and moral and policy arguments to address the issues of greatest contention in subsequent exchanges. the way in which information is used and publicized is also vitally important to global health negotiations , which are usually conducted in public, or at least in an open transparent process. scienti fi c papers may be appropriate sources for data but will seldom present information in a way that is most amenable to policy makers or public discussion. civil society organizations often have more freedom to advocate for a policy case than other parties and can be important in raising public awareness and support for policy change. they may appeal to the public through traditional and new media and, for example, by utilizing celebrity power. in the period leading up to formal exchange the parties to a negotiation often produce initial position papers setting out their aims and objectives and the relevant evidence on which they draw. they may seek to form a wider coalition for their position by conducting consultations with other parties and groups. this brings a danger that they may trap themselves into commitments that provide no room for negotiation. thus it is important for global health diplomacy to ensure that the interests of all parties are recognized and that positions statements focus on values and goals rather than speci fi c solutions to the exclusion of other options. the exchange of views during the diagnosis phase helps to ensure there is a shared understanding of the issue to resolve differences of interpretation and to focus negotiations on points of contention. it should also help each of the parties to understand the perspectives of the others which may be constrained by national economic, cultural, and political circumstances. technical knowledge may also be required as global health issues often require some understanding of public health impacts or options for cost-effective intervention. where a health issue involves other policy sectors, such as trade, agriculture or the environment, cross-sector knowledge is essential. the dispute between the ministry of health in thailand and the pharmaceutical company abbott laboratories over the compulsory licensing of the hiv/aids drug kaletra (a combination of ritonavir and lopinavir) described by lee ( in press ) illustrates the need to bring together different types of technical knowledge. negotiations between the ministry and private company required specialist knowledge of the drugs themselves and their effectiveness, knowledge of public health conditions and speci fi cally the prevalence of hiv/aids and access to relevant medicines in thailand as well (continued) once the issues have been clari fi ed and information and interests shared, it may be realized that the parties can proceed directly to agreement. however, as many global health issues are complex and multi-faceted it may be necessary to design a speci fi c formula for agreement for the resolution of outstanding issues. the formula de fi nes the negotiating space (the limits within which agreement can be reached) and the terms in which agreement will be reached. it is important for the formula to be kept relatively simple but with suf fi cient scope to allow all parties to bene fi t from the eventual agreement. the formula identi fi es the points of disagreement and the terms in which these will be negotiated. thus for example in relation to tobacco control a study was carried out to determine the form of agreement that would be most appropriate and most likely to gain support from member states of the who. the design of the detailed negotiating process requires agreement upon: the objectives of discussion, the issues to be resolved and the broad principles • on which agreement might be based. the participants including representatives of groups of states and possibly civil • society organizations that might be invited as participants or observers. the forum for discussion, which might be an existing international agency such • as the wha or united nations general assembly or a special meeting or discussion process at some neutral location. the chair and secretariat to mediate the meeting, agreeable to all parties. • the process of the meeting including the timescale, stages of negotiation, • arrangements for media coverage and the issue of communiqués. details of meeting arrangements such as the layout, provision for break out dis-• cussions and other factors that affect the atmosphere of the exchange. the method of agreement whether by consensus, voting or informal agreement • subject to later rati fi cation . the language(s) of the agreement can be important since languages impart cul-• tural assumptions and some allow greater ambiguity of expression than others. participants in such exchanges will also need to establish their own rules of engagement, for example who will lead the delegation, what are their negotiating box (continued) as detailed understanding of the legal fl exibilities available under the trips agreement, and its interpretation in the subsequent decisions on the implementation of paragraphs - of the doha declaration on the trips agreement and public health. objectives and walk away points and what freedom do they have to negotiate compromises, to what extent can they represent other members of a group and how will they report back to the governments or groups that they represent. the processes of framing the issue, the alignment of interests , gathering and using information and design of the formula for agreement can be seen as steps in preparation for detailed negotiations, which as drager et al. ( ) note is of fundamental importance to the success of health negotiations. in conventional negotiation theory bargaining is often characterized by strategic offers and counter offers, with trades proceeding from larger scale claims and concessions to smaller adjustments as differences between parties are resolved. there may be elements of game theory applied with opening moves design to probe the position of others rather as in a chess game. while elements of this sort of bargaining can be seen in global health negotiation it is more likely that issues will be resolved through a managed process of exchange in accordance with a process designed as described in the previous section. before commencing the detailed exchange process the secretariat may produce an outline draft as a basis for negotiation. this may establish principles for the resolution of issues with areas of disagreement couched in broad terms acceptable to most participants for more detailed discussion. the initial draft may be itself a product of prior discussion and negotiation since, as in any negotiation, an opening proposition can anchor expectations as to the outcome and may de fi ne what would be considered success or failure in the talks. setting expectations too high can be a mistake as it can lead to a perception of failure if they are not met, expectations set too low may result in outcomes that do not challenge participants to seek creative solutions. typically the parties reviewing the draft will identify areas which they would wish to see amended and various changes in wording will be proposed to the secretariat and discussed in detailed sessions before agreeing upon a communiqué signifying general agreement. headline discussions may be accompanied by other forms of diplomacy and exchange to resolve misunderstanding and barriers to agreement. for example, where a policy may have a fi nancial impact on one or more countries, there may be side room discussions of mechanisms to offset or reduce the economic impact by aid or trade mechanisms. civil society organizations may exert moral pressure on negotiators from the perspectives they bring of people affected by the policy and by astute use of the media. the search for agreement can be described as a process in which a range of reciprocal exchanges builds mutual obligation and understanding on which broader agreements can be based. the participants in most global health negotiations seek an outcome from which all parties can claim success. this is essential since although agreements may be rati fi ed and set in international law, compliance depends largely upon the willing acceptance of the agreement by the signatories. theoretical models of negotiation stress the importance of con fi rming the agreement, it is often said that nothing is agreed until everything is agreed. the point at which a negotiation culminates in an agreement is therefore of great importance. this can also be true of agreements on global health, many of which are negotiated "down to the wire". while agreement to a communiqués may be seen as a successful outcome to detailed negotiation, in many cases there will be a further stage in which the agreement is formally agreed by a un body with the legal status required to establish international law. this will require careful wording of agreements to be signed, together with clear proposals for monitoring its observance. terms included in the document and the legal obligations assumed by signatories to the agreement should be as clear as possible, though some parties may intentionally leave "wiggle room" for subsequent interpretation. in many cases states sign an agreement but reserve the right to con fi rm their legal assent to the law in national legislation. this may be because internal political mechanisms require the agreement of legislative bodies, particularly in federal states such as the usa. thus in the case of the fctc outlined in box , while president bush signed the convention he did not submit it for senate approval. it may seem that there should be no further negotiation of the terms of an international treaty between the acceptance of a communiqué and rati fi cation . but in practice there are often further negotiations at the time of rati fi cation and subsequent adoption and implementation by states. discussions at this stage will focus on the de fi nition of terms and their speci fi c application, how agreements are monitored and on the conjuncture of different international obligations. these are often the most dif fi cult and crucial issues. moreover as spector and zartman ( ) note, effective implementation of any international agreement requires ongoing monitoring over many years. whether issues can be resolved by conciliation between the states, by arbitration by an international agency or by reference to the international court of justice will often depend upon circumstances. the who may be required to examine the performance of states and raise questions about the extent of their observance of global treaties. international agreements thus help to de fi ne the roles and regimes of agencies like who in global governance. and as the role and functions of international agencies evolves this will in turn in fl uence the way international agreements are applied. thus global health negotiation can be seen as a mechanism that drives the ongoing evolution of global governance for health as an open system responding to its geopolitical context. since global health treaties and agreements often also imply a moral obligation, there is a further "court" at which disputes can be raised, which is the court of public opinion. civil society organizations often play a valuable role in holding governments or international companies to account in this way, pointing out infringements of human rights or failures to meet their obligation under international agreements and laws. chapter discusses the leadership role of who in global health negotiations . but organizational leadership is also essential for the negotiation of global health issues at regional, national and local levels. this is not achieved by command and control, planning and budgeting or by evidence and analysis alone, but by working with others to share ownership of and responsibility for global health and build mutual respect and trust. discussion of the negotiation process would be incomplete without recognition of the importance of the skills required to lead such negotiations. the examples given in later chapters provide many instances of the ways in which personal leadership has brought people from different countries and organizations together to achieve common goals. the qualities required are described by marcus et al. ( ) , as "meta leadership", which requires: an encompassing vision of the values of global health, the political context and • the situation as seen from all perspectives, in order to frame the issue in a way that can be accepted by all participants. the epicenter of this outbreak with more con fi rmed human cases and deaths from the disease than any other country. stopping virus sharing was therefore seen as a serious threat to measures to counter a potential global pandemic. the indonesian government claimed that samples were being used by pharmaceutical companies to produce patented vaccines for high-income countries which would be unaffordable to indonesia. moreover they pointed out that the convention on biological diversity of requires that countries from which genetic material is drawn should share the bene fi ts of its use. what followed from this dispute was a protracted negotiation of the interpretation of the international health regulation and other international agreements which affect the conditions applied to the sharing of virus samples. these negotiations described by irwin ( ) are still ongoing, they invoke wider issues concerning capacity for vaccine production, the rights of states to share the bene fi ts of virus sharing, the role of who and funding of global public goods for health. the emotional intelligence required to understand and empathize with different • perspectives and in fl uence thinking and action across national, cultural and institutional boundaries by engendering shared understanding and common purpose. the ability to encourage and draw on shared leadership from other individuals, • institutions and organizations with different skills and perspectives to empower them to act together to achieve common goals. the personal integrity, self-awareness and self-control required to lead negotia-• tions unbiased by any prejudgement, to "speak truth to power" where necessary and thereby earn the trust of people from different countries and organizations. meta leadership is demonstrated by many of the practical examples as shown in all chapters of this book, it is best learnt by re fl ecting on experience of leading global health negotiations, perhaps fi rst across local organizations and then with increasingly challenging international contexts. complex international interdisciplinary negotiation often requires distributed leadership at many different levels as shown in the south african access to medicines case introduced in box . the south african medicines act of was signed into law by president nelson mandela, but by , when the issue came to the pretoria high court, the new president thabo mbeki was denying the existence of hiv/aids and his health ministers were falling into line. despite the strong institutional and personal support for south africa's position by dr gro harlem brundtland of the who, it was felt that the pharmaceutical companies would win their appeal against the act and fearing this implementation of the act was suspended. the pharmaceutical manufacturers association seemed certain to win, they even appeared to have the backing of ko fi annan, the eu and the usa. one man called zackie achtmat, a gay hiv-positive south african of mixed race, made a difference. leading the tac he vowed not to take antiretroviral treatment until it was available to all south africans. tac won the right to present their case in court. and they made their voices heard beyond south africa. working with international gay and lesbian groups and the support of ngos led by ellen't hoen of médecins sans frontières they built a worldwide campaign for access to medicines that ensured that clinton and annan shifted their rhetoric and european countries began to back down. facing mounting public disapproval the pharmaceutical companies withdrew their case in a meeting with nelson mandela. zackie continued to campaign against thabo mbeki's refusal to fully fund hiv/aids treatment and eventually became seriously ill until persuaded by a personal appeal from nelson mandela to abandon his pledge to refuse treatment. experience of global health negotiations shows the importance of sound diagnosis including the way issues are framed, the alignment of interests and the development and presentation of information. this can help to prepare for the time when the issue is ripe for resolution, perhaps as a result of unfolding events or as a shared understanding of common interests and concerns for global public goods emerges. the formula for the resolution of issues including consideration of the form and nature of any international agreement and the terms in which it can be resolved is crucial to successful negotiation of an agreement. but even when formal agreement is reached diplomatic negotiations centred on the international agency responsible for monitoring the agreement are likely to continue. such negotiations shape the roles and regimes of the international agencies and are the essential basis for global governance for health. while this calls for shared organization leadership at every level it also depends upon on the personal leadership qualities of key individuals. does everyone interpret human rights to health in the same way? if not why not? . describe a negotiation process for a health issue with which you are familiar give examples of global health issues arising in other policy contextssecurity, trade or development? what are the advantages and disadvantages of forming a group of nations or a coalition of civil society organizations to press for global health policy change? . if you are to take part in a consultation on a global health issue what information would you seek? what do you think are the most important points to consider in setting up a global health negotiating process? what can ensure that an international agreement on a global health issue is implemented effectively, what can go wrong? what competence do you feel you have to lead global health negotiations , how can you build your capability in this fi eld? . who showed leadership in the south africa access to medicines case and who did not? references drager getting to yes: negotiating an agreement without giving in . london: random house business books indonesia, h n , and global health diplomacy framing health and foreign policy: lessons for global health diplomacy twenty-fi rst century global health diplomacy brazil and the framework convention on tobacco control: global health diplomacy as soft power renegotiating health care: resolving con fl ict to build collaboration getting it done: post agreement negotiation and international regimes . washington dc: united states institute of peace press. an analysis of the link between diplomatic negotiations of the implementation of international agreements and the regimes of global governance institutions the practical negotiator further reading negotiation, chapter manual for un delegates, conference process, procedure and negotiation key: cord- -yxttl gh authors: siegel, frederic r. title: progressive adaptation: the key to sustaining a growing global population date: - - journal: countering st century social-environmental threats to growing global populations doi: . / - - - - _ sha: doc_id: cord_uid: yxttl gh adaptation is an evolving long-term process during which a population of life forms adjusts to changes in its habitat and surrounding environments. adaptation by the global community as a unit is vital to cope with the effects of increasing populations, global warming/climate change, the chemical, biological, and physical impacts on life-sustaining ecosystems, and competition for life sustaining and economically important natural resources. the latter include water, food, energy, metal ores, industrial minerals, and wood. within this framework, it is necessary to adapt as well to changes in local and regional physical conditions brought on by natural and anthropogenic hazards, by health threats of epidemic or pandemic reach, by social conditions such as conflicts driven by religious and ethnic fanaticism, and by tribalism and clan ties. the principal problems with growing populations do not involve space although population density is a problem unto itself for reasons discussed in previous chapters. the main problems are how to nourish people with food and water. the chronic malnutrition that about billion people suffered from in is likely to grow in number in some regions due to global warming/climate change because humans cannot adapt to less food if they are already at subsistence rations. for example, the population in sub-saharan africa is million people. the population is projected to increase to about . billion in , an increase of about %. within the same time frame, the united nations estimates that acreage under maize cultivation in the region will decline by % because of heat and drought brought on by climate change. the loss of arable land for food production can be countered in sub-saharan africa if marker assisted hybridization of maize or maize genetically modified to withstand heat and drought come onto the seed market together with modified seeds for other food staples and if african nations that do not now accept gmo seeds do so in the future. if not, nations favored for food production by climate change will have a moral obligation to provide food staples to people in nations with declining food production at accessible costs based on their economies. it is clear that what happens in sub-saharan africa and other regions with declining cultivation acreage or that will bear other effects of climate change (e.g., drought, shifting rain patterns) will affect the rest of the worldwide community politically, economically, and socially. the earth's problems that associate with global warming/climate change will be further discussed in the last section of this chapter. water is the staff of life. it keeps the body hydrated and is necessary to grow food crops, hydrate food animals, and grow feed grains. chemically or biologically polluted water does not serve these ends. if ingested, contaminated water can result in sickness as discussed in chap. . water stokes industry and manufacturing as well, thus keeping economies in many countries contributing to a population's wellbeing by providing employment, goods, and services. ideally, these businesses contribute their fair share to a tax base that supports social needs (e.g., education, healthcare, maintenance of infrastructure). factory owners adapt and plan against water shortages by having a water recycling system in place but may also slow or stop production until operational water conditions return. citizens with a reliable water supply can adapt to periods of water shortage by limiting use according to mandates by government officials but still have water for basic daily needs. however, persons in nations with a chronic per capita water shortage may not have this option to serve their daily needs unless water is imported or new water sources are found (see chap. ). if imported water is not an option to meet immediate essential needs, an alternative adaptation for people (and animals) is to try to reach a location where water would be available to them. with growing populations, per capita water availability is greatly diminished (table . ), water shortages become endemic, and people are at risk of existing at subsistence levels or dying. most at risk from the lack of a basic water ration are pregnant women, infants, young children, and old people. water wars are a future possibility as nations battle for their peoples' survival unless political differences are set aside and projects are supported to develop and share water sources. in a welcome effort, jordan, israel, and the palestinian authority signed a memorandum of understanding in the world bank, december , with specific aims: ( ) produce millions of cubic meters of drinking water for a water-deficient region; ( ) pipe million cubic meters of water annually * km ( mi) from the red sea to the dead sea; ( ) build a desalination plant at aqaba that would supply water to aqaba and eilat; ( ) the israeli water utility would supply - million cubic meters of drinking water to the palestinian authority for the west bank population at a reduced cost; and ( ) there would be an inflow of water to slow and in the future perhaps abate and reverse the shrinking of the dead sea. funding for the estimated $ million, year project will come from the world bank, donor nations, and philanthropic groups. as the global population increases and more people in developing and less developed nations have more disposable income, there will be a growing draw on natural resources other than water and food to service their industrial, agricultural, and manufacturing needs and wants. competition can force economic wars among national and multinational corporations for the resources necessary to provide goods and services and thus drive up prices for resources. industries and manufacturing units that cannot compete economically for natural resources will shut down, thus contributing to unemployment and downturns in economies because of falling domestic demand. to keep order in the increasingly interdependent world economy, accommodation for shared natural resources (or substitutes for them) at affordable prices is the adaptationnecessary. this can be mandated by the world trade organization backed by other practical-minded international groups. another adverse effect of growing populations that is a national resource that can be lost at the expense of some countries to the benefit of others is brain power. this brain power has been cultivated at excellent universities in developing countries, often times at little or no cost to students (e.g., in medicine, science, engineering, economics, the arts) who attend and graduate in increasing numbers. where there are too many well-educated professionals but lack of employment opportunities for them in their fields of expertise, educated people have the option of relocating to another country that can nurture and use the expertise. many adapt to the employment problem by taking up this option. this may mean moving from a developing country to a developed country or from a less developed country to a developing or developed country. ultimately, this loss of citizens with special skills can hurt a country. to counter this brain drain or reverse it, a country can adapt by investing in its future to create programs and conditions that keep talented professionals home, or if they have emigrated, entice them to return. china and india are examples of countries that have successfully taken this tact. when there are increases in a population because of immigration, problems can ensue between immigrants and a general population. adaptation to diversity and the multicultural experiences it brings to a community is often not a comfortable change. the antipathy of some in a host country is based on slowness of the immigrants to learn the language and inability of host country citizens to understand what immigrants are saying among themselves. this makes citizens feel uneasy. some view immigrants as a threat to their own or a family member's employment or advancement. race difference is a factor that some cannot readily adapt to as is ethnicity with its traditions and customs unfamiliar to the general public. religion can be divisive if adherents to its beliefs engage in acts of hatred detrimental to the host country fueled by fundamentalists and zealots who interpret religious writings as giving them license to commit crimes or absolving them of the crimes. sadly, many citizens paint an entire religious community with the taint of the relatively few evildoers. adaptation to diversity is essential for our earth's citizenry with joint efforts by all to resolve worldwide issues (e.g., global warming/climate change) so as to become the keys to providing a sound future for coming generations. there has to be a shared attack on global threats, no matter what the language, race, ethnicity, or religious beliefs are, no matter social or economic status, no matter whether a threat affects less developed, developing, or developed countries. adaptation is a progressive process when dealing with natural hazards because as each type of natural hazard impacts global communities over time, lessons are learned from each one that give direction to the methods of adjustment. adaptation to living where hazards can be expected to strike and where populations continue to increase is dependent on what we learn from the study of past hazards. we can use this evaluation of measured and observed data to minimize the immediate effects and aftermaths of hazards and protect citizens from injury, death, and from damage or destruction of property or infrastructure when hazards strike in the future. in areas prone to earthquakes, we know that earthquakes do not kill and injure people but that collapsing buildings and infrastructure do. earthquakes are not predictable so that there is no adaptation by a timely evacuation to minimize deaths and injury. however, building structures to make them more earthquake resistant can save lives, reduce injuries, and protect property. thus, after a high-magnitude earthquake, forensic engineering teams come to assess the damage and determine where and why damage and destruction took place within the context of the magnitude of an earthquake, the type of motion it originated (shaking, jarring, rolling), its duration, the area it affected, and the geologic properties of rocks underlying structures' foundations. hazard assessment teams also evaluate other factors that contributed to additional damage such as ruptured gas lines that feed fires and ruptured water lines that inhibit fire control. the engineers establish how construction can be improved in the future in terms of construction techniques and materials to prevent the types of collapses and utility failures they investigated. municipalities revise building codes accordingly to direct reconstruction and future building projects. where possible, structures that withstood an earthquake with minor or no visible damage should be retrofitted to improve their resistance to the next "big one." with each event, we gain more data on how to better construct earthquake-resistant structures and alter building codes to more stringent specifications. in theory, this adaptationto an irregularly recurring global event is good, but in practice it is most applicable to nations with the economic resources for reconstruction according to revised building codes and where there is no corruption to allow a bypass of the code. the same can be stated for retrofitting to give more resistance to earthquakes to existing structures. many developed nations and nations rich in commodity exports (e.g., oil) have a moral obligation to donate funds, material, and expertise to help citizens in economically disadvantaged nations recover from a destructive earthquake. some commodity-rich and economically sound nations do not do so directly, whereas others, big and small, rally to help disaster victims. for example, immediately after megatyphoon haiyan devastated many regions in the central philippines in , israel sent medical doctors and nurses and field hospitals to help philippine citizens recover from the impacts of the typhoon. as discussed in an earlier chapter, volcanoes are predictable in terms of becoming active by emitting wisps of smoke, bulging on a slope, warming of the soil or nearby pond or lake waters, emitting increasing concentrations of gases, and showing increased low-frequency seismicity. however, this activity does not always result in an eruption. a marked increase in measurements and observations, especially the low-frequency seismic activity, suggests that an eruption is imminent. adaptation to living and working on or near a volcano means investing in equipment to monitor volcanic activity and listening to alerts from scientists monitoring its activity and being ready to evacuate by gathering important papers and precious mementos and prepared to load into transportation for evacuation to safe locations. governments adapt by charging geologists to map out areas considered as high-, moderate-, and low-hazard zones in the volcano environs. geologists do this by studying rocks deposited from past eruptions and assessments of the topography. municipalities then pass zoning regulations applicable to the hazard level. governments have adapted to repeated periodic flooding in areas by creating flood control systems described in chap. . dams hold water during times of heavy and/ or extended rainfall and release any overflow into channels that move water away from urban or rural population centers. levees increase the volume of water that can move through a channel, thereby keeping it from spreading into populated areas and cultivated farmland. for smaller waterways that flow through cities, municipalities may invest in deepening, widening, and straightening channels as well as erecting walls so that more water can flow through the area more rapidly without coming out of a channel. governments define zones on flood plains according to a recurrence interval of damaging floods (e.g., years) as being off limits for residential and factory/plant construction. as much as we plan to adjust to living in an area prone to flooding, there is always the possibility of a megaevent that can overcome in situ control systems. therefore, as described chap. , governments adapt to this possibility by installing flood prediction equipment in drainage basins to provide warning to those at risk from rising and sometimes raging waters. the warning gives people time to gather important documents and personal treasures and evacuate to safe areas. the apparent increase in the frequency and magnitude of storms and resulting flooding in recent years is thought by many weather scientists to be related to global warming and the increased amount of moisture in the atmosphere from warmer oceans that gathers in clouds and precipitates during storms. this will be discussed further in this chapter. adaptation to extreme weather events such as an extended period of drought, heat waves, and frigid weather means preparation to wait them out. some municipalities adapt to repeated, sometimes seasonal, times of short-term drought by storing a - month water supply in surface or underground reservoirs during periods of normal precipitation that can be tapped (conservatively) as needed. others may plan to move water via pipes or water tankers from where it is plentiful to where drought conditions exist. otherwise, to survive, people move as best they can to where they have access to water. in instances of years long drought, crops and livestock and other life forms may be lost. heat waves can kill. adaptation to heat wave conditions means that water has to be available to people to avoid dehydration. where possible, homes should have air-conditioning or fans to keep people comfortable and municipalities should have cooling centers to which people can go. personnel should check on senior citizens and escort them to cooling centers if necessary. clearly, economically advantaged nations have the resources to give support to citizens during natural hazards such as these. these nations, international organizations, and ngos have a moral obligation to help economically disadvantaged nations as is possible when hazard conditions such as these threaten populations. the most extreme of weather conditions that can injure and kill people and destroy housing and infrastructure are tropical storms that evolve into violent hurricanes (typhoons, monsoons) by increasing wind speeds and sucking up moisture (water) as they track across oceans toward land. when these storms make landfall, they drive storm surges that can wreak havoc onshore communities, and as they move inland precipitate heavy rains that cause life-threatening and destructive flooding. these violent storms are destructive to coastal populations and island nations and have regional reach inland as they move along paths until they finally spend their energy or move out to sea. on november , , the typhoon named haiyan, the strongest recorded typhoon ever to make landfall smashed into the central philippines killing more than , people, injuring about , , and displacing almost , people. there was a -m (* ft) storm surge driven by winds measured at over km/h ( mi/h) with gusts reaching km/h ( mi/h). the typhoon flattened the city of tacloban that was home to , residents, and there was major flooding inland. the weather alerts led to a government call for evacuation away from the predicted path of the storm, and about million people followed the evacuation warning, surely saving many lives. access to aid typhoon-ravaged areas was difficult, and there were shortages of water, food, and medical care for many evacuees for several days. the philippine central government and local officials were not prepared to deal with a storm of this magnitude but help started arriving from many nations worldwide. there was a post-event concern of attending to sanitation needs of survivors to prevent outbreaks of diseases such as cholera, typhoid fever, hepatitis, and dysentery. if the philippine government had adapted by adopting better policies with respect to response to high-category typhoons in addition to the call for evacuation, the impact of haiyan would have been ameliorated. one would hope that this deficiency would be dealt with to limit the effects of future like disasters. evacuation to prevent injury and death in coastal zones that could be struck by high winds, heavy sustained rains, and storm surges is dependent on weather bureau forecasts and warnings from police, firefighters, or other government-authorized personnel. homeowners adapt to hurricanes by securing roofing with additional nails or special fasteners as a retrofit precaution and by boarding up windows on structures before an incoming storm hits. governments have adapted to the onslaught of violent high-energy storms by constructing seawalls of varying designs and heights to protect population centers by damping the force of storm surges. in china, for example, a seawall . m (* ft) in height and that has been heightened in the past protects shanghai from the full damaging effects of high-category typhoons. as a result of rising sea level, the shanghai seawall and other that protect coastal cities from being flooded by surges from high-energy tropical storms will have to be heightened to afford a greater degree of protection to people and property. wildfires can be a natural hazard when ignited by a lightening strike. however, most wildfires are started by human carelessness such as tossing a lit cigarette on a forest floor or failing to completely extinguish a campfire, or by arsonists. one may adapt to living in an area with a history of wildfires in two ways, neither of which is practical or promises % protection. first would be to clear an area of vegetation in a -m ( ft) swath around a dwelling or site for building. second would be to build with nonflammable materials so that embers propelled during a wildfire could not ignite a structure. adaptation to the advance of a wildfire would be to heed warnings to evacuate carrying a prepared case with important documents and other items of personal value. to delay evacuation by going back to retrieve something from then home can be fatal as it was for two people in a recent (june, ) wildfire that destroyed almost homes in colorado springs, colorado, usa. when there is a hazard event coming that calls for evacuation, responsible and often economically advantaged governments have adapted to the threat by designating evacuation routes, by providing transportation for people who need it, by having evacuation centers stocked with water and food, cots and blankets, basic medical supplies and medical personnel, and by having phone service available for people that need it. in the case of a primary or triggered hazard that happens with little or no warning (e.g., an earthquake, a tsunami, a volcanic mud flow), search and rescue teams should be ready to move in soon after dangerous conditions ease and they can move with safety. there should be medical attention to treat injured survivors, and stations set up as soon as possible to provide water, food, and other essentials available to those that survived with little or no physical hurt. these first steps at adaptation are the keys to survival. recovery after a shock phase can be long and drawn out, depending in grand part on a nation's social and economic resources and physical and economic assistance from other nations, international institutions, and ngos. change on our earth's inhabitants global warming is a fact attested to by an overwhelming majority of the scientific community and unwaveringly supported by a february joint publication of the us national academy of sciences and the royal academy in the uk on the causes and evidence for global warming [ ] . as noted in earlier chapters, during the past century, measurements show that the earth has warmed by * . °c (* . °f). global warming is an ongoing process that is attributed in grand part to a slow but continuous and increasing buildup of greenhouse gases in the atmosphere. the greenhouse gas most associated with global warming is carbon dioxide (co ). a plot of the increase of co content in the atmosphere with time against the increase in global temperature shows an excellent correlation of one with the other. additional lesser contributors include methane (ch ), nitrous oxide (no ), and chlorofluorocarbons (cfcs). with the beginning of the industrial revolution and the increased use of coal as the principal energy source, the content of co in the atmosphere was parts per million ( . %). the combustion of coal and later oil (petroleum) and natural gas emits co to the atmosphere. initially, and for many years thereafter, the added greenhouse gases were taken up by vegetation for photosynthesis and was also absorbed by the oceans and other water bodies. this kept the atmosphere co close to the ppm pre-industrial level. however, with increased industrialization, the need for electrical power, and the use of internal combustion engines, the amount of co generated was greater than what could be absorbed by nature and the content of co in the atmosphere increased. during june , its concentration reached more than ppm, an increase of over % over the pre-industrial concentration (scripps institute of oceanography mauna loa measurement). the increasing co content, other greenhouse gases, aerosols, and particles acted as a media that admitted sunlight (heat energy) to the earth's surface but did not let all of the heat escape back into the atmosphere. this abets global warming. in the past two to three decades, the rush to industrialization in developing countries (e.g., china, india, and brazil) and their growing power needs and vehicular use has thwarted the implementation of international agreements to reduce emissions from coal-fired power plants, other industrial and manufacturing operations, and the transportation sector. a direct consequence of global warming is sea level rise (slr) caused by the progressive melting of icecaps and ice sheets in greenland, the arctic, and antarctica, and of mountain glaciers in the himalayas, the alps, the rocky mountains, and the andes. the * -cm (* in) sea level rise during the past century may see a rise of another * cm (* in)- m (* in) during this twenty-first century. one-third of the rise would be from the expansion of warmer sea water, one-third from icecap and ice sheet melt, and one-third from mountain glacier melt [ ] . in , other researchers used computer models on existing data and proposed that % of sea level rise between and was from glacial melt [ ] . following the same line of investigation, other scientists studied satellite data and ground measurements from alaska, the canadian arctic, greenland, the southern andes, the himalayas, and other high mountains of asia and estimated that glacier contributions to sea level rise from to was % and together with ice sheet melt explained % of slr [ ] . a publication in estimated that ocean thermal expansion - m deep and - m deep contributed up to % to sea level rise [ ] . these latter two estimations are in line with the ipcc prediction for melting ice and ocean thermal expansion contribution to the estimated rise of sea level by the end of the century [ ] . with a rise in sea level, marine waters encroach on land. as the rise continues, possibly at an increasing rate, it threatens habitation in lowlying islands, coastal villages and farmland in lowlying zones, and heavily populated cities worldwide settled on inshore terrain close to sea level (e.g., bangkok, ho chi minh city, jakarta, manila, miami, new york, boston, buenos aires, london, rotterdam). rising sea level and warming of ocean waters have other ramifications that affect coastal communities as well as inland areas. as explained in chap. , the warmer surface water releases more water vapor with heat energy into the atmosphere. when the water vapor molecules condense in clouds, heat energy is released. this energy gives more force to tropical storms as they form, track to shore, and move inland, or storms that move close to and along a coast. these storms may transition to hurricanes (typhoons, monsoons) with the violent winds that cause destruction, and heavy rainfall that triggers flooding if they move onto land. we recognize that rising sea level means that tropical storms that impact a coast with storm surges have a farther reach inland with their destructive energy that is more pronounced when the surge occurs at high tide. the surges also saturate farmland they reach with salt water that harms crops. they also carry salt water into fresh water marshes and ponds, thus disrupting ecosystems there. the increase in the number of these extreme weather events and the increase in violence and destruction they wreak on land compared with like weather events in the recent past (e.g., during the past years) strongly suggest that they are fueled to a significant degree by global warming. there are two possibilities for adapting to the effects of rising sea level on coastal urban centers, one impractical, the other very costly but doable. the impractical adaptation possibility is to move at-risk population centers inland, out of the reach of the destructive tropical storms. this does not lessen the threat of flooding. the move is possible in some cases where land is available, but such a move is not economically feasible. one practical but costly adaptation to mitigate encroachment from sea level rise and the effects of tropical storm surges is to surround cities at risk within place seawalls - m higher than recorded high tides or higher depending on historical records and contemporary published data. the walls can have a concave configuration so that surging waves lose energy when their lower parts hit and are curled back on themselves damping some wave energy or there can be a different configuration best for the site(s) to be protected. similarly, gates buried at strategic locations where there is ship access to consider can be built to be hydraulically driven so that they can rise from a near shore seabed site to mitigate the effects of storm surges. both techniques have been used at different global locations. we have read that climate change affects land-based agricultural production, both for crops and animal husbandry. the warming climate at higher mid-hemispheric latitudes and at higher altitudes does not favor the growth and normal yield and/or quality of many crops. depending upon the degree of climate change and the linked change(s) that may follow it, farmers can adapt in several ways to maintain or increase crop yield and nutrition value. for example, when warming starts diminishing the productivity of a traditional crop, farmers can sow crops that are known to grow well in warmer temperature and give a satisfactory economic benefit. however, new groups of weeds, pests, and diseases will migrate to the warmer growth environment and will have to be dealt with in order to protect the new crops. where the effect of global warming reduces water supply for rain-fed agriculture, for crops irrigated with surface waters, and for groundwater-irrigated crops when aquifer recharge does not balances discharge, agriculturalists can adapt in two ways. first is the use of a more efficient irrigation method that delivers water directly to a growing plant (e.g., drip or focused irrigation). this minimizes runoff and loss to evaporation. second and similar to what was mentioned earlier is to sow a crop that needs less water to thrive and that delivers a good yield, good-quality product. another result of global warming for some farmlands is a longer growing season. in this situation, growers can adapt by planting earlier and have the possibility of double cropping. they can also grow a cultivar that is later maturing and that gives a product that brings a good market price. however, switching to new crops in a warmer growth environment means that there will be an invasion of a new set of weeds, pests, and diseases to ward off. in any efficient operation, and as emphasized in earlier chapters, farmers adjust to a changing growth environment for a given cultivar by applying the optimum amounts of fertilizer and other agricultural chemicals as might be needed that nurture and protect it most effectively. this reduces agricultural costs and lessens runoff of these chemicals to ecosystems where they can be harmful. global warming can bring on abnormal weather extremes that affect agricultural productivity. in these cases, farmers have to plan ahead based on recent history of these conditions in their regions. drought, heat waves, and long-term rain or heavy rain in a short time present problems for both cultivars and food animals. periods of less than average precipitation may last months or years. depending on the amount of the deficit precipitation, adaptation can include storing water in reservoirs and cisterns during times of rainfall to be tapped during a drought to sustain food animals and crops during a short-term, not too severe drought. there is also the option of trucking in water to sustain livestock. long-term droughts when precipitation deficits are high take their toll on plants and animals to the detriment of agriculture in a region especially when accompanied by heat waves. they have caused recent disasters for crops and food animals on all continents less antarctica. farmers either wait out the "bad times," change the type of cropping they do, the livestock they tend to, or change careers. the adaptation from crops that have been grown successfully before the effects of global warming reduced yields and quality of a harvest, to those "same" crops that can grow successfully under the advancing warming changes just described generally means that hybridized species have to be developed and used as warming increases at a location and slowly tracks to higher latitudes and higher altitudes. thus, growers turn to plants that are created by hybridization as described in chap. : traditional methods and marker-assisted selection methods within the same species, and genetically engineered (-modified, -manipulated) methods using different species. hybridization is a slow process, sped up markedly by genetic engineering, a method that yields foodstuff not accepted by the european union and many nations outside the union, especially in africa. bred species are developed to carry one or more characteristics that favor crop resilience against the effects of climate change. these include resistance to disease, weeds, and pests, and tolerant of drought (water stress), heat, short-term inundation, and short-term saline exposure (see chap. ). hybrids have also been developed to give higher yields and more nutritious crops. thus far, research has been focused mainly on improving seed for world staples such as rice, maize (corn), wheat, sorghum, and soybean. there have been great successes where hybrid crops were agriculturalists' adaptation so that the possibility exists that we can feed the earth's growing populations and reduce chronic malnutrition. when this is coupled with the opening of additional arable acreage and the use of improved farming methods for seeding, watering, and harvesting, global food security can be strengthened for the existing world population and the future generations on earth. however, this will require economic and technical input by developed nations and international groups. without basic sustenance, people will have less resistance to diseases and there may be local or regional population crashes if diseases evolve into epidemics or pandemics that invade susceptible populations. warming of the open ocean water, enclosed aquaculture operations in ocean waters and on land water bodies has affected marine fisheries and marine and estuarine aquaculture that grow food fish and shellfish, and lakes that sustain fisheries. in marine fisheries worldwide (e.g., in the north atlantic, off the coast of peru, off the coast of the philippines), some food fish or fish captured for other purposes (e.g., to use in pet food, to use to make fertilizer) have migrated to cooler water in ecosystems with conditions conducive to their spawning and growth. in some cases, predators follow fish they prey upon that have migrated to cooler waters, but in other cases they find new prey to sustain them. in other situations, they may become prey for larger fish in an ecosystem. fishing fleets adapt by following the fish they hunt into cooler waters where ideally they capture the hunted species in quantities allotted them by national and international fishery governing body regulations. if the quota system is followed, this will allow recovery of fish populations and sustainable harvesting. aquaculture operations that provide important supplies of food fish worldwide can adapt to warming waters by raising food fish or shellfish that will grow and multiply under the changed range of day/night temperature conditions if the fish they are farming cannot survive in the warmer waters. aquaculturalists also have the option to move their facilities to cooler-temperature waters, but the economic feasibility of doing this has to be evaluated by a benefit to cost analysis. this analysis has to be for the time frame during which the cooler-ecosystem waters are estimated to remain stable within the framework of a time range against global warming/climate change. another adaptation is that food fish currently being raised can be genetically engineered to be resistant to a warmer growth environment without changing their nutrition yield, growth rate, and ability to reproduce. there are diseases that are global threats, others that put regions at risk, and yet others that menace smaller political divisions. humans adapt to the threat of sickness in a population or a sickness itself in several ways. scientists develop methods to eradicate a virus or bacterium health threat, or a chemical/radioactivity threat. failing this, health professionals act to control a disease, to slow or minimize its transmission, and to apply approved therapies and support research to find therapies to treat an illness if one is transmitted. the following discussion draws strongly on the disease fact sheets put out by the world health organization. vaccines provide a main line of defense against many diseases. smallpox has been eradicated on earth by vaccination. polio has all but been eradicated globally except for a few pockets of the disease in pakistan, afghanistan, and nigeria where, in some cases, religious fundamentalists have beaten and killed health workers tasked with giving the vaccine to children, and in other cases where parents have been warned by the zealots against allowing their children to be vaccinated. recently, polio cases were diagnosed mainly in somalia but also in kenya. this is attributed to the fact that by , , children in somalia have not received the vaccine and are at risk from this highly contagious disease. it is also attributed to crossborder migration of infected persons into kenya. both governments are stepping up their vaccination programs. there were cases of polio diagnosed in the rest of the world in . measles is a global disease that can be prevented by a vaccine that is safe and cost-effective. measles may soon reach the near-eradication stage. in and subsequent years, . million people, mainly children under years of age, died from measles. since , billion children were vaccinated, million in . by , % of the world's children received the measles vaccine, up from % in . from to , deaths from measles dropped to %, from , to , . when the vaccination rate reaches %, mainly in low-income countries, the world will have brought another disease close to elimination [ ] . seasonal influenza is a global viral illness that afflicts - million people. the sickness kills , - , people with severe symptoms annually. transmission of the virus takes place when an infected individual coughs or sneezes without covering his/her mouth and releases droplets that can be inhaled by someone up to a meter away. transmission can also be from hands carrying the virus. seasonal influenza affects all age groups, but children less than years old, people over , and those with complicating medical problems are most at risk. influenza is a disease to be controlled. the principal control is by safe and effective vaccines that can prevent - % of influenza cases in healthy adults. secondary controls are obvious for infected persons: cover the mouth when sneezing or coughing, and wash the hands frequently. the influenza vaccine is taken once annually. because strains of the influenza virus change from year to year, adaptation is needed. the adaptation is via a vaccine that is prepared with or strains that scientists determine will be most common during a coming season [ ] . other types of influenza and respiratory illnesses have the potential to cause an epidemic or pandemic. they include avian flu and its strains and swine flu if the strains develop the ability for person-to-person transmission after infection, and sars (severe acute respiratory syndrome) and middle east respiratory syndrome (mers) because there is human-to-human transmission of the sicknesses. to the present, the outbreaks of the animal influenza diseases have been contained by quarantining infected people during treatment and by culling flocks and herds, or if available, vaccination of healthy animals. the latter two respiratory illnesses are caused by the coronavirus, and infected people have been in isolation wards. for sars, an illness that broke out in and spread to countries, isolation of victims and treatment with antiviral drugs and steroids stopped the disease during . mers is a recent ( / ) illness that has been confined to jordan, saudi arabia, qatar, and the united arab emirates. the mers virus has been found in camels. infected persons are quarantined in hospitals, but an effective drug treatment is still being sought to complement the normal hospital care-afforded patients. hiv/aids is a global epidemic that killed million people in three decades since . worldwide, in , there were million people with hiv, mainly ( million or %) in sub-saharan africa and south/southeast asia. the illness is caused by the exchange of body fluids (semen, vaginal excretions, blood, breast milk) from an infected individual with an uninfected person. more than % of the cases of hiv are from heterosexual activity. there is no vaccine against hiv/aids, no cure for it, but there is a cocktail of medicines (antiretroviral treatment) that control viral replication and allow an infected person's immune system to strengthen. this keeps the illness at bay and afflicted people in general good health and productive in their communities. in , only . million (less than %) of those with hiv in low and middle economies received the antiretroviral treatment. this is changing as more hiv carriers have access to antiretroviral therapy and there are more donations from economically advantaged countries to support hiv stabilization and reduction programs. the number of new cases of hiv is not exploding because more than % of those infected are following protocols that reduce the transmission of the disease. the prevention of transmission methods include access to male and female condoms, blood screening before transfusions, and needle and syringe exchange programs for sterile injections by drug users. hiv testing and education programs and hiv treatment help prevent transmission because individuals in continuous treatment have a very low probability of passing on the disease. male circumcision reduces the infection in men by about %. there is still much progress to be made because there were . million new cases of hiv in , with . million of that total in sub-saharan africa. the hiv/aids is a global sickness that is slowly coming under control because of generous donations from governments and foundations in developed countries added to what low-and middle-income countries themselves provide to lower the prevalence and incidence of hiv in their populations [ ] . tuberculosis (tb) infected . million people globally in , killing . million persons. it is a bacterial disease that spreads among people when infected individuals cough, sneeze, or spit, releasing bacteria into the air where they can be inhaled by others a meter away. although tb occurs worldwide, developing countries carry the largest burden of cases and deaths ( %). the bulk of new cases are regional in asia ( %) with sub-saharan africa reporting a large share as well with , new cases per million inhabitants. there is no vaccination for tb, but the disease can be treated and cured. the treatment is a half-year course of four antimicrobial drugs that must be taken without fail and thus requires continual supervision by healthcare personnel. more than million people have been treated and cured of tb since and perhaps million lives saved by following the who stop tb strategy protocols including securing adequate, sustained financing, ensuring early reliable detection and diagnosis, and providing approved treatment with a secure effective drug supply. the number of people infected with tb is declining, and from to , the tb death rate dropped more than %. the success in dealing with tb is muted somewhat because a strain of the bacterium that causes tb has evolved to be multidrug resistant (mdr-tb). in , , cases of this variant were reported (of the . million cases worldwide), mainly from india, china, and the russian federation. these are treated with, but do not always respond to, the most effective anti-tb drugs. research into new drugs to deal with this problem is ongoing [ ] . there is the question of whether people visiting or immigrating from these countries should be screened before a host country issues them entry visas. regional illnesses threaten the health of s of millions of people mainly in tropical and subtropical areas and often affecting children. one of these, the guinea worm disease, is trending toward elimination, if not eradication. this is a parasitic disease caused when people swallow water contaminated with infected water fleas (microscopic copepods) carrying worm larva. the worms release, penetrate the intestines, and move through the body migrating under the skin until they emerge causing swelling and blistering. people infected with guinea worm disease cannot contribute to their communities for months. during the mid- s, there were . million cases mainly in african nations. but attention to where the sources were so that they could be avoided and treated, and assistance in generating clean water, were adaptations that brought the number of cases down to less than , in . the number of cases continued to decline and was reduced to in in four african countries: south sudan, chad, ethiopia, and mali. there is no vaccine against guinea worm disease. health officials adapt to counter this sickness in several ways. as noted above, access to clean drinking water is the best way to prevent infection. the prevention or transmission of the worms from infected individuals to healthy persons by proper treatment and hygiene and the use of the larvacide temephos to eliminate the parasite-infected water flea vector and other prevention protocols are important in the control and effort to eliminate/eradicate the disease [ ]. the (jimmy) carter institute, atlanta, georgia, usa, has been a principle force since in the fight to rid the world of guinea worm disease. in tropical and subtropical regions, there are three mosquito-vectored diseases that put millions of people at risk: yellow fever, malaria, and dengue fever. yellow fever is an endemic viral disease in tropical regions of africa and latin america with , cases reported annually that cause , deaths. there is no set treatment for afflicted people, but there is an adaptive preventive measure. a vaccine against yellow fever is available that is safe, affordable, and that gives lifelong immunity to the disease with one dose after - days for % of the people vaccinated. when there is the onset of a yellow fever outbreak where the population lacks vaccination protection, mosquito control is an essential first step in adaptation to prevent or slowdown transmission of the yellow fever virus. spraying insecticides to eliminate breeding sites and kill adult mosquitos is the control used during epidemics to make time for vaccination campaigns in a population and for immunity to take hold. there are limitations to the application of the yellow fever vaccine. first is that babies less than months of age should not be vaccinated or, during an epidemic babies less than - months of age should not receive the vaccine. second, pregnant women should not be vaccinated except when there is an outbreak of the disease. third, people with a strong allergy to egg protein or those with a marked immunodeficiency or with a thymus problem should not receive the vaccine [ ] . malaria is a parasitic disease caused by the bite of an infected mosquito. there is no vaccine against malaria, but one is undergoing a clinical trial in seven african nations with results expected in . a use or no use decision as a control method for malaria will be made in . promising results from an early-stage clinical trial of an unconventional vaccine prepared with live, weakened sporozoites of the malaria parasite were published in . plasmodium falciparum was given to healthy - year-old volunteers intravenously. the volunteers were grouped to receive - doses and subsequently exposed to bite by five mosquitoes carrying the parasite. none of the six that received five doses were infected with malaria. three of the that received four doses became infected, whereas of the that received lower doses became infected. of that received no vaccine, became infected. those that became infected were treated with malarial drugs and cured. clearly, higher dosages give protection against infection by malaria [ ] . more research and extensive clinical trials are necessary to determine how children respond to the vaccine with adjusted dosages and whether the results from earlystage trial are reproducible in larger volunteer populations. if the results of additional clinical trials go well, the hurdle of producing enough vaccine and adapting it to injection has to be faced. forty percent of the deaths from malaria are of african children in the democratic republic of congo and nigeria. in addition to sub-saharan africa, populations in asia (especially india and the greater mekong region) and latin america suffer from the disease. the effort to deal with the disease that is preventable and curable now centers on control and treatment to reduce the number of cases. in , the who reported that there were million cases and , deaths (with an uncertainty range of , - , ). in a report, researchers suggested that the number of deaths was understated and that their computer model gave a figure for almost double, , , deaths ( % uncertainty interval of , - , , ) [ ] . the who stood by its figure stating that much of the data in the cited study were based on verbal testimony of how people had died, not on laboratory diagnosis of samples. either figure represents too many deaths from the disease and have to be reduced. mosquito control is the adaptation that can reduce the transmission of the disease greatly. this includes personal protection by use of proper clothing and/or the application of mosquito repellent, the use of longlasting insecticidal (pyrethroids treated) nets to kill mosquitos and prevent nighttime bites, and indoor residual spraying (remains effective for months). those people infected can be treated with oral artemisinin monotherapy followed by a second drug. failure to complete the treatment as prescribed leaves parasites in a person's blood. no other antimalarial treatment is available so that parasite resistance could become a serious problem. for visitors to a malaria region, antimalarial drugs taken before, during, and after a trip can protect them from the disease. many countries in tropical and subtropical areas have used the above-cited strategies and others to work toward the elimination of malaria. malaria eradication is the goal of the who [ ] . dengue fever is a female mosquito-borne virus that infects people with an influenza-like disease in tropical and subtropical regions worldwide. the disease can kill if it evolves to severe dengue. it is endemic in latin america and asia where most cases now occur. since the s, the sickness has spread to more than countries putting about % of the world's population ( . billion people) at risk. dengue fever is especially endemic to urban/semi-urban environments. humans are the main carrier of the virus. after a mosquito bites an infected person, each subsequent bite by the infected mosquito creates another carrier. a mosquito can bite many people each time it feeds. in the americas alone, there were . billion cases of dengue fever reported in with , being severe dengue. there is no vaccination against dengue fever, but research continues to develop one. the main treatment for afflicted persons is to keep them hydrated. adaptation to deal with slowing or stopping the spread of dengue fever involves three main tracks in addition to spraying insecticide to kill mosquitos. the best control method to prevent the transmission of the virus is to deprive mosquitos of sites with shallow, standing water where they can lay eggs and multiply. control can be improved if communities cover and clean water storage containers regularly, and use proven insecticides on them as necessary. finally, individual protection such as the use of mosquito repellants and insecticide-impregnated bed nets can help reduce the incidence of dengue fever as it has with malaria [ ] . although controls are known, they are not always applied because of economics and other factors that prevent access to protection methods. the result is that the number of cases of dengue fever reported continues to grow globally. as populations increase in urban locations, the incidence of dengue fever can be expected to increase as well unless strict controls are enforced until a safe and cost-effective vaccine is developed. a positive aspect of the dengue fever problem is that recovery from one serotype of the virus gives immunity for life. however, there are four serotypes of the infectious virus so that recovery from one leaves a person susceptible to the others [ ] . chagas is another regional disease. it infects - million people annually, mostly in latin american countries. it is a parasitic illness that evolves after the bite of a blood-feeding triatomine bug, often on the face, where it defecates close by leaving parasite-bearing feces. parasites access the body when the feces are inadvertently smeared into the bite, the eyes, the mouth, or any skin lesion. the parasites circulate in the blood expressing their presence as a purplish swelling of one eyelid or as a skin lesion. there are several other symptoms as well in this acute stage of the illness, but these may be absent or mild. if diagnosed early during this stage, chagas disease is treatable. the parasite is killed with the medicines benznodazole and nifurtimox taken for months. there are limitations as to who can take these medicines (e.g., not by pregnant women or people with kidney or liver problems). the untreated sickness can cause cardiac alterations and digestive problems that show up - years after an untreated infection. chagas disease can be spread by blood transfusion and by organ transplant, making blood screening for the parasite essential before a procedure. it can also pass to a fetus from an infected woman. there is no vaccination against the illness so that control of the vector (triatomine sp.) is necessary. the controls adapted by many municipalities include insecticide spraying inside a home, the use of treated bed nets, and hygiene practices that protect food, its preparation, and its storage before eating it [ ] . the sickness may recur if control practices become lax. chagas disease is spreading as populations emigrate from latin america to northern countries. blood screening of visitors or immigrants from the countries where chagas is endemic may be necessary, and treatment followed by an infected individual before a host country issues an entrance visa. this would prevent the ingress and possible spread of chagas. outbreaks of diseases in town and cities is most often caused by bacterium-contaminated water or food and poor sanitation. sicknesses such as cholera, typhoid, and various other diarrhea types are examples of such diseases. they are all highly infectious if good hygiene practices are not followed. these diseases are endemic in many countries where populations do not have access to safe water and adequate sanitation. there are vaccinations for some of these sicknesses that may require more than one dose, but they may not be completely effective or long lasting and require revaccination at times specified by medical personnel (e.g., after - years). otherwise, infected persons can be treated with medicines such as oral rehydration pills or antibiotics. adaptation for prevention is easier called for than realistically available: washing hands with soap and clean water after visiting the toilet, and as noted above, access to safe water and good sanitation. given the millions of people infected by these bacterial diseases and the hundreds of thousand that die from them annually, generally in economically disadvantages countries, there should be an expanding global priority to eliminate the disease-causing conditions, and preparedness to combat an outbreak when it is reported. there are important factors to consider when adopting plans to halt or meliorate the effects of health threats to people in the near and extended future. one is the climate change-driven spread of tropical and subtropical diseases discussed earlier to newly warmer and moister higher-latitude and higher-altitude zones. another is the growth of populations mainly in tropical and subtropical regions in africa, asia, and latin america. together with this latter factor are the increasing populations and population densities in urban centers especially in the regions just cited. an additional factor to consider is whether there is accessibility to populations by healthcare workers or by people to healthcare clinics or hospitals, well-staffed and well-stocked with necessary pharmaceuticals. certainly, future planning has to include funding to support research to develop vaccines for diseases that do not have vaccination as an option against an illness (e. g., malaria, dengue fever) . in addition, improvement of vaccines that are available but that are not completely effective in terms of protection or the length of time they are effective should be a priority in pharmaceutical and biotechnology laboratories. scientists presented a fine review of the status of vaccine research from the design and development of vaccines to discussion of vaccines and infectious diseases (e.g., hiv, malaria, tuberculosis, pneumococcal disease, and influenza) [ ] . they also discuss vaccines against enteric infections and viral diseases of livestock as well as vaccines against non-infectious diseases (e.g., cancer) and against chronic noninfectious diseases. continued and repeated education classes on how to prevent the transmission of diseases and free supplies of materials that work to this end (e.g., insecticide-treated bed netting, male and female condoms) are essential to reducing the prevalence and incidence of diseases as are safe water and uncontaminated food. as new medicines or combinations of medicines are developed, tested, and found to be effective in controlling diseases, they become part of the protocol for either curing disease or controlling disease to reduce transmission while allowing persons to carry on with their lives. in these times of easy and rapid migration, one wonders whether screening of visitors or immigrants for diseases known to be endemic or active in the countries or regions from which they come should be required so as to prevent a carrier from infecting others and spreading a disease (e.g., chagas disease, cholera, tuberculosis). this was done at airports during the sars scare for people leaving or entering a country (e.g., china) and likely limited the transmission of the sars virus and spread of the disease. preparedness for a disease outbreak, response to an outbreak, and management of resources during and post-outbreak are the keys to adapting to health threats that could affect future generations. this means developing the capability to extend the reach of health services to regions where climate change brings warmer, moister conditions to higher-latitude and higher-altitude ecosystems that are now reached by disease vectors that have expanded into these formerly cooler and drier environments as a result of global warming. adapting to this reality and planning ahead makes it possible to deal with and stem an incipient outbreak of disease before it is transmitted and spread to the general population. this becomes essential when there is a future disease outbreak in large, dense populations in tropical and subtropical urban centers as well as those in regions warmed and humidified by climate change to subtropical and tropical settings. remember that urban populations worldwide, especially in africa, asia, and latin america, are where much of the global population growth will take place during the next few generations. under these conditions, diseases can spread rapidly in many ways. these include from bites of vectors, by respired droplets after an infected person coughs or sneezes, and by touching surfaces bearing viruses, bacteria, or parasites. diseases are also spread by ingestion of contaminated water and/or tainted food, and by other methods of infection transmission. disease transmission can be checked by rapid response teams with appropriate and sufficient supplies to treat (and perhaps places to quarantine) those in the infected population. lastly, it must be noted that there are many other diseases in addition to those cited previously for which prevention, treatment, and cures are research priorities in laboratories worldwide. in addition, there are addiction diseases that can trigger health problems in important segments of society. these include smoking (e.g., emphysema, lung cancer), alcoholism (e.g., cirrhosis of the liver), drugs (e.g., various psychological and physical ills), and overeating (obesity, diabetes, high blood pressure). adaptation to these health threats involves public education forums through various media outlets, counseling, and sponsored groups with their individual group meeting, and programs are assisting many in breaking from an addiction to the benefit of a healthier life. adaptation to meet the health challenges in the past, and in contemporary times has been a slow, progressive adventure with many successes but with much yet to be done. this is the planned path for the future: meet the challenges of societal health threats, resolve many, and keep researching to resolve others. a special ipcc report in examines in a general way adaptation to a changing climate as a risk management approach [ ] . it uses pre-planning to reduce exposure and vulnerability to extreme hazard events by preparing for them beforehand, responding to their impacts on people, structures, and infrastructure, and having in place recovery systems that can act when a danger condition eases. in this way, there will be an ability of populations to cope with future risks brought on by a changing force with which a hazard impacts a community, changes in the frequency of an occurrence, and extension of the spatial reach of its destructive power. much of this has been discussed in the chapters of the book you are reading. an understanding of what is being done now to adapt to the various problems society faces during the second decade of the twenty-first stimulates proposals of how to adapt to them as global conditions change in the future. to this end, the world bank commissioned a study on the effects global warming as it increased from . °c that exists on our planet now to what can be expected if the warming reached °c, a change that many scientists believe we can adapt to, and then reached °c as warming continues [ ] . the study centered on regions with high population growth and great susceptibility to be negatively impacted by climate changes: ( ) sub-saharan africa where food production is at risk: ( ) southeast asia where coastal zones and productivity are at risk; and ( ) south asia where there could be extremes of water scarcity and excess. the effects of higher temperatures from global warming and climate change included what has been discussed in previous chapters of this book: heat, drought, sea level rise, coastal zones, typhoons, flooding, river runoff, water availability, ecosystem shifts, crop yields, fishing, aquaculture, livestock, health and poverty, and tourism. projections such as those published in the world bank study give impetus to governments, international institutions, multinational companies, private foundations, and ngos to think now, to invest now, and to research now for adaptations that can be realized in good time and that will provide global citizenry with a good quality of life where needed. in this book, we have examined existing human populations and the problems they are experiencing in the second decade of the twenty-first century and have also considered growing populations globally and additional problems future generations will experience. we have discussed strategies on how to cope with manyfaceted threats to citizens. these include how to nourish those who need food and water, how to shelter people safely from natural and anthropogenic hazards, how to provide them with healthcare, education, and employment, and how to prepare them for the evolving global warming and the physical and biological dangers that ensue from climate change. given the present global conditions with about % of our earth's population suffering from malnutrition and more than % not having access to safe water, our capability of nourishing a billion and a half more people by is in question. also problematical is our capability to provide for an additional billion people years later, or a total of at least . billion people by the turn of the century, that is, if we reach those population figures or have population crashes such as from pandemics that can kill scores of millions if a disease is not immediately treatable, or an unlikely but possible nuclear conflagration that could do the same. less likely yet is an explosion of a small asteroid or comet in the atmosphere such as happened in a poorly inhabited area of siberia in . here, an exploding mass more than m in size knocked down millions of trees in an area greater than , km (close to mi ) with energy thought to be , times greater than the hiroshima atomic bomb. clearly, such an event could kill the population of a megacity if it were to occur. another question is whether national governments are economically strong enough and have the will to set priorities that adopt strategies to protect citizens from natural (e.g., earthquakes) and anthropogenic (e.g., pollution) hazards as well as from extreme weather conditions that are supported by global warming (pollution of the atmosphere) but are naturally occurring. countries can also improve social and economic conditions by investing in health care and education for their citizens in order to form a sound and knowledgeable cadre that would be attractive to investors interested in locating a development project that would provide employment. again, this is in question given limited national economic capabilities and the increasing numbers of people to be accommodated, especially in several developing and less developed countries in africa, asia, latin america, and the middle east. at this point, we must ask, "what is the carrying capacity of the earth?" have we reached it at billion given the billions who are today under served in developing and less developed countries? some scientists will answer yes, whereas others believe that advances in agriculture and technology can allow population expansion although to what point is not defined. can countries that are poisoning their environments do a turn around to save their citizens from grief? can they exert controls on operations that create unhealthy conditions that sicken people, lessen agricultural production, and otherwise disrupt local, regional, and global climate change: evidence and causes ( p) intergovernmental panel on climate change ( ) climate change (as four part report). part . the physical science basis mitigation of climate change past and future sea level change from the surface mass balance of glaciers a reconciled estimate of glacier contributions to sea level rise ocean thermal expansion and its contribution to sea level rise tuberculosis. fact sheet no. p . world health organization ( ) dracuncukiasis (guinea-worm disease) protection against malaria by intravenous immunization with a non-replicating sporozoite vaccine global mortality between and : a systematic analysis world health organization ( ) malaria. fact sheet no. p . world health organization ( ) dengue and severe dengue chagas disease (american trypanosomiasis). fact sheet no vaccines and global health ) ipcc special report summary for policy makers. managing the risks of extreme events and disasters to advance climate change adaptation turn down the heat: climate extremes regional impacts and the case for resilience. a report for the world bank prepared by potsdam institute for climate impact research and climate analytics key: cord- -yqu ykc authors: nan title: early warning systems a state of the art analysis and future directions date: - - journal: nan doi: . /j.envdev. . . sha: doc_id: cord_uid: yqu ykc nan united nations' international strategy for disaster reduction (isdr), it integrates (united nations, ) : . risk knowledge: risk assessment provides essential information to set priorities for mitigation and prevention strategies and designing early warning systems. . monitoring and predicting: systems with monitoring and predicting capabilities provide timely estimates of the potential risk faced by communities, economies and the environment. . disseminating information: communication systems are needed for delivering warning messages to the potentially affected locations to alert local and regional governmental agencies. the messages need to be reliable, synthetic and simple to be understood by authorities and the public. . response: coordination, good governance and appropriate action plans are key points in effective early warning. likewise, public awareness and education are critical aspects of disaster mitigation. failure of any part of the system will imply failure of the whole system. for example, accurate warnings will have no impact if the population is not prepared or if the alerts are received but not disseminated by the agencies receiving the messages. the basic idea behind early warning is that the earlier and more accurately we are able to predict short-and long term potential risks associated with natural and human induced hazards, the more likely we will be able to manage and mitigate a disaster's impact on society, economies, and environment. environmental hazards can be associated with: ongoing and rapid/sudden-onset threats and slow-onset (or ''creeping'') threats: . ongoing and rapid/sudden-onset: these include such hazards as follows: accidental oil spills, nuclear plant failures, and chemical plant accidents -such as inadvertent chemical releases to the air or into rivers and water bodies -geological hazards and hydro-meteorological hazards (except droughts). . slow-onset (or ''creeping''): incremental but long-term and cumulative environmental changes that usually receive little attention in their early phases but which, over time, may cause serious crises. these include such issues as deteriorating air and water quality, soil pollution, acid rain, climate change, desertification processes (including soil erosion and land degradation), drought, ecosystems change, deforestation and forest fragmentation, loss of biodiversity and habitats, nitrogen overloading, radioactive waste, coastal erosion, pressures on living marine resources, rapid and unplanned urban growth, environment and health issues (emerging and re-emerging infectious diseases and links to environmental change), land cover/land changes, and environmental impacts of conflict, among others. such creeping changes are often left unaddressed as policy-makers choose or need to cope with immediate crises. eventually, neglected creeping changes may become urgent crises that are more costly to deal with. slow-onset threats can be classified into location-specific environmental threats, new emerging science and contemporary environmental threats (table ) . rapid/sudden-onset and slow-onset events will provide different amounts of available warning time. fig. shows warning times for climatic hazards. early warning systems may provide seconds of available warning time for earthquakes to months of warning for droughts, which are the quickest and slowest onset hazards, respectively. specifically, early warning systems provide tens of seconds of warning for earthquakes, days to hours for volcanic eruptions, and hours for tsunamis. tornado warnings provide minutes of lead-time for response. hurricane warning time varies from weeks to hours. the warning time provided by warning systems, increases to years or even decades of leadtime available for slow-onset threats (such as el niñ o, global warming etc., as shown in fig. ). drought warning time is in the range of months to weeks. slow-onset (or creeping) changes may cause serious problems to environment and society, if preventive measures are not taken when needed. such creeping environmental changes require effective early warning technologies due to the high potential impact of incremental cumulative changes on society and the environment. (golnaraghi, ) . the graph shows the timeliness of early warning systems for hydrometeorological hazards and the area of impact (by specifying the diameter of the spherical area) for climatic hazards. early warning systems help to reduce economic losses and mitigate the number of injuries or deaths from a disaster, by providing information that allows individuals and communities to protect their lives and property. early warning information empowers people to take action prior to a disaster. if well integrated with risk assessment studies and communication and action plans, early warning systems can lead to substantive benefits. effective early warning systems embrace the following aspects: risk analysis; monitoring and predicting location and intensity of the disaster; communicating alerts to authorities and to those potentially affected; and responding to the disaster. the early warning system has to address all aspects. monitoring and predicting is only one part of the early warning process. this step provides the input information for the early warning process that needs to be disseminated to those whose responsibility is to respond (fig. ) . early warnings may be disseminated to targeted users (local early warning applications) or broadly to communities, regions or to media (regional or global early warning applications). this information gives the possibility of taking action to initiate mitigation or security measures before a catastrophic event occurs. when monitoring and predicting systems are associated with communication systems and response plans, they are considered early warning systems (glantz, ) . commonly, however, early warning systems lack one or more elements. in fact, a review of existing early warning systems shows that in most cases communication systems and adequate response plans are missing. to be effective, warnings also must be timely so as to provide enough lead-time for responding; reliable, so that those responsible for responding to the warning will feel confident in taking action; and simple, so as to be understood. timeliness often conflicts with the desire to have reliable predictions, which become more accurate as more observations are collected from the monitoring system . thus, there is an inevitable trade-off between the amount of warning time available and the reliability of the predictions provided by the ews. an initial alert signal may be sent to give the maximum amount of warning time when a minimum level of prediction accuracy has been reached. however, the prediction accuracy for the location and size of the event will continue to improve as more data are collected by the monitoring system part of the ews network. it must be understood that every prediction, by its very nature, is associated with uncertainty. because of the uncertainties associated with the predicted parameters that characterize the incoming disaster, it is possible that a wrong decision may be made. two kinds of wrong decisions may occur : missed alarm (or false negative), when the mitigation action is not taken when it should have been or false alarm (or false positive), when the mitigation action is taken when it should not have been. finally, the message should communicate the level of uncertainty and expected cost of taking action but also be stated in simple language so as to be understood by those who receive it. most often, there is a communication gap between ew specialists who use technical and engineering language and the ews users, who are generally outside of the scientific community. to avoid this, these early warnings need to be reported concisely, in layman's terms and without scientific jargon. an effective early warning system needs an effective communication system. early warning communication systems have two main components (second international conference on early warning (ewcii), ): communication infrastructure hardware that must be reliable and robust, especially during the disaster; and appropriate and effective interactions among the main actors of the early warning process, such as the scientific community, stakeholders, decision-makers, the public, and the media. redundancy of communication systems is essential for disaster management, while emergency power supplies and back-up systems are critical in order to avoid the collapse of communication systems after disasters occur. in addition, to ensure the communication systems operate reliably and effectively during and after a disaster occurs, and to avoid network congestion, frequencies and channels must be reserved and dedicated to disaster relief operations. many communication tools are currently available for warning dissemination, such as short message service (sms) (cellular phone text messaging), e-mail, radio, tv and web service. information and communication technology (ict) is a key element in early warning, which plays an important role in disaster communication and disseminating information to organizations in charge of responding to warnings and to the public during and after a disaster (tubtiang, ) . today, the decentralization of information and data through the world wide web makes it possible for millions of people worldwide to have easy, instantaneous access to a vast amount of diverse online information. this powerful communication medium has spread rapidly to interconnect our world, enabling near-real-time communication and data exchanges worldwide. according to the internet world stats database, as of december , global documented internet usage was . billion people. thus, the internet has become an important medium to access and deliver information worldwide in a very timely fashion. in addition, remote sensing satellites now provide a continuous stream of data. they are capable of rapidly and effectively detecting hazards, such as transboundary air pollutants, wildfires, deforestation, changes in water levels, and natural hazards. with rapid advances in data collection, analysis, visualization and dissemination, including technologies such as remote sensing, geographical information systems (gis), web mapping, sensor webs, telecommunications and ever-growing internet connectivity, it is now feasible to deliver relevant information on a regular basis to a worldwide audience relatively inexpensively. in recent years, commercial companies such as google, yahoo, and microsoft have started incorporating maps and satellite imagery into their products and services, delivering compelling visual images and providing easy tools that everyone can use to add to their geographic knowledge. ews: decision making procedure based on cost-benefit analysis. to improve the performance of ews, a performance based decision making procedure needs to be based on the expected consequences of taking action, in terms of the probability of a false and missed alarm. an innovative approach sets the threshold based on the acceptable probability of false (missed) alarms, from a cost-benefit analysis . consider the case of a ews decision making strategy based on raising the alarm if a critical severity level, a, is predicted to be exceeded at a site. the decision of whether to activate the alarm or not is based on the predicted severity of the event. a decision model that takes into account the uncertainty of the prediction and the consequences of taking action will be capable of controlling and reducing the incidence of false and missed alerts. the proposed decision making procedure intends to fill this gap. the ews will provide the user with a real-time prediction of the severity of the event,ŜðtÞ, and its error, e tot ðtÞ. during the course of the event, the increase in available data will improve prediction accuracy. the prediction and its uncertainty are updated as more data come in. the actual severity of the event, e tot , is unknown and may be defined by adding the prediction error to the predicted value,Ŝ. the potential probability of false (missed) alarm is given by the probability of being less (greater) than the critical threshold; it becomes an actual probability of false (missed) alarm if the alarm is (not) raised: referring to the principle of maximum entropy (jaynes, ) , the prediction error is modelled by gaussian distribution, representing the most uninformative distribution possible due to lack of information. hence, at time t, the actual severity of the event, s, may be modelled with a gaussian distribution, having mean equal to the predictionŜðtÞ and uncertainty equal to s tot ðtÞ, that is the standard deviation of the prediction error e tot ðtÞ. eqs. ( ) and ( ) may be written as : where f represents the gaussian cumulative distribution function. the tolerable level at which mitigation action should be taken can be determined from a cost-benefit analysis by minimizing the cost of taking action: where c save are the savings due to mitigation actions and c fa is the cost of false alert. note that the tolerable levels a and b sum up to one which directly exhibits the trade-off between the threshold probabilities that are tolerable for false and missed alarms. the methodology offers an effective approach for decision making under uncertainty focusing on user requirements in terms of reliability and cost of action. information is now available in a near-real-time mode from a variety of sources at global and local levels. in the coming years, the multi-scaled global information network will greatly improve thanks to new technological advances that facilitate the global distribution of data and information at all levels. globalization and rapid communication provides an unprecedented opportunity to catalyse effective action at every level by rapidly providing authorities and the general public with high-quality and scientifically credible information in a timely fashion. the dissemination of warnings often follows a cascade process, which starts at the international or national level and then moves outwards or downwards in scale to regional and community levels (twigg, ) . early warnings may activate other early warnings at different authoritative levels, flowing down in responsibility roles, although all are equally necessary for effective early warning. standard protocols play a fundamental role in addressing the challenge of effective coordination and data exchange among the actors in the early warning process and it aids in the process for warning communication and dissemination. the common alerting protocol (cap), really simple syndication (rss) and extensible markup language (xml) are examples of standard data interchange formats for structured information that can be applied to warning messages for a broad range of information management and warning dissemination systems. the advantage of standard format alerts is that they are compatible with all information systems, warning systems, media, and most importantly, with new technologies such as web services. cap, for example, defines a single standard message format for all hazards, which can activate multiple warning systems at the same time and with a single input. this guarantees consistency of warning messages and would easily replace specific application-oriented messages with a single multihazard message format. cap is compatible with all types of information systems and public alerting systems (including broadcast radio and television), public and private data networks, multi-lingual warning systems and emerging technologies such as internet web services and existing systems such as the us national emergency alert system and the national oceanic and atmospheric organization (noaa) weather radio. cap uses extensible markup language (xml), which contains information about the alert message, the specific hazard event, and appropriate responses, including the urgency of action to be taken, severity of the event, and certainty of the information. for early warning systems to be effective, it is essential that they be integrated into policies for disaster mitigation. good governance priorities include protecting the public from disasters through the implementation of disaster risk reduction policies. it is clear that natural phenomena cannot be prevented, but their human, socio-economic and environmental impacts can and should be minimized through appropriate measures, including risk and vulnerability reduction strategies, early warning, and appropriate action plans. most often, these problems are given attention during or immediately after a disaster. disaster risk reduction measures require long term plans and early warning should be seen as a strategy to effectively reduce the growing vulnerability of communities and assets. the information provided by early warning systems enables authorities and institutions at various levels to immediately and effectively respond to a disaster. it is crucial that local government, local institutions, and communities be involved in the entire policy-making process, so they are fully aware and prepared to respond with short and long-term action plans. the early warning process, as previously described, is composed of main stages: risk assessment, monitoring and predicting, disseminating and communicating warnings, and response. within this framework, the first phase, when short-and long-term actions plans are laid out based on risk assessment analysis, is the realm of institutional and political actors. then ew acquires a technical dimension in the monitoring and predicting phase, while in the communication phase, ew involves both technical and institutional responsibility. the response phase then involves many more sectors, such as national and local institutions, non-governmental organizations, communities, and individuals. below is a summary of recommendations for effective decision making within the early warning process (sarevitz et al., ) . prediction efforts by the scientific community alone are insufficient for decision making. the scientific community and policy-makers should outline the strategy for effective and timely decision making by indicating what information is needed by decision-makers, how predictions will be used, how reliable the prediction must be to produce an effective response, and how to communicate this information and the tolerable prediction uncertainty so that the information can be received and understood by authorities and public. a miscommunicated or misused prediction can result in costs to society. prediction, communication, and use of the information are necessary factors in effective decision making within the early warning process. wishing not to appear ''alarmist'' or to avoid criticism, local and national governments have sometimes kept the public in the dark when receiving technical information regarding imminent threats. the lack of clear and easy-to-use information can sometimes confuse people and undermine their confidence in public officials. conversely, there are quite a few cases where the public may have refused to respond to early warnings from authorities, and have therefore exposed themselves to danger or forced governments to impose removal measures. in any case, clear and balanced information is critical, even when some level of uncertainty remains. for this reason, the information's uncertainty level must be communicated to users together with the early warning . resources must be allocated wisely and priorities should be set, based on risk assessment, for long-and short-term decision making, such as investing in local early warning systems, education, or enhanced monitoring and observational systems. in addition, decision-makers need to be able to set priorities for timely and effective response to a disaster when it occurs based on the information received from the early warning system. decision-makers should receive necessary training on how to use the information received when an alert is issued and what that information means. institutional networks should be developed with clear responsibilities. complex problems such as disaster mitigation and response require multidisciplinary research, multi-sector policy and planning, multi-stakeholder participation, and networking involving all the participants of the process, such as the scientific research community (including social sciences aspects), land use planning, environment, finance, development, education, health, energy, communications, transportation, labour, and social security and national defence. decentralization in the decision making process could lead to optimal solutions by clarifying local government and community responsibilities. collaboration will improve efficiency, credibility, accountability, trust, and costeffectiveness. this collaboration consists of joint research projects, sharing information and participatory strategic planning and programming. because there are numerous actors involved in early warning response plans (such as governing authorities, municipalities, townships, and local communities), the decision making and legal framework of responsibilities should be set up in advance in order to be prepared when a disaster occurs. hurricane katrina in showed gaps in the legal frameworks and definition of responsibilities that exacerbated the disaster. such ineffective decision making must be dealt with to avoid future disasters such as the one in new orleans. earth observation (eo), through measuring and monitoring, provides an insight and understanding into earth's complex processes and changes. eo includes measurements that can be made directly or by sensors in-situ or remotely (i.e. satellite remote sensing, aerial surveys, land or oceanbased monitoring systems, fig. ), to provide key information to models or other tools to support decision making processes. eo assists governments and civil society to identify and shape corrective and new measures to achieve sustainable development through original, scientifically valid assessments and early warning information on the recent and potential long-term consequences of human activities on the biosphere. at a time when the world community is striving to identify the impacts of human actions on the planet's life support system, time sequenced satellite images help to determine these impacts and provide unique, visible and scientifically convincing evidence that human actions are causing substantial changes to the earth's environment and natural resource base (i.e. ecosystems changes, urban growth, transboundary pollutants, loss of wetlands, etc.). by enhancing the visualization of scientific information on environmental change, satellite imagery will enhance environmental management and raise the awareness of emerging environmental threats. eo provides the opportunity to explore, to discover, and to understand the world in which we live from the unique vantage point of space. the following section discusses the potential role of eo for each type of environmental threat. . . ongoing and rapid/sudden-onset environmental threats . . . oil spills earth observation is increasingly used to detect illegal marine discharges and oil spills. infra-red (ir) video and photography from airborne platforms, thermal infrared imaging, airborne laser fluorosensors, airborne and satellite optical sensors, as well as airborne and satellite synthetic aperture radar (sar) are used for this purpose. sar has the advantage of also providing data during cloud cover conditions and darkness, unlike optical sensors. in addition, optical-sensor techniques applied to oil spills detection are associated to a high number of false alarms, more often cloud shadows, sun glint, and other conditions such as precipitation, fog, and the amounts of daylight present also may be erroneously associated with oil spills. for this reason, sar is preferred over optical sensors, especially when spills cover vast areas of the marine environment, and when the oil cannot be seen or discriminated against the background. sar detects changes in sea-surface roughness patterns modified by oil spills. the largest shortcoming of oil spills detection using sar images is accurate discrimination between oil spills and natural films (brekke and soldberg, ) . to date, operational application of satellite imagery for oil spill detection still remains a challenge due to limited spatial and temporal resolution. in addition, processing times are often too long for operational purposes, and it is still not possible to measure the thickness of the oil spill (mansor et al., ; us fig. . illustration of multiple observing systems in use on the ground, at sea, in the atmosphere and from space for monitoring and researching the climate system (wmo, ). interior, minerals management service, ) . existing applications are presented in the section . chemical and nuclear accidents may have disastrous consequences, such as the accident in bhopal, india, which killed more than and injured about , and the explosion of the reactors of the nuclear power plant in chernobyl, ukraine, which was the worst such accident to date, affecting part of the soviet union, eastern europe, scandinavia, and later, western europe. meteorological factors such as wind speed and direction, turbulence, stability layers, humidity, cloudiness, precipitation and topographical features, influence the impact of chemical and nuclear accidents and have to be taken into account in decision models. in some cases, emergencies are localized while in others, transport processes are most important. eo provides key data for monitoring and forecasting the dispersion and spread of the substance. geohazards associated with geological processes such as earthquakes, landslides, and volcanic eruptions are mainly controlled by ground deformation. eo data allows monitoring of key physical parameters associated with geohazards, such as deformation, plate movements, seismic monitoring, baseline topographic, and geoscience mapping. eo products are useful for detection and mitigation before the event, and for damage assessment during the aftermath. for geohazards, stereo optical and radar interferometry associated with ground-based global positioning system (gps) and seismic networks are used. for volcanic eruptions additional parameters are observed such as temperature and gas emissions. ground based measurements have the advantage of being continuous in time but have limited spatial extent, while satellite observations cover wide areas but are not continuous in time. these data need to be integrated for an improved and more comprehensive approach (committee on earth observation satellites (ceos), ; integrated global observing strategy (igos-p), ). earthquakes are due to a sudden release of stresses accumulated around the faults in the earth's crust. this energy is released through seismic waves that travel from the origin zone, which cause the ground to shake. severe earthquakes can affect buildings and populations. the level of damage depends on many factors, such as the intensity and depth of the earthquake, and the vulnerability of structures and their distance from the earthquake's origin. for earthquakes, information on the location and magnitude of the event first needs to be conveyed to responsible authorities. this information is used by seismic early warning systems to activate security measures within seconds after the earthquake's origin and before strong shaking occurs at the site. shakemaps generated within five minutes provide essential information to assess the intensity of ground shaking and the damaged areas. the combination of data from seismic networks and gps may help to increase reliability and timeliness of this information. earthquake frequency and probability shakemaps based on historical seismicity and base maps (geological, soil type, active faults, hydrological, and dems), assist in the earthquake mitigation phase and need to be included in the building code design process for improved land use and building practices. for responses, additional data are needed, such as seismicity, intensity, strain, dems, soil type, moisture conditions, infrastructure and population, to produce post-event damage maps. thermal information needs to continuously be monitored. this is obtained from low/medium resolution ir imagery from polar and geostationary satellites for thermal background characterization (advanced very high resolution radiometer (avhrr), atsr, modis and goes) together with deformation from edm and/or gps network; borehole strainmetres; and sar interferometry. landslides are displacements of earth, rock, and debris caused by heavy rains, floods, earthquakes, volcanoes, and wildfires. useful information for landslides and ground instability include the following: hazard zonation maps (landslides, debris flows, rockfalls, subsidence, and ground instability scenarios) during the mitigation phase, associated with landlside inventories, dem, deformation (gps network; sar interferometry; other surveys such as leveling, laser scanning, aerial, etc.), hydrology, geology, soil, geophysical, geotechnical, climatic, seismic zonation maps, land cover, land use, and historical archives. forecasting the location and extent of ground instability or landslides is quite challenging. landslides can be preceded by cracks, accelerating movement, and rock fall activity. real-time monitoring of key parameters thus becomes essential. the observed acceleration, deformation or displacement, exceeding a theoretical pre-fixed threshold is the trigger for issuing an alert signal. an alternative approach is based on hydrologic forecasting. it should be said that for large areas site-specific monitoring is not feasible. in this case, hazard mapping associated with monitoring of high risk zones remains the best option for warning. local rapid mapping of affected areas, updated scenarios and real-time monitoring (deformation, seismic data, and weather forecasts) assist during the response phase. a tsunami is a series of ocean waves generated by sudden displacements in the sea floor, landslides, or volcanic activity. although a tsunami cannot be prevented, the impact of a tsunami can be mitigated through community preparedness, timely warnings, and effective response. observations of seismic activity, sea floor bathymetry, topography, sea level data (tide gauge observations of sea height; real-time tsunami warning buoy data; deep ocean assessment and reporting of tsunamis (dart) buoys and sea-level variations from the topex/poseidon and jason, the european space agency's envisat, and the us navy's geosat follow-on), are used in combination with tsunami models to create inundation and evacuation maps and to issue tsunami watches and warnings. volcanic eruptions may be mild, releasing steam and gases or lava flows, or they can be violent explosions that release ashes and gases into the atmosphere. volcanic eruptions can destroy land and communities living in their path, affect air quality, and even influence the earth's climate. volcanic ash can impact aviation and communications. data needs for volcanic eruptions include hazard zonation maps, real-time seismic, deformation (electronic distance measurement (edm) and/or gps network; leveling and tilt networks; borehole strainmeters; gravity surveys; sar interferometry), thermal (landsat, aster, geostationary operational environmental satellites (goes), modis); air borne ir cameras; medium-high resolution heat flux imagery and gas emissions (cospec, licor surveys); satellite imagery (i.e., aster) and digital elevation maps (dem). as soon as the volcanic unrest initiates, information needs to be timely and relatively high-resolution. once the eruption starts, the flow of information has to speed up. seismic behaviour and deformation patterns need to be observed throughout the eruption especially to detect a change of eruption site ( - seismometers ideally with -directional sensors; a regional network). hydro-meteorological hazards include the wide variety of meteorological, hydrological and climate phenomena that can pose a threat to life, property and the environment. these types of hazards are monitored using the meteorological, or weather, satellite programs, beginning in the early s. in the united states, nasa, noaa, and the department of defense (dod) have all been involved with developing and operating weather satellites. in europe, esa and eumetsat (european organisation for the exploitation of meteorological satellites) operate the meteorological satellite system (us centennial of flight commission). data from geostationary satellite and polar microwave derived products (goes) and polar orbiters (microwave data from the defense meteorological satellite program (dmsp), special sensor microwave/imager (ssm/i), noaa/advanced microwave sounding unit (amsu), and tropical rainfall measuring mission (trmm)) are key in weather analysis and forecasting. goes has the capability of observing the atmosphere and its cloud cover from the global scale down to the storm scale, frequently and at high resolution. microwave data are available on only an intermittent basis, but are strongly related to cloud and atmospheric properties. is key for monitoring meteorological processes from the global scale to the synoptic scale to the mesoscale and finally to the storm scale. (scofield et al., ) . goes and poes weather satellites provide useful information on precipitation, moisture, temperature, winds and soil wetness, which is combined with ground observation. floods are often triggered by severe storms, tropical cyclones, and tornadoes. the number of floods has continued to rise steadily; together with droughts, they have become the most deadly disasters over the past decades. the increase in losses from floods is also due to climate variability, which has caused increased precipitation in parts of the northern hemisphere (natural hazards working group, ) . floods can be deadly, particularly when they arrive without warning. in particular, polar orbital and geostationary satellite data are used for flood observation. polar orbital satellites include optical low (avhrr), medium (landsat, spot, irs) and high resolution (ikonos) and microwave sensors (high (sar-radarsat, jers and ers) and low resolution passive sensors (ssmi). meteorological satellites include goes and , meteosat, gms, the indian insat and the russian goms; and polar orbitals such as noaa (noaa ) and ssmi. for storms, additional parameters are monitored, such as sea surface temperature, air humidity, surface wind speed, rain estimates (from dmsp/ssmi, trmm, ers, quikscat, avhrr, radarsat). trmm offers unique opportunities to examine tropical cyclones. with trmm, scientists are able to make extremely precise radar measurements of tropical storms over the oceans and identify their intensity variations, providing invaluable insights into the dynamics of tropical storms and rainfall. epidemics such as malaria and meningitis are linked to environmental factors. satellite data can provide essential information on these factors and help to better understand diseases. as an example, the esa epidemio project, launched in , utilizes data from esa's envisat or the french space agency's spot, and field data to gather information on the spread of epidemics, helping to better prepare for epidemic outbreaks. geo, with who and other partners, are working together on the meningitis environmental risk information technologies (merit) project to better understand the relationship between meningitis and environmental factors using remote sensing. wildfires pose a threat to lives and properties and are often connected to secondary effects such as landslides, erosion, and changes in water quality. wildfires may be natural processes, human induced for agriculture purposes, or just the result of human negligence. wildfire detection using satellite technologies is possible thanks to significant temperature difference between the earth's surface (usually not exceeding - c) and the heat of fire ( - c), which results in a thousand times difference in heat radiation generated by these objects. noaa (avhrr radiometer with m spatial resolution and km swath width) and earth observing satellites (eos) (terra and aqua satellites with modis radiometer installed on them with , and m spatial resolution and km swath width) are the most widely used modern satellites for operative fire monitoring (klaver et al., ) . high-resolution sensors, such as the landsat thematic mapper, spot multispectral scanner, or national oceanic and atmospheric administration's avhrr or modis, are used for fire potential definition. sensors used for fire detection and monitoring include avhrr, which has a thermal sensor and daily overflights, the defense meteorological satellite program's optical linescan system (ols) sensor, which has daily overflights and operationally collects visible images during its nighttime pass, and the modis land rapid response system. avhrr and higher resolution images (spot, landsat, and radar) can be used to assess the extent and impact of the fire. smog is the product of human and natural activities, such as industry, transportation, wildfires, volcanic eruptions, etc. and can have serious effects on human health and the environment. a variety of eo tools are available to monitor air quality. the national aeronautics and space administration (nasa) and the european space agency (esa) both have instruments to monitor air quality. the canadian mopitt (measurements of pollution in the troposphere) aboard the terra satellite monitors the lower atmosphere to observe how it interacts with the land and ocean biospheres, distribution, transport, sources, and sinks of carbon monoxide and methane in the troposphere. the total ozone mapping spectrometer (toms) instrument measures the total amount of ozone in a column of atmosphere as well as cloud cover over the entire globe. additionally, toms measures the amount of solar radiation escaping from the top of the atmosphere to accurately estimate the amount of ultraviolet radiation that reaches the earth's surface. the ozone monitoring instrument (omi) on aura will continue the toms record for total ozone and other atmospheric parameters related to ozone chemistry and climate. the omi instrument distinguishes between aerosol types, such as smoke, dust, and sulphates, and can measure cloud pressure and coverage. esa's schiamachy (scanning imaging absorption spectro-meter for atmospheric chartography) maps atmosphere over a very wide wavelength range ( - nm), which allows detection of trace gases, ozone and related gases, clouds and dust particles throughout the atmosphere (athena global, ) . the moderate resolution imaging spectroradiometer (modis) sensor measures the relative amount of aerosols and the relative size of aerosol particles-solid or liquid particles suspended in the atmosphere. examples of such aerosols include dust, sea salts, volcanic ash, and smoke. the modis aerosol optical depth product is a measure of how much light airborne particles prevent from passing through a column of atmosphere. new technologies are also being explored for monitoring air quality, such as mobile phones equipped with simple sensors to empower citizens to collect and share real-time air quality measurements. this technology is being developed by a consortium called urban atmospheres. the traditional methods of monitoring coastal water quality require scientists to use boats to gather water samples, typically on a monthly basis because of the high costs of these surveys. this method captures episodic events affecting water quality, such as the seasonal freshwater runoff, but is not able to monitor and detect fast changes. satellite data provide measures of key indicators of water qualityturbidity and water clarity -to help monitor fast changes in factors that affect water quality, such as winds, tides and human influences including pollution and runoff. geoeye's sea-viewing wide field-ofview sensor (seawifs) instrument, launched aboard the orbview- satellite in , collects ocean colour data used to determine factors affecting global change, particularly ocean ecology and chemistry. modis sensor, launched aboard the aqua satellite in , together with its counterpart instrument aboard the terra satellite, collects measurements from the entire earth surface every - days and can also provide measurements of turbidity (bjorn-hansen, ) . overall, air and water quality monitoring coverage still appears to be irregular and adequate and available in real-time only for some contaminants (global earth observation system of systems, ). . . . . droughts. noaa's national weather service (nws) defines a drought as ''a period of abnormally dry weather sufficiently prolonged for the lack of water to cause serious hydrologic imbalance in the affected area.'' drought can be classified by using different definitions: meteorological (deviation from normal precipitation); agricultural (abnormal soil moisture conditions); hydrological (related to abnormal water resources); and socio-economic (when water shortage impacts people's lives and economies). a comprehensive and integrated approach is required to monitor droughts, due to the complex nature of the problem. although all types of droughts originate from a precipitation deficiency, it is insufficient to monitor solely this parameter to assess severity and resultant impacts (world meteorological organization, ) . effective drought early warning systems must integrate precipitation and other climatic parameters with water information such as streamflow, snow pack, groundwater levels, reservoir and lake levels, and soil moisture, into a comprehensive assessment of current and future drought and water supply conditions (svoboda et al., ) . in particular, there are key parameters that are used in a composite product developed from a rich information stream, including climate indices, numerical models, and the input of regional and local experts. these are as follows: ) palmer drought severity index (based on precipitation data, temperature data, division constants (water capacity of the soil, etc.) and previous history of the indices). ) soil moisture model percentile (calculated through a hydrological model that takes observed precipitation and temperature and calculates soil moisture, evaporation and runoff. the potential evaporation is estimated from observed temperature). ) daily stream flow percentiles. ) percent of normal precipitation. ) standardized precipitation index, and ) remotely sensed vegetation health index. additional indicators may include the palmer crop moisture index, keetch-byram drought index, fire danger index, evaporation-related observations such as relative humidity and temperature departure from normal, reservoir and lake levels, groundwater levels, field observations of surface soil moisture, and snowpack observations. some of these indices and indicators are computed for point locations, and others are computed for climate divisions, drainage (hydrological) basins, or other geographical regions (svoboda et al., ) . a complete list of drought products can be found on noaa's national environmental satellite, data, & information service (noaanesdis) web page. . . . . desertification. desertification refers to the degradation of land in arid, semi-arid, and dry sub-humid areas due to climatic variations or human activity. desertification can occur due to inappropriate land use, overgrazing, deforestation, and over-exploitation. land degradation affects many countries worldwide and has its greatest impact in africa. in spite of the potential benefits of eo information, the lack of awareness of the value and availability of information, inadequate institutional resources and financial problems are the most frequent challenges to overcome in detecting desertification (sarmap, ) . in , through a project called desertwatch, esa has developed a set of indicators based principally on land surface parameters retrieved from satellite observations for monitoring land degradation and desertification. desertwatch is being tested and applied in mozambique, portugal, and brazil. the un food and agriculture organization's global information and early warning system (giews). these provide information on food availability, market prices and livelihoods. the observations of climate-related variables on a global scale have made it possible to document and analyse the behaviour of earth's climate, made available through programs as follows: the ioc-wmo-unep-icsu global ocean observing system (goos); the fao-wmo-unesco-unepicsu global terrestrial observing system (gtos); the wmo global observing system (gos) and global atmosphere watch (gaw); the research observing systems and observing systems research of the wmo-ioc-icsu world climate research programme (wcrp) and other climate relevant international programs; and wmo-unesco-icsuioc-unep global climate observing system (gcos). the intergovernmental panel on climate change (ipcc) periodically reviews and assesses the most recent scientific, technical and socio-economic information produced worldwide relevant to the understanding of climate change. hundreds of scientists worldwide contribute to the preparation and review of these reports. according to the recent ipcc report, the atmospheric buildup of greenhouse gases is already shaping the earth's climate and ecosystems from the poles to the tropics, which face inevitable, possibly profound, alteration. the ipcc has predicted widening droughts in southern europe and the middle east, sub-saharan africa, the american southwest and mexico, and flooding that could imperil low-lying islands and the crowded river deltas of southern asia. it stressed that many of the regions facing the greatest risks are among the world's poorest. information about the impacts of climate variability impact information is needed by communities and resource managers to adapt and prepare for larger fluctuations as global climate change becomes more evident. this information includes evidence of changes occurring due to climate variability, such as loss of ecosystems, ice melting, coastal degradation, and severe droughts. such information will provide policy-makers scientifically valid assessment and early warning information on the current and potential long-term consequences of human activities on the environment. (i.e., ecosystem changes, loss of biodiversity and habitats, land cover/land changes, coastal erosion, urban growth, etc.). landsat satellites (series - ) are extensively used to monitor location-specific environmental changes. they have the great advantage of providing repetitive, synoptic, global coverage of high-resolution multi-spectral imagery (fadhil, ) . landsat can be used for change detection applications to identify differences in the state of an object or phenomenon by comparing the satellite imagery at different times. change detection is key in natural resources management (singh, ) . central to this theme is the characterization, monitoring and understanding of land cover and land use change, since they have a major impact on sustainable land use, biodiversity, conservation, biogeochemical cycles, as well as land-atmosphere interactions affecting climate and they are indicators of climate change, especially at a regional level (igos-p, ) . the united nations environment programme's (unep) bestselling publication one planet, many people: atlas of our changing environment, which shows before and after satellite photos to document changes to the earth's surface over the past years, proves the importance and impact of visual evidence of environmental change in hotspots. the atlas contains some remarkable landsat satellite imagery and illustrates the alarming rate of environmental destruction. through the innovative use of some satellite images, ground photos and maps, the atlas provides visual proof of global environmental changes -both positive and negative -resulting from natural processes and human activities. case studies include themes such as atmosphere, coastal areas, waters, forests, croplands, grasslands, urban areas, and tundra and polar regions. the atlas demonstrates how our growing numbers and our consumption patterns are shrinking our natural resource base. the aim of this report is to identify current gaps and future needs of early warning systems through the analysis of the state of the art of existing early warning and monitoring systems for environmental hazards. among existing early warning/monitoring systems, only systems that provide publicly accessible information and products have been included in the analysis. for the present study, several sources have been used, such as the global survey of early warning systems (united nations, ) together with the online inventory of early warning systems on isdr's platform for the promotion of early warning (ppew) website, and several additional online sources, technical reports and scientific articles listed in the references. for each hazard type, a gap analysis has been carried out to identify critical aspects and future needs of ews, considering aspects such as geographical coverage, and essential ews elements such as monitoring and prediction capability, communication systems and application of early warning information in responses. below is the outcome of the review of existing early warning/monitoring systems for each hazard type. details of all systems, organized in tables by hazard type, are listed in the appendix. the current gaps identified for each hazard type could be related to technological, organizational, communication or geographical coverage aspects. to assess the geographical coverage of existing systems for each hazard type, the existing systems have been imposed on the hazard's risk map. for this analysis, the maps of risks of mortality and economic loss were taken from natural disaster hotspots: a global risk analysis, a report from the world bank (dilley et al., ) . to detect operational oil spills, satellite overpasses and aerial surveillance flights need to be used in an integrated manner. in many countries in northern europe, the ksat manual approach is currently used to identify oil spills from the satellite images. ksat has provided this operational service since , and in europe, use of satellites for oil spill detection is well established and well integrated within the national and regional oil pollution surveillance and response chains. operational algorithms utilizing satellite-borne c-band sar instruments (radarsat- , envisat, radarsat- ) are also being developed for oil-spill detection in the baltic sea area. releases of a hazardous substance from industrial accidents can have immediate adverse effects on human and animal life or the environment. wmo together with iaea provides specialized meteorological support to environmental emergency response related to nuclear accidents and radiological emergencies. the wmo network of eight specialized numerical modelling centres called regional specialized meteorological centres (rsmcs) provides predictions of the movement of contaminants in the atmosphere. the inter-agency committee on the response to nuclear accidents (iacrna) of the iaea, coordinates the international intergovernmental organizations responding to nuclear and radiological emergencies. iacrna members are: the european commission (ec), the european police office (europol), the food and agriculture organization of the united nations (fao), iaea, the international civil aviation organization (icao), the international criminal police organization (interpol), the nuclear energy agency of the organization for economic co-operation and development (oecd/nea), the pan american health organization (paho), unep, the united nations office for the co-ordination of humanitarian affairs (un-ocha), the united nations office for outer space affairs (unoosa), the world health organization (who), and wmo. the agency's goal is to provide support during incidents or emergencies by providing near real-time reporting of information through the following: the incident and emergency centre (iec), which maintains a h oncall system for rapid initial assessment, and if needed, triggers response operations; the emergency notification and assistance convention website (enac), which allows the exchange of information on nuclear accidents or radiological emergencies; and the nuclear event webbased system (news), which provides information on all significant events in nuclear power plants, research reactors, nuclear fuel cycle facilities and occurrences involving radiation sources or the transport of radioactive material. the global chemical incident alert and response system of the international programme on chemical safety, which is part of who, focuses on disease outbreaks from chemical releases and also provides technical assistance to member states for response to chemical incidents and emergencies. formal and informal sources are used to collect information and if necessary, additional information and verification is sought through official channels: national authorities, who offices, who collaborating centres, other united nations agencies, and members of the communicable disease global outbreak alert and response network (goarn), internet-based resources, particularly the global public health intelligence network (gphin) and promed-mail. based on this information, a risk assessment is carried out to determine the potential impact and if assistance needs to be offered to member states. . . . geological hazards . . . . earthquakes. earthquake early warning systems are a relatively new approach to seismic risk reduction. they provide a rapid estimate of seismic parameters such as magnitude and location associated with a seismic event based on the first seconds of seismic data registered at the epicentre. this information can then be used to predict ground motion parameters of engineering interest including peak ground acceleration and spectral acceleration. earthquake warning systems are currently operational in mexico, japan, romania, taiwan and turkey (espinosa aranda et al., ; wu et al., ; wu and teng, ; odaka et al., ; kamigaichi, ; nakamura, ; horiuchi et al., ) . systems are under development for seismic risk mitigation in california and italy. local and national scale seismic early warning systems, which provide seismic information between a few seconds and tens of seconds before shaking occurs at the target site, are used for a variety of applications such as shutting down power plants, stopping trains, evacuating buildings, closing gas valves, and alerting wide segments of the population through the tv, among others. on the global scale, multi-national initiatives, such as the us geological survey (usgs) and geo-forschungs netz (geofon), operate global seismic networks for seismic monitoring but do not provide seismic early warning information. today, the usgs in cooperation with incorporated research institutions for seismology (iris) operates the global seismic networks (gsn), which comprises more than stations providing free, real-time, open access data. geofon collects information from several networks and makes this information available to the public online. usgs earthquake notification service (ens) provides publicly available e-mail notification for earthquakes worldwide within minutes for earthquakes in us and within min for events worldwide. usgs also provides near-real-time maps of ground motion and shaking intensity following significant earthquakes. this product, called shakemap, is being used for post-earthquake response and recovery, public and scientific information, as well as for preparedness exercises and disaster planning. effective early warning technologies for earthquakes are much more challenging to develop than for other natural hazards because warning times range from only a few seconds in the area close to a rupturing fault to a minute or so (heaton, ; allen and kanamori, ; kanamori, ) . several local and regional applications exist worldwide but no global system exists or could possibly exist for seismic early warning at global scale, due to timing constraints. earthquake early warning systems applications must be designed at the local or regional level. although various early warning systems exist worldwide at the local or regional scale, there are still high seismic risk areas that lack early warning applications, such as peru, chile, iran, pakistan, and india. the international consortium on landslides (icl), created at the kyoto symposium in january , is an international non-governmental and non-profit scientific organization, which is supported by the united nations educational, scientific and cultural organization (unesco), the wmo, fao, and the united nations international strategy for disaster reduction (un/isdr). icl's mission is to promote landslide research for the benefit of society and the environment and promote a global, multidisciplinary programme regarding landslides. icl provides information about current landslides on its website, streaming this information from various sources such as the geological survey of canada. this information does not provide any early warning since it is based on news reports after the events have occurred. enhancing icl's existing organizational infrastructure by improving landslide prediction capability would allow icl to provide early warning to authorities and populations. technologies for slopes monitoring has greatly improved, but currently only few slopes are being monitored at a global scale. the use of these technologies would be greatly beneficial for mitigating losses from landslides worldwide. . . . . tsunamis. the indian ocean tsunami of december killed people and left . million homeless. it highlighted gaps and deficiencies in existing tsunami warning systems. in response to this disaster, in june the intergovernmental oceanographic commission (ioc) secretariat was mandated by its member states to coordinate the implementation of a tsunami warning system for the indian ocean, the northeast atlantic and mediterranean, and the caribbean. efforts to develop these systems are ongoing. since march , the indonesian meteorological, climatological and geophysical agency has been operating the german-indonesian tsunami early warning system for the indian ocean. milestones, such as the development of the automatic data processing software and underwater communication for the transmission of pressure data from the ocean floor to a warning centre, have been reached. these systems will be part of the global ocean observing system (goos), which will be part of geoss. the pacific basin is monitored by the pacific tsunami warning system (ptws), which was established by member states and is operated by the pacific tsunami warning center (ptwc), located near honolulu, hawaii. ptwc monitors stations throughout the pacific basin to issue tsunami warnings to member states, serving as the regional centre for hawaii and as a national and international tsunami information centre. it is part of the ptws effort. noaa national weather service operates ptwc and the alaska tsunami warning center (atwc) in palmer, alaska, which serves as the regional tsunami warning center for alaska, british columbia, washington, oregon, and california. ptws monitors seismic stations operated by ptwc, usgs and atwc to detect potentially tsunamigenic earthquakes. such earthquakes meet specific criteria for generation of a tsunami in terms of location, depth, and magnitude. ptws issues tsunami warnings to potentially affected areas, by providing estimates of tsunami arrival times and areas potentially most affected. if a significant tsunami is detected, the tsunami warning is extended to the pacific basin. the international tsunami information center (itic), under the auspices of ioc, aims to mitigate tsunami risk by providing guidance and assistance to improve education and preparedness. itic also provides a complete list of tsunami events worldwide. official tsunami bulletins are released by ptwc, atwc, and the japan meteorological agency (jma). regional and national tsunami information centres exist worldwide; the complete list is available from ioc. currently, no global tsunami warning system is in place. in addition, fully operational tsunami early warning systems are needed for the indian ocean and the caribbean. initial steps have been taken in this direction. in , noaa established the caribbean tsunami warning program as the first step towards the development of a caribbean tsunami warning center. since , steps have been taken to develop an indian ocean tsunami system, such as establishing tsunami information centres and deploying real-time sea level stations and deep ocean buoys in countries bordering indian ocean. in , the united states agency for international development (usaid) launched the us indian ocean tsunami warning systems program as the us government's direct contribution to the international effort led by the ioc. since then, there are ongoing activities, such as germany's -year german-indonesia tsunami early warning system program with indonesia, the tsunami regional trust fund established in , and the united kingdom's tsunami funds reserved for early warning capacity building. nevertheless, on july , only one month after the announcement that the indian ocean's tsunami warning system was operational, a tsunami in java, indonesia, killed hundreds of people. on that day, tsunami warnings were issued to alert jakarta but there was not enough time to alert the coastal areas. the july tsunami disaster illustrates that there are still operational gaps to be solved in the indian ocean tsunami early warning system, notably in warning coastal communities on time. . . . . volcanic eruptions. volcanic eruptions are always anticipated by precursor activities. in fact, seismic monitoring, ground deformation monitoring, gas monitoring, visual observations, and surveying are used to monitor volcanic activity. volcano observatories are distributed worldwide. a complete list of volcano observatories is available at the world organization of volcanic observatories (wovo) website. however, there is still a divide between developed and developing countries. in particular, a large number of observatories and research centres monitor volcanoes in japan and the united states very well. most central and south american countries (mexico, guatemala, el salvador, nicaragua, costa rica, colombia, ecuador, peru, chile, trinidad, and the antilles) have volcano observatories that provide public access to volcanic activity information. in africa, only two countries (congo and cameroon) have volcano monitoring observatories and they do not provide public access to information. only a small number, probably fewer than , of the world's volcanoes are well monitored, mostly due to inadequate resources in poor countries (national hazards working group, ) . there is a need to fill this gap by increasing the coverage of volcanic observatories. currently, there is no global early warning system for volcanic eruptions except for aviation safety. global volcanic activity information is provided by the smithsonian institution, which partners with the usgs under the global volcanism program to provide online access to volcanic activity information, collected from volcano observatories worldwide. reports and warnings are available on a daily basis. weekly and monthly summary reports are also available, but these only report changes in volcanic activity level, ash advisories, and news reports. the information is also available through google earth. this information is essential for the aviation sector, which must be alerted to ash-producing eruptions. there are several ash advisory centres distributed worldwide, in london, toulouse, anchorage, washington, montreal, darwin, wellington, tokyo, and buenos aires. however, there is a need to coordinate interaction and data sharing among the approximately volcano observatories that make up wovo. esa is developing globvolcano, an information system to provide earth observations for volcanic risk monitoring. . . . . wildfires. early warning methodologies for wildfires are based on the prediction of precursors, such as fuel loads and lightning danger. these parameters are relevant for triggering prediction, but once the fire has begun, fire behaviour and pattern modelling are fundamental for estimating fire propagation patterns. most industrial countries have ew capabilities in place, while most developing countries have neither fire early warning nor monitoring systems in place (goldammer et al., ) . local and regional scale fire monitoring systems are available for canada, south america, mexico and south africa. an interactive mapping service based on google maps and eo imagery from inpe, the brazilian space research institute, has been available since september . individuals can contribute with information from the ground; in only months the service has received million reports on forest fires and illegal logging, making it one of the most successful web sites in brazil; it has had real impact through follow up legal initiatives and parliamentary enquiries. wildfire information is available worldwide through the global fire monitoring center (gfmc), a global portal for fire data products, information, and monitoring. this information is accessible to the public through the gfmc website but is not actively disseminated. the gfmc provides global fire products through a worldwide network of cooperating institutions. gfmc fire products include the following: fire danger maps and forecasts, which provide assessment of fire onset risk; near realtime fire events information; an archive of global fire information; and assistance and support in the case of a fire emergency. global fire weather forecasts are provided by the experimental climate prediction center (ecpc), which also provides national and regional scale forecasts. noaa provides experimental, potential fire products based on estimated intensity and duration of vegetation stress, which can be used as a proxy for assessment of potential fire danger. the webfire mapper, part of fao's global fire information management system (gfims), initially developed by the university of maryland and financially supported by nasa, provides near real-time information on active fires worldwide, detected by the modis rapid response system. the webfire mapper integrates satellite data with gis technologies for active fire information. this information is available to the public through the website and e-mail alerts. the european forest fire information system also provides information on current fire situations and forecasts for europe and the mediterranean area. although global scale fire monitoring systems exist, an internationally standardized approach is required to create a globally comprehensive early fire warning system. integration of existing fire monitoring systems could significantly improve fire monitoring and early warning capabilities. an information network must be developed to disseminate early warnings about wild-fire danger at both the global and local levels, to quickly detect and report fires, and to enhance rapid fire detection and classification capabilities at national and regional levels. the global early warning system for wild-fires, which is under development as part of the global earth observation system of systems (geoss) effort, will address these issues. . . . . floods. among natural hazards that are currently increasing in frequency, floods are the deadliest. this study shows there is inadequate coverage of flood warning and monitoring systems, especially in developing or least developed countries such as china, india, bangladesh, nepal, west africa, and brazil. at the local scale, there are several stand-alone warning systems, for example, in guatemala, honduras, el salvador, nicaragua, zimbabwe, south africa, belize, czech republic, and germany. however, they do not provide public access to information. the european flood alert system (efas), which is an initiative by ec-jrc, provides information on the possibility of river flooding occurring within the next three days. efas also provides an overview of current floods based on information received from the national hydrological services and the global runoff data center in germany. floods are monitored worldwide from the dartmouth flood observatory, which provides public access to major flood information, satellite images and estimated discharge. orbital remote sensing (advanced scanning microradiometer (amsr-e and quickscat)) is used to detect and map major floods worldwide. satellite microwave sensors can monitor, at a global scale and on a daily basis, increases of floodplain water surface without cloud interference. the dartmouth flood observatory provides estimated discharge and satellite images of major floods worldwide but does not provide forecasts of flood conditions or precipitation amounts that could allow flood warnings to be issued days in advance of events. noaa provides observed hydrologic conditions of major us river basins and predicted values of precipitation for rivers in the united states. noaa also provides information on excessive rainfall that could lead to flash-flooding and if necessary warnings are issued within h in advance. ifnet global flood alert system (gfas) uses global satellite precipitation estimates for flood forecasting and warning. the gfas website publishes useful public information for flood forecasting and warning, such as precipitation probability estimates, but the system is currently running on a trial basis. at a global scale, flood monitoring systems are more developed than flood early warning systems. for this reason, existing technologies for flood monitoring must be improved to increase prediction capabilities and flood warning lead times. . . . . severe weather, storms and tropical cyclones. at the global level, the world weather watch (www) and hydrology and water resources programmes coordinated by wmo provide global collection, analysis and distribution of weather observations, forecasts and warnings. the www is composed of the global observing system (gos), which provides the observed meteorological data; the global telecommunications system (gts), which reports observations, forecasts and other products and the global data processing system (gdps), which provides weather analyses, forecasts and other products. the www is an operational framework of coordinated national systems, operated by national governments. the tropical cyclone programme (tcp) is also part of the www. tcp is in charge of issuing tropical cyclones and hurricanes forecasts, warnings and advisories, and seeks to promote and coordinate efforts to mitigate risks associated with tropical cyclones. tcp has established tropical cyclone committees that extend across regional bodies (regional specialized meteorological centres (rsmc)), which, together with national meteorological and hydrological services (nmhss), monitor tropical cyclones globally and issue official warnings to the regional meteorological services of countries at risk. regional bodies worldwide have adopted standardized wmo-tcp operational plans and manuals, which promote internationally accepted procedures in terms of units, terminology, data and information exchange, operational procedures, and telecommunication of cyclone information. each member of a regional body is normally responsible for its land and coastal waters warnings. a complete list of wmo members and rsmcs is available on the wmo-tcp website. wmo then collects cyclone information and visualizes it on world maps. the university of hawaii collects information from wmo and provides online information on cyclone categories, wind speed, and current and predicted courses. although comprehensive coverage of early warning systems for storms and tropical cyclones is available, recent disasters such as hurricane katrina of have highlighted inadequacies in early warning system technologies for enabling effective and timely emergency response. there is a pressing need to improve communication between the sectors involved by strengthening the links between scientific research, organizations responsible for issuing warnings, and authorities in charge of responding to these warnings. while the www is an efficient framework of existing rsmc, nmhss and networks, national capacities in most developing countries need improvements in order to effectively issue and manage early warnings. action plans must also be improved. epidemics pose a significant threat worldwide, particularly in those areas that are already affected by other serious hazards, poverty, or under-development. epidemics spread easily across country borders. globalization increases the potential of a catastrophic disease outbreak: there is the risk that millions of people worldwide could potentially be affected. a global disease outbreak early warning system is urgently needed. who is already working in this field through the epidemic and pandemic alert and response, which provides real-time information on disease outbreaks, and goarn. the who member countries, disease experts, institutions, agencies, and laboratories, part of an outbreak verification list, are constantly informed of rumoured and confirmed outbreaks. the who constantly monitors anthrax, avian influenza, crimean-congo hemorrhagic fever (cchf), dengue haemorrhagic fever, ebola haemorrhagic fever, hepatitis, influenza, lassa fever, marburg haemorrhagic fever, meningococcal disease, plague, rift valley fever, severe acute respiratory syndrome (sars), tularaemia, and yellow fever. a global early warning system for animal diseases transmissible to humans was formally launched in july by the fao, the world organization for animal health (oie), and who. the global early warning and response system for major animal diseases, including zoonoses (glews) monitors outbreaks of major animal diseases worldwide. a malaria early warning system is not yet available and the need for system development is pressing, especially in sub-saharan africa where malaria causes more than one million deaths every year. the iri institute at columbia university provides malaria risk maps based on rainfall anomaly, which is one of the factors influencing malaria outbreak and distribution, but no warning is disseminated to the potentially affected population. in addition, the malaria atlas project (map) supported by the wellcome trust, the global fund to fight aids, tuberculosis and malaria, the university of oxford-li ka shing foundation global health programme and others, aims to disseminate free, accurate and up-to-date information on malaria. the map is a joint effort of researchers from around the globe working in different fields (from public health to mathematics, geography and epidemiology). map produces and makes available a range of maps and estimates to support effective planning of malaria control at national and international scales. air pollution affects developing and developed countries without exception. for this reason, air quality monitoring and early warning systems are in place in most countries worldwide. nevertheless, there is still a technological divide between developed and developing countries; in fact, these systems are most developed in the united states, canada, and europe. there are several successful cases to mention in asia (taiwan, china, hong kong, korea, japan, and thailand), a few in latin america (argentina, brazil, and mexico city) and only one in africa (cape town, south africa). most of the existing systems focus on real-time air quality monitoring by collecting and analysing pollutant concentration measurements from ground stations. satellite observation is extremely useful for aviation and tropospheric ozone monitoring, which is done by nasa and esa. air quality information is communicated mainly through web services. the us environmental protection agency (epa) provides an e-mail alert service (epa airnow) only available in the us and the ministry of environment of ontario, canada, also provides e-mail alerts. the epa airnow notification service provides air quality information in real-time to subscribers via e-mail, cell phone or pager, allowing them to take steps to protect their health in critical situations. while current air quality information is provided by each of the air quality monitoring systems listed in the appendix, few sources provide forecasts. the following agencies provide forecasts, which are fundamental for early warning: us epa, esa, prev'air, and the environmental agencies of belgium, germany, and canada (see the appendix). prediction capability is an essential component of the early warning process. existing air quality monitoring systems need to be improved in order to provide predictions to users days in advance so they can act when unhealthy air quality conditions occur. . . . . drought. drought early warning systems are the least developed systems due its complex processes and environmental and social impacts. the study of existing drought early warning systems shows that only a few such systems exist worldwide. on a regional scale, the fews net for eastern africa, afghanistan, and central america reports on current famine conditions, including droughts, by providing monthly bulletins that are accessible on the fews net web page. for the united states, the us drought monitor (svoboda et al., ) provides current drought conditions at the national and state level through an interactive map available on the website accompanied by a narrative on current drought impacts and a brief description of forecasts for the following week. the us drought monitor, a joint effort between the us department of agriculture (usda), noaa, the climate prediction center, the university of nebraska lincoln and others, has become the best available product for droughts (svoboda et al., ) . it has a unique approach that integrates multiple drought indicators with field information and expert input, and provides information through a single easy-to-read map of current drought conditions and short notes on drought forecast conditions. for china, the beijing climate center (bcc) of the china meteorological administration (cma) monitors drought development. based on precipitation and soil moisture monitoring from an agricultural meteorological station network and remote-sensing-based monitoring from cma's national satellite meteorological center, a drought report and a map on current drought conditions are produced daily and made available on their website. the european commission joint research center (ec-jrc) provides publicly available drought-relevant information through the following real-time online maps: daily soil moisture maps of europe; daily soil moisture anomaly maps of europe; and daily maps of the forecasted top soil moisture development in europe ( -day trend). at a global scale, two institutions (fao's global information and early warning system on food and agriculture (giews) and benfield hazard research center of the university college london) provide some information on major droughts occurring worldwide. the fao-giews provides information on countries facing food insecurity through monthly briefing reports on crop prospects and food situations, including drought information, together with an interactive map of countries in crisis, available through the fao website. benfield hazard research center uses various data to produce a monthly map of current drought conditions accompanied by a short description for each country. in addition, the wmo provides useful global meteorological information, such as precipitation levels, cloudiness, and weather forecasts, which are visualized on a clickable map on the wmo website. existing approaches for drought early warning must be improved. due to the complex nature of droughts, a comprehensive and integrated approach (such as the one adopted by the us drought monitor) that would consider numerous drought indicators is required for drought monitoring and early warning. in addition, for large parts of the world suffering from severe droughts, early warning systems are not yet in place, such as in western and southern africa, and in eastern africa where fews net is available but no drought forecast is provided. parts of europe (spain, parts of france, southern sweden, and northern poland) are characterized by high drought risk but have no system in place. india, parts of thailand, turkey, iran, iraq, eastern china, areas of ecuador, colombia, and the south-eastern and western parts of australia also require a drought warning system. . . . . desertification. the united nations convention to combat desertification (unccd), signed by governments in , aims to promote local action programs and international activities. national action programmes at the regional or sub-regional levels are key instruments for implementing the convention and are often supported by action programmes at sub-regional and regional levels. these programs lay out regional and local action plans and strategies to combat desertification. the unccd website provides a desertification map together with documentation, reports, and briefing notes on the implementation of action programs for each country worldwide. currently no desertification early warning system is fully implemented, despite their potential to mitigate desertification. . . . . food security. the fao's giews supports policy-makers by delivering periodic reports through the giews web page and an e-mail service. giews also promotes collaboration and data exchange with other organizations and governments. the frequency of briefs and reports -which are released monthly or bimonthly -may not be adequate for early warning purposes. the wfp is also involved in disseminating reports and news on famine crises through its web service. no active dissemination is provided by wfp. another service is fews net, a collaborative effort of the usgs, united states agency for international development (usaid), nasa, and noaa, which reports on food insecurity conditions and issues watches and warnings to decision-makers. these bulletins are also available on their website. food security prediction estimates and maps would be extremely useful for emergency response, resources allocation, and early warning. the food security and nutrition working group (fsnwg) serves as a platform to promote the disaster risk reduction agenda in the region and provides monthly updates on food security through maps and reports available on its website. fewsnet and fsnwg were instrumental in predicting the food crisis in - in the east african region in a timely manner. nevertheless these early warnings did not lead to early action to address the food crisis. if they had been used adequately, the impacts of the serious humanitarian crisis in the horn of africa could have been partially mitigated (ververs, ) . nearly all efforts to cope with climate change or variability focus on either mitigation to reduce emissions or on adaptation to adjust to changes in climate. although it is imperative to continue with these efforts, the on-going pace of climate change and the slow international response suggests that a third option is becoming increasingly important: to protect the population against the immediate threat and consequences of climate-related extreme events, including heat waves, forest fires, floods and droughts, by providing it with timely, reliable and actionable warnings. although great strides have been made in developing climate-related warning systems over the past few years, current systems only deal with some aspects of climate related risks or hazards, and have large gaps in geographic coverage. information exists for melting glaciers, lake water level, sea height and sea surface temperature anomalies, el nino and la nina. the national snow and ice data center (nsidc)-ice concentration and snow extent provides near real-time data on daily global ice concentration and snow coverage. the usda, in cooperation with the nasa and the university of maryland, routinely monitors lake and reservoir height variations for approximately lakes worldwide and provides online public access to lake water level data. information on sea height anomaly (sha) and significant wave height data are available from altimeter jason- , topex, ers- , envisat and gfo on a near-real time basis with an average -day delay. this information is provided by noaa. additionally, near real-time sea surface temperature (sst) products are available from noaa's goes and poes, as well as nasa's eos, aqua and terra. the international research institute (iri) for climate and society provides a monthly summary of the el nino and la nina southern oscillation, providing forecast summary, probabilistic forecasts, and a sea surface temperature index. however, these systems are still far from providing the coverage and scope that is needed and technically feasible. large parts of the world's most vulnerable regions are still not covered by a comprehensive early warning system. most systems only deal with one aspect of climate-related risks or hazards, e.g., heat waves or drought. finally, most systems do not cover the entire early warning landscape from collection of meteorological data to delivery and response of users. recently, the world meteorological organization proposed a global framework for climate services, which aims to strengthen the global cooperative system for collecting, processing and exchanging observations and for using climate-related information (wmo, ). early warning technologies appear to be mature in certain fields but not yet in others. considerable progress has been made, thanks to advances in scientific research and in communication and information technologies. nevertheless, a significant amount of work remains to fill existing technological, communication, and geographical coverage gaps. early warning technologies are now available for almost all types of hazards, although for some hazards (such as droughts and landslides) these technologies are still less developed. most countries appear to have early warning systems for disaster risk reduction. however, there is still a technological and national capacity divide between developed and developing countries. from an operational point of view, some elements of the early warning process are not yet mature. in particular, it is essential to strengthen the links between sectors involved in early warning, including organizations responsible for issuing warnings and the authorities in charge of responding to these warnings, as well as promoting good governance and appropriate action plans. it is generally recognized that it is fundamental to establish effective early warning systems to better identify the risk and occurrence of hazards and to better monitor the population's level of vulnerability. although several early warning systems are in place at the global scale in most countries for most hazard types, there is the need ''to work expeditiously towards the establishment of a worldwide early warning system for all natural hazards with regional nodes, building on existing national and regional capacity such as the newly established indian ocean tsunami warning and mitigation system'' ( un world summit outcome). by building upon ongoing efforts to promote early warning, a multi-hazard early warning system will have a critical role in preventing hazardous events from turning into disasters. a globally comprehensive early warning system can be built, based on the many existing systems and capacities. this will not be a single, centrally planned and commanded system, but a networked and coordinated assemblage of nationally owned and operated systems. it will make use of existing observation networks, warning centres, modelling and forecasting capacities, telecommunication networks, and preparedness and response capacities (united nations, ) . a global approach to early warning will also guarantee consistency of warning messages and mitigation approaches globally thus improving coordination at a multi-level and multi-sector scale among the different national actors such as the technical agencies, the academic community, disaster managers, civil society, and the international community. the next section provides an analysis of existing global early warning/monitoring systems that aggregate multi-hazard information. this section presents the results of a comparative analysis of multi-hazard global monitoring/ early warning systems. the aim of this analysis is to assess the effectiveness of existing global scale multi-hazard systems and define the set of needs suggested by comparing existing services. it assesses existing monitoring/early warning systems (singh and grasso, ) , chosen to be multi-hazard with global coverage, such as wfp's (the un food aid agency's) hews; alertnet, the humanitarian information alert service by reuters; reliefweb, the humanitarian information alert service by un-ocha; gdacs (global disaster alert and coordination system), a joint initiative of the united nations office for the coordination of humanitarian affairs (un-ocha) and the ec-jrc; and usgs ens. these systems have been analysed for the type of events covered, variety of output/ communication forms and range of users served. these systems cover a range of hazards and communicate results using a variety of methods. usgs ens only provides information on earthquakes and volcanic eruptions through the volcano hazards program (vhp) in collaboration with smithsonian institution. reliefweb focuses on natural hazards (earthquakes, tsunamis, severe weather, volcanic eruptions, storms, floods, droughts, cyclones, insect infestation, fires, and technological hazards) and health; alertnet additionally provides information on food insecurity and conflicts. gdacs provides timely information on natural hazards (earthquakes, tsunamis, volcanic eruptions, floods, and cyclones). hews informs users on earthquakes, severe weather, volcanic eruptions, floods, and locusts. existing systems, such as hews, post the information on a website, provide mobile phone and rss services, and gdacs sends emails, sms and faxes to users. the gdacs notification service mostly addresses humanitarian organizations, rescue teams or aid agencies. alertnet provides information to users through a web service, e-mail, sms and reports. reliefweb uses web services, e-mail and reports to disseminate information to users. reliefweb and alertnet also use new communications tools (facebook and twitter). ocha's virtual on-site operations coordination centre (virtual-osocc) enables real-time information exchange by all actors of the international disaster response community during the early phases following disasters. this service has been integrated within gdacs but is restricted to disaster managers. the only natural event notification provided by usgs e-mail service is earthquakes. hews offers no e-mail notifications for natural events. alertnet and reliefweb inform users on natural hazards and on health, food and security issues. usgs, reliefweb, alertnet and gdacs serve a wide a variety of users such as international organizations, humanitarian aid, policy/decision-makers, and civil society (fig. ) . the optimal global coverage multi-hazard system has to be as comprehensive as possible in terms of content, output and range of users. it will enhance existing systems by streaming data and information from existing sources and it will deliver this information in a variety of user-friendly formats to reach the widest range of users. by building on existing systems the multi-hazard system will inherit both the technological and geographical coverage gaps and limitations of existing early warning systems. the review analysis performed in the section ''inventory of early warning systems'' has shown that for some hazards (such as droughts and landslides) these technologies are still less developed and for tsunamis these systems are still under development for areas at risk. the analysis has shown that there is still a technological and national capacity divide between developed and developing countries. from an operational point of view, the links and communication networks between all sectors involved (organizations responsible for issuing warnings and the authorities in charge of responding to these warnings) need improvement. similarly, good governance and appropriate action plans need to be promoted. overcoming these gaps and enhancing, integrating, and coordinating existing systems is the first priority for the development of a global scale multi-hazard early warning system . early warning technologies have greatly benefited from recent advances in communication and information technologies and an improved knowledge on natural hazards and the underlying science. nevertheless many gaps still exist in early warning technologies and capacities, especially in the developing world, and a lot more has to be done to develop a global scale multi-hazard system. operational gaps need to be filled for slow-onset hazards both in monitoring, communication and response phases. effective and timely decision making is needed for slow onset hazards. below are some recommendations: ( ) fill existing gaps: the section identified the weaknesses and gaps in existing early warning systems. technological, geographical coverage, and capacity gaps exist, in addition to operational gaps for slow-onset hazards. in particular, actions need to be taken to improve prediction capabilities for landslides hazard aimed at developing a landslides early warning system. likewise, there is a pressing need to improve existing prediction capabilities for droughts. a global early fire warning system is not yet in place, the tsunami early warning systems for the indian ocean and the caribbean are not yet fully operational and a desertification early warning system has not been developed yet. there are ongoing efforts to develop these systems, such as the gfmc effort for the global fire ews, the indian ocean tsunami warning system operated by indonesia and a noaa led effort in the caribbean. a malaria early warning system is mandatory for africa, where one million deaths occur every year due to malaria. climate variability impacts need to be monitored within a global and coordinated effort, and the global framework for climate services needs to be further elaborated and operationalized. local earthquake early warning systems applications are needed in high seismic risk areas, where early warning systems are not yet in place. air quality and flood systems require improvements in prediction capabilities. dust storms and transboundary early warning systems do not yet exist. a coordinated volcanic early warning system that would integrate existing resources is also needed as well as an increase in coverage of volcanic observatories. particular attention should be paid to fill gaps in decision making processes for slow-onset hazards. their extent and impact are challenging to quantify. for this reason, actions and response are far more difficult tasks for slow-onset hazards than they are for other natural hazards. an institutional mechanism to regularly monitor and communicate slow-onset changes is needed to keep changes under review and to enable rational and timely decisions to be taken based on improved information. ( ) build capacity: the evaluation study of existing early warning systems (the section ) highlighted that a technological divide between developed and developing countries still exists. it is critical to develop basic early warning infrastructures and capacities in parts of the developing world most affected by disasters; it is also important to promote education programs on disaster mitigation and preparedness and integrate disaster mitigation plans into the broader development context. poor countries suffer greater economic losses from disasters than rich countries. development plays a key role and has a significant impact on disaster risk. almost percent of the people exposed to the deadliest hazards, earthquakes, floods, cyclones and droughts live in the developing world. the impact of disasters is mostly influenced by previous development choices. by integrating disaster mitigation strategies into planning and policies, the effects of disasters can be sensibly reduced and managed. ''disaster risk is not inevitable, but on the contrary can be managed and reduced through appropriate development actions'' (united nations development programme-undp, ) . it is through ''risk-sensitive development planning that countries can help reduce disaster risks''. key targets for capacity building include the following: . developing national research, monitoring and assessment capacity, including training in assessment and early warning. . supporting national and regional institutions in data collection, analysis and monitoring of natural and man-made hazards. . providing access to scientific and technological information, including information on stateof-the-art technologies. . education and awareness-raising, including networking among universities with programmes of excellence in the field of the emergency management. . organizing of training courses for local decision-makers and communities. . bridging the gap between emergency relief and long-term development. ( ) bridge the gaps between science and decision making, and strengthen coordination and communication links: scientific and technological advances in modelling, monitoring and predicting capabilities could bring immense benefits to early warning if science were effectively translated into disaster management actions. bridging the gap between scientific research and decision making will make it possible to fully exploit capacities of early warning technologies for societal benefit. the major challenge is to ensure that early warnings result in prompt responses by governments and potentially the international community. this requires that information be effectively disseminated in an accessible form down to the end user. this is achievable by adopting standard formats and easy-to-use tools for information dissemination, such as interactive maps, emails, sms, etc. the adoption of standard formats (such as the common alerting protocol cap) for disseminating and exchanging information has to be promoted. the advantage of standard format alerts is their compatibility with all information systems, warning systems, media, and most importantly, with new technologies such as web services. the adoption of standard formats guarantees consistency of warning messages and is compatible with all types of information systems and public alerting systems, including broadcast radio and television as well as public and private data networks, with multi-lingual warning systems and emerging technologies. this would easily replace specific application oriented messages and will allow the merging of warning messages from several early warning systems into a single multihazard message format. finally, it is critical to strengthen coordination and communication links by defining responsibility mechanisms and appropriate action plans. more often, time-sequenced warning messages are released in early warning processes, implying a decrease in warning times available for action and in reliability of the information. this trade-off needs to be addressed. the content and views expressed in this publication are those of the authors and do not necessarily reflect the views or policies, or carry the endorsement of the contributory organizations or the united nations environment programme (unep). the designations employed and the presentation of material in this publication do not imply the expression of any opinion whatsoever on the part of unep concerning the legal status of any country, territory or city or its authorities, or concerning the delimitation of its frontiers and boundaries. reference to a commercial company or product in this publication does not imply the endorsement of unep. & maps, photos, and illustrations as specified. this publication may be reproduced in whole or in part and in any form for educational or non-profit purposes without special permission from the copyright holder, provided acknowledgement of the source is made. unep would appreciate receiving a copy of any publication that uses this publication as a source. no use of this publication may be made for resale or any other commercial purpose whatsoever without prior permission in writing from unep. applications for such permission, with a statement of purpose and intent of the reproduction, should be addressed to the director, division of communications and public information (dcpi), unep, p.o. box , nairobi , kenya. the use of information from this publication concerning proprietary products for publicity or advertising is not permitted. citation: unep ( adaptation: ( ) actions taken to help communities and ecosystems cope with changing climate conditions (unfccc). ( ) genetically determined characteristic that enhances the ability of an organism to cope with its environment (cbd). aerosols: a collection of airborne solid or liquid particles, with a typical size between . and mm, that resides in the atmosphere for at least several hours. aerosols may be of either natural or anthropogenic origin. air quality: smog is the product of human and natural activities such as industry, transportation, wild-fires, volcanic eruptions, etc. and can have serious effects on human health and the environment. us epa uses and air quality index (aqi) which is calculated on five major air pollutants regulated by the clean air act: ground-level ozone, particle pollution (also known as particulate matter), carbon monoxide, sulfur dioxide, and nitrogen dioxide. for each of these pollutants, epa has established national air quality standards to protect public health. groundlevel ozone and airborne particles are the two pollutants that pose the greatest threat to human health in this country. biodiversity: the variety of life on earth, including diversity at the genetic level, among species and among ecosystems and habitats. it includes diversity in abundance, distribution and in behaviour. biodiversity also incorporates human cultural diversity, which can both be affected by the same drivers as biodiversity, and itself has impacts on the diversity of genes, other species and ecosystems. biofuels: fuel produced from dry organic matter or combustible oils from plants, such as alcohol from fermented sugar, black liquor from the paper manufacturing process, wood and soybean oil. biomass: organic material, both above ground and below ground, and both living and dead, such as trees, crops, grasses, tree litter and roots. capacity: the combination of all the strengths, attributes and resources available within a community, society or organization that can be used to achieve agreed goals. comment: capacity may include infrastructure and physical means, institutions, societal coping abilities, as well as human knowledge, skills and collective attributes such as social relationships, leadership and management. capacity also may be described as capability. capacity assessment is a term for the process by which the capacity of a group is reviewed against desired goals, and the capacity gaps are identified for further action. capacity building: process of developing the technical skills, institutional capability, and personnel. climate change: change of climate, which is attributed directly or indirectly to human activity that alters the composition of the global atmosphere and which is in addition to natural climate variability observed over comparable time periods. climate variability: variations in the mean state and other statistics (such as standard deviations and the occurrence of extremes) of the climate on all temporal and spatial scales beyond that of individual weather events. variability may be due to natural internal processes in the climate system (internal variability), or to variations in natural or anthropogenic external forcing (external variability). common alerting protocol: the common alerting protocol (cap) provides an open, nonproprietary digital message format for all types of alerts and notifications. it does not address any particular application or telecommunications method. the cap format is compatible with emerging techniques, such as web services, as well as existing formats including the specific area message encoding (same) used for the united states' national oceanic and atmospheric administration (noaa) weather radio and the emergency alert system (eas). cost-benefit analysis: a technique designed to determine the feasibility of a project or plan by quantifying its costs and benefits. cyclone: an atmospheric closed circulation rotating counter clockwise in the northern hemisphere and clockwise in the southern hemisphere. deforestation: the direct human-induced conversion of forested land to non-forested land. desertification: degradation of land in arid, semi-arid and dry sub-humid areas, resulting from various factors, including climatic variations and human activities. disaster: a serious disruption of the functioning of a community or a society involving widespread human, material, economic or environmental losses and impacts, which exceeds the ability of the affected community or society to cope using its own resources. comment: disasters are often described as a result of the combination of: the exposure to a hazard; the conditions of vulnerability that are present; and insufficient capacity or measures to reduce or cope with the potential negative consequences. disaster impacts may include loss of life, injury, disease and other negative effects on human physical, mental and social well-being, together with damage to property, destruction of assets, loss of services, social and economic disruption and environmental degradation. disaster risk: the potential disaster losses, in lives, health status, livelihoods, assets and services, which could occur to a particular community or a society over some specified future time period. comment: the definition of disaster risk reflects the concept of disasters as the outcome of continuously present conditions of risk. disaster risk comprises different types of potential losses which are often difficult to quantify. nevertheless, with knowledge of the prevailing hazards and the patterns of population and socio-economic development, disaster risks can be assessed and mapped, in broad terms at least. disaster risk reduction: the concept and practice of reducing disaster risks through systematic efforts to analyse and manage the causal factors of disasters, including through reduced exposure to hazards, lessened vulnerability of people and property, wise management of land and the environment, and improved preparedness for adverse events. comment: a comprehensive approach to reduce disaster risks is set out in the united nations-endorsed hyogo framework for action, adopted in , whose expected outcome is ''the substantial reduction of disaster losses, in lives and the social, economic and environmental assets of communities and countries.'' the international strategy for disaster reduction (isdr) system provides a vehicle for cooperation among governments, organisations and civil society actors to assist in the implementation of the framework. note that while the term ''disaster reduction'' is sometimes used, the term ''disaster risk reduction'' provides a better recognition of the ongoing nature of disaster risks and the ongoing potential to reduce these risks. droughts: a period of abnormally dry weather sufficiently prolonged for the lack of water to cause serious hydrologic imbalance in the affected area. early warning system: the set of capacities needed to generate and disseminate timely and meaningful warning information to enable individuals, communities and organizations threatened by a hazard to prepare and to act appropriately and in sufficient time to reduce the possibility of harm or loss. comment: this definition encompasses the range of factors necessary to achieve effective responses to warnings. a people-centred early warning system necessarily comprises four key elements: knowledge of the risks; monitoring, analysis and forecasting of the hazards; communication or dissemination of alerts and warnings; and local capabilities to respond to the warnings received. the expression ''end-to-end warning system'' is also used to emphasize that warning systems need to span all steps from hazard detection through to community response. earth observation: earth observation, through measuring and monitoring, provides an insight and understanding into earth's complex processes and changes. eo include measurements that can be made directly or by sensors in-situ or remotely (i.e. satellite remote sensing, aerial surveys, land or ocean-based monitoring systems, fig. ), to provide key information to models or other tools to support decision making processes. earthquakes: earthquakes are due to a sudden release of stresses accumulated around the faults in the earth's crust. this energy is released through seismic waves that travel from the origin zone, which cause the ground to shake. severe earthquakes can affect buildings and populations. the level of damage depends on many factors such as intensity of the earthquake, depth, vulnerability of the structures, and distance from the earthquake origin. ecosystem: dynamic complex of plant, animal, microorganism communities and their non-living environment, interacting as a functional unit. ecosystems are irrespective of political boundaries. el niñ o-southern oscillation: a complex interaction of the tropical pacific ocean and the global atmosphere that results in irregularly occurring episodes of changed ocean and weather patterns in many parts of the world, often with significant impacts over many months, such as altered marine habitats, rainfall changes, floods, droughts, and changes in storm patterns. comment: the el nino part of the el nino-southern oscillation (enso) phenomenon refers to the well-above average ocean temperatures that occur along the coasts of ecuador, peru and northern chile and across the eastern equatorial pacific ocean, while la nina part refers to the opposite circumstances when well-below-average ocean temperatures occur. the southern oscillation refers to the accompanying changes in the global air pressure patterns that are associated with the changed weather patterns experienced in different parts of the world. emergency management: the organization and management of resources and responsibilities for addressing all aspects of emergencies, in particular preparedness, response and initial recovery steps. comment: a crisis or emergency is a threatening condition that requires urgent action. effective emergency action can avoid the escalation of an event into a disaster. emergency management involves plans and institutional arrangements to engage and guide the efforts of government, non-government, voluntary and private agencies in comprehensive and coordinated ways to respond to the entire spectrum of emergency needs. the expression ''disaster management'' is sometimes used instead of emergency management. extensible markup language: a markup language that defines a set of rules for encoding documents in a format that is both human-readable and machine-readable. e-waste: a generic term encompassing various forms of electrical and electronic equipment that has ceased to be of value and is disposed of. a practical definition of e-waste is ''any electrically powered appliance that fails to satisfy the current owner for its originally intended purpose.'' false alarm: in the context of early warning systems, a false alarm is defined as the situation in which an alarm is activated when it should not have been. fine particle: particulate matter suspended in the atmosphere less than . mm in size (pm . ). floods: an overflow of water onto normally dry land. theinundation of a normally dry area caused by rising water in an existing waterway, such as a river, stream, or drainage ditch. ponding of water at or near the point where the rain fell. flooding is a longer term event than flash flooding: it may last days or weeks. floods are often triggered by severe storms, tropical cyclones, and tornadoes. food security: when all people at all times have access to sufficient, safe, nutritious food to maintain a healthy and active life. forecast: definite statement or statistical estimate of the likely occurrence of a future event or conditions for a specific area. comment: in meteorology a forecast refers to a future condition, whereas a warning refers to a potentially dangerous future condition. forest: land spanning more than . ha with trees higher than m and a canopy cover of more than percent, or trees able to reach these thresholds in situ. it does not include land that is predominantly under agricultural or urban land use. gaussian distribution: the gaussian (normal) distribution was historically called the law of errors. it was used by gauss to model errors in astronomical observations, which is why it is usually referred to as the gaussian distribution. geological hazard: geological process or phenomenon that may cause loss of life, injury or other health impacts, property damage, loss of livelihoods and services, social and economic disruption, or environmental damage. comment: geological hazards include internal earth processes, such as earthquakes, volcanic activity and emissions, and related geophysical processes such as mass movements, landslides, rockslides, surface collapses, and debris or mud flows. hydrometeorological factors are important contributors to some of these processes. tsunamis are difficult to categorize; although they are triggered by undersea earthquakes and other geological events, they are essentially an oceanic process that is manifested as a coastal water-related hazard. within this report, tsunamis are included in the geological hazards group. geographic information system: a computerized system organizing data sets through a geographical referencing of all data included in its collections. the potential for earthquake early warning in southern california oregon department of environmental quality. water quality credit trading in oregon: a case study report disaster management support group (dmsg) ceos disaster management support group report. the use of earth observing satellites for hazard support: assessments & scenarios. final report of the ceos disaster management support group natural disaster hotspots: a global risk analysis mexico city seismic alert system environmental change monitoring by geoinformation technology for baghdad and its neighboring areas geoss -year implementation plan reference document early warning systems early warning of wildland fires usable science: early warning systems: do's and don'ts automated decision procedure for earthquake early warning automated decision procedure for earthquake early warning a model for a seismic computerized alert network an automatic processing system for broadcasting earthquake alarms global observations of the land, a proposed theme to the igos-partnership-version probability theory: the logic of science jma earthquake early warning real-time seismology and earthquake damage mitigation global forest fire watch: wildfire potential, detection, monitoring and assessment oil spill detection and monitoring from satellite image on a rational strong motion index compared with other various indices the role of a new method of quickly estimating epicentral distance and magnitude from a single seismic record prediction, science, decision making and the future of nature university of valencia,eos.d c. chinese academy of forestry effective early warning -use of hazard maps as a tool for effective risk communication among policy makers and communities -session organized by the government of japan global environmental alert service digital change detection techniques using remotely sensed data the drought monitor ict in pre-disaster awareness and preparedness. presented at the apt-itu joint meeting for ict role in disaster management early warning systems for natural disasters reduction undp-united nations development programme bureau for crisis prevention and recovery united nations convention to combat desertification the east african food crisis: did regional early warning systems function climate knowledge for action: a global framework for climate services-empowering the most vulnerable quick and reliable determination of magnitude for seismic early warning a virtual sub-network approach to earthquake early warning key: cord- -fdn c hx authors: leanza, matthias title: the darkened horizon: two modes of organizing pandemics date: - - journal: how organizations manage the future doi: . / - - - - _ sha: doc_id: cord_uid: fdn c hx this chapter deals with the recent darkening of the future horizon in the global fight against pandemics. since roughly the year , the world health organization has collaborated with a large number of local actors and made a concentrated effort to protect the world’s population against emerging infectious diseases, such as severe acute respiratory syndrome (sars), swine flu, ebola and zika. although efforts have been made so that the spread of future infectious diseases will be contained through early intervention, the actors in charge anticipate that the extant measures will fail to some degree. they believe it is simply impossible to prevent all pandemics from happening. but steps can and should be taken to lessen the impact of an unavoidable pandemic through emergency preparation. this chapter deals with organizations and organizational networks as key actors in these processes of emergency planning. without the capacity of organizations to produce binding decisions for their members, which makes planning for an uncertain future possible, pandemic preparedness would not be feasible—especially not on a global scale. the horizon has darkened. the future no longer seems like an open space full of opportunities and risks. rather, what is in store appears to be deeply threatening. whether one thinks of global warming, terrorism or the continuing instability of the banking and finance sector, our expectations for the future in many areas of public life exemplify what craig calhoun ( , p. ) calls an 'emergency imaginary': 'a discourse of emergencies is now', as he wrote more than years ago in a diagnosis that is even more applicable today, 'central to international affairs. it shapes not only humanitarian assistance, but also military intervention and the pursuit of public health.' due to this emergency imaginary, we feel that our social institutions, our health and well-being, and even, as in the case of global warming, the future of mankind as such are deeply endangered. m. leanza (*) sociology department, university of basel, basel, switzerland this chapter deals with the recent darkening of the future horizon in the global fight against pandemics. around the year , the world health organization (who) started collaborating with a large number of local actors and made a concentrated effort to protect the world's population against emerging infectious diseases such as severe acute respiratory syndrome (sars), swine flu, ebola and zika. although efforts have been made so that the spread of future infectious diseases will be contained through early intervention, the actors in charge expect the extant measures to fail to some degree. they believe it is simply impossible to prevent all pandemics from happening. but steps can and should be taken through emergency preparation to lessen an unavoidable pandemic's impact. as andrew lakoff ( , pp. - ) summarizes: preparedness assumes the disruptive, potentially catastrophic nature of certain events. since the probability and severity of such events cannot be calculated, the only way to avert catastrophes is to have plans to address them already in place and to have exercised for their eventuality-in other words, to maintain an ongoing capability to respond appropriately. in recent years, scholars of security studies, cultural studies and other research areas have paid much attention to these developments in emergency preparedness, which, it is worth noting, are not limited to the domain of public health. this issue has primarily been addressed at two levels: first, by changing global security policies after the / attacks, and, second, by scrutinizing the narratives and rhetorical strategies through which the emergency imaginary is constructed and gains plausibility (e.g. massumi ; aradau and van munster ; horn ) . in this chapter, i will focus on organizations as key actors in these processes of emergency planning. without the capacity of organizations to produce binding decisions for their members, which allows them to plan for an uncertain future, pandemic preparedness would not be feasibleespecially not on a global scale. i will unfold my argument in four steps. with regard to the who, which was established in , i will discuss the question of how supranational coordination and planning for the future is rendered possible by building formal organizations and organizational networks at a global level. i will then highlight some aspects of the attempts undertaken by the who and its partners after the year to fight pandemics on a global scale. my analysis of relevant policy papers, legal norms and manuals shows that two different though complementary strategies are applied: early intervention and emergency planning. these are, as i will discuss more explicitly in the final section, two different kinds of organizing (for) the future or, to put it differently, two modes of how organizations manage pandemics. the overall aim of the empirical analysis offered in this chapter is to reconstruct organizational programmes and rationales rather than to give an account of the actual operations of these systems. the focus lies on public discourses and normative texts and not so much on the 'inside' of these organizations, meaning their day-to-day routines and practices. contagious diseases do not stop at state borders. pathogens circulate without regard for political and administrative spheres of influence. what gilles deleuze and félix guattari ( , introduction) establish for rhizomes in general also applies to infection chains in particular: by growing rampantly, they produce a 'deterritorializing effect'. pathogens connect distant regions and different kinds of people; zoonoses even trespass the boundary between animals and humans. by doing so, communicable diseases create spaces and communalities that did not exist before. this is also the reason why every epidemic requires new maps (e.g. koch ) . even though pathogens do not stop at state borders, sovereignty ends there, and the difficult terrain of diplomacy begins. the international sanitary conferences, which took place between and , made a first step towards creating a global field of public health (howard-jones ; bynum ) . while the first couple of these conferences-there were in all-dealt primarily, though not exclusively, with cholera, further diseases and topics were discussed and negotiated beginning in the s. laborious agreements regarding quarantine, inspection and surveillance measures were worked out and in some cases ratified. but the field of global health diplomacy did not receive a coordination and control unit until with the establishment of the who as a specialized agency of the united nations (zimmer ) . in passing the international health regulations (ihr) of , which superseded the international sanitation regulations of , the who established standards and norms with a legally binding character for its signatory states. the primary goal of these regulations was to provide 'maximum security against the international spread of disease with the minimum interference with world traffic' (who , p. ) . to this end, epidemiological surveillance and alarm systems were installed in signatory states, or already existing structures were expanded. in addition, the who made more specific efforts to combat infectious diseases. one of the first large projects was the global malaria eradication program ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . in order to defeat the dangerous tropical disease, the insecticide ddt (dichloro-diphenyl-trichloroethane) was used liberally and repeatedly in over countries. even though certain regions profited from this measure, the actors in charge had to accept in the end that this goal was, on the whole, too ambitious (zimmer , pp. - ) . more successful, however, was the vaccination programme against smallpox, which was enacted in and intensified in (fenner et al. (fenner et al. , pp. - , . after roughly years, it finally reached its goal. in , the who announced: 'smallpox is dead!' (ibid., p. ). sovereign nation states use the mechanism of formal organization to cooperate in this and further policy areas of international concern. while 'leagues of subjects' within a state 'savour of unlawful design', as thomas hobbes ( , p. ) famously wrote in leviathan, 'leagues between commonwealths, over whom there is no human power established to keep them all in awe, are not only lawful, but also profitable for the time they last'. as well as mutual agreements and legally binding contracts, inter-or supranational organizations are a specific form taken by such leagues today. drawing on niklas luhmann ( ) , organizations can be perceived as a type of social system that is defined by formal membership roles and processes of decision-making. as inter-or supranational organizations demonstrate, not only natural but also legal persons, such as states, can become members of organizations. by entering an organization, sovereign nation states are, in principle, capable of producing collectively binding decisions on a global level, without losing their autonomy to a sovereign world state. today, a wide range of organizations constitute the global field of public health and disease control (youde , part ) . besides the who, they include the world bank, unaids (which was established in ) and governmental and nongovernmental organizations. these organizations are the main action centres within the field of global public health. they deliver expertise, develop policies, launch programmes and mobilize the global community. to achieve their goals, they regularly ally with other organizations and build networks that can be activated when necessary. this especially holds true for the global fight against pandemics. in certain respects, in order to deal with an unfolding threat, organizational networks have to spread as rampantly as the pathogens themselves. otherwise they will be unable to prevent further harm. in , and thus very much in the shadow of the global aids crisis, the who laid the foundation for a new regime in the global fight against pandemics by setting up the global outbreak alert and response network (goarn). since then it has acted in more than cases (mackenzie et al. ). through 'rapid identification, verification and communication of threats' (who , p. ), goarn seeks to contain the spread of infectious diseases, especially highly infectious ones. 'no single institution or country', so the main argument for this international cooperation goes, 'has all of the capacities to respond to international public health emergencies caused by epidemics and by new and emerging infectious diseases' (who n.d.) . in - , the sars pandemic, which resulted in nearly registered deaths, triggered a global health alarm due to goarn, though the communication of this risk kindled by the predicted future potential of the pandemic outstripped, in certain respects, its actual impact (smith ; ong ). the thoroughly redesigned ihr from , which came into force in , further developed and shaped this process. in contrast to the regulations it replaced-the international sanitation and health regulations of and , which, in comparison, were quite static since they only applied to a specific catalogue of communicable diseasethe ihr now includes an early warning system that seeks to detect every potential 'public health emergency of international concern' (pheic) (fidler ) . the focus is on so-called points of entry, especially sea-and airports (who a, pp. - , - ) . the member states of the who are responsible for implementing this global safety net at the local level; they must establish surveillance, contact and coordination units. in germany, for instance, the federal office of civil protection and disaster assistance coordinates and oversees this implementation process in cooperation with the robert koch institute. the robert koch institute, in turn, works with the european centre for disease prevention and control, which is an important partner of goarn. because many different kinds of organizations across a wide range of countries are connected in this network, it is necessary to standardize decision-making. without the 'structural coupling' (maturana and varela , pp. - ) of a shared decision process, cooperation and coordination between the participating organizations would not be feasible. decisions would simply not be able to circulate within the network. instead, they would have to be re-evaluated at every nodal point. for this reason, the ihr (who a, pp. - ; see also who ) stipulates a risk-assessment matrix for signatory countries: after a local surveillance unit has detected an event 'that may constitute a public health emergency of international concern' (who a, p. ) , three yes/no questions regarding its actual and potential impact must be answered. then, it is determined whether the event should be rated as unusual or unexpected. if the answers are all positive, the who must be notified within hours. if they are not all positive, there are two further levels of such yes/no questions, which address the risk of international spread and, in a final step, the possibility that countries or other entities would impose international travel or trade restrictions in response to the outbreak. the answers to these questions then determine whether notifying the who is required or not. this decision-making tool can be understood as an 'attention filter'. since there are now many globally connected surveillance units, mechanisms have to be installed that not only allow and trigger but also suppress communication between them. otherwise, the network would be flooded with more information than it can process. in other words, the elements within this structure would be too closely connected. nonetheless, the goal is to set the attention thresholds as low as possible. even if notifying the who is not required at one point, the event in question has to be kept under surveillance. this, of course, does not prevent the situation from being evaluated incorrectly. the - ebola outbreak, for instance, was declared a pheic relatively late because the actors in charge initially viewed it as only a local problem of a poor region in west africa (lakoff et al. ) . together with the attention thresholds, the reaction times of the relevant public health organizations are also to be lowered. while the decentralized structure of networks improves the alarm function, since attention is widely distributed, a missing or weakly developed action centre has an adverse effect on the intervention function. in defiance of all network rhetoric, the global fight against pandemics cannot proceed without the structural principles of hierarchy and the distribution of tasks. according to the ihr, after being informed of a positive risk assessment by local organizations, the who has to provide them with further information and instructions and send experts to the affected regions (who a, pp. - , - , - ) . the who is the 'obligatory passage point' (callon ) for this process. a combination of the network, hierarchy and the distribution of tasks aims to make rapid intervention possible. even though the who wants, in principle, global traffic to flow without any hindrance, in some cases a temporary interruption of the circulation of goods and people may be considered necessary to protect global public health (stephenson ; opitz ) . the ihr and national regulations therefore stipulate travel restrictions on certain people and allow measures like quarantine and isolation to be imposed. in an age of global flows and a greater awareness of fundamental rights, this specific kind of intervention has to some extent become problematic. as the first principle of the ihr states 'the implementation of these regulations shall be with full respect for the dignity, human rights and fundamental freedoms of persons' (who a, p. ) . similarly, the who ( , p. ) explained in : 'in emergency situations, the enjoyment of individual human rights and civil liberties may have to be limited in the public interest. however, efforts to protect individual rights should be part of any policy. measures that limit individual rights and civil liberties must be necessary, reasonable, proportional, equitable, non-discriminatory and in full compliance with national and international laws.' besides these reservations, the global fight against pandemics cannot proceed without restrictive measures, as the sars pandemic and ebola outbreak have shown. although a concentrated global effort has been made to prevent pandemics via early detection and rapid response, the actors in charge expect them to happen. it is only a matter of time, they believe, until the next health emergency occurs. 'influenza experts agree', the who ( b, pp. vi-vii) warned in , 'that another pandemic is likely to happen but are unable to say when. the specific characteristics of a future pandemic virus cannot be predicted. nobody knows how pathogenic a new virus would be, and which age groups it would affect.' although its exact time of emergence, etiological nature and epidemiological distribution pattern may be unpredictable, it is considered a fact that the next pandemic will occur in the near or not so distant future (see also macphil ). a glossy brochure on pandemic planning by the us department of homeland security ( , p. ) presented a similar way of looking at things. in a quotation in the brochure, the us secretary of health and human services, mike leavitt, states: 'some will say this discussion of the avian flu is an overreaction. some may say, "did we cry the wolf?" the reality is that if the h n virus does not trigger pandemic flu, there will be another virus that will. ' this statement demonstrates that the general trend of thinking about emergencies and accidents as 'normal' has permeated the field of global public health (calhoun ; lakoff ) . in the s, in many areas of public life, the future was already perceived as unsafe and potentially catastrophic, and this view was intensified after the year (aradau and van munster ; horn ) . although the future horizon has darkened with the looming prospect of ecological, political and economic crises, not all hope is lost. the occurrence of (massive) harm might be inevitable, but what can yet be prevented is the worst-case scenario. it is assumed that through emergency planning, the severity of the potential damage can be lessened. this is what 'preparedness' means: acting, deciding and governing under conditions of insecurity (lentzos and rose ; anderson ) . as the who explained in : 'although it is not considered feasible to halt the spread of a pandemic virus, it should be possible to minimize its consequences through advance preparation to meet the challenge' (who c, p. ) . in his address to the nd world health assembly in , the un secretary-general, ban ki-moon, posed the same question: 'how do we build resilience in an age of unpredictability and interconnection?' through emergency planning is his answer. 'this is how we will make the global community more resilient. this is how we ensure that wherever the next threat to health, peace or economic stability may emerge, we will be ready.' of special interest in this regard are critical infrastructures, such as water supply, that might be affected by a severe disease outbreak. local public health emergency centres, which the who ( ) assembled as a global network (eoc-net) in , are responsible for the planning process. as well as taking stock of the available resources and contingents in a country or region, scenario planning and agent-based computer simulations are of fundamental importance ; they enable us to imagine possible scenarios via enactment and visualization without the necessity of making any probability assumptions. it is believed that in order to be prepared for future emergencies, the organizational imagination must to some extent be liberated from restrictions imposed by past experiences. organizations are of crucial importance for the planning process. for instance, the who guidelines, whole-of-society pandemic readiness, aim 'to support integrated planning and preparations for pandemic influenza across all sectors of society, including public and private sector organizations and essential services' (who , p. ) . to strengthen organizational resiliency against the stresses and strains that may result from a pandemic, thorough preparation is required. 'in the absence of early and effective planning, countries may face wider social and economic disruption, significant threats to the continuity of essential services, lower production levels, distribution difficulties, and shortages of supplies' (p. ). emergency planning is furthermore imperative since '[t]he failure of businesses to sustain operations would add to the economic consequences of a pandemic. some business sectors will be especially vulnerable (e.g. those dependent on tourism and travel), and certain groups in society are likely to suffer more than others' (p. ). the 'readiness framework' therefore asks all organizations that provide basic services such as food, water, health, defence, law and order, finance, transportation, telecommunications and energy to prepare for pandemics via simulation exercises and drills based on different scenarios. furthermore, business continuity plans have to be developed. for this purpose, a pandemic coordinator should be assigned to oversee the planning process. all organizations that are crucial for public life are strongly advised to prepare themselves for the next pandemic. given the interdependencies between these organizations, general preparedness is the only way to prevent a complete breakdown. or, as the guidelines put it: 'it is prudent to plan for the worst, while hoping for the best' (p. ). according to lakoff ( ) , today's highly differentiated field of global health is characterized by, among other things, the juxtaposition of two regimes: global health security and humanitarian biomedicine. 'each of these regimes', he elaborates, 'combines normative and technical elements to provide a rationale for managing infectious disease on a global scale. they each envision a form of social life that requires the fulfillment of an innovative technological project. however, the two regimes rest on very different visions of both the social order that is at stake in global health and the most appropriate technical means of achieving it' (p. ). while global health security turns its attention to emerging infectious diseases, 'which are seen to threaten wealthy countries, and which typically (though not always) emanate from asia, sub-saharan africa, latin america', humanitarian biomedicine deals with 'diseases that currently afflict the poorer nations of the world, such as malaria, tuberculosis, and hiv/aids' (p. ). in addition to lakoff's ( lakoff's ( , see also distinction between the two regimes of global health, my analysis highlights two layers that are encompassed by one of these regimes, the global fight against emerging infectious diseases. the two modes of organizing of such pandemics are not organizations themselves. they are programmes that structure the organizational decision-making and the corresponding membership roles. in analysing these programmes, the focus lies not so much on the actual operation of the system-since it is always a creative translation of cognitive and normative schemes into concrete practice-but rather on the intended actions of the system. a first line of defence is defined through early intervention. for this purpose, a wide and ramified organizational network is put in place. it allows pandemics to be detected while they are still emerging, and this makes it possible to limit the potential scope of their spread. because the goal is to prevent a further unfolding of potential threats into actual damages, time is of the essence in detection. the organizations must react quickly while ensuring, at same time, that the information they generate, process and communicate to others is reliable. the strategies they decide to follow also have to be effective. otherwise the primary goal is not achieved: preventing pandemics from happening. in reality, this highly ambitious goal cannot always be met. but the organizations in charge know their limitations and are therefore requested to install a second line of defence: emergency planning. all organizations that are critical for society are asked to have emergency plans in place so that, in the case of a pandemic, they would still be able to react. the goal here shifts from preventing the spread of disease towards securing the 'autopoiesis' (maturana and varela , pp. - ) of the system, meaning its ability to reproduce itself even under enormous environmental pressures. while early intervention requires organizations to be capable of acting quickly, pandemic preparedness aims to produce robust systems that are immune to breakdown. despite operating from different angles, these two modes of organizing pandemics are complementary. early intervention relates to preventable damages. the underlying assumption is that pandemics can be avoided through early detection and rapid response. the future scenario of early intervention is therefore an altogether positive one, in which organizations are capable of doing their job in the face of danger, namely containing infectious diseases. pandemic preparedness, in contrast, works not with one but with two kinds of damages: primary damages, which cannot be prevented, and preventable consequential damages, which pose an existential threat. the aim is still to prevent harm, but preparedness does not focus on the pandemics per se but on the fatal repercussions that they might have for societies. this is a minimal form of prevention, and it is no longer believed that it is possible to escape such a pandemic unscathed. both modes of relating to the future do not exclude but rather complement each other. if early intervention does not work in a specific scenario, there is still a second prevention strategy, which, of course, can only partially contain the effects of the pandemic since (massive) harm will have already occurred. but by strengthening the resilience of organizations and societies, pandemic preparedness aims to preserve existential functions and operations. in his by now classic essay from , charles perrow describes organizations, especially large ones, as a key element of modern societies. according to perrow, fundamental social functions are maintained by private and public organizations. this also holds true for responding to pandemics. in a 'society of organizations' (perrow ) , it is organizations and their professionals who manage pandemics. but two kinds of organizations have to be distinguished which correspond to the two modes or programmes for managing emerging infectious diseases: first, organizations and professionals in the public health sector try to prevent pandemics through early intervention (and further preventative measures, such as vaccination programmes). it is their job to protect the general public from health risks; this is the purpose of these specialized organizations and the goal of their corresponding professional activities. second, and in contrast, all organizations that provide basic services for society are asked to make emergency plans and prepare themselves for the next pandemic. this includes public health organizations but is also addressed to, first and foremost, private and public organizations that provide food, water, defence, law and order, finance, transportation, telecommunications and energy. the second programme is no less ambitious than the first. organizations and professionals in the public health sector may not always succeed in preventing pandemics: as we have seen, they are well aware of this fact, and that is why emergency plans are developed in the first place. but this implies that, in principle, all organizations that provide basic services for society have to professionalize themselves in this specific area. one could describe this as a 'colonization' of non-health organizations through public health imperatives. this is, of course, not a completely new development if one considers, for instance, company doctors or health and safety officers. furthermore, many large organizations have undergone a professionalization in areas that do not traditionally belong to their core activities, such as when they maintain legal, public relations or research departments, or when they offer childcare or psychological counselling to their employees. to some extent, this is a likely consequence of the 'functional differentiation of modern societies' (luhmann ) : even if organizations are typically specialized in providing only one or two services, they have to take further social functions into account. what is new here is the kind of task, that is, preparing for pandemics in order to prevent the worst-case scenario-a complete breakdown of the system that would result from the absence of employees due to illness. in a society of organizations, the autopoiesis of society as whole cannot be separated from the autopoiesis of its organizations. preserving society in a public health emergency depends on keeping organizations functional. for measures of disease assessment and control in germany, see the 'gesetz zur neuordnung seuchenrechtlicher vorschriften for a discussion of how biosecurity intertwines the field of public health with the security sector, see also fidler and gostin preemption, precaution, preparedness: anticipatory action and future geographies politics of catastrophe: genealogies of the unknown policing hearts of darkness: aspects of the international sanitary conferences a world of emergencies: fear, intervention, and the limits of cosmopolitan order some elements of a sociology of translation: domestication of the scallops and the fishermen of st brieuc bay pandemic influenza: preparedness, response, and recovery; guide for critical infrastructure and key resources european centre for disease prevention and control smallpox and its eradication from international sanitary conventions to global health security: the new international health regulations biosecurity in the global age: biological weapons, public health, and the rule of law leviathan or the matter, forme & power of a common-wealth ecclesiasticall and civil the scientific background of the international sanitary conferences - resilience and solidarity: our best response to crisis. address to the nd world health assembly mapping medical disasters: ebola makes old lessons preparing for the next emergency two regimes of global health governing insecurity: contingency planning, protection, resilience funktionen und folgen formaler organisation the global outbreak alert and response network a predictable unpredictability: the h n pandemic and the concept of 'strategic uncertainty' within global public health fear (the spectrum said) the tree of knowledge: the biological roots of human understanding assembling around sars: technology, body heat, and political fever in risk society regulating epidemic space: the nomos of global circulation defining epidemics in computer simulation models: how do definitions influence conclusions? a society of organizations responding to global infectious disease outbreaks: lessons from sars on the role of risk perception, communication and management emerging infectious diseases/emerging forms of biological sovereignty who checklist for influenza pandemic preparedness planning. geneva: who. ---. c. who global influenza preparedness plan: the role of who and recommendations for national measures before and during pandemics welt ohne krankheit: geschichte der internationalen gesundheitspolitik - key: cord- -lor tfe authors: asgary, ali; ozdemir, ali ihsan; Özyürek, hale title: small and medium enterprises and global risks: evidence from manufacturing smes in turkey date: - - journal: int j disaster risk sci doi: . /s - - - sha: doc_id: cord_uid: lor tfe this study investigated how small and medium enterprises (smes) in a country perceive major global risks. the aim was to explore how country attributes and circumstances affect sme assessments of the likelihood, impacts, and rankings of global risks, and to find out if sme risk assessment and rankings differ from the global rankings. data were gathered using an online survey of manufacturing smes in turkey. the results show that global economic risks and geopolitical risks are of major concern for smes, and environmental risks are at the bottom of their ranking. among the economic risks, fiscal crises in key economies and high structural unemployment or underemployment were found to be the highest risks for the smes. failure of regional or global governance, failure of national governance, and interstate conflict with regional consequences were found to be among the top geopolitical risks for the smes. the smes considered the risk of large-scale cyber-attacks and massive incident of data fraud/theft to be relatively higher than other global technological risks. profound social instability and failure of urban planning were among the top societal risks for the smes. although the global environmental and disaster risks were ranked lowest on the list, man-made environmental damage and disasters and major natural hazard-induced disasters were ranked the highest among this group of risks. overall, the results show that smes at a country level, for example turkey, perceive global risks differently than the major global players. small and medium enterprises (smes) face many small and large internal and external risks. while they can better control much of the internal risks through risk management and treatment measures, they are more vulnerable to external risks because these risks are often beyond their control, influence, radar, and capacity to manage. the world economic forum (wef) has created, assessed, and monitored global risks since , using a survey of about major global stakeholders and players. by the wef definition, a global risk is ''an uncertain event or condition that, if it occurs, can cause significant negative impact for several countries or industries within the next years'' (world economic forum , p. ). small and medium enterprises are playing a vital role in local, national, and global economies and are very important in job and income generation (chowdhury ; oecd ; chatterjee et al. ) . at least % of the firms in both developed and developing countries are smes (mbuyisa and leonard ) . they account for - % of gdp in developed and developing countries (igwe et al. ) and generate about % of the global industrial production and % of the world's exports (sharma and bhagwat ; mbuyisa and leonard ) . small and medium enterprises are the backbone of the european economy, with more than . % of all non-financial businesses, % of total value added, and . % of total employment (briozzo and cardone-riportella ; european commission ) . in japan, more than . % of all firms are smes, they employ more than % of the workforce, and create more than % of all added value of the manufacturing industry (yoshino and taghizadeh-hesary ) . small and medium enterprises comprised . % of the firms in turkey in and were involved in . % of export and . % of import (kaya and uzay ) . considering their size and roles in the national and global economies and the fact that the enhancement of the private sector's resilience depends on risk reduction by smes (chatterjee et al. ) , more studies are needed to better understand various aspects of sme risk management. small and medium enterprises, like large corporations, face a significant number of risks, and their survival and resilience are important for national and global economies. however, smes are less prepared to manage the risks, and the institutional supports for them are rather weak (han and nigg ) . small and medium enterprises around the world, particularly in developing and emerging economies do not have strong risk management, business continuity, and crisis management cultures and systems in place (asgary et al. ; yuwen et al. ; kaya and uzay ) . most of smes not have the resources and expertise to focus on these activities and therefore are more vulnerable to internal and external risks and disruptive shocks (leopoulos et al. ; marks and thomalla ) . to minimize the impacts, it is important that smes become more aware of global risks, as well as assess, monitor, and enhance their risk management and business continuity management capacities (güneş and teker ; brustbauer ; kaya and uzay ) . the goals of this study were twofold: ( ) to examine whether country attributes and circumstances affect sme assessments of the likelihood, impacts, and rankings of global risks; and ( ) to find out if sme risk assessment and rankings differ from global rankings. small and medium enterprises in manufacturing in an emerging economy with global footprints were selected because, unlike the wef that takes its samples from large international players, the sample smes are small individual players in the global economy and it is important to see how they view the global risks. the global risk report by the world economic forum (wef ) examines important global risks that are classified into five categories: economic, environmental, geopolitical, societal, and technological (table ) . these risks are evaluated annually based on global players and stakeholder views of the risks. according to the wef global risk report, extreme weather events, failure of climate-change mitigation and adaptation, natural disasters, data fraud or theft, cyber-attacks, man-made environmental damages and disasters, large-scale involuntary migration, biodiversity loss and ecosystem collapse, water crises, and asset bubbles in a major economy were ranked the top global risks in terms of likelihood. weapons of mass destruction, failure of climate-change mitigation and adaptation, extreme weather events, water crises, natural disasters, biodiversity loss and ecosystem collapse, cyber-attacks, critical information infrastructure breakdown, man-made global economic risks have significant implications for smes, particularly those in the manufacturing sector. asset bubbles in a major economy can increase the production costs through inflation, wage increases and labor shortages, and access to financial resources that will impact the global economy (zheng et al. ) . global financial crises cause substantial downturn in the formation of new smes, their performance, and their existence in the market. the - world financial and economic crisis severely impacted smes. as interest rates started to rise, many smes were bankrupted due to the credit crunch, tight monetary policies, and decline in domestic and international demands (filardo ; wehinger ) . the number of bankrupted smes in south korea, for example, particularly in the manufacturing sector, increased by nearly % from to (gregory et al. ) . the economic crisis induced severe socioeconomic impacts worldwide and impacted smes in almost every economy, far beyond expectations, through fast domino effects that caused massive sme closures, downsizing, and reduced the number of new ventures (chowdhury ; sannajust ). small and medium enterprises were under extreme pressures and experienced devastating decrease in demand and revenues, increased lay-offs, and stressful working environments (kossyva et al. ). close to % of the smes in belgium and the netherlands, for example, experienced extended delays in their receivables (kossyva et al. ) . small and medium enterprises in the united states lost . million jobs (gagliardi et al. ) . during this global turmoil, turkish smes were also impacted heavily (karadag ) . during an economic crisis, smes are more vulnerable because of weak cash flow and financial structures, low equity reserves, limited adaptation potential and flexibility for downsizing, liquidation problems, too much dependency on external financial resources, tightened credit lines, payment delays on receivables, lack of resources, and lack of necessary skills to adopt or make necessary strategic decisions (ates et al. ; sannajust ; wehinger ; karadag ) . failure of aging and insecure energy, transportation, and communications infrastructure can have major short-and long-term risks for sme performance and competitiveness. high structural unemployment lowers demand for goods and services and impacts smes significantly (alegre and chiva ) . illicit trade reduces sme competitiveness in the global market. in countries with higher levels of economic risk, smes have less of a chance to flourish (mekinc et al. ) . energy is an important input for sme production and logistics. if energy prices are not manageable or controlable, smes face major uncertainties about energy costs and availability (mulhall and bryson ) . energy price shocks raise sme production costs (kilian ) and compromise their individual and collective competitiveness in the global economy. it is mainly because smes are usually less flexible with respect to their energy sources and smes in the manufacturing sector are very energy intensive, that unpredicted fluctuations in energy prices impact them extensively. energy price shock events have become more frequent and a consistent feature of the energy markets in recent years (mulhall and bryson ) . as the global demand for energy increases, more shock events in the energy prices are expected. finally, unmanageable high inflation rates at national and global levels pose risks to smes through higher interest rates (cefis and marsili ; gül et al. ). small and medium enterprises around the globe, particularly those that are part of the global supply chains, are exposed to various types of global environmental and disaster risks that can have devastating impacts on smes (auzzir et al. ). these enterprises are highly vulnerable to and not well prepared for most of the global environmental and disaster risks (crichton ; schaefer et al. ) . they are vulnerable to environmental disaster risks on four fronts: capital, labor, logistics, and markets (ballesteros and sonny ) . environmental and disaster risk events can damage and disrupt the supply chain networks in which many smes are embedded. they can also damage sme assets, premises, and inventories, disrupt their operations, increase their production costs, and reduce their revenues and long-term growth potentials (snyder and shen ; griffiths , ; asgary et al. ) . small and medium enterprises have limited capabilities to recover from these events and bring their operations, revenue, and profit back to pre-event conditions (asgary et al. ) . considering the links that exist between climate change and extreme events, it is expected that these events will increase in the future (ipcc ). small and medium enterprises face significant climate change-related environmental and regulatory risks (schaefer et al. ) . major costly floods, severe heat and cold waves, heavy rains and extreme storms with higher frequency and intensity are observed globally. extreme events not only cause disruptions and destruction to smes, but also create major challenges for their continuity of operations and future planning (gunawansa and kua ; gasbarro et al. studies show that overall about % of smes do not reopen following a major disaster (ballesteros and sonny ) . of the us companies that experience disasters, for example, % never reopen, and another % close within years (weinhofer and busch ; ballesteros and sonny ) . small and medium enterprises are worse off after disaster events compared to before disaster because they are relatively resource constrained, less resilient, are mainly informal and some of them do not fully comply or are not requested to follow standards and codes, lack necessary insurance, do not carry out risk assessments, and are often without business continuity plans (ye and abe ; undp ; ballesteros and sonny ; halkos et al. ) . being prone to multiple natural hazards such as flooding, earthquakes, and drought, natural hazards and disasters have affected smes in turkey as well. the earthquake had significant economic impacts on the enterprise sector, ranging from usd . to . billion in damages (oecd ) , most of it from the loss in manufacturing (usd to million). about . % of the total manufacturing industry were damaged in five provinces, and , smes suffered heavy physical damages. ezgi ( ) reported that the vast majority of smes had little preparedness before the earthquake and only % of them invested in insurance before the earthquake. a world of geopolitical instability and uncertainty is a major concern for all sectors and businesses, but more so for smes. many of these risks are cross border with global consequences. while existing international political and economic agreements such as those of the world trade organization (wto) are weakened by unilateralism, there is little evidence that new and better multilateralism agreements are replacing them (pascual-ramsay ; asgary and ozdemir ). rather these agreements are being replaced by fragmentation, bilateralism, regionalism, as well as local and short-term interests (pascual-ramsay ; asgary and ozdemir ). the international economy and its key players, including smes, are becoming more exposed and vulnerable to existing and emerging geopolitical risks and uncertainties (pascual-ramsay ) . studies show that terrorist attacks, for example, even though they are very small in terms of direct physical impact zones, have economic impacts that are often substantial and very extensive. repeated terrorist attacks in one country not only impact the economy of that country but create spillover impacts for neighboring countries and the global economy. terrorist attacks discourage foreign investments and capital inflows and cause significant loss of economic activities and international trade (abadie and gardeazabal ; araz-takay et al. ). these risks can also increase insurance, transaction, transportation, and security costs for smes. turkey as an emerging economy located in a geopolitically complex region (middle east and north africa), with several potentially failing neighboring states, and as a member of various types of regional agreements, has a unique situation in terms of geopolitical risks. turkey has been suffering from terrorism and dealing with regional conflicts, both of which have had various impacts on the smes. the presence of terrorist activities has impacted the emergence and growth of smes and the overall economic performance in the country. bilgel and karahasan ( ) found that after the rise of terrorism, the per capita real gdp in eastern and southeastern anatolia declined by about . %. other studies also found that terrorism has a major negative impact on foreign direct investments in turkey (omay et al. ). global societal risks have specific implications for smes. failure of urban planning leads to declining cities, informal urban growth or sprawl, and poor and fragile infrastructure with significant social, environmental, and health issues (asgary and ozdemir ). such urban environments are not able to adequately support enterpreneurship activities that can compete at national and global levels. cities without efficient and interconnected transportation systems, with significant air pollution, and unaffordable land and housing prices are not attractive for entrepreneurship growth (tursab and tuader ). but sme engagement in risk management and critical infrastructure protection is an effective way to reduce the impact of future disasters in urban areas (chatterjee et al. ; chatterjee et al. ) . food and water crises are other important global risks that can affect smes in several ways, particularly those in the agri-food business and those that are in water-intensive manufacturing sectors. social instability as another global risk is not healthy for sme growth and competitiveness. global pandemics such as the severe acute respiratory syndrome (sars) pandemic and the h n pandemic can have immediate direct and indirect impacts on smes. for example, sars had major impacts on smes, particularly those in the tourism and hospitality sector in heavily impacted countries such as china, canada, thailand, and hong kong (kuo et al. ) . studies have found that many smes do not recognize pandemics as a meaningful risk. although governments have tried to raise awareness and provide resources to enhance pandemic preparedness by smes, awareness or concern and actual preparedness have not changed much, and most smes do not have appropriate preparedness and continuity plans for future pandemics (watkins et al. ) . armed conflicts, interstate wars, natural hazards and disasters, and climate change are creating widespread involuntary and forced displacement around the globe. population displacements have a range of economic, social, and political impacts on both source and host countries (tumen ; salgado-gálvez ) . the impacts of forced migration on smes have not been studied yet, but it may have both positive and negative impacts. at least smes can be considered a solution for some of these problems by providing job opportunities for displaced people. turkey has received more than million displaced people from syria since the start of conflict in (onur ). adverse consequences of technological advances could be very diverse and consequential for smes, especially those in the manufacturing sector. new technologies such as robotics, autonomous vehicles and drones, automation, smart phones, artificial intelligence, -d printing, cloud computing and big data, and new materials are among the new technologies that can have unintended consequences and risks for manufacturing smes. these technologies have the potential to reduce outsourcing. studies predict that % of the jobs in the united states (much of them in smes) are at high risk of being automated over the next years, especially in manufacturing, logistics, and administrative support (pascual-ramsay ). these advances will possibly reduce employment opportunities for workers in manufacturing smes and will challenge smes survival. while information technology brings significant growth opportunities for smes through knowledge and information availability, business communication, cost savings and efficiency, improving decision making, responsiveness, and overall flexibility (mbuyisa and leonard ) , technology also introduces risks, including data theft, disruptions, and cyber-attacks (chacko and harris ) . like other institutions, smes are dependent on internet and information technology and a substantial number of their sales and orders are handled through cyberspace and networks. any major failure and disruption of the national and global information infrastructure and networks due to large-scale disaster events can have significant negative impacts on smes. such disruptions can have severe consequences for smes that are very vulnerable and without adequate protection. small and medium enterprises use these technologies in production and service delivery, distribution, sales, and marketing. data breaches, cyber security, and intentional or accidental technological failures can disrupt or significantly damage the short-and long-term operation as well as the existence of smes. following the wef ( ), this study uses a qualitative risk assessment (qra) approach. this will allow us to compare the results of the study with the global risk report results. qualitative risk assessment is one of the most widely used risk assessment approaches because of its low cost and ease of use and it is quick to perform (modarres ) . in qra, potential likelihoods and consequences are assessed using qualitative scales such as low, medium, and high. qualitative risk assessment uses subjective likelihood and consequence values collected from experts and decision makers and, as such, they are not always perfect estimates and are subject to biases and heuristics (talbot ) . assessed likelihoods and consequences for selected risks are then ploted in a two-dimensional space to generate a risk matrix. various risk matrix forms and sizes have been reported in risk assessment reports. a risk matrix is used to visualize, compare, and rank different risks based on their locations in the matrix. color coding is mostly used to show the importance of each risk. the risk matrix approach is also used for indicating possible risk control measures and to record the inherent, current, and target levels of risk (hopkin ) . a risk matrix provides some basis for risk treatments and management. risks that are located in the top righthand corner of the risk matrix (often colored in red) have higher likelihoods and impacts. these risks are very critical and need to be controled. risks that are in the lower (colored in green) and middle part (colored in orange or yellow) of the matrix should be monitored and checked regularly. although the risk matrix method has been criticized by scholars and professionals (cox ; ni et al. ; bao et al. ) , it is an invaluable tool for fast, effective, and practical risk assessment (talbot ) . data were collected from a sample of manufacturing smes in turkey. small and medium enterprises in turkey are categorized into three groups of micro, small, and medium-sized enterprises based on their employee numbers and annual revenues. micro firms are those with less than employees and less than usd , annual turnover. small firms are those with less than employees and less than usd . million annual turnover, and medium-sized firms are those with less than employees and less than usd . million annual turnover (karadag ) . to assess and evaluate the risks, a questionnaire survey, including questions, was developed. several questions collected general information about the production type, years in operation, city of operation, position of responder in the business, percent of production for export, percent of imported production materials, and export countries. in two sets of questions sme representatives provided their opinion about the consequences and likelihoods of global risks. samples of a risk likelihood question and a risk consequences question are: . review the following global economic risks and give your opinion on the likelihood of these risks occurring in the manufacturing sector in turkey over the next years. • critical infrastructure failure: • very unlikely • unlikely • somewhat likely • likely • very likely . please review the following global economic risks and give your opinion about the potential impacts/consequences of these risks on the manufacturing sector in turkey over the next years. • critical infrastructure failure: the questionnaire was designed and distributed using google form. small and medium enterprises operating in the manufacturing sector (nace revision. in c class through - ) were included in the population framework. these are smes in the nace classes that are registered with the kosgeb (small and medium industry development organization, turkey) and had an approved kobİ (sme) certificate in . the survey link was emailed to about , smes on april . potential respondents were asked to complete the online survey by may . by the deadline, completed responses had been received. the sample covers smes in different manufacturing areas. after the unspecified ''other'' manufacturing subgroup ( ), smes in food products ( ), textiles ( ), machinery and equipment ( ), furniture ( ), fabricated metal ( ), basic metal ( ), wood products ( ), rubber and plastic ( ), electrical equipment ( ), and chemical products ( ) had the highest number of participants in this study. the questionnaire was completed by various individuals within each sample business, including managers ( ), owners ( ), accounting managers ( ), financial managers ( ), business partners ( ), board members ( ), engineers ( ), and other employees ( ). sample smes are operating in different cities and geographic regions in turkey, including marmara ( ), central anotolia ( ), aegean ( ), black sea ( ), mediterranean ( ), eastern anotolia ( ), and southeastern anotolia ( ). the majority of the sample businesses ( ) have been in operation for less than years, only have been in operation for to years, between and years, and the rest ( ) have been in business for more than years. about . % of the sample businesses were micro businesses, . % small businesses, and about . % were medium-sized enterprises. more than % of the smes export their products to varying degrees. they export to a large list of neighboring and european countries in particular. the sample smes also import some of their raw materials and equipment, and about % use imported products in their productions. using the methodology on collected data respondents perceived likelihood of the global risks and their impacts were identified and risk values were calculated, and risk matrix was generated using the risk values. this section presents the key findings. almost all global economic risks are perceived to have very high and high likelihoods by the sample turkish smes (fig. a) . however, fiscal crises in key economies, high structural unemployment or underemployment, and severe energy price shock are among the most likely risks according to the sample enterprises. a majority of the smes thought that catastrophic and severe impacts can be expected from the economic risks, particularly unmanageable inflation, high structural unemployment or underemployment, and fiscal crises in key economies (fig. b) . global environmental risks seem to have relatively lower likelihoods to the sample smes, compared with the global economic risks (fig. a) . man-made environmental damages caused by human and major natural hazards and disasters show higher perceived likelihood. the perceived impacts from these risks were scored lower as well. among these risks, environmental damages caused by human are perceived to have slightly higher impacts for the sample businesses (fig. b) . figure a and b show the sample sme respondents' opinion about the likelihoods and the consequences of the global geopolitical risks. failure of national governance and failure of regional or global governance, and largescale terrorist attacks have the highest average perceived likelihood in this risk category. however, the impacts are assessed to be higher for interstate conflicts with regional consequences, followed by the failure of national governance, and failure of regional or global governance. among global societal risks failure of urban planning and profound social instability were perceived to have the highest likelihood and impact averages among the sample businesses (fig. a, b) figure a and b present the stated likelihoods and consequences of the global technological risks. while the likelihood of all these risks is perceived to be high, largescale cyber-attacks and large data fraud are among the top in this risk group. although the means of the impacts are lower for most of these risks, except for the negative consequences of technological developments, more smes stated that the consequences of large-scale cyber-attacks and large-scale data fraud are expected to be severe and catastrophic. risks can be calculated as the multiplication of likelihood by impacts (table ) . using the mean values of each risk category, economic and technological risks are perceived to have the highest likelihood levels followed by geopolitical risks (fig. a) . in terms of impacts, however, economic risks and geopolitical risks take the first and second ranks followed by technological risks. societal and environmental risks are considered to have lower impacts (fig. b) . in terms of the overall risk, the results show that economic risks and geopolitical risks take the first and second place, followed by technological risks (fig. c) . using the qualitative risk analysis methodology and perceived likelihood and impact data, a risk matrix was generated. although the horizontal and vertical axes take the values to , the matrix axes have been rescaled for better visualization. this risk matrix displays the means of stated likelihoods and consequences for each risk. risks at the top right and in the red colored area are risks with higher than average likelihoods and consequences. risks in the lower left part of the matrix and colored green are considered to be low. figure presents the resulting risk matrix for the businesses and the risks. most economic risks are in the upper part of the risk matrix, followed by some geopolitical risks. large-scale data fraud is the only technological risk that falls into the same area. majority of environmental and societal risks, although scattered diagonally in the risk matrix, are in the lower part of the matrix. this study examined the global risks from the perspective of manufacturing smes with global footprints in the emerging economy of turkey. the main aim was to understand whether and to what extent country-and industry-specific contexts and conditions affect smes perceptions of the global risks. key findings are discussed here. first, overall the results suggest that regardless of the ranking, the global risks are of high concern for smes in turkey. the average likelihood for all global risks is . and the average impact is . . the minimum perceived likelihood (infectious desease) is . and the minimum perceived impact (severe weather events) is . . these figures confirm that all global risks are of concern for the smes and have significant implications for them, particularly those in the manufacturing sector (zheng et al. ) . second, findings indicate that the smes' perceived risks at the country level (turkey) significantly varied from those perceived by the global companies in the global risk report (world economic forum ) (table ) . while this study does not examine the underlying causes of these differences, it is evident that the smes' major concerns are global economic and geopolitical risks, both in terms of the likelihoods and the impacts. individual smes in turkey have been exposed and impacted more by the global economic risks than other risks. our findings are consistent with a few different but related research conducted by gül et al. ( ) , topçu ( ) , and deloitte ( ) that economic and financial risks such as devaluation of the turkish lira, interest rate risk, breakdown in cash flow or liquidity risk, credit risk, and increase in input prices were the key risks that businesses are facing in turkey. third, it is not surprising that smes' highest perceived risks are economic and geopolitical risks. studies demonstrate that financial and economic crises cause substantial (gregory et al. ; zheng et al. ; chowdhury ; filardo ; kossyva et al. ) . small and medium enterprises are very vulnerable to economic and financial crises as they are forced to close, downsize, and reduce the number of new ventures due to sharp decrease in demand and revenues (ates et al. ; sannajust ; wehinger ) . in today's global economy, turkish smes are not exempt from this, and they have been frequently impacted by such risks in the past two decades as well (karadag ) . moreover, giving high likelihood and high impact values for financial crises and other economic risks can be explained by the fact that turkish economy has deficit in international trade (abbasoglu et al. ) and highly rely on external energy sources such as oil and natural gas. fourth, failure of regional or global governance and failure of national governance are the geopolitical risks that are among the top perceived risks by the smes in this study. these risks have been largely felt by turkish smes in recent years. turkey has been in close proximity to a number of regional conflicts with potential impacts on the smes (omay et al. ; bilgel and karahasan ) and because of their vulnerability (pascual-ramsay ) and awareness of these risks, such risks are perceived highly both in terms of the likelihoods and the impacts. fifth, the sample smes also consider the likelihood of large data fraud/theft and large-scale cyber-attacks to be high. this is possibly due to the increasing dependency of the smes to the internet and the increasing number of cyber attacks and data theft in recent years (mbuyisa and leonard ) . while smes do not consider the impacts of these risks as high as their likelihoods, still these risks can cause disruptions and severe consequences to them, particularly because they are not well equipped to manage these risks. a recent report published by allianz ( ) confirms that smes in turkey increasingly recognize their cyber vulnerability and risks. finally, the relatively lower perceived likelihoods and impacts of the global risks by the sample smes can be attributed to the fact that small businesses may not be directly and highly impacted by distance environmental risks such as major natural hazard-induced disasters and that the awareness about some of the environmental risks among the smes may be lower than other risks. moreover, turkey has not experienced a major natural hazard-induced disaster in the past years, and major weather events have been very local. the results of this study indicate the importance of addressing global risk assessments by smes. as more and more smes are connected with the national and global economies, their awareness about theses risks and the impacts that they could have for them will increase. this awareness can help smes to take these risks into consideration and prepare themselves for such risks. this study highlighted that smes' perceptions of the global risks are different from the businesses that operate at large scale at the global level. it also demonstrated that country's circumstances can affect smes' assessments of the likelihood, impacts, and rankings of global risks. it demonstrated that smes are more concerned about economic risks and risks that directly impact economic systems and variables, particularly geopolitical risks. environmental risks, while important, are not at the top of the list for smes. considering the significant role that smes play in local and national economies and the fact that they are concerned most about global economic and geopolitical risks, it can be argued that efforts towards lowering global economic and geopolitical risks can significantly benefit smes. since turkey's smes have been in a relatively unique situation in the past two decades with respect to some of the major global risks, similar studies in countries in other parts of the world may shed more light on how country contexts and type and size of businesses impact smes' perceptions of global risks. it was beyond the scope of this study to examine the smes' risk and business continuity actions taken to manage and mitigate the risks. future studies can also investigate whether and how smes prepare themselves for global risks. open access this article is licensed under a creative commons attribution . international license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons licence, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons licence, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. to view a copy of this licence, visit http://creativecommons. org/licenses/by/ . /. terrorism and the world economy the turkish current account deficit linking entrepreneurial orientation and firm performance: the role of organizational learning capability and innovation performance allianz risk baromter sme business risks the endogenous and non-linear relationship between terrorism and economic performance: turkish evidence global risks and tourism industry in turkey disaster recovery and business continuity after the flood in pakistan: case of small 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recovery. background paper for the global assessment report on disaster risk reduction tackle the problem when it gets here: pandemic preparedness among small and medium businesses building up resilience of construction sector smes and their supply chains to extreme weather events smes and the credit crunch: current financing difficulties, policy measures and a review of literature corporate strategies for managing climate risks the global risks report the impacts of natural disasters on global supply chains. artnet working paper series the role of smes in asia and their difficulties in accessing finance. asian development bank institute controlling town industry explosion hazard in china towards a system of open cities in china: home prices, fdi flows and air quality in major cities acknowledgements this research has been partially supported by the scientific and technological research council of turkey (tubitak) through the -fellowship program for visiting scientists and scientists on sabbatical leave. the project has been also supported in part by york university's advanced disaster, emergency, and rapid response simulation (adersim) funded by ontario research fund. key: cord- - mx thr authors: neuwirth, rostam j. title: gaia —a ‘glocal agency in anthropocene’: cognitive and institutional change as ‘legal science fiction’ date: - - journal: a post-wto international legal order doi: . / - - - - _ sha: doc_id: cord_uid: mx thr to assess a future scenario of the world without a wto, the present chapter projects the reader into the distant future of the year by which time the global community is aiming to establish gaia, the so-called “glocal agency in anthropocene”. gaia is designed as the first truly integrated global institution with a universal character with the aim to tackle the complex and multiversal governance challenges of humanity and the planet as a whole. this chapter marks both a legally and a scientifically fictitious account of the years from until , from a dystopian and a utopian perspective, with the aim of highlighting the importance of cognition for legal and institutional change. the need for cognitive change is driven by changes in the environment, and by the challenges resulting from a perceived acceleration of the pace of change and the unprecedented levels of technological complexity. both change and complexity increase the relevance of cognition, as laws and policies adopted in one area are more likely to affect their success or failure and that of the global governance system as a whole. thus, this chapter predicts that the foremost necessity for law in the future is to build on novel and enhanced modes of human cognition to deal better with complexity and rapid change. why do we remember the past and not the future? we are writing at the end of the year , and marking a period of efforts towards the establishment of a new and comprehensive global governance mechanism, known, for short, as "gaia ". gaia stands for "glocal agency in anthropocene", and describes a project for a novel institutional framework to be set up with the objective of tackling humanity's most urgent problems and glocally governing and sustainably developing human affairs in the future. the future is what matters the most right now, as the world is hoping to recover from the devastating effects of the time period known as the "digital dark age". this is the era from until when-as the result of an internet blackout (outage)-all prior digital resources, including records and archives, became inaccessible and, because of the wide prevalence of the internet of things (iot), the same happened to most related technical applications and utilities. in short, this dark period wiped out all digitally or electronically stored data. as a consequence, it not only paralysed all technical facilities and caused millions of casualties, but also led to a collective loss of humanity's memory, which, furthermore, caused a loss of identity. many still speculate about what triggered the meltdown of the former information society based on the internet, with the suggested causes ranging from scientific, economic, and political to cognitive and, notably, legal reasons. for instance, scientific explanations range from a cyberattack using malware to a nuclear blackout caused by the detonation of an atomic warhead in outer space, an accident at cern creating a black hole in geneva following a malfunction of the large hadron collider ii, or a failure of the g network in combination with a data overload on the world wide web caused by states' geopolitical struggles and the monopolistic tendencies of various tech giants. other people invoke politicoeconomic explanations, simply citing the second global financial crisis of , which was caused by trade and currency wars that, inter alia, eroded the finances needed for the maintenance of the internet's sophisticated infrastructure. environmental factors are also often named, such as floods and rising sea levels, increased volcanic activity and earthquakes, combined with heatwaves and global pandemics, which disrupted or paralysed the energy supply by damaging its essential facilities. politics also played a role, as populism and racism increased, further fragmenting society into ever smaller units, down to its most vulnerable minority, the individual. constitutional democracies came under threat from changes that were, at first, undetectably small but that eventually combined and posed a serious threat. in legal circles, the fragmentation of international law, the rise of norm conflicts due to bad regulation, overregulation and the automation that took over several fields of law are mentioned as the prime causes of the inability of humanity to halt the dangers of the conditions it had created for itself. it again became obvious that the rule of law needed not just legal texts but also stable institutional guarantors at both the national and the global levels. it is more likely that the blackout was due to a combination of interrelated factors in an environment characterized by an increasing complexity and ever faster pace of change. since time immemorial, humanity has struggled with change or, notably, with its perception of change, since this perception may itself have been subject to change. however, since the last millennium many observers have noted an apparent effect of an acceleration of change or so-called "time shrinking". this trend for change to accelerate started to pose a major threat to lawmakers and policymakers and, in particular, to law, as it became more difficult to "preserve its integrity over time, while managing to address the newly emerging circumstances that continually arise throughout our history". another threat to law came from unprecedented levels of technological innovation, which culminated in a situation in which the regulation of specific industries and technologies, such as those of artificial intelligence, nanotechnology, big data and genetics, failed to find a successful balance between their unknown risks and their expected benefits. in short, excessive levels of specialization, not met by an adequate general understanding, led technological progress to spin out of control. thus, by the year the international legal order had witnessed the disastrous effects of a gradual loss of control caused by decades of neglecting first subtle and later obvious signs of multiple law and policy failures. these policy failures culminated in the failed attempts to reform the most important international institutions, the united nations (un) and the world trade organization (wto), in a holistic and comprehensive manner. there was a failure to bridge the rift that was caused when the international trade organization (ito) did not materialize; the ito would have complemented the institutional balance between the three bretton woods sisters, the ito, the imf and the world bank. in other words, the institutional failure of the ito to materialize also meant that greater coherence, or to integrate trade and non-trade concerns, was renounced as an ideal for global governance. the separation between the un on the one hand and the gatt on the other, can also be regarded as a further strong manifestation of a dualistic mode of thinking based on binary logic. most of all, it was the beginning of a failure of cognitive modes of thinking to keep pace with technological changes in the context so as to provide a stable and coherent global institutional framework for the governance of global affairs. historically, the gatt was characterised as having found "itself without an inadequate legal and constitutional base and required to fill a vacuum created by the failure of the ito". the situation also meant that attempts to reconcile trade and non-trade concerns in both substantive and institutional terms was postponed to a distant day. this delay later led to the emergence of the "trade linkage debate", by which different pairs of "trade and . . ." problems were supposed to be reconciled. lacking their reconciliation, criticism of the wto also became louder and culminated in the protests accompanying the seattle wto ministerial conference. since then, the failure to address non-trade concerns and to achieve greater policy coherence continued and provided further momentum to the procedural crisis affecting the wto dispute settlement body. in sum, a lack of political will as much as outdated cognitive modes framed by dualistic thinking led to the law being inadequate to meet the institutional and substantive challenges. to exemplify the impact of cognition on whether the law meets the demands put upon it, the present chapter divides the time between the year and into two opposite scenarios. first, sect. traces the lost years by drawing up a dystopian johnson ( ), p. . harari ( ), p. . jackson ( ), p. . dimatteo ( scenario, in which cognition remained largely static and dualistic, such that changes did not keep pace with the speed of technological and scientific innovation. section is more utopian, in the sense that it relies on a newly acquired cognitive mode of thinking as exemplified by synaesthesia, which not only allows for the development of actions as causes of change but also includes a review and evaluation of the consequences. the conclusion finds that an entirely new mode of cognition, triggered by linguistic changes that are reflected in a recent rise of oxymora and paradoxes, opens a new perspective on how lawyers can help to both predict and shape the future. fail' in the world of theory, there are many dichotomies. in the real world, there are many divisions and divides. in the world of power, all too often, these divisions, divides, and dichotomies serve to maintain and reinforce existing imbalanced and skewed power relations between individuals, communities, governments, and nation-states. in the world of power, it is indeed divide and rule. in attempts to describe the evolution of the multilateral trading regime from until , so-called "digital historians" have argued that december marked the decisive moment and unofficial date of the decline of the world trade organization. although aggressive regionalism, unilateral measures and resulting trade wars as well as inertia in addressing the trade linkage debate and interinstitutional linkages between the wto and the un had been eroding the multilateral trading regime for some time before, it was on that day that the wto's dispute settlement system became dysfunctional following the expiration of the terms of two of the three remaining members of the appellate body (ab). this left the ab with fewer than the three members required by art. . dsu to serve on appeal cases. as with many international organizations, nation states and other legal constructs before it, the official decline of the wto and the multilateral trading regime as a whole started slowly and then ended abruptly. the decline was probably the result of a chain of missed opportunities for the reform and adaptation of the relevant system to changes in the context, which notably saw a strong trend towards greater convergence of various industries, technologies and products. this convergence further increased the need for the consideration of non-trade concerns and greater policy coherence. for some time, the system lingered on and ministerial conferences were merely held without achieving tangible results, continuing the deplorable tradition that began with the launch of the doha development round in . most wto members engaged in either a relapse into unilateral measures adopted at the domestic level or a rat race to join numerous regional trade agreements. however, in both cases, the most important challenges faced at that time, in the form of institutional gaps, regulatory fragmentation and overregulation, were not tackled, either nationally or regionally, let alone globally. numerous calls and suggestions for institutional reform to achieve greater policy coherence, under the aegis of the so-called "trade linkage debate" discussing various "trade and . . . problems" or how to better link trade with non-trade issues, were ignored. in this regard, more importantly, the cognitive and conceptual dimension of trade policy was not duly considered, as "transformational change in the institutions and politics of international trade" were found to go "hand in hand with cognitive change" as andrew t. f. lang wrote. he also found a nexus between cognitive change and institutional reform being linked to the criticism of the wto and notably the failure to address the trade linkage debate. as a result, from this time on, the international system, or, more accurately, the remaining "international systemic chaos", was described as having moved "away from an assembly of distinct, territorial, sovereign, legally equal states toward different, more hierarchical, and in many ways more complicated structures". even though an attempt was launched in to reform the united nations organization in order to streamline the coordination of its many specialized organizations and to enhance the coherence of global policymaking by "delivering as one", the management of this reform eventually proved to be an oxymoron before it failed altogether. for a long time, the un's work in its core areas, from development to the environment, was described as fragmented, and its inefficient governance structure contributed to "policy incoherence, duplication and operational ineffectiveness across the system". what could be framed as a "trade and technology" problem, the earlier us-china trade disputes ( - ), also caused frictions in the innovation of new technologies and especially in the realm of telecommunication and information technologies. these frictions led to a further fragmentation of the internet and the market for information and communication technologies (ict). russia initiated the creation of an alternate web, which was later also used by the remaining brics countries, pauwelyn ( ) with other countries following suit. moreover, it was common for the governance gaps and frequent legal inconsistencies between the various fragments of laws governing international trade and commerce to be abused by artificial intelligence and unregulated algorithms, those lacking a kind of lex algoritmica, meaning that global business generally operated in a "black box" inaccessible to consumers and lawmakers. from a commercial perspective, the "world wide web" (www), which was intended to become a "wireless world wide web" (wwww) by virtue of the transition to the g network, became further fragmented by national and regional firewalls as well as restrictive measures known as geolocation measures. other conflicts, in the form of regulatory paradoxes framed as dichotomies, such as those of "goods versus services", "free trade in data versus data localization", or "regulatory fragmentation versus technological convergence", were also ignored. in the same way, in other sectors covered by the gatt, gats and trips agreements, the multilateral trading rules were further eroded by trade disputes in which different claims were met by defences made on the basis of national security concerns. known as the "trade and security" problem, questions about the selfjudging nature of the security exceptions widened the institutional gap opened by the split between the un system and the gatt/wto system caused by the failure of the international trade organization (ito) to materialize. this institutional rift had, since , left the world with a conflict of norms in the form of a "catch xxi" or "trade and security" dilemma. after the wto ruling in russia -measures in transit in , in which the panel held that it had jurisdiction to determine whether the requirements of article xxi of the gatt were satisfied, other countries simply refused to respond to requests for consultations and boycotted the relevant meetings. in the end, the invocation of the security exceptions further eroded belief in the wto and accelerated its demise. the broader conditions in the global economy also grew dimmer and were closely related to the "trade and energy" problem. from as early as , the tipping point in the production of oil was reached, meaning that conventional crude oil production pasquale ( ) . yu ( ), pp. - . smith and woods ( ) , pp. - . burri ( ) was not rising to match increasing demand. the "all-oil peak" meant that, after decades of controversy over its arrival, there was a drastic dampening in economic growth and, actually, the inauguration of an era of global depression. notably, for oil-producing and other resource-rich countries, the so-called "paradox of plenty" aggravated, and the ensuing economic disaster also led to, the collapse of their constitutional system, and also triggered new waves of political violence. since human civilization was a sensitive "complex adaptive system", other countries too, and the globe as a whole, also were drawn into a downward spiral of economic recession and political instability. institutionally, the proliferation and fragmentation of energy organizations and the failure to address the "global energy governance gap" by reforming existing energy agencies or creating a global energy agency, further contributed to the resulting disaster. the complexity of the global economy could also be seen in the connection between trade, the environment and energy. in parallel, numerous efforts towards achieving greater sustainability in economic development based on renewable energies were also unable to offset the devastating effects of the disruptive consequences of the "all-oil peak" and the ensuing global energy crisis on economies and societies around the world. the result was a global energy crisis in that disrupted most global trade in both goods and services and caused stock crashes through inflationary pressures, and later accelerated the eventual collapse of the international monetary system as it had done during the oil crisis. renewable energies were also incapable of averting the crisis, even though the impact of the paris agreement, adopted with the objective of responding to the threat of climate change, had no negative effect on the global economy or on countries' welfare gains. because of the absence of a coherent global regulatory framework, renewable energies remained expensive and investments often did not materialize. in this context, it was also a failure when the wto membership addressed the "trade and environment" problem by, inter alia, reforming the wto subsidies agreement, which resulted in various trade disputes challenging green policies. the lack of global competition rules, as a result of the abandonment of a project in that was one of four "singapore issues", led to the emergence of various multinational tech giants, which widely abused their dominant positions, explored tax loopholes, and competed unfairly in courts, patent offices and markets. they were also crucial in meddling in elections and were accused of undermining democratic institutions. no efficient dispute settlement system under the multilateral trading regime, and a lack of legal standing for private parties, both natural and legal murray and king ( ) , pp. - . hall and klitgaard ( ) , p. . ahmed ( ) . downie ( ) , p. . cosbey and mavroidis ( ), pp. - . demedts ( ), pp. - . ginsburg and huq ( ), p. . persons, in domestic or supranational courts caused further havoc and greater inequality among global citizens. as early as , inequality was reported to be standing at unprecedented levels, and it was claimed that "just eight men own the same wealth as the poorest half of the world". these inequalities, dividing societies around the world, not only perpetuated themselves but even increased, with devastating effects on the global economy and the environment. another aspect of inequality was found in the "trade and development" link, another complex and cross-cutting "trade and . . ." problem. cutting a long story short, the development discourse continued along the "developing versus developed country" dichotomy, despite calls to the contrary and even its abandonment by the world bank in . even though the definition of "official development assistance" (oda) evolved, it continued to be understood as resource flows from developed to developing countries. with the mindset unchanged, the language use of "developed-developing countries" also remained the same. as a result, the us and the eu continued, on the one hand, to subsidize their agricultural producers and to reap excessive benefits from royalties on various patented and copyrighted products, while on the other, they kept granting support through official development assistance programs to a large number of developing countries. this practice continued to impede the development of local industries in the targeted countries. moreover, the uncertainty surrounding the meaning of "development status" further eroded the wto's status after the us began to challenge it in . at the same time, the trade and development problem was closely tied to the "trade and finance" problem. generally, the trade and finance link suffered from the failure of the ito mentioned above, and the absence of a coherent framework for both trade and finance became manifest in the problem of so-called "currency manipulation", that is, the depreciation of a country's currency relative to other currencies so as to develop a large global and bilateral trade surplus. despite the three organizations, the wto, the imf and the world bank, having pledged to enhance their policy coherence, their inter-institutional dialogues did not yield tangible results and the use of policy coherence was criticized instead as a way to introduce policy conformance. an economy for the %. oxfam briefing paper, january . https://www-cdn.oxfam.org/ s fs-public/file_attachments/bp-economy-for- -percent- -en.pdf. neuwirth ( ), pp. - . hynes and scott ( ) . moyo ( ) thomas ( ) , pp. - . staiger and sykes ( ) , pp. - . grabel ( ), pp. - . put briefly, the "trade and finance issue" also remained unsolved, and the two respective regulatory regimes of trade and of finance continued to evolve side by side in dramatically different directions in spite of being mutually interdependent systems. this had a serious impact on the world as the regulatory gap between them grew even more intense while the technological reality saw them increasingly converge notably with the emergence of the blockchain technology that underlies cryptocurrencies. cryptocurrencies, from bitcoin to altcoin, proliferated and gradually disrupted business and financial services as well as the global economy. this meant that, in parallel to the third currency war between the world currencies (the dollar, the euro and the yuan), which began in , a digital currency war also began to be waged. in this digital currency war, the traditional world currencies fought against emerging digital currencies backed both by state and non-state actors. the ensuing chaos of currency wars brought about a loss of state control over financial markets and a rise of a global underground economy thriving on tax evasion and criminal activities. it all culminated in a collapse of global trade and finance and ended with the second global financial crisis of the twenty-first century, which began on "black wednesday" of october . together with military conflicts, global health pandemics, like the large-scale outbreak of the novel coronavirus (ncov) infectious disease, and various natural disasters, like large scales rainforest wildfires and bushfires, caused by climate change and other anthropogenic factors, the total disruption of the global economy created a dangerous dynamic, causing a severe migratory wave that increased the number of forcibly displaced people from about million people in to . billion less than years later. the crisis of migratory flows was aggravated by national governments and courts, who denied the affected persons the status of climate refugees. at the same time, after an erosion of the rule of law in the majority of countries around the world, ever more restrictive national policies regarding citizenship in general, and dual citizenship in particular, also increased the number of stateless persons, who were thus deprived of all fundamental rights within and across state borders. the european union, paralysed by endless brexit debates and the united kingdom's final exit from the eu on january , made little progress in reforming gadbaw ( ) , p. . tapscott and tapscott ( ) . rickards ( ) weissbrodt and collins ( ), pp. - . its institutions, the single market, the single currency or its taxation system. on the contrary, past achievements in the four freedoms were scaled down as the result of nationalist policies in many member states. the eu's so-called "luxembourg treaty", negotiated under the eu presidency of luxembourg, added nothing that substantively remedied the lost opportunity of creating a constitution for europe in . the eu's failure to become the world's most competitive market (the lisbon strategy) extended the lost decade of the eu, which began in , when, to a lost near-half century. many more regional integration projects worldwide also stagnated. for instance, the brics, representing % of the world's population in and initially set up as a "cooperation and dialogue forum" between brazil, russia, india, china and south africa in order to defy differences and make a difference in global governance, saw no progress, such as by seeking greater policy coherence based on more closely coordinating institutionalizing their cooperation. similarly, the positive effects on infrastructure development based on the belt and road initiative (bri), initiated by the chinese government in , were largely neutralized by opposition from the us and several european countries. the african union also failed to prevent the food security crisis that hit the african continent in and that pushed the achievement of the objectives enshrined in agenda into an even more distant future. in sum, despite the emergence of a creative economy, which was initially fostered by the potential of new and innovative technologies, the sustainable development goals were still not realized by . across the globe, political disagreements prevented action for greater regulatory harmonization, while centrifugal forces and fragmentation intensified. legally, a patchwork of isolated areas of law continued to grow, as did the number of regional trade agreements, which were violated or withdrawn from faster than they were negotiated. put simply, the so-called "global governance paradox", or the logical loop that a global platform was needed in order to create a global platform, proved a problem that was too difficult to tackle in conceptual and cognitive terms. with no consistent global legal order, fragmentation prevailed and led to the aggravation of the negative effects of "trade and . . ." problems on global peace and welfare. neuwirth ( ), p. . neuwirth et al. ( ) and neuwirth and svetlicinii ( ) . onyutha ( onyutha ( ), pp. onyutha ( - african union ( ) progress report on the implementation of agenda first ten-year implementation plan. available at: https://archives.au.int/handle/ / . the limits of my language mean the limits of my world. in , historians are still pondering the reasons for the collapse of the wto. some attribute it to isolationist us trade policies and the political turmoil around brexit, while others tend to focus on the rise of first asian and subsequently african countries. however, a different view identifies this failure as the beginning of the end of "end of . . . stories" or a drastic paradigm shift in cognition. cognition had reached a tipping point in human evolution following two centuries of rapid technological innovations, which "shaped consciousness directly". linguistic changes also confirmed this cognitive shift, mostly through the rise of essentially oxymoronic concepts. as a result of these external factors, epigeneticists found biological and cognitive changes occurring in parallel. new organs of cognition hence emerged, as humans were evolving biologically and consciously. as a visible result, even by % of new-born children displayed conditions of synaesthesia, i.e. the ability to better connect stimuli received from different sensory organs, which improved the skills to foresee developments and solve complex problems as well as enhanced their abilities of abstract thought. related changes in educational policies were implemented, with the goal of creating a "world brain", or "an enhanced educational system through the whole body of mankind", designed to "replace our multitude of uncoordinated ganglia, our powerless miscellany of universities, research institutions, literatures with a purpose, national educational systems and the like". this goal was to be achieved by fostering oxymoronic learning methods and giving training in both bivalent and polyvalent logic, complemented by training in multilingualism and oxymoronic thinking. for the trade and health link, the novel coronavirus (ncov) pandemic underscored once more the strong links between international trade, public healthcare and the global economy. as a result, the global healthcare system was integrated with a future trading system and backed by a consistent set of global innovation rules consisting of competition rules, intellectual property laws and fiscal incentives, which prevented price discrimination in pharmaceutical products and secured global access to affordable medicines. additionally, universal healthcare was provided freely by a combination of measures that combined both traditional and conventional medicines. based on further changes in perception, such as through the development of technologies for the visualization of auras, medical diagnosis improved and conventional, traditional and alternative medicines as well as mental health strategies were all integrated into a coherent set of laws and policies. further changes in healthcare were influenced by discoveries in so-called "life after life studies", which transcended the life-death dichotomy as the result of a greater awareness of the missing link in a globally coherent health policy. research on near-death experiences scientifically confirmed popular and religious beliefs about life after life. overall, a new cognitive mindset emerged in parallel with technical tools, leading to a new conception of the areas of economics, politics and law. for instance, the global economy became more sustainable, based on the spirit of "degrowth", which rejected the illusion of endless economic growth by advocating for a "democratically-led shrinking of production and consumption with the aim of achieving social justice and ecological sustainability". at the same time, new and cleaner energy resources were derived from nuclear fusion developed by the iter project, helping to decarbonize the world's energy system. various new and renewable energies complemented this. since a g initiative formulated in , the global community embraced an ambitious tax agenda to improve cooperation and transparency on the basis of a strategy for a global taxation system. this initiative originally included a global financial transaction tax to fund the new global governance system. it later included a digital tax on the world's tech giants, which levied taxes in the places where the goods and services were sold rather than the places where the company was based. it also introduced a global minimum tax rate to prevent a company from shifting its sales to a country with lower taxes. finally, a robotic tax, aided by the creation of a single global cryptocurrency (sgcc), covered all activities based on automation to compensate for the disruptive effects of automation on the global labour market. together, these measures helped to contain the outbreak of currency wars and related trade/finance disputes. on the other hand, the changes in the taxation system also helped to reverse the former trend of higher income taxes as opposed to lower corporate taxes. the new system achieved an optimal balance, with around % income tax, % corporate tax (including on digital activities) and % robotic tax, as measures towards greater global tax justice. these and other fiscal policies were introduced in coherence with other incentives to end the poverty trap. the cognitive shift also remodelled the international multilevel governance system towards a "glocal" and holarchic system in which local, largely selfgoverning, entities were complemented by various regional regimes often organized into mega-regional blocks, with those of an inclusive global system enshrined in the gaia charter of . holarchy here means a system in which various selfregulating entities function as autonomous wholes in supra-ordination to their parts but, at the same time, also as dependent parts in subordination to controls on higher levels their local environment. the foundation is a polyvalent logic by which the links between stakeholders at different levels are supported by a dynamic system of subsidiarity and an open method of coordination. it is based on a set of different criteria that the best possible level of regulation is determined without any prior bias towards either the local or the global level of governance. the same method is also applied to territorial questions, such as national sovereignty is no longer fixed but where territorial boundaries are drawn based on a similar set of criteria. thus, like in the quantum world, different political entities, and even national governments' competences, can overlap and even be superimposed without being perceived in conflict. changes in cognition facilitated the adoption of the gaia charter, as the global community finally found the "common language" to tackle the "global governance paradox" successfully. the paradox was that, in order to create a global legal order, the world community needed a global governance platform that had not previously existed, confirming that linguistic and cognitive changes are quintessential to institutional change. structurally, the gaia was based on an institutional setting in which every "trade and . . ." problem was coordinated by a "coherence committee", with the competence to avoid conflict between different policy goals. the functioning of the institutional framework was aided by an e-governance system, which used intelligent algorithms to consolidate redundant norms and detect incoherent measures. however, artificial intelligence was considered not only to be hype but also to be an oxymoron, and, in relation to law and policy, artificial intelligence measures were strictly bound by the requirement inherited from the former eu general data protection regulation that they could not be implemented and enforced "without any human intervention". brock and pogge ( ), pp. - . thang dao and edenhofer ( ), pp. - . koestler ( ), pp. - . neuwirth ( halpin and roeben ( ) in substantive terms, existing sources of global law were codified into a single legal document, the gaia code, a global constitutional text that reduced the previous disarray of international laws. in this way, former conflicts between norms that arose because of dichotomies that were too simplistic to account for real complexity, be it between electronic and traditional modes of consumption of goods (gatt) and services (gats), between ip law and competition law, or between international trade law and various subfields of general public international law in the name of "self-contained regimes", were no longer unavoidable and irresolvable. in this context, global competition rules were integrated and enhanced so as to not only guarantee the sustainable economic development of the global market but also "solve social problems ranging from unemployment to income inequality and indeed to improve the functioning of democracy itself". other necessary changes simply came with changes in cognition and understanding, and did not require a change in language as they occurred earlier when a higher court reconsidered its established case law. for instance, in the field of global economic law, the national treatment provisions of gatt article iii, gats article xvii and article of trips were now no longer merely interpreted as prohibiting discrimination between domestic and imported goods or services but also as encompassing "all measures having an equivalent effect on consumers in covered markets". this became necessary to cover personalized price discrimination made possible by the data economy. these cognitive changes, plus a seamless global wireless web, also ended the western failure of the territorial national state. as a result, the "four freedoms" related to the free movement of goods, services, persons and capital, became recognized as ubiquitous civil right and a global reality. the various systemic changes resulting from cognitive changes were supported by, and helped to establish, an effective and inclusive global dispute settlement mechanism, which recognized the right to bring an action and to be heard in court (locus standi) of not only international organizations, states and multinational corporations but also natural persons. it effectively aligned the former wto dispute settlement system with investor-state arbitration. both systems were elevated to a "world trade court" embedded within a fully-fledged global judicial body, the gaia tribunal, that was vested with various constitutional powers to sanction and enforce the rulings it issued. overall, the new institutional design based on these cognitive changes was said to have helped to "improve and eventually overcome the perceived lack of legitimacy of international courts and tribunals in the eyes of the governments, the legal community and civil society". conclusion: 'dystopian utopia' or oxymora to predict the future by creating it my project was retarded by laws of nature. the world was not prepared for it. it was too far ahead of time. but the same laws will prevail in the end and make it a triumphal success. a dystopian or a utopian future, does it matter? after all, from the "perspective of the brain, there's a thin line between a good decision and a bad decision". it seems, though, that what matters to everyone is the future, because the future is "where we are all going to spend the rest of our lives". however, perhaps this must also not be the case as, paradoxically, most (or all) dichotomies have a limitation in that they not only trade accuracy for simplicity, but also provide an invisible barrier to a vision of the bigger picture. this is where subtle linguistic changes may gradually trigger cognitive changes and eventually bring in legal and institutional changes, in the same way as dripping water hollows out stone, even though the cognitive habits of binary or dualistic thinking are said to die hard. easy or difficult, it is a source of encouragement for everyone, as we may, à la longue, be able to bring about the change we desire, given that institutional change is possible once a cognitive change has occurred. the recent rise in the number of oxymora and paradoxes, however, seems to indicate this "creative" possibility. for instance, various concepts implicitly reflecting the tensions between prediction and destiny within the confines of past and present, such as science fiction or free will, have been qualified as oxymora. in their context (and possibly in the context of all paradoxes), time therefore appears as the clue, or the key we need to find to unlock the limitations inherent in our current linear perception of time. the fact is that the grammar of many modern languages, conjugating verbs in the "present," "past," and "future" tenses, was said to not be "well-adapted for speaking about the real temporal structure of reality, which is more complex". various "nostalgic visionaries", dimitropoulos ( ) lang ( ) , p. . csicsery-ronay jr. ( ), p. ("as its name implies, science fiction is an oxymoron."). crewe ( ) , p. . rovelli ( ), p. . like herbert g. wells or jules verne, however, transcended the past-future dichotomy in their writings, thereby anticipating many future inventions. lawyers, too, can act in this way, as their work is often similar to that of science fiction authors, given that they can help in translating fiction into legal fact or turning dreams into reality by combining "the law as it is" (lex lata) with "the law as it should be" (de lege ferenda) perspectives. for lawyers to achieve this creative goal and to synthesize the two competing scenarios of the future beyond the wto outlined in this chapter, it will be necessary, first, to work actively towards a cognitive change. applied to legal reasoning, it means to transcend an exclusively dualistic mode of reasoning, which means to solely rely on the "law of the excluded middle" (i.e. "everything must either be or not be."). applied to the regulation of global trade, this kind of "either/or thinking" or that something either belongs to the sphere of trade or is classified as a "non-trade concern" must be complemented by the law of the included middle. the law of the included middle can be achieved through oxymoronic thinking by way of which, for instance, trade and non-trade concerns are not opposed to each other but where their apparent contradiction can be resolved at a higher level of reality or complexity. more concretely, lawyers must be able cognitively to transcend the iron law of binary logic by also being versatile in reasoning based on polyvalent logic-a kind of multivalued logic in which there can be more than two truth values. a good way to remind ourselves of this is given in the following quote: "laws may differ but they do not conflict: the only possible conflict is in the mind of the judge". in this regard, legal education seems the best place to begin. thus, addressing problems by legally expressing them solely using dichotomies is no longer apt to deal with their underlying complexity. it also means that a purely static approach should be complemented with a more dynamic one to ensure that laws are adopted in a way that embraces change ex ante and makes them fit for the future. in institutional terms, a more dynamic approach is also needed, as otherwise we merely observe their initial rise and subsequent demise. in this respect, discursive institutionalism provides an excellent complement, as it regards norms as "dynamic, intersubjective constructs rather than static structures". ultimately, it is submitted here that, based on this cognitive change, novel models of global institutions, like gaia , can emerge. second, the cognitive changes of polyvalent or oxymoronic thinking, when combined with new organs of perception as symbolized by synaesthesia, will enable another important insight, which lies in the realization that the best way to predict the future is by creating (and regulating) it. this insight puts the theory of a selffulfilling prophecy into a new light, one which proves that theory and practice are intimately linked and that sociological predictions are "products of an era, co-determinants of what they assert". when applied to humanity as a whole, predicting the future by creating it (and regulating it accordingly) means that if we plan something and act upon it coherently and persistently, it is more likely to happen, eventually. this, however, first requires a cognitive change in the understanding of humanity as a divided amalgam of different peoples or nations instead of an organic whole united in its diversity. only then can an adequate global governance mechanism capable of putting the necessary global legal order into place be expected to be brought forth. in short, the global governance paradox and other apparent contradictions can only be successfully addressed by expanding our reasoning from bivalent to polyvalent modes of thinking, as reflected in synaesthesia or in new optimized ways to receive and channel information through our different senses or, in legal terms, different institutions. applied to the dichotomy of the past versus the future, a new cognitive mode may one day enable humans to recall the fundamental importance of the present, that is, the magical power of the present to rewrite both the world of yesterday and the world of tomorrow. by the same token, humans can then eventually use the same magic to control the outcome between the two apparently opposite scenarios, the dystopian and the utopian one. for now, the two scenarios outlined in this chapter cannot answer the questions of whether or not, in our perception, linear time exists, or whether or not we have free will or all fate (including the fate of the wto) is already written in a comprehensive book of destiny. this chapter is equally unable to say whether a post-wto legal order will be able to avoid global disaster and humanity's as well as nature's 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revolution: how the technology behind bitcoin and other cryptocurrencies is changing the world. penguin, new york ten hoopen g et al ( ) auditory isochrony: time shrinking and temporal patterns my inventions and other writings on the fiscal strategies of escaping poverty-environment traps towards sustainable growth balance-of-payments crises in the developing world: balancing trade, finance and development in the new economic order a proposal for international monetary reform big data and personalized price discrimination in eu competition law technology and progress in jules verne, or anticipation in reverse a propos de la lex ferenda the human rights of stateless persons felt time: the psychology of how we perceive time requiem for a paradox: the dubious rise and inevitable fall of hipster antitrust currency wars: offense and defense through systemic thinking a hater's guide to geoblocking key: cord- -qgqzr n authors: albrecht, harro title: global health. die gesundheit der welt in der internationalen politik date: - - journal: nan doi: . /s - - - sha: doc_id: cord_uid: qgqzr n with the adoption of the millenium development goals in , global health attracted notice to a worldwide public. this article analyzes the origins, the concept and the universal relevance of global health, discusses several international development programs (supported by the usa, the un, as well as and by private organizations) and examines their effects and their sustainability. während dieser sechs tage knüpfte george w. bush an seine am wenigsten gewürdigten außenpolitischen erfolge an. unbemerkt v.a. von der europäischen Öffentlichkeit hatte der us-präsident eines der umfangreichsten gesundheitsprogramme für entwicklungsländer angeschoben. schon hatte er den president's emergency plan for aids relief (pepfar) aus der taufe gehoben und zwei jahre später die president's malaria initiative (pmi). diese entscheidungen waren zwei erkenntnissen zu verdanken: erstens stellte die weltbank fest, dass gesundheitsprobleme in entwicklungsländern keineswegs nur lästige geldvernichter seien, sondern eine fundamentale ursache der armut. zweitens hatte die clinton-administration um die jahrtausendwende die weltweite aids-epidemie als mögliche gefährdung der inneren sicherheit der usa eingestuft. es ging um eine milliarde menschen weltweit, die bis heute keinen zugang zu einem gesundheitswesen haben, um , millionen kinder unter fünf jahren, die jedes jahr durch vermeidbare ursachen sterben, um zusammen fünf millionen menschen, die jedes jahr einer von nur drei krankheiten zum opfer fallen: aids, tuberkulose und malaria. mehr entwicklungshilfe im kampf gegen krankheiten und insbesondere aids, so die hoffnung der us-regierung, würde nicht nur den betroffenen helfen, sondern auch einen spürbaren wirtschaftlichen aufschwung in den ärmsten ländern nach sich ziehen und dadurch weltweit die sicherheitslage verbessern. diese außenpolitischen interessen decken sich mit den humanitären anstrengungen der weltgemeinschaft. unter diesem vorzeichen eröffnet sich die chance auf eine neue, nachhaltige verbesserung der gesundheitssituation der Ärmsten. zum ersten mal besteht die möglichkeit, dass die visionäre erklärung der weltgesundheitsorganisation (world heath organization, who) "gesundheit für alle" von alma ata aus dem jahr gestalt annimmt. doch wirken die außen-und sicherheitspolitischen motive maßgeblicher staaten darin nicht als störfaktoren? am anfang der neuen entwicklungshilfepläne stand ein diplomatisches problem, für das dringend eine lösung gefunden werden musste. john ruggie, zu diesem zeitpunkt persönlicher berater des un-generalsekretärs kofi annan, war mit einer heiklen mission betraut. die vereinten nationen steckten in den vorbereitungen für das gipfeltreffen zum millennium im september in new york. "die regierungen waren tief beunruhigt darüber, dass das treffen ähnlich inhaltsleer verlaufen würde wie das fünfzigste jubiläum der un-gründung", erinnert sich ruggie , der inzwischen politikwissenschaft an der harvard kennedy school of government lehrt. ohne ein vorzeigbares gemeinsames arbeitsziel hätten viele staaten ihre teilnahme abgesagt. also suchte annans berater mit seinen kollegen nach themen, die von möglichst allen staatsoberhäuptern akzeptiert werden würden. gesundheit und entwicklung erschienen unverdächtiger als sicherheitsfragen. die idee kam an, und so zielten schließlich drei von acht beschlossenen millennium-entwicklungszielen ( alle diese anstrengungen führen das wort global im namen. doch was genau ist global health? nach der definition des institute of medicine in washington, d.c. beschäftigt sich global health mit gesundheitsproblemen, welche die nationalen grenzen überschreiten, die lebensumstände und erfahrungen anderer staaten beeinflussen und die am besten durch kooperation gelöst werden können. in global health trifft also definitionsgemäß gesundheit auf außenpolitik. erdacht werden die global health-konzepte vor allem an us-universitäten wie harvard und columbia und dort vor allem an den schools of public health. für diese art von "schulen" existierte bislang im deutschen sprachraum keine entsprechung. das ist insbesondere deshalb erstaunlich, weil die public health-idee sich aus Überlegungen des deutschen arztes und politikers rudolf virchow aus dem . jahrhundert ableitet (goschler (marmot/ wilkinson ) . weil public health dabei nicht nur die pathologie spezifischer erkrankungen, sondern auch die lebensbedingungen des menschen einbezieht, berührt das fachgebiet unter anderem auch fragen der wirtschaft, psychologie, politik und kultur -oder wie rudolf virchow es ausdrückte: "die medicin ist eine sociale wissenschaft, und die politik ist nichts weiter als medicin im großen." global health als ausdehnung von public health im weltweiten maßstab ist eines der umfassendsten wissenschaftsgebiete. es beschäftigt sich mit problemen der lebensumwelt, des handels, des wirtschaftswachstums, der sozialen entwicklung, der nationalen sicherheit und der menschenrechte. weil in entwicklungsländern das geld für staatlich finanzierte individuelle therapien fehlt, ist public health hier die vorherrschende medizinische ausrichtung. dies bedeutet, dass krankheitsprävention priorität vor der behandlung von krankheiten genießt, und wenn therapiert werden muss, dann möglichst nur solche erkrankungen, bei denen mit minimalem einsatz die größte wirkung für die meisten menschen erzielt werden können. viele schwere erkrankungen, etwa fortgeschrittene krebserkrankungen, werden also nicht mit hilfe öffentlicher mittel therapiert. wer eine individuelle gesundheitsleistung dringend benötigt, muss sie in entwicklungsländern selbst bezahlen, und so verwundert es nicht, dass in diesen ländern über achtzig prozent der gesundheitskosten von den kranken übernommen werden. weil global health vor allem public health-methoden anwendet, sind die zielgebiete dieser disziplin die entwicklungsländer. die einseitige ausrichtung des blickes der wohlhabenden staaten auf die ärmeren länder aber erscheint in zeiten der globalisierung wenig sinnvoll. heute liegt es näher, das wort global wörtlich zu nehmen und keine unterschiede zwischen nord und süd, reich und arm zu machen. durch das rapide bevölkerungswachstum, den abbau der handelsschranken und den internationalen massenverkehr ist zum ersten mal in der geschichte der menschheit die gesundheit jedes einzelnen relevant für die gesundheit aller anderen. die klimaerwärmung, v.a. von den industrieländern verursacht, verändert die lebensbedingungen weltweit. die radioaktiven substanzen des explodierten kernreaktors in tschernobyl hatten noch tausende kilometer entfernt auswirkungen auf die gesundheit der menschen. wenn in einem deutschen krankenhaus eine krankenschwester aus malawi oder den philippinen arbeitet, dann fehlt sie in ihrem heimatland. infektionskrankheiten wie influenza oder sars sind unter umständen nur einige flugstunden von einer der megastädte der welt entfernt. umgekehrt übernehmen jene menschen in den entwicklungsländern, die über ein wenig wohlstand verfügen, den westlichen lebensstil mit Überernährung und bewegungsmangel. inzwischen hat die zahl der herzinfarkte und diabetesfälle auch in tropischen breitengraden extrem zugenommen (kawachi/wamala ) . die idee von global health wörtlich zu nehmen hieße aber auch, dass jedes land verantwortung für die gesundheitsprobleme in einem anderem übernehmen muss. genauso wie im zusammenhang mit der Öffnung der weltmärkte und der globalisierung über notwendige neue soziale standards diskutiert wird, braucht auch die weltgesundheit ethische rahmenbedingungen. es darf nicht sein, dass entwicklungen in einem staat auf kosten der bevölkerung eines anderen gehen. ansätze dieses verantwortungsprinzips sind in den internationalen gesundheitsvorschriften der weltgesundheitsorganisation verankert. sie geben der who das recht, im fall von epidemien untersuchungen in einem land durchzuführen und reisewarnungen auszusprechen. viele fragen bleiben bisher jedoch unberücksichtigt -etwa jene, ob etwas unternommen werden soll, wenn medizinisches personal aus einem entwicklungsland durch bessere bezahlung in reiche länder gelockt wird. gleichzeitig eröffnet die globalisierung aber auch chancen, die gesundheit im globalen maßstab zu verbessern. inzwischen haben schwellenländer wie brasilien und indien mit der produktion günstiger medikamente begonnen und beispielsweise die therapie von tuberkulose auch in den ärmsten ländern ermöglicht. die Überwachung von epidemien und die frühwarnung vor naturkatastrophen und hungersnöten über die moderne telekommunikation und internet sind heute besser denn je entwickelt. erfahrungen aus vielen tausend gesundheitsprojekten liegen vor, die wege aufzeigen, wie menschen mit wenig geld geholfen werden kann. allein die orale rehydrationstherapie (ort) mit einer einfachen zucker-salz-lösung rettete millionen durchfallerkrankter kinder das leben (banerjee ; levine ) . daneben sind aufgrund der zunahme chronischer erkrankungen public health-konzepte auch in entwickelten ländern mehr denn je gefragt. global health aber kennt im augenblick vor allem eine blickrichtung: die aus dem reichen norden in den armen süden. der begriff ist zum synonym geworden für gesundheitsbezogene entwicklungshilfe vor allem durch die usa (kickbusch ) . zwar geben die usa mit , prozent des bruttoinlandsprodukts vergleichsweise wenig für die entwicklungshilfe aus. in absoluten zahlen aber überragt diese summe zusammen mit dem gewaltigen privaten spendenaufkommen z.b. von microsoft-gründer bill gates und dem investor warren buffet die entwicklungshilfeausgaben aller anderen länder. die amerikanische agenda folgt einem geist, den der brite alex de waal, direktor des social science research council in new york city, als das ergebnis einer "erlösungs-agenda" beschrieb, "der Überzeugung, dass eine kombination aus geld, technologie und gutem willen jedes problem lösen kann. religiöse gruppen fügen noch den ‚glauben' hinzu" (de waal : ) . so ist die bill & melinda gates-stiftung für ihre suche nach technischen lösungen, etwa neuen impfstoffen, und für ihre zielorientiertheit bekannt. genauso strebt die us-regierung schnell erreichbare ergebnisse an, die der wählerschaft präsentiert werden können. eine umfassende strategie zur langfristigen verbesserung der lebensverhältnisse, wie sie rudolf virchow vorschwebte und wie sie auch an vielen amerikanischen schools of public health gelehrt wird, passt allerdings nicht zu den vorstellungen amerikanischer politik. in den usa ist alles, was im entferntesten nach sozialismus aussieht, verpönt. public health aber ist vom grundgedanken her sozialistisch, weil sie die fürsorgepflicht des staates für die gesundheit der bürger fordert. so glänzen sozialistische staaten wie kuba, der indische bundesstaat kerala oder früher russland bei geringem mitteleinsatz oft mit bemerkenswerten gesundheitsdaten. die durchschnittliche lebenserwartung in kerala beträgt jahre bei einem pro-kopf-jahreseinkommen von rund us-dollar. auf welche weise ideologie und außen-und innenpolitische agenden die neuen großprogramme prägen, zeigt eindrücklich das beispiel von uganda, das im zentrum der neuen global health-bewegung steht. schon kurz nach der machtübernahme klärte ugandas neuer präsident yoweri museveni als einer der wenigen afrikanischen staatsoberhäupter die bevölkerung schonungslos über die neue immunschwächekrankheit aids auf ( de waal ; green ) . museveni war dabei nicht in erster linie von der sorge um die gesundheit der massen getrieben, sondern von jener um die potentielle schwächung seiner streitkräfte. nach der rebellion hatte der sozialist sechzig offiziere zum training nach kuba fliegen lassen. dort waren zu dieser zeit hiv-tests obligatorisch. als der noch ahnungslose ugandische präsident wenig später auf einer konferenz in simbabwe erschien, nahm ihn fidel castro zur seite und warnte seinen bundesgenossen: "du weißt, dass du ein großes problem in deinem land hast?" es hatte sich in kuba herausgestellt, dass achtzehn der getesteten soldaten das tödliche virus in sich trugen. die antiretrovirale therapie war noch nicht weit entwickelt und ohne geld in der staatskasse blieb museveni nichts anderes übrig, als seine landsleute in radiospots, mit plakaten, kundgebungen und theatershows zur enthaltsamkeit und ehelicher treue anzuhalten. das konzept ging offenbar auf, denn in den folgenden jahren sank die aids-rate deutlich. diese erfolgsgeschichte war der anfang des wandels der erkrankung aids zum politikum aids. deshalb ist uganda heute der größte nutznießer des neuen engagements der internationalen gemeinschaft in sachen aids. allein im jahr flossen vom global fund, von weltbank und pepfar millionen us-dollar in die staatskasse ugandas. dies ist mehr als das gesamte gesundheitsbudget für alle anderen krankheiten zusammen genommen. der ununterbrochene strom an aids-gebundenen zuwendungen versetzt den präsidenten in die lage, seinen landsleuten immer neue programme offerieren zu können. mitsprache und demokratische prozesse entwickeln sich unter diesen bedingungen nur zögerlich, und nun steht yoweri museveni im zweiundzwanzigsten jahr seiner alleinherrschaft. man könnte sagen, die aids-hilfsgelder haben diese un-demokratische regierung erst stabilisiert. dass es auch anders geht, zeigt das konzept des global fund. dieser gibt seine gelder zwar direkt an die regierungen und überlässt ihnen die verteilung. in uganda zog er jedoch nach gravierenden fällen von korruption weitere geldzusagen zurück -eine aufsehen erregende maßnahme, die noch heute von ugandas zeitungen intensiv diskutiert wird und die zeigt, wie eine schärfere kontrolle bei der vergabe von hilfsgeldern auch demokratische debatten begünstigen kann. die pepfar-uganda-liason begann mit einem treffen zweier sehr ungleicher männer in einem flugzeug: edward green, medizin-anthropologe aus harvard, und richard holbrooke, ehemaliger us-botschafter bei den vereinten nationen. holbrooke hatte sich schon lange für den kampf gegen aids eingesetzt, weil er die infektionskrankheit für eine größere bedrohung der nationalen sicherheit hielt als etwa die verbreitung von nuklearwaffen und die explosive lage im nahen und mittleren osten. anfang des jahres übernahmen die usa den vorsitz des sicherheitsrates der vereinten nationen, und holbrooke nutzte die chance, um aids auf die agenda zu bringen. zum ersten mal in der geschichte des un-sicherheitsrates war gesundheit der gegenstand der debatte. im folgenden jahr schied holbrooke aus den vereinten nationen aus und setzte sich vehement bei kofi annan und george w. bush für einen aids-fond im umfang von zehn milliarden us-dollar ein. es sollte noch zwei jahre dauern, bis holbrookes vorstellungen sogar übertroffen wurden. gab george w. bush den president's emergency plan for aids relief aus: milliarden us-dollar, auf fünfzehn länder verteilt für einen zeitraum von fünf jahren. ende des jahres flogen green und holbrooke zusammen mit einer -köpfigen delegation auf eine aids-informationstour in vier afrikanische länder. green war begeistert und inspiriert von den anfänglichen erfolgen der treue-kampagne musevenis. im gepäck trug der harvard-professor deshalb ein exemplar seines damals frisch veröffentlichten buches "rethinking aids prevention" (green ) . darin legt green dar, dass er die reduktion der anzahl der sexualpartner für die schärfste waffe im kampf gegen aids halte -wobei er den einsatz von kondomen nicht ausschließe. holbrooke "hat in den ersten tagen mein buch gelesen und war davon sehr angetan. er hat gesagt: das ist wirklich gut", erinnert sich green. aber auch der us-gesundheitsminister tommy thompson hatte im flugzeug gesessen und den medizin-anthropologen nach der reise zum gespräch einbestellt. auf diese weise wurde green zum berater der konservativen us-regierung und uganda einer der hauptempfänger des geldsegens. das daraus resultierende programm war jedoch höchst umstritten. ein drittel des pepfar-geldes sollte zur verfügung stehen für kampagnen zur enthaltsamkeit und treue unter dem motto "abstinence, be faithful and condoms" (abc) -wobei kondome nur unter risikogruppen wie prostituierten und drogensüchtigen propagiert werden durften. die liberale aids-szene in den usa hielt die an christlichen werten orientierte abc-kampagne für eine katastrophale abkehr von der in den usa bewährten strategie des "safer sex und kondome für alle". außerdem bemängelten kritiker, dass pepfar-projekte vollständig parallel zum restlichen gesundheitssystem implementiert würden. sie verfügten über die besseren laborausstattungen, über autos und einen konstanten strom an medikamenten, und sie zahlten dem personal höhere gehälter. dadurch sei das programm zwar effektiv, aber belaste die ressourcen des restlichen gesundheitssystems und sei somit nicht nachhaltig. eine bessere alternative sei das finanzierungsmodell des global fund gewesen, statt das gros der mittel in die us-anstrengung pepfar zu investieren. sicherheitspolitische bedenken des größten entwicklungshilfefinanziers hatten aids auf die internationale agenda gebracht, und die vorstellungen der usa hatten die ausführung der programme geprägt. die konzepte funktionieren im kern noch immer nach dem prinzip der helfenden hand in zeiten des krieges, bei Überflutungen, dürrekatastrophen oder epidemien. dieses herkömmliche, karitative motiv aber verfolgt nicht die langfristige konsolidierung maroder gesundheitssysteme. "wir leben angetrieben durch den gates-buffet-effekt in glücklichen zeiten der globalen public health", schrieb susan erikson ( ) , "doch es gibt ein paar gesundheitsziele, die man nicht mit geld wird kaufen können, weil einflussreiche staaten aktiv eine außenpolitik verfolgen, die diesen zielen diametral entgegengesetzt ist." dazu zählen handelsabkommen, die die ernährungssicherheit bedrohen, lockangebote für medizinisches personal armer länder und multinationale unternehmen, die erfolgreich ihre patente für essenzielle medikamente verteidigen. "wenn andere interessen wie die nationale sicherheit als bedroht angesehen werden, ist gesundheit von zweitrangiger bedeutung", schreibt erikson. (masanja et al. ) . das moratorium zeitigte schon bald einen erfolg: gerade haben wissenschaftliche studien belegt, dass das ostafrikanische land auf gutem wege ist, das millenniumsziel der verminderung der kindersterblichkeit zu erreichen. csis commission on smart power. a smarter, more secure america health is global. proposals for a uk government-wide strategy getting political. fighting for global health rudolf virchow. mediziner -anthropologe -politiker. köln rethinking aids prevention. learning from successes in developing countries globalization and health influence and opportunity. reflections on the u.s. role in global public health case studies in global health. millions saved social determinants of health oslo ministerial declaration -global health. a pressing foreign policy issue of our time aids and power. why there is no political crisis -yet key: cord- - mfiie authors: aykut, stefan c.; morena, edouard; foyer, jean title: ‘incantatory’ governance: global climate politics’ performative turn and its wider significance for global politics date: - - journal: int polit doi: . /s - - - sha: doc_id: cord_uid: mfiie the paris agreement represents a deep-rooted change in global climate governance. while existing scholarly assessments highlight central institutional features of the paris shift, they tend to overlook its symbolic and discursive dimensions. our analysis shows that the paris architecture combines two core elements: an iterative pledge and review process to stimulate global climate action, and a ‘performative’ narrative aimed at aligning actors’ expectations on the prospect of a low-carbon future. we therefore suggest calling it an incantatory system of governance. we then examine the origins of the new approach and find that the rise of ‘soft law’ approaches and communicative techniques in global climate governance are both indicative of a broader process: the entry of management culture in international organisations. against this backdrop, we examine the prospects, limitations and caveats of the new approach and discuss its wider implications for global politics. the paris agreement adopted in december is widely considered as a major breakthrough in global climate governance, with the potential of becoming a blueprint for other governance arenas (jordan et al. ) . and yet, just years after its adoption, it was already in jeopardy when us president trump announced on june his intention to withdraw from the treaty. the decision completely paralysed negotiations at the un climate summit cop in bonn in november of that same year. interestingly, however, the atmosphere was very different at the 'bonn zone', an area dedicated to non-state and sub-state climate efforts and just a few hundred metres away from the official conference space. a highlight of the 'bonn zone' was the launch of the #wearestillin coalition. under the leadership of billionaire philanthropist, former new york city mayor and un special envoy for climate action michael bloomberg, as well as california governor jerry brown, the coalition brought together american cities, states and businesses committed to fulfilling the us's national emission reduction commitments through bottom-up action. the mood was similarly upbeat at the one planet summit in paris a month later. convened by french president emmanuel macron to mark the cop 's second anniversary, the summit provided business and ngo leaders, representatives from international organisations and national and multilateral development banks, heads of state and government, philanthropists and mayors with an opportunity to both reassert their commitment to the paris agreement and to announce new measures for its implementation. the 'bonn zone' and one planet summit are revealing of the current state of global climate governance. they are symptomatic of more deep-rooted shifts in its organisation, in the levels of engagement, in the actors involved, and the mechanisms through which it operates and produces effects. global climate policy is now understood as a process that transcends the united nations framework convention on climate change (unfccc), and of which transnational initiatives and private governance schemes constitute an integral part (moncel and van asselt ) . furthermore, it is no longer aimed at the production and enforcement of binding reduction targets for states, but builds on a flexible 'pledge and review' system combining voluntary pledges by public and private actors alike, and binding reporting and transparency rules for states (keohane and oppenheimer ) . taken together, these changes have been described as a shift away from a 'regulatory' and towards a 'catalytic and facilitative model' of global governance (hale ) . while such assessments highlight central aspects of the paris shift, they also contain significant blind spots. the bulk of stand-alone articles and special issues on post-paris climate governance focusses on negotiation dynamics and outcomes, the interpretation of the agreement's legal dispositions, or institutional innovations in the post-paris process (jordan et al. ) . in doing so, such analyses tend to overlook an important feature of the new governance regime: its symbolic and discursive dimensions. as illustrated by the examples above, the post-paris process conveys a central role to the emission of 'signals' and the creation of 'momentum' for climate action, through carefully orchestrated global moments such as the one planet summit and climate action summits and highly publicised private initiatives like #werestillin. in other words, in this new governance, performances, symbols and narratives appear to be just as important as the production of rules, institutions and instruments. we therefore suggest calling the new approach an incantatory system of governance. on a general level, the notion of 'incantation' points to the ritualised and repetitive dimensions of global climate governance, with its annual meetings and recurring calls to urgency and action (little ) , as well as to the theatrical dramaturgy of climate summits and their filiation to the 'society of spectacle' (death ) . more specifically, it permits to capture what we believe constitutes a distinctive feature of the new approach: the fact that communicative and symbolic devices are explicitly recognised, by its architects and promoters, as core instruments in the agreement's implementation. a central element in this context is the grand narrative of an ongoing 'planetary transition' to a decarbonised world economy, which is crafted and circulated by key governance actors. by using the notion of incantation, we also wish to engage a discussion on the origins and wider significance of this governance shift. in an increasingly fragmented (biermann et al. ), marketised (newell and privatised (park et al. ) global governance landscape, 'soft law' approaches resting on voluntary commitments (abbott and snidal ) , indicators and best practices (merry ) have been on the rise over the last decades. the paris shift fits within this broader set of transformations, inspired by the adoption of new public management (npm) methods in international organisations. we suggest that these two dynamics-the weakening of legal and regulatory frameworks, and the inflationary use of communicative devices-can be understood as two sides of the same phenomenon: the importation of a business culture in global governance. finally, the notion of incantation points to the need to renew the methods with which we study global climate governance. our aim is not to present the new approach as ineffective per se, but to understand how it plays out in practice, and better appreciate its prospects, risks and caveats. this requires examining the role of rituals, symbols and discourses in global governance, analyse how they produce effects and study how they relate to, or combine with, more traditional governance methods-such as the negotiation of legal documents and the action of international organisations. in line with collaborative event ethnography (campbell et al. ), our analysis is therefore based on repeated collective observations of different spaces of global climate governance, particularly during the paris cop. there, we studied the circulation of people and documents, practices of text production and editing, the role of diplomatic rituals and political performances, as well as civil society mobilisations, scientific events and business happenings . we also analysed how philanthropic foundations and think tanks shaped the 'road to paris' and the discursive context surrounding cop (morena ) . in this paper, we connect the findings of these different lines of research. drawing on discourse analysis (bäckstrand and lövbrand ) , we also reconstruct the narratives circulated by promoters of the new governance approach. that being said, the article's primary goal is to advance a broader conceptual argument. the empirical material serves to shed light on our argument rather than provide a comprehensive, rigorous analysis of one conference or one discourse. the paris approach introduces a series of institutional innovations. it marks a transition from a 'regulatory' approach to global climate governance, with detailed rules and obligations that apply to developed states, to a 'hybrid' system that both combines voluntary submissions and binding review cycles for all states and associates a wider range of stakeholders. however, in the eyes of its architects and main proponents, the new approach does not only rest on new institutions, it also centrally relies on new discursive and symbolic elements. instead of legally binding reduction targets and sanctions for non-compliance, the governance framework laid out in the paris agreement is based on the submission and review of freely determined policy pledges, or nationally determined contributions (ndcs). however, the approach also differs significantly from purely voluntary systems. on the substantive side, it sets two long-term temperature goals: keeping global warming 'well below' °c and 'pursuing efforts' to stay below . °c. the cop decision also sets out the figure of billion usd per year towards developing countries' adaptation and emissions reduction efforts. apart from the . °c target, these figures had already been laid out in the contested copenhagen accord in . accordingly, the paris agreement's main innovations are procedural, rather than substantive (oberthür and bodle ). an 'enhanced transparency framework' is set up to ensure the publicity and comparability of ndcs; a 'global stocktake' is scheduled every years to collectively evaluate the adequacy of national efforts; based on this assessment, countries are expected to 'ratchet up' their pledges in line with the agreement's long-term goals. in sum, the paris framework establishes legally binding obligations of conduct, but no obligations of result (bodansky ) . its implementation has been described as a 'two level game' in which the capacity of domestic civil societies to exert pressure on their governments plays a decisive role (keohane and oppenheimer ) . the paris architecture is therefore understood by its proponents as an iterative process, in which 'the many interdependent parts […] interact in mutually facilitative ways' (hale and roger : ) . the agreement also broadens the scope of stakeholders that participate in global climate governance. in addition to developed countries, developing countries as well as private and subnational actors are encouraged to submit emission reduction pledges. in this respect, paris not only marks a historic break with the north-south divide in global climate politics; it also confirms the rise of 'private authority' and corporate self-regulation in global governance (pattberg ; andonova ) . from centrepiece of a unified and centralised climate regime, the unfccc is now considered as only one of many elements that collectively make up a broad landscape of 'transnational climate governance' (betsill et al. ; bulkeley et al. ). in the lead-up to the paris conference, climate governance scholars reassessed the unfccc's role. they encouraged it to take on an 'orchestrating' function for climate action by states, as well as businesses, cities, regions and federated states (abbott and snidal ; moncel and van asselt ; hale and roger ) . orchestration is thereby defined as an 'indirect mode of governance that relies on soft inducements', as the orchestrator 'works through like-minded intermediaries, catalysing their formation, encouraging and assisting them and steering their activities through support and other incentives' (abbott : ). an oft-cited example is the unfccc's non-state actor zone for climate action (nazca), an online platform launched in 'where actors from around the globe-countries, regions, cities, companies, investors and other organisations-can display their commitments to act on climate change.' to further encourage transnational climate action and link it to the un process, the unfccc also promoted 'high-level champions' for climate action. the 'champions'-usually personalities from the business, political and cultural spheres-put their professional networks and celebrity in the service of climate action. in return, the un arena provides social prestige and symbolic recognition to these individuals. initiatives such as nazca portal or the high-level champions are envisioned as more than mere appendages to national efforts. they are a constitutive 'fourth pillar' of global climate governance alongside mitigation, adaptation and climate finance, intended to 'galvanize' and 'catalyse' global climate action (hale ) . the underlying image is that of a virtuous cycle, in which experiences of past cooperation create trust and confidence among actors and alter their future preferences (bang et al. ) . the concept of 'catalytic cooperation' (hale ) neatly captures this idea. it rests on the claim that global mitigation efforts have wrongly been portrayed as a classic case of a prisoner's dilemma. instead, it is argued that climate action entails first mover benefits for pioneers and increasing returns as the number of followers increases. this may lead to normative change through 'norm cascades' and 'tipping points' that transform the incentive structure and hence the nature of the problem. hence, 'the entire purpose of a catalytic regime' like the paris agreement 'is to shift actors' preferences over time in favour of cooperation' (hale : ) . given the importance of norms, trust and preferences in this governance setup, however, surprisingly little attention have been paid in the literature to global climate governance's symbolic and discursive dimensions. indeed, the defining feature of contemporary climate governance is that signals, narratives and performative moments are at its core. this is explicitly recognised by key proponents of the new approach. laurence tubiana, special envoy of the french presidency to the cop negotiations and one of the architects of the paris agreement, presents the treaty as a 'selffulfilling prophecy', whereby positive narratives 'by producing a convergence of rational anticipations […] contribute as much to change as the agreement itself.' the main objective of post-paris climate governance is no longer the production of new legal norms, but the alignment of state and non-state actors' expectations on the prospect of a low-carbon future. the 'signals' and 'momentum' generated by the governance process underpin the voluntary architecture of the agreement. while the origins of the bottom-up approach in global climate governance are often traced back to the copenhagen climate conference (cop ), fully capturing how and why it came about, and what constitutes its specificities, requires us to go further back in time. indeed, voluntary approaches have been part of the discussions since the beginning of climate talks in the s. we also need to expand our horizons to other areas of global politics, as the approach adopted in paris echoes a wider 'managerial turn' in global politics. prevailing accounts of the paris shift tend to focus on dynamics within the climate regime. and indeed, the idea of a voluntary framework to coordinate the global mitigation effort historically emerged in the run-up to the rio conference. at that time, the eu favoured a 'targets and timetables' approach based on binding reduction commitments for industrialised countries. the us administration criticised the proposal as overtly 'top-down' and 'rigid', arguing that climate governance should involve a more flexible 'bottom-up' approach (bodansky : ) . as a compromise solution, japan suggested in july a pledge and review system combining voluntary country submissions and an international review process to track implementation. however, the targets and timetables approach ultimately won over in kyoto in (damian ) . the voluntary approach resurfaced in the run-up to the copenhagen conference, where countries negotiated on a successor treaty to the kyoto protocol. two years earlier, the so-called 'bali action plan' had introduced the concept of 'nationally appropriate mitigation actions' as a means of getting developing countries to contribute to the mitigation effort. the idea was to encourage emerging economies to make voluntary pledges that would be subject to measurement, reporting and verification (mrv). this, it was hoped, would trigger an incremental process, whereby pledges would progressively be strengthened and ultimately be converted into binding commitments. in the midst of the copenhagen collapse, however, the voluntary approach was ultimately extended to the global north as well. intended nationally determined contributions (indcs) were introduced as a compromise solution between 'nationally appropriate mitigation actions' and the quantified emissions reduction objectives that applied to developed states under the kyoto protocol. the origins of the voluntary approach can therefore be traced back to the early years of the climate regime. there are, however, important differences between the initial proposals and the paris approach. these relate not only to the specific ways in which the paris agreement combines binding and non-binding elements, but also to the broader global setting in which the new climate governance is embedded. this setting differs significantly from the early s. in the post-cold war context of the rio conference, the widely held view was that global governance unfolds mainly through global institution building and the gradual strengthening of international law (levy et al. ; zangl and zürn ) . advocates of pledge and review in the early climate negotiations could therefore frame such a system as a first, incremental step towards more substantial commitments later on (bodansky : ) . this argument appears less plausible today, as the voluntary turn in climate governance coincides with major transformations in global governance. the global diffusion of 'regulatory capitalism' (lévi-faur ) and the rise of 'private authority' (hall and biersteker ; pattberg ) challenge the long-standing supremacy of states and international organisations in global affairs. in a multi-actor world (kaul et al. ) , global governance no longer unfolds through state-led multilateralism alone, but also through forms of 'transnational regulation', 'hybrid governance arrangements' (graz ; andonova ) and networks of corporate self-regulation (müller and cloiseau ; short ) . these transformations had as a corollary the introduction of new governance methods, which originated in the business sector. in the s, new management techniques such as total quality management aimed to provide firms with 'remote control' over their increasingly transnational production chains, through a circular procedural sequence of goal-setting, reporting and auditing (power ) . these techniques inspired a range of national administration reforms during the 'managerial moment' of the s and s (kroeze and keulen ; pollitt and bouckaert ) , before spreading to the global level. corporate social and environmental responsibility (cser) schemes, which rely on a similar circular process of pledging, reporting and review, contributed to this dissemination (zumbansen ; crane et al. ) . through partnerships in such schemes, members of ngos think tanks and international organisations were progressively 'acculturated' to business methods, practices and vocabulary (conley and williams : , ). the spread of cser is also associated with a process of private 're-regulation' (logsdon and wood ; conley and williams ) , whereby businesses became recognised sources of policy proposals at the international level (müller ) . international organisations followed suit over the next decades and increasingly adopted 'soft' and 'experimental' governance methods (sabel and zeitlin ; eckert and börzel ) . the millennium development goals (mdgs), the un global compact and the eu's open method of coordination-three processes launched at the turn of the millennium-constitute paradigmatic examples for this trend. all three combine the definition of common goals, decentralised implementation methods and collective review and benchmarking mechanisms. in addition to coinciding with a broader 'managerial turn', international organisations' adoption of more flexible governance modes also signals their increasing difficulty to develop and enforce binding rules on states (hale et al. ) . hence, the open method of coordination was launched in response to critiques of the eu's overly centralised power structure (regent ; schout et al. ) , while the mdgs came on the back of more than a decade of structural adjustment programmes that spurred growing resistance among developing countries (mcarthur ; shawki ) . the direct consequence of these evolutions is a shift in the normative horizon of global governance. if international relations scholars could still claim in the s that the 'main purpose' of international regimes was 'to harmonize national legislation or to establish rules that can be applied by and to states' (zartman : ) , this no longer pertains to this new type of governance arrangements. from a system organised around the production of legal documents to be transposed into national law, global governance shifted towards a system grounded on the definition of shared goals, voluntary commitments by state and non-state actors, and global review and monitoring processes. while un climate governance was somewhat of a latecomer in adopting the new governance modes, it had been affected by these broader trends well before the copenhagen and paris conferences. since the turn of the millennium, a new 'transnational climate governance landscape' (bulkeley et al. ) progressively took root through the emergence of corporate social responsibility schemes (bulkeley and newell : ) , transnational city networks (betsill and bulkeley ) and corporate carbon trading systems (bernstein et al. ). in the climate diplomacy space, this evolution was closely scrutinised and promoted by a well-experienced and well-connected group of diplomats, ngo, foundation and business representatives, climate policy and communications experts in close contact with the unfccc secretariat and key parties to the convention (morena ) . bringing together individuals with a history of involvement in the international climate diplomacy space-through initiatives like the global call for climate action (gcca) or project catalyst, or informal networks such as the croissant conspiracy or the lionesses -, the international policies and politics initiative (ippi) provides a telling example of how non-state actors strategically mobilised to orientate the international climate debate. participants in the initiative's mid- 'lake tornow' meeting close to berlin include representatives from foundations (ecf, ciff, vasuda), development ngos (oxfam, care international), environmental ngos (greenpeace, wwf), campaign networks (can international, .org, avaaz, gcca), business networks (the climate group), think tanks (e g, wri, ucs, ecofys, track , iddri, germanwatch, grantham lse) and strategic communications (climate nexus) (morena : for participants in ippi, the failure to reach an agreement in was a direct consequence of stakeholders' disregard for wider political and non-state actor dynamics and their influence. experts from the think tank third generation environmentalism (e g, founded in ), for instance, suggested that the copenhagen collapse had shown that 'climate diplomacy has shifted from a relatively narrow focus on the unfccc process, to a more complex and wider discipline that now engages new constituencies and embraces broader geopolitical discussions' (mabey et al. : ) . as johannes meier, ceo of the european climate foundation (ecf, founded in ) explains, experts and activists had failed to recognise that change happens 'in rather oblique and non-linear ways' and that there is a 'need to pay more attention to politics and even to the polity' (meier ) . in its strategy document, ecf further argues that 'the radical policy change that will be required' entails moving not only policy-makers, but 'society as a whole, from the progressive to the conservative, right to left, engaged and disinterested' (european climate foundation : ). the new priority in the lead-up to paris was therefore to stimulate actions at multiple levels and locations, both within and beyond the unfccc, and involve a wide range of stakeholders, to create the conditions for a new type of global climate agreement. the idea was to deliver an agreement that combined a long-term goal that sends 'a clear signal to policy makers, businesses, investors and the public that the low-carbon climate-resilient economy is inevitable' (morgan et al. : ) , with 'bottom-up' commitments that are regularly updated and subject to robust transparency and accountability provisions. this, it was suggested, would enable climate diplomacy to use the 'groundswell' of 'nonstate action' to 'reinvigorate' global climate governance (chan et al. ) . through these and similar proposals in the run-up to paris, climate policy experts and representatives from think tanks, philanthropic foundations and environmental ngos successfully positioned the pledge and review approach as a credible and pragmatic alternative to the legally binding, top-down system that had prevailed up to copenhagen. critical governance scholars and ethnographers of global institutions have long argued that discourses, narratives and symbols constitute key elements in the making of global orders and pointed to the importance of rituals and performances in global mega-events like un climate summits. and indeed, beyond the -page treaty and accompanying -page cop decision, the paris cop also gave birth to the mobilising narrative of an ongoing 'planetary transition' to a low-carbon economy. the making of this narrative can be traced back to the aftermath of cop in copenhagen, when the production and dissemination of discursive frames became a central concern for climate governance actors. in the process, communication practices became a key strategic tool for the architects of the paris approach. making sense of the contemporary transformations of global climate governance requires an analytical vocabulary that adequately captures its discursive and symbolic dimensions. this points to at least two existing lines of research. first, research on discourses and norms highlights the constitutive power of language, knowledge and ideas in global environmental governance (bernstein ; oels ; pettenger ; hughes and paterson ) . lövbrand ( , ) , for instance, show how three broad discursive formations-'ecological modernization', 'green governmentality' and 'civic environmentalism'-distinctly shaped global climate politics in the post-kyoto and post-copenhagen eras. global climate discourses also extend beyond the realm of un climate diplomacy. they have disciplining effects on the everyday and participate in the creation of subjectivities (paterson and stripple ) . they provide 'discursive hooks' to actors seeking entry into the climate arena (allan ) and enable strategies of 'climate bandwagoning' (jinnah ) . moreover, their circulation contributes to a 'climatisation of global debates', whereby issues formerly unrelated to climate policy are increasingly scrutinised through a 'climatic lens' oels ) . un summits, which attract new actors and issues into the climate arena, play an important role in this progressive extension of the thematic scope and symbolic reach of climate governance. this resonates with a second line of research which focuses on the symbolic and performative dimensions of global environmental summits (blühdorn ; campbell et al. ) . ethnographer paul little ( ) provides a fascinating account of the role of performances and rituals at the rio conference. analysing the endless litany of speeches by heads of state and government during the opening ceremony, he shows how these conveyed to the respective home audiences the idea that 'world leaders' were best suited to address global problems. death ( ) makes a similar argument in a foucauldian study of 'theatrical techniques' at the he argues, has come to constitute a 'distinct technology of government'. despite being unsuccessful in terms of negotiations, the two summits constituted attempts 'to inspire and conduct the self-optimisation of the watching global audience'. for these authors, global mega-conferences cannot be reduced to formal negotiation outcomes; they are also important loci for the production of meaning, through the emission of signals, frames and narratives. such perspectives permit to shed new light on the discursive context of the pre-paris process. indeed, copenhagen also marks the start of a new 'positive' narrative around climate change, which would come to form a core feature of the new climate governance. for the group of stakeholders mentioned above, copenhagen had not only been a diplomatic fiasco, but also a failure in terms of communication. it had effectively failed to shape the overall narrative on climate change in a positive way (morena : , ) . too little attention had been paid to the symbolic and discursive dimensions of climate diplomacy. to succeed, the paris conference therefore had to send 'unambiguous signals that the world will shift its economic and social activity toward more climate-friendly and sustainable pathways' (oberthür et al. : ) . to do this, a range of individuals were mobilised and tools were created to ensure that stakeholders in the climate debate sent the right message to the right audience at the right time (morena ) . communications efforts were orchestrated by discreet 'unbranded' initiatives such as the global strategic communications council (gscc) or climate briefing service (cbs) whose communications experts '[coordinated stakeholder] voices at the national and international levels to help shape the national offers as they are being drafted and the thinking around the international agreement'. they focused their communications efforts on global and national climate-relevant 'moments' leading-up to the paris conference; from g and g summits, to the rio + conference ( ) and associated green growth/green economy agenda, to china's adoption of its new -year plan, to the launching of climate-related reports (ipcc reports, new climate economy report, unep emissions gap reports…). these communications efforts mobilised a wide range of stakeholders, from climate 'outsiders' active on the margins of the official negotiation process to climate 'insiders' working closely with parties to draft a new treaty (de moor et al. ; newell ) . christiana figueres, unfccc executive secretary at the time, played a key role in these efforts. she provides a fascinating account of her intense lobbying work for a climate agreement in a recent nature commentary. her primary task, she contends, consisted in spreading optimism: i immediately realized that, before we could consider the political, technical and legal parameters of an eventual agreement, i had to dedicate myself to changing the mood: there could be no victory without optimism. i decided to set a clear intention: even if we did not know precisely how, a global deal would emerge, simply because it was necessary. it was that contagious frame of mind that led to effective decision-making, despite the enormous complexities under which we were operating. when the paris agreement was achieved, the optimism that people felt about the future was palpable -but, in fact, optimism had been the primary input. (figueres ) among the groups that actively promoted a new climate narrative were also progressive business interests like the we mean business coalition launched at the nyc climate week (benabou et al. ) . in its first report the climate has changed, the coalition argues that 'the transition to a low-carbon economy is already happening' (we mean business : xiv) and attempts to demonstrate that 'ambitious climate action makes business sense' (ibid.: viii). the transition is depicted as a dynamic, polycentric process where 'bold business action' and ambitious policy-making are mutually reinforcing (ibid.: vii). a follow-up publication shaping a catalytic paris agreement contains a detailed proposal for a new climate treaty (we mean business ) . according to the authors, such an agreement should combine voluntary and binding elements to '[create] an inclusive enabling environment for all stakeholders-including business' and fix an ambitious temperature target to 'send a political signal that long-term decarbonisation is inevitable' (ibid.: ). in other words, its purpose would be largely symbolic. by further substantiating the narrative of an ongoing and unavoidable low-carbon transition, the successful adoption of an 'ambitious' agreement would encourage low-carbon efforts by businesses, investors and citizens. this would in turn generate momentum for more ambitious national policies, thereby setting in motion a self-reinforcing process towards decarbonisation. as former us secretary of state john kerry explains in the rolling stone: if nations are taking it seriously and setting targets, even if they don't make them, that will generate massive investment and a huge amount of private-sector activity […] and then you have to hope that somebody comes up with clean-energy technology, which makes it competitive with fossil fuel, and then, boom, you get your low-carbon economy. in the lead-up, during and on the back of cop , the agreement's core architects set up an elaborate communications campaign whose purpose was to shape a new climate narrative centred on three elements: the low-carbon transition is already underway; it presents unprecedented economic opportunities, and its successful implementation rests on the cooperation of actors from all sections of society. this, it was believed, would generate 'momentum' around the 'paris moment', and more generally the benefits of decisive climate action. for the architects of the paris approach, narratives and signals were not only key to achieving a positive outcome at cop ; they are equally important in the implementation of the paris agreement. for laurence tubiana, the post-paris process '[is] all about momentum.' christiana figueres ( ) urges all stakeholders 'to move firmly into a state of stubborn optimism' and to 'conceive of success and take immediate steps towards it'. following the adoption of the paris agreement and its subsequent ratification and entry into force, a priority for its main proponents was therefore to keep the 'paris prophecy' alive in the hope that this would lead stakeholders to ramp up their levels of ambition in the lead-up to the next global stocktake in . forging the right narrative and controlling the discursive context of global climate governance thereby become key concerns. in the final chapter, 'a new story' from their book, the future we choose, c. figueres and tom rivett-carnac describe this task as follows: right now, the predominant stories we are telling ourselves about the climate crisis are not very inspiring. but a new story can reinvigorate our efforts. when the story changes, everything changes (figueres and rivett-carnac : ) . the purpose of climate summits changes accordingly. in the post-paris period, negotiations increasingly lose their pivotal role. instead of focusing on the arduous and conflict-ridden process of political bargaining, rituals and performances occupy centre stage. 'the ideal cop would send a positive signal(s) to the international community, including investors, regarding the parties' and other stakeholders' direction of travel' writes susan biniaz ( : ) , lead climate lawyer for the u.s. state department from to and another key actor in paris. in a growing number of high-level and highly mediatised climate action summits, the unfccc now takes on the role of 'travelling salesman' for ambitious climate action. cops or climate action summits are essentially about communicating on the urgency of the climate crisis, highlighting the economic and social benefits of climate action and showcasing existing efforts-especially corporate climate action-to address the crisis (aykut et al. ) . hence, while rituals, discourses, theatrical techniques and political performances have always played an important role in global politics more generally, the post-paris climate governance stands out. whereas in other governance arenas their role tends to be understated or played down, in the climate arena, communicative and symbolic elements are explicitly recognised as core instruments in the implementation of the paris agreement. we suggest the term 'incantatory governance' to characterise this new approach. in so doing, we aim to highlight both the iterative, cyclical process created by the paris agreement's review mechanism and the central role of performative narratives and signals in the post-paris setup. as pointed out earlier, our intention is not to dismiss the approach as 'merely' symbolic and therefore ineffective. ethnographic research shows that incantatory rituals can produce real-world effects and fulfil important social functions. claude lévi-strauss, for instance, famously investigated the 'pragmatic effectiveness of symbols' in shamanistic cure (muniesa : ) . the repetitive utterance of words and mobilisation of symbols, he writes, 'provoke[s] an experience', which can produce therapeutic effects (lévi-strauss : ) . an increasing body of research shows that modern institutions also heavily rely on symbols, rituals and narratives: storytelling and drama constitute key features of contemporary management culture (czarniawska ) , while 'fictional expectations' shape the functioning of capitalist systems (beckert ) . accordingly, death ( : - ) criticises what he terms the 'anti-theatrical prejudice' in social science scholarship. 'symbolic aspects of summitry are not sideshops', he contends, 'but essential to the manner in which summits govern the conduct of global politics'. instead of opposing 'symbolic' politics to a hypothetical 'real' politics, we should accept that symbols and narratives form part and parcel of contemporary liberal governmentality (blühdorn ; death ) . the imminent conclusion of the regime building process therefore represents a critical juncture not only for un climate governance, but also for social science research. what are the prospects, risks and caveats of the new approach? as the focus shifts from negotiation to implementation, a new chapter opens for the unfccc and its annual cops. while a thorough assessment of the effectiveness of the new governance approach would be premature, developments since the paris cop point towards two main issues with the new approach. president donald trump's decision in june to withdraw from the paris agreement represented a severe test for the post-paris process. given the historical responsibility and political weight of the usa, the decision weakened the unfccc as the central forum of global climate governance. by sending a very negative signal, the us administration's retreat also threatened to undermine the 'paris prophecy', which, as we have shown, forms a crucial part of the post-paris climate governance framework. to uphold the momentum, it therefore became essential to show that the international community-state and non-state actors alike-was still committed to the goals laid out in the paris agreement, with or without us federal support. in response to trump's decision, the international climate community coordinated a series of high-profile initiatives. notable examples include the #wearestil-lin and america's pledge initiatives. in both cases, the idea was to reaffirm the fact that despite trump's decision, the usa, through the combined efforts of business leaders, university chancellors, mayors and state governors, would fulfil-and even surpass-its paris commitments. in addition to mobilising non-state and sub-state actors, the priority was also to find a new 'climate champion' and saviour of multilateralism to fill in the gap created by the us exit. despite his status as relative newcomer to the climate cause, french president emmanuel macron was rapidly elevated to the rank of 'champion of the earth'. the organisation of a press conference at the elysée palace the day after trump's announcement in june and the hosting of the one planet summit in december were coordinated efforts to retain control of the overall climate narrative and through this, keep the 'paris prophecy' alive. in our view, these and other concerted efforts to 'save' the paris agreement and 'ramp up ambition', by being almost exclusively centred on the production of narratives and signals, pose the risk of further 'virtualising' global climate governance (carrier and west ). moreover, the paris approach's 'performative' dimension complicates the task of publicly recognising that targets-such as the . °c target-are out of reach (geden a) . faced with the need to uphold a positive storyline, stakeholders of global climate governance are incentivised to 'move the goal posts' through 'creative accounting' or unproven techno-fixes, as exemplified by the massive amounts of 'negative emission technologies' included in global decarbonisation scenarios (anderson ; geden b) . by doing so, they risk delaying the necessary acknowledgement that current modes of development are inherently unsustainable. in other words, there is a real danger of deepening the rift between an 'international community' seemingly committed to ambitious climate action and the reality of 'business as usual' in a rapidly warming world. this discrepancy is not unique to the current period. the last decades saw a growing disconnect, or 'schism' (aykut and dahan ; aykut ) , between, on the one hand, a slow and procedural un arena focused on negotiating carbon emission reductions, and on the other hand, a staggering acceleration of a series of phenomena that are at the heart of the climate crisis but outside of climate governance's remit. chief among these are the dynamics of economic and financial globalisation, the expansion of extractivist development models and the global spread of western consumerist lifestyles. indeed, 'climate policy' is an inherently crosscutting policy domain. it touches on a range of very different issues, from development and energy policy, to trade and financial regulation, as well as agriculture and urban planning. yet, the governance of these issues follows very different logics. the voluntary and soft-law approach to climate governance contrasts with the situation in other issue areas. some of these are regulated through 'hard law', enforced by international organisations, while others are exempt from global regulation, and governed instead through global market dynamics and power relations (kingsbury ) . each governance arrangement draws on specific tools and mechanisms to exert influence on relevant actors and practices. the shift in global climate governance brought about through the paris agreement has exacerbated these differences. indeed, while it is very ambitious in terms of its global temperature targets, the paris agreement is evasive when it comes to spelling out the changes that will be required to attain them. there is no mention, for instance, of phasing out fossil fuels or 'decarbonising' the global economy, nor, for that matter, of encouraging renewables or energy efficiency. another important issue that is completely absent from the text is international trade regulation (brandi et al. ) . this links back to the 'fragmentation' of global governance, whereby the management of a problem falls upon diverse international organisations with potentially contradictory objectives (biermann et al. ). these fragmentations owe nothing to chance but are rather the product of structural 'selectivities' that are rooted in the global order and protected by powerful interests (brunnengräber ) . saudi arabia and other fossil fuel interests, for instance, actively worked to prevent any discussion on energy questions within the climate convention, so as to thwart any international regulation in that domain (aykut and castro ; depledge ) . the same applies to trade, whose absence from the climate negotiations is due to the active efforts of a coalition of industrialised and emerging economies (luterbacher and norrlöf ) . it is worth noting, however, that the similarities between the two cases stop there. unlike energy, international trade is regulated through a fairly robust international organisation, the world trade organisation (wto) and a number of legally binding bilateral treaties (mattli and woods ). from 'non-governed' issues where the strongest get their way (such as energy), to issues that are regulated through legally binding treaties (such as trade), to those managed through soft law (such as human rights and most environmental issues), we are in the midst of an increasingly complex global governance landscape. this landscape is not set in stone but is the product of political strategies and historical struggles that continue to act as barriers to an effective management of the climate crisis. the multi-dimensional nature of the problem calls for an in-depth rethinking of the established global order, beginning with the existing division of labour and hierarchy between international organisations, and the regulatory void when it comes to strategic domains such as fossil fuel production and trade. scholars of international relations generally agree that a central feature of international regimes is that actors' expectations converge in a given area of international relations (krasner ) . while it has generally been thought that such convergence is best reached through binding regulations and the building of strong international organisations, this no longer holds for paris-type governance arrangements. a growing body of scholarship therefore examines the paris shift and considers its consequences. in this article, we argued for the need to broaden the perspective adopted in this literature along two broad lines. we first suggested to re-embed the voluntary turn in climate governance within broader transformations in the ways that global problems are governed. in the course of these transformations, neo-managerial tools and techniques are increasingly adopted by international organisations. second, we argued that the new climate governance is not only characterised by institutional innovations. it also builds on narratives and signals as central means of implementation, by aligning actors' expectations and coordinating their behaviour towards a low-carbon future. based on these observations, we suggest the term incantatory governance to characterise the paris framework. the term highlights the iterative nature of the new 'bottom-up' and voluntary governance process. it also points to the increasing prominence of communicative devices and marketing techniques in global climate governance. our analysis suggests that both of these evolutionsthe rise of 'soft law' approaches and the widespread deployment of communicative techniques-reflect a much broader process: the entry of management culture, techniques and actors into global environmental governance. having said this, we consider the analyses laid out in this article as no more than a starting point. we hope that they will inspire further research on the discursive and performative dimensions of the new climate governance, but also beyond. indeed, given the climate arena's central position in global politics, one can expect other governance spaces to draw inspiration from it. this makes it all the more important to scrutinise the mechanisms of post-paris climate governance, evaluate their effectiveness, signal potential drawbacks and understand the governance shift's wider implications. one final observation should be made relating to the challenges facing those who express more fundamental reservations about the brave new world of 'performative' or, as we have termed it, 'incantatory' governance. critical perspectives are important in order to both problematise the selective and fractioned geographies of global regulation and highlight the shortcomings of a climate governance architecture that brushes aside issues that are key to solving the problem. and yet, there is little room for radical or fundamental critique under the current climate governance since such critique risks undermining the 'paris prophecy' by sending negative 'signals'. how then can we avoid both complacent self-censorship and a sterile, and potentially destructive, critical stance? we can perhaps begin by recognising that in a fractured and divided world, and in the face of multiple and interrelated crises, the paris agreement provides a snapshot of what can presently be expected from the un system and the unfccc process. it therefore goes without saying that the climate problem cannot be solved within the un system alone and that the paris agreement only forms one piece of a much larger puzzle. solving this puzzle will require actions at multiple levels and in a wide range of arenas. while this includes businesses, it also encompasses states and regulations, other international organisations, as well as collective mobilisations and social movements, which appear as key to shifting current power relations in favour of transformative change. it will also involve long and arduous efforts to re-politicise the climate debate and show the connections between climate change and other important issues that have traditionally been ignored in, or excluded from global climate governance. with their own rituals, heroes and discourses, recent and innovative climate protests, from 'fridays for future' to extinction rebellion, can be interpreted as attempts to do just that. our concluding remark is inspired by the current situation of global confinement and lockdown in the struggle against the covid- virus. in many countries, and especially of the global north, the measures imposed by governments to address this global health crisis are unprecedented since world war ii. the command-and-control approach combining quarantines, curfews and emergency laws stands at the antipodes of the managerial and 'incantatory' governance approach that we just analysed. it is too soon to say how this crisis and its political and economic consequences will affect the prospects of global decarbonisation. however, the contrast between these two governance models-one centred on transnational coordination through signals and narratives, the other on commandand-control and the sovereign power of nation-states-is striking. it could well be, therefore, that the covid- experience deeply affects and transforms, yet again, 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makes good business sense the business brief. shaping a catalytic paris agreement make law, not war: internationale und transnationale verrechtlichung als baustein für global governance two's company and more's a crowd. the complexities of multilateral negotiation the conundrum of corporate social responsibility: reflections on the changing nature of firms and states key: cord- -vtids ns authors: laxminarayan, ramanan title: trans-boundary commons in infectious diseases date: - - journal: nan doi: . /oxrep/grv sha: doc_id: cord_uid: vtids ns emerging threats to global health, including drug-resistant pathogens, emerging pandemics, and outbreaks, represent global trans-boundary commons problems where the actions of individual countries have consequences for other countries. here, we review what economic analysis can offer in countering these problems through the design of interventions that modify the behaviour of institutions and nations in the direction of greatest global good. the past century has been marked by significant improvements in life expectancy, due to greater child survival and reductions in infectious disease. the greatest victories in global health have come through globally coordinated actions-the eradication of small pox in , the global polio eradication initiative (still ongoing), and the sharp reductions in malaria through the global malaria eradication program (gmep) in the s. just the first two of these initiatives resulted in roughly . m deaths averted each year (unicef, ; ehreth, ) , and the gmep was responsible for eliminating malaria in countries (kouznetsov, ) . largely as a consequence of these efforts and of improvements in wellbeing that have translated into better ability to prevent and treat infectious diseases, these conditions have diminished in importance as a source of ill health across much of the world. according to the global burden of disease estimates, the percentage of disability-adjusted life years (dalys) due to prominent infectious diseases (comprised of the following four cause groups: hiv/aids and tuberculosis; diarrhoea/lower respiratory infections/other infectious diseases; neglected tropical diseases and malaria; and other communicable diseases) decreased from . per cent in to . per cent in , while the percentage of deaths due to prominent infectious diseases decreased from to . per cent (ihme ) . nevertheless, infectious diseases continue to be a significant source of ill health globally and a number of the world's emerging global health threats involve infectious diseases that can easily cross boundaries. the emergence of a new infectious disease-ebola being the most recent example-poses a significant risk to other countries, no matter where it arises. the risk is not uniform: countries that are connected by geography or population movement with the country where the disease emerges, and those with weak health systems are particularly vulnerable. but there are counter-examples as well. new delhi metallo-β-lactamase (ndm) enzymes that cause drug resistance in bacteria, which were first reported in from one patient hospitalized in sweden, are now reported globally (nordmann et al., ) . multiple factors including human population growth, land-use changes, and infectious diseases originating from wildlife (also known as zoonoses) are accelerating the frequency with which infectious diseases emerge (jones et al., ) . even if the direct health toll from these emerging infections does not approach the levels that were observed during the global flu pandemic, when nearly m people died, these infections can nevertheless do serious damage to economies, health, and health systems by virtue of their speed of attack. ebola has killed roughly , people in the last year, mostly focused in the west african countries of guinea, liberia, and sierra leone, and resulted in a per cent loss of gdp in these countries (world bank, ) . a recent study projected that after - months of disruptions, the accumulation of a large connected cluster of children unvaccinated for measles across guinea, liberia, and sierra leone resulted in between , and , additional child deaths due to measles alone (takahashi et al., ) . the deaths of healthcare personnel may have ripple effects down the road and could even discourage people seeking to train to be tomorrow's healthcare workers. the overall damage to health systems due to the large numbers of health system professionals lost to ebola will only become apparent in coming years. drug resistance is now a global problem and threatens public health in nations regardless of economic status (laxminarayan et al., ) . antibiotic-resistant gonorrhoea emerged in vietnam in (holmes et al., ) , before spreading to the philippines and finally to the united states (rasnake et al., ) . ndm enzymes are now in nearly every country, as discussed earlier. in this paper, we discuss the global health threats that involve 'commons' problems. with such problems, the actions undertaken in one country have consequences for other countries, but these are 'externalities' that are not taken into consideration by decisionmakers. for instance, a country may not report a disease outbreak for fear that it would discourage tourism, but the failure to report the outbreak could put other countries at risk. other examples of country-level actions with global consequences include inadequate vaccination coverage; slow progress on disease elimination; failure to report and contain pandemic flu, antibiotic resistance, and counterfeit drugs; and climate-related health threats. we provide some examples and case studies of such negative externalities across borders. then, we discuss the need for international cooperation for tackling these global health threats. the remainder of the paper is organized as follows. section ii describes trans-boundary externalities in tackling infectious diseases. section iii deals with incentives for surveillance and reporting of disease outbreaks. section iv addresses incentives for disease elimination and eradication. section v addresses incentives and financing mechanisms for controlling drug-resistant pathogens. section vi concludes the paper. early examples of international medical cooperation in the modern age were based on the idea that because infectious diseases do not respect national boundaries, meaningful control necessarily transcends national programmes. the first international sanitary conference was convened in paris in to discuss the quarantine of ships to contain plague, yellow fever, and cholera; it predated the first geneva conventions on treatment of war casualties by years (stern and markel, ) . more recently, campaigns to eliminate smallpox and eradicate malaria have been built on the idea that infectious disease control depends not just on national priorities but also on the priorities of one's neighbours and trading partners. an understanding of transnational disease transmission was deeply rooted in the gmep, which was launched in . funding from the top contributors to the special account for malaria by member countries during - accounted for per cent of overall contributions over this period (table ) . of these contributors, only saudi arabia had any significant malaria. malariacontrol investments in the current era are also likely to be largely externally funded, but contributions are not likely to continue indefinitely. therefore, the gains made from control have to be sufficiently large not just in the focal country but also in neighbouring countries so that malaria control will continue to be a priority for national planners even after the donors have exited. malaria control benefits the country in which it occurs, of course, but in the longer term, its neighbours benefit as well because they face fewer cases of imported malaria. the spatial coordination problems introduced by trans-boundary malaria are also relevant for the problem of regional elimination within large countries, especially those with frequent in-country movement, such as india. in contrast, china has managed to eliminate malaria from most of the interior of the country, but imported malaria remains a problem on its southern border. the extent of the 'external' benefit (to a neighbour) depends on malaria prevalence in that neighbour and the frequency and direction of overland migration. if malaria is common, then the benefit of fewer imported cases is minimal. however, the benefits can be large if the neighbour has eliminated malaria but still has to deal with cases imported from the focal country. barrett describes four equilibria in interactions between two countries that share an infectious disease (barrett, ) . in the first equilibrium, neither country engages in control, irrespective of what the other country does. in the second, each country eliminates the disease, irrespective of what its neighbour decides to do. in the third, each country eliminates the disease only if the other can be relied upon to do so. in the fourth, one country does not eliminate the disease, irrespective of what the other does. when countries are not identical in either epidemiological conditions or economic prosperity, it may be in the interest of some countries to eliminate malaria but for others not to, even if all others have eliminated malaria. yet elimination may be the optimal outcome for the two countries as whole. this is the case in which richer adjacent countries have financed elimination in poorer countries, as we observe in the lubombo spatial development initiative (lsdi). lubombo spatial development initiative lsdi offers a recent example of trans-boundary control of infectious disease (sharp et al., ) . malaria control was seen as an essential element of economic development in the lubombo region of eastern swaziland, southern mozambique (maputo), and north-eastern kwazulu natal province in south africa. malaria prevalence in these three regions was closely intertwined because of the frequent migration of people (sharp and le sueur, ) . most malaria cases in swaziland and kwazulu natal were imported from mozambique: for instance, nearly per cent of the malaria cases in kwazulu were in the district adjoining mozambique. between november and february , indoor residual spraying with bendiocarb insecticide was carried out twice a year in mozambique. spraying started in zone ( figure ) and proceeded incrementally, eventually covering seven districts and a population of roughly , people. in swaziland, where there were no other changes in malaria control efforts over the same time period, new malaria cases declined by per cent (table ). malaria cases declined by per cent in mpumalanga province, probably because during this period, indoor residual spraying and artemisinin-combination treatment were introduced on the south africa side of the border. nevertheless, the sharp decline in malaria in swaziland and south africa was attributable at least in part to efforts in mozambique, which were largely paid for by south africa and, to a lesser extent, by the global fund to fight aids, tuberculosis and malaria. west african river blindness programme coordinated financing, specifically with reference to multi-lateral financing to more than one country, is essential to permit a coordinated approach to disease control. however, such coordination has rarely been accomplished outside of global disease eradication programmes. there are a few examples of regionally coordinated financing such as against river blindness. the onchocerciasis control programme (ocp), which was launched in , covered major portions of seven western african countries (burkina faso, benin, ghana, côte d'ivoire, mali, niger, and togo). because the initial set of countries did not cover the limits of the breeding sites of the main vector, the savannah blackfly, the programme was expanded in to also include guinea, guinea-bissau, senegal, and sierra leone. a rare example of a transnational disease control effort launched by the world bank (kim and benton, ) , ocp relied on regionally coordinated larvicide spraying along the niger river to control black fly populations, and, at its peak, the programme covered m people in countries. this coordinated funding was in recognition of the fact that controlling black fly populations in a single country would be infeasible and required the cooperation of all seven countries on the niger river. through the mectizan donation programme, which was initiated in , onchocerciasis was eliminated as a public health problem in west africa. over the period - , the programme prevented , cases of blindness, and brought about m hectares of arable land-enough to feed an additional m people a year-back into productive use. the earliest efforts in global cooperation in the context of sanitary conventions, which required countries to report cholera outbreaks, subsequently led to the establishment of the pan american health organization, a pre-cursor to the world health organization (who) in the twentieth century. despite the benefits of warnings and reports on infectious disease outbreaks, there are few incentives for countries to report disease outbreaks that occur within their borders. current international health regulations, which were first enacted in and most recently revised in , require countries to report disease outbreaks. however, as there are no penalties for non-reporting, reporting depends on the goodwill of nations (baker and fidler, ) . this may not be entirely true since 'the consequences of non-compliance may include a tarnished international image, increased morbidity/mortality of affected populations, unilateral travel and trade restrictions, economic and social disruption and public outrage' (who, ) . specifically, if countries do not report promptly, other countries may take actions to moderate their trade and travel relations with the target country for fear that a future outbreak may also not be reported. we have discussed this in detail below as ex ante sanctions that precede an actual future outbreak. from a practical standpoint, countries face conflicting incentives as to whether or not to report an outbreak. on the one hand, reporting brings the near certainty of trade sanctions that can impose large costs. for example, when peru reported an outbreak of cholera in , its south american neighbours imposed an immediate ban on peruvian food products. the $ m cost of these sanctions and the additional $ m lost from reduced tourist activity far exceeded the domestic health and productivity costs of the epidemic (panisset, ) . on the other hand, countries may report an outbreak in the belief that the information will be reported anyway through the media or informal channels. furthermore, reporting an outbreak may result in international assistance for containing the outbreak. for instance, in the same peruvian outbreak, foreign aid in the form of rehydration salts, saline solution, and antibiotics, while unable to prevent an epidemic, helped to significantly reduce the death rate (brooke, ; suárez and bradford, ) . the appearance of new infections is determined by a number of factors, but generally is mediated by large growing populations that have poor nutrition and lack access to medical care (woolhouse and gowtage-sequeria, ) . however, despite the regular appearance of novel infections (woolhouse et al., ) , few infections are able to spread effectively within a population. over the last century, although more than diseases are believed to have emerged, only five novel diseases have swept across the globe-three were novel strains of influenza, another was hiv/aids, and more recently we saw the spread of sars, which emerged in china in november and spread around the world infecting more than , people in countries and killing approximately before it was contained (zhong et al., ) . further delays in reporting sars by china could have resulted in catastrophic consequences worldwide if the pathogen had been more virulent (heymann and rodier, ) . there is evidence that countries respond to external incentives on whether or not they report infectious disease outbreaks. an outbreak of meningococcal meningitis during the hajj resulted in more vaccination requirements for travellers coming to saudi arabia (laxminarayan et al., ) . these requirements, which were introduced in , were associated with reduced reporting of meningitis outbreaks among countries in sub-saharan africa, especially among countries with relatively few cases reported between and . the announcement of a programme in to assist countries with immediate vaccines conditional on their reporting of outbreaks was associated with an increase in reporting among countries that had previously not reported meningitis outbreaks (laxminarayan et al., ) . incentives for surveillance and reporting lie at the heart of an effective strategy to respond to avian influenza . mathematical models have suggested that it may be possible to contain an emerging pandemic of avian influenza if detection and reporting of cases suggestive of increased human transmission occurs within approximately weeks of the initial case (ferguson et al., ; longini et al., ) . while the who is responsible for coordinating the global response to human cases of avian influenza, decisions on establishing surveillance networks and reporting of outbreaks are the province of national governments. incentives to report an outbreak once it has been detected are only one part of the story, since an outbreak must first be detected. incentives to invest in surveillance to detect an outbreak are likely to be endogenous, and depend on whether or not a country wishes to report an outbreak (malani and laxminarayan, ) . these incentives are driven in part by the 'private' value of early detection to the individual country, but also by the likely consequences of the availability of this information to the rest of the world, either through the act of formal reporting or by informal channels, such as news reports or rumours. the greater the anticipated sanctions, the less likely a country will be to invest in surveillance. conversely, the higher the perceived benefit of international assistance in preventing or ameliorating the cost of an outbreak, the greater the likely investment in surveillance. current international mechanisms to encourage better reporting of disease have, by and large, ignored the economic dilemma and strategic behaviour of countries with emergent outbreaks. investments in surveillance also depend on the likelihood that the detected outbreak will produce a significant epidemic. the more a country believes a disease will arise and spread, the more significant the incentive to invest in surveillance. however, this investment can be tempered by the likelihood of false positives-the detection of a disease when none exists (malani and laxminarayan, ) . thus, a trade-off exists between investing in increased surveillance and investing in more accurate surveillance. a government's decision to report an outbreak can be modelled as a signalling game in which a country has private but imperfect evidence of an outbreak (malani and laxminarayan, ). an important conclusion is that not all kinds of sanctions may discourage reporting. what does this mean? let us divide sanctions into two kinds. ex ante sanctions are imposed in the form of reduced trade and travel contact with countries that are perceived to be poor at reporting disease outbreaks promptly. it is for this reason that west africa is not a favoured tourist destination-even in the absence of ebola, one is never quite sure if the system is able to detect and report this and other diseases. in contrast, an ex post sanction is imposed following a disease outbreak. ex post sanctions discourage detection and reporting since they kick in only after an outbreak has been announced. however, ex ante sanctions do not deter reporting and if anything they encourage reporting so that countries can signal that they are on top of their disease surveillance programmes. furthermore, ex ante sanctions based on fears of an undetected outbreak can reduce reliance on ex post sanctions as ways of controlling outbreaks. second, improving the quality of surveillance networks to detect outbreaks may not promote the disclosure of an outbreak because the forgone trade from reporting truthfully is that much greater. in sum, obtaining accurate information about potential epidemics is as much about incentives for reporting as it is about the capability and accuracy of surveillance networks. solving trans-boundary disease problems requires coordinated financing solutions, as has been evident with global eradication programmes. eradication of a disease means that it is no longer prevalent in any country in the world and requires elimination in every country. elimination, however, requires only the absence of the disease from a single country. global small pox eradication was largely paid for by the united states, even though countries like india stood to gain from the reduction in the number of deaths but were unable to achieve elimination on their own. however, the united states continues to recoup its roughly $ m investment in small pox eradication every days through not having to vaccinate its citizens against the disease. the optimal coverage with a vaccination programme of a disease that can be eradicated is given by p c = /( −r ) where r is the reproductive number of the disease-the number of secondary infections generated by a single infected patient entering a completely susceptible population. note that this critical rate of vaccination coverage depends only on the reproductive number (an epidemiological variable) and not on the costs of vaccination averted or any other economic variables. eradication may not be optimal in the case of all diseases, however. for diseases like measles, where the pathogen can be easily engineered through artificial methods and re-introduced into the population, there is no option of stopping vaccination. indeed, the current cohort of immunized individuals represents a valuable stock that is not easily replaceable in the short term. the optimal level of vaccination coverage of a disease for which vaccination must continue even after the disease has been eliminated can be computed as below. total costs to society include the costs of the vaccination campaign (vaccination costs), which we assume to increase exponentially with coverage, and costs of infection (infection costs) that we use as an index of the severity of the disease. the assumption that costs are increasing exponentially with coverage is consistent with the idea that reaching the most difficult to access and geographically remote populations involves increasing marginal costs. the total infection costs are proportional to the total number of the infective individuals in the population. because there is little evidence for increasing or decreasing marginal costs of infection within a single population (the change in total costs that arises from having one additional infection in the population), we assume constant marginal cost and model the costs of infection as a linear function of the infected. the total cost of the vaccination plus infection is then, with per capita burden c i . the cost of coverage is c(p) = ae xp , where a is the cost of vaccinating the first child (the cost of setting up the programme), and x captures the increase in costs with the increasing coverage p. when there is no immigration, we can calculate the economic optimum by minimizing eq. to find the level of coverage that minimizes total costs, which is independent of transmission. if the economic optimum p i is above the critical elimination threshold, p c = − /  , the optimal strategy is to eliminate the infection locally: (details in appendix in klepac et al. ( ) ). local elimination can be optimal also in the case of very severe diseases. in fact, for large enough per capita burden c i , i.e. the economic optimum p i is always above p c , and optimal vaccination coverage p* is reduced to the critical elimination threshold determined by  (eq. ). the optimal level of vaccination coverage for a disease that cannot be eradicated is a function of only economic parameters. indeed, epidemiological parameters play no role at all. local elimination is optimal only for low  values that result in a critical elimination threshold p c that is smaller than p i . moreover, adding immigration of infection to a single population precludes elimination by local vaccination alone. drug resistance is a global commons problem and covers the full range of infectious disease-causing pathogens from viruses, bacteria, fungi, and parasites through to disease vectors including mosquitoes, blackflies, and sandflies. resistance can arise in any single country and move globally. in this section, we focus on bacterial resistance and parasite resistance in the context of malaria. the global burden of resistance is poorly quantified but is likely to be concentrated in three major categories: increasing costs of resistant infections, increasing costs of antibiotics, and inability to perform procedures that rely on effective antibiotics to prevent infection. a primary burden of resistance is that resistant infections are more expensive to treat, and patients infected with resistant strains of bacteria are more likely to require longer hospitalization and face higher treatment costs than patients infected with drug susceptible strains (holmberg et al., ; the genesis report, ). an estimated , people die each year in europe from antibiotic-resistant bacteria (ecdc/emea joint technical report, ). in the united states in , an estimated , invasive methicillin-resistant staphylococcus aureus, or mrsa, infections required hospitalization and were associated with , deaths (klevens et al., ) . these estimates are useful for indicating the order of magnitude, but are imprecise because resistant infections are more common in individuals on long courses of antibiotic treatment: it is difficult to ascertain whether resistance is the cause of death or a correlate of long antibiotic treatment, hospitalization, and underlying sickness. in low-and middle-income countries, where the ability to pay for second-line drugs is limited, worse health outcomes are common, particularly in newborn children. even with effective antibiotics, neonatal infections are the major cause of neonatal deaths, which in turn account for more than a third of the global burden of child mortality (zaidi et al., ) . over half of neonates with extended spectrum beta-lactamase (esbl) sepsis are likely to die (versus a quarter of neonates with non-esbl infections), and a half of neonates with mrsa die (versus per cent of neonates with methicillinsensitive staphylococcus aureus) (kayange et al., ) . at these rates of mortality, one can estimate roughly , neonatal deaths attributable to gram-negative organisms and s. aureus, and , neonatal deaths attributable to esbl resistance and mrsa in india alone. a further cost of resistance is that associated with the cost of introducing new, expensive, antimicrobials to replace old ineffective ones (office of technology assessment, ) . this represents forgone resources that society could deploy elsewhere (reed et al., ) . according to one estimate, between and , increases in drug resistance raised the cost of treating ear infections by about per cent in the united states ($ m) (howard and rask, ) . resistance can also render broader health system functions such as surgeries, transplantations, and chemotherapy ineffective (laxminarayan et al., ) . a recent study estimated that, without effective antibiotics, - per cent of patients undergoing total hip replacements would have a postoperative infection, with a case-fatality rate of roughly per cent (smith and coast, ) . this category of burden affects both low-and middle-income as well as highincome countries and is likely to be the predominant way in which resistance drives up health care costs. take the case of drugs to treat malaria. the use of antimalarials places selection pressure on parasites to evolve resistance to these drugs. moreover, resistance is bound to arise when these drugs are misused, and could have adverse consequences for all malaria-endemic countries. efforts to manage resistance across national borders would have to rely on international agreements and regulations (walker et al., ) or on tax or subsidy instruments (arrow et al., ) . in the absence of such agreements and regulation, countries are unable to commit themselves to an optimal use of antibiotics, which would be in all countries' interests. at the macroeconomic level, a too intensive use of antibiotics in the health sector results in excessive levels of resistance both for that country and to the rest of the world (cornes et al., ) . a supranational authority would have to consider both the externality benefits of antibiotic use, in terms of reducing infections, and the costs, in terms of resistance (rudholm, ) . whether antibiotic consumption should be taxed or subsidized to reach the first-best outcome then depends on the relative magnitude of the externalities. in practice, the consequences of antibiotic use in sectors such as to make livestock grow faster involve little by way of positive externalities but impose resistance costs on other sectors and should therefore be taxed. a new class of antimalarial drugs, called artemisinins, requires a different way of thinking about optimal subsidies to manage resistance. when chloroquine, a oncepowerful antimalarial drug, became obsolete, the public health world was left with the challenge of optimally deploying the last remaining effective drug class, artemisinins. the who has recommended that artemisinins be used in combination with a partner drug that is unrelated to artemisinin's mechanism of action and genetic bases of resistance, so that a single mutation cannot encode resistance to both components (who, ) . artemisinin combination treatments (acts), if used instead of monotherapies of either artemisinin or the partner drug on its own, should slow the emergence of antimalarial resistance. however, the who guidelines are routinely flouted because monotherapies are much less expensive than acts. in response to this problem, an institute of medicine report (arrow et al., ) recommended establishing an international fund to buy acts at producer cost and resell them at a small fraction of that cost. on economic efficiency grounds there is a second-best case for subsidizing acts, because the ideal policy-taxing monotherapies and other antimalarials according to the marginal external cost from the elevated risk of the evolution of resistance-is infeasible, given their widespread use in the informal sector. the efficiency argument is further strengthened by the positive externality, to the extent that effective treatment of one individual reduces the risk of infection transmission to other individuals. laxminarayan et al. ( ) show that it is possible to determine the optimal subsidy in a dynamic diseasemodelling framework. bioeconomic analysis has been helpful for determining whether the social benefit from the subsidy, in terms of delayed resistance and saved lives, exceeds the social cost of resistance because of increased use of acts (laxminarayan et al., ) . it was also instrumental in turning an idea into the affordable medicines facility for malaria (amfm), a global financing system launched in early . amfm was formally evaluated in . in the six pilots where the programme was implemented to a substantial degree, amfm met or exceeded benchmarks for availability, price, and market share of quality-assured acts. in private, for-profit pharmacies, the quality-assured act market share at baseline ranged from to per cent (tougher et al., ) . a drawback of this evaluation was that it did not attempt to measure the impact on malaria prevalence or artemisinin resistance, both of which would have been difficult to ascribe to the intervention in the timeframe of the evaluation. nevertheless, the global fund to fight aids, tuberculosis and malaria made a political decision to discontinue amfm based on political objections raised by some country delegations (arrow et al., ) . one way to improve the efficiency of amfm resources was possibly to target children, though it would avert significantly fewer deaths. however, the benefits of a child-targeted subsidy (i.e. deaths averted) are eroded as leakage increases (i.e. older individuals taking young child-targeted doses), with few of the benefits (i.e. reductions in overall prevalence) of a universal subsidy (klein et al., ) . although potentially more cost-effective, a child-targeted subsidy must contain measures to reduce the possibility of leakage. most global health problems are 'commons problems'. therefore, it is often essential to have cooperative financing mechanisms for global health interventions, whether to eradicate disease, encourage appropriate levels of disease surveillance and reporting, or to reduce the likelihood of drug resistance. innovative financing that takes into account cross-country spillovers can play a critical role in arriving at globally optimal outcomes. for instance, in the case of the amfm subsidy, a high-level financing mechanism that lowers the cost of quality acts to all countries, including those that were at highest risk of using monotherapies, both enabled access to effective treatment and also reduced the threat of resistance. no bilateral financing solution could have achieved the same impact because of potential leakage to other countries, as discussed earlier. a global mechanism that is able to provide resources that incentivize surveillance and reporting of disease outbreaks can successfully counter the disincentives faced by countries for prompt reporting. again, bilateral assistance that simply focuses on subsidizing surveillance but does not pay attention to the lack of incentives for reporting cannot solve the problem. the three exemplars of trans-boundary problems that we have discussed can be applied to other global health problems with a public goods nature. saving lives, buying time: economics of malaria drugs in an age of resistance, board on global health the affordable medicines facility-malaria: killing it slowly global public health surveillance under new international health regulations the smallpox eradication game peru's neighbors halt food imports', the new york times drugs and pests: intertemporal production externalities the bacterial challenge: time to react the global value of vaccination strategies for containing an emerging influenza pandemic in southeast asia the recent history of malaria control and eradication global surveillance, national surveillance, and sars health and economic impacts of antimicrobial resistance studies of venereal disease. i. probenecidprocaine penicillin g combination and tetracycline hydrochloride in the treatment of "penicillinresistant the impact of resistance on antibiotic demand in patients with ear infections gbd cause patterns global trends in emerging infectious diseases predictors of positive blood culture and deaths among neonates with suspected neonatal sepsis in a tertiary hospital cost-benefit analysis of the onchocerciasis control program (ocp)', world bank technical paper cost-effectiveness analysis of childtargeted subsidies for artemisinin combination therapies using a bioeconomic malaria model invasive methicillin-resistant staphylococcus aureus infections in the united states malaria control by application of indoor spraying of residual insecticides in tropical africa and its impact on community health will a global subsidy of new antimalarials delay the emergence of resistance and save lives? extending the cure: policy responses to the growing threat of antibiotic resistance should new antimalarial drugs be subsidized? antibiotic resistance-the need for global solutions containing pandemic influenza at the source incentives for surveillance and reporting of infectious disease outbreaks operational strategies to achieve and maintain malaria elimination global spread of carbapenemase-producing enterobacteriaceae impact of antibiotic-resistant bacteria: a report to the us congress international health statecraft: foreign policy and public health in peru's cholera epidemic history of us military contributions to the study of sexually transmitted diseases socioeconomic issues related to antibiotic use economic implications of antibiotic resistance in a global economy malaria in south africa--the past, the present and selected implications for the future seven years of regional malaria control collaboration the true cost of antimicrobial resistance the economic impact of the cholera epidemic in peru: an application of the cost of illness methodology', water and sanitation for health project reduced vaccination and the risk of measles and other childhood infections post-ebola the real war on drugs: bacteria are winning effect of the affordable medicines facility-malaria (amfm) on the availability, price, and market share of quality-assured artemisinin-based combination therapies in seven countries: a before-and-after analysis of outlet survey data vaccines bring diseases under control', unicef, the progress of nations frequently asked questions about the international health regulations host range and emerging and reemerging pathogens temporal trends in the discovery of human viruses the economic impact of ebola on sub-saharan africa: updated estimates for hospital-acquired neonatal infections in developing countries epidemiology and cause of severe acute respiratory syndrome (sars) in guangdong, people's republic of china key: cord- - ddala r authors: pastukhova, maria; westphal, kirsten title: governing the global energy transformation date: - - journal: the geopolitics of the global energy transition doi: . / - - - - _ sha: doc_id: cord_uid: ddala r an effective and efficient governance is key for the global energy transformation. we argue that the process under the paris agreement, its ‘rulebook’ and the nationally determined contributions (ndcs) will have to be accompanied by focused and tailored governance mechanisms in the energy realm. the energy sector itself is key to limiting global warming to two degrees centigrade compared to the preindustrial level, because it is responsible for over two-thirds of global greenhouse gas emissions. yet, neither the energy transition nor energy governance start from scratch. energy governance is already happening on many levels: the local, the national, the regional and the global. these multi-level governance structures are necessary to enable, facilitate, and accelerate the energy transition(s) on the ground. they have to be adapted, however, to the changing and transforming energy world as we argue in the conclusions. in a first step, we conceptualize the notion of ‘energy transition’ and relate it to the concept of ‘energy transformation’. we argue that it is necessary to firstly move beyond the normative and target-driven idea(s) behind ‘transition’ and to secondly bring in the systemic aspects of energy transformation. moreover, energy security, economic efficiency, sustainability and climate neutrality have emerged over time as the guiding paradigms, forming a strategic quadrangle, as opposed to a strategic triangle, traditionally used to define energy security. in a second step, we present an overview of the current international energy governance system where multilayered governance structures have developed over time. we argue that the existing architecture is stemming from the past and is neither fit for governing the energy transition, nor even reflecting the proccesses underway in todays’ world. in a third step, we highlight that the energy transformation has and will have tremendous techno-economic, socio-technical and political (cherp et al. ) effects that have both internal and external dimensions. moreover, the transformation comes with (geo)political effects as it changes the political economy of energy on all levels: the global, the regional, the national and the local. in the final step, we look at ways forward. we argue that it is necessary to preserve existing multilateral institutions and to strengthen them. moreover, we assume that governance approaches towards and inside regions will have to be re-shaped or even created from scratch. we conclude that the crumbling of the global liberal order and the crises of multilateralism are complicating the approach to a better governance of the energy transition on the global level. moreover, we witness the emergence of illiberal tendencies in the western democracies as well. climate and energy are playing into the polarization of societies as the two topics emerged as a major cleavage and a conflict line. we emphasize that a just and inclusive energy transition, both on national and international levels, is necessary to keep countries and the world on a sustainable energy transformation path. the challenge faced by the planet is indeed systemic. national and the local. in the final step, we look at ways forward. we argue that it is necessary to preserve existing multilateral institutions and to strengthen them. moreover, we assume that governance approaches towards and inside regions will have to be re-shaped or even created from scratch. we conclude that the crumbling of the global liberal order and the crises of multilateralism are complicating the approach to a better governance of the energy transition on the global level. moreover, we witness the emergence of illiberal tendencies in the western democracies as well. climate and energy are playing into the polarization of societies as the two topics emerged as a major cleavage and a conflict line. we emphasize that a just and inclusive energy transition, both on national and international levels, is necessary to keep countries and the world on a sustainable energy transformation path. the challenge faced by the planet is indeed systemic. if governance of the energy transition is to be exercised effectively and efficiently, a common understanding of 'energy transition' seems to be helpful and necessary. nowadays, 'energy transition' is a concept widely accepted and operationalized by national governments, regional and international bodies and non-governmental organizations alike. although the term "energiewende" has been first introduced in the early s by the german Ökoinstitut (krause ) , it hasn't found its way into the vocabulary of policymaking until the twenty-first century. yet, when germany published the "energy concept for environmentally sound, reliable and affordable energy supply" (bmwi and bmu ), which was readapted after the nuclear accident in fukushima by the energy concept and the related package on the "energiewende", its english pendant 'energy transition' has become the international buzzword for a shift towards cleaner and more sustainable energy systems. as omnipresent and relevant the term 'energy transition' might be nowadays, it is remarkably difficult to grasp, not least because of the lacking conceptual clarity and uniformity. the lack of both a comprehensive definition and a theoretical framework to support the concept of energy transition is not only lamentable from a scientific point of view: the resulting lack of common understanding among (inter)national actors also incapacitates the development of functioning international governance mechanisms to address this global issue. the main reason for this lack of conceptual integrity lies in the broadly preferred focus on the "toolbox", that is, the single components or tasks of the energy transition. energy transition is most commonly defined extensionally (see fig. ), e.g. through its components such as the increasing share of renewable energy sources in the total energy mix (irena, iea), energy efficiency (eu, ipeec, irena), phase-out of fossil fuels (irena, eu) and nuclear energy (german fed. gov.), electrification of the transport sector (iea, eu), development of carbon capture and storage technologies (norway, saudi arabia). an important observation at this point is, that the set of these components differs among countries, regions and organizations according to their respective agenda. in other words: the global community lacks a uniformly agreed energy transition agenda. the respective policy approaches are guided by a set of paradigms, the central one often being energy security. traditionally, in the eu and in the oecd countries, energy security has been defined through the strategic energy triangle, consisting of the three objectives of security of supply, sustainability and economic efficiency. yet, there has always been the issue of prioritization of these objectives, given that there are not only synergies but also trade-offs between the policies addressing them. on the other side, the world energy council highlights that countries face an energy trilemma of addressing security of supply, ecological sustainability and energy justice simultaneously. the different wording chosen by the world energy council illustrates the variety of notions associated with the paradigms across the globe. while security aspects have been at the heart of energy governance since the emergence of the first energy institutions, the economic aspects have been gradually added afterwards, whereby their definition differs largely across the world. in the oecd countries, economic efficiency, competitiveness and affordability are prevailing notions. in other parts of the world, energy equity and energy justice underpin the economic, or better socio-economic angle of energy policies. the concept of energy transition is pervasively used as a normative one, it is also often tailored to fit certain policy objectives or to underpin specific measures and steps. therefore, international fora such as the g or the world energy council make the case for multiple energy transitions, i.e. structural shifts in the energy system of each country according to its respective goals and economic and resource potential (g ; wec ) . it is obvious that the various positions of countries in energy trading (influenced by their world market share/their position as a net importer/net exporter), in the globalized economy (trade surplus/deficit), with regard to their respective degrees of economic and social development (population growth/industrialization/urbanization) (bradshaw ) as well as to the state of the energy system and the level of access to modern energy supplies determine the weighing of objectives and the prioritization of energy policy goals. with climate change mitigation, adaption and resilience added to the set of objectives, this diversity of priorities has proven to be a heavy burden and at times an obstacle for energy and climate governance beyond national levels (ibid.). multilateral initiatives aiming to shape energy relations are in general hampered by widely scattered interests, which exacerbate the already considerable existing uncertainties. as a result, states have pursued very different pathways in energy governance: in the oecd area, it has been above all a matter of safeguarding prosperity; the post-socialist states have had to deal with the after-effects of the soviet era, including the task of socio-economic transformation and a search for a new position in the global economy. the 'resource curse' and rent-seeking patterns have determined the energy dilemma of the energy-rich countries, while the question of sufficient access to energy has occupied the energy-poor countries (ibid.). in addition to the traditional paradigms, sustainable development and growth have become key concerns. since the second decade of the s, the two key objectives of security of supply and climate protection have been accompanied by the goals of sustainable development and a fair and equal supply of energy worldwide, above all promoted by the united nations. at that time, the united nations also began to take an active stance on sustainable energy with its sustainable energy for all (se all) initiative. in the same vein, the millennium development goals were translated into the sustainable development goals (sdgs) in . goal is to ensure access to affordable, reliable, sustainable and modern energy for all by . sustainable development is very much connected to the issues of energy justice and energy poverty, but also to environmental protection, and more specifically, protection of water, soil and air. in the same year of , the paris agreement on climate change was signed. according to the paris agreement, countries' ambitions on ndcs have to progress in -year cycles. according to art . of the agreement, the ndcs should be formulated in line with the goal to keep global warming well below the degrees celsius compared to pre-industrial levels and pursue efforts to limit temperature increase to . °. the paris agreement, the consecutive conferences of parties (cops) and reports by the united nations framework convention on climate change (un fccc) have added a sense of urgency to the issue of climate protection, but at the same time possibly aggravated the dilemmas in addressing all four objectives even further. local air, soil and water pollution as part of sustainable development are in many countries a major driver and mitigating climate change comes as a transformation dividend (goldthau et al. ) , rather than as a policy goal on its own. although sustainable development has become a major underlying theme, e.g. also in the international energy agency and its world energy outlook(s), and climate is often subsumed under 'sustainability', we argue that both, climate and sustainability constitute paradigms in their own right. therefore, we suggest that a strategic energy quadrangle rather than a triangle is informing energy policies across the globe. energy security, economic efficiency, sustainable development and climate change mitigation, adaptation and resilience form four major angles or baskets, to which countries associate very different notions. at the same time, however, these four angles significantly overlap and create and numerous synergies to exploit and lift. to summarize, when it comes to energy transition governance, countries differ in terms of their starting points, their path dependencies and their future pathways as well as their ambitions. in view of this diversity, the paris agreement, its rulebook as well as the bottom-up mechanism of nationally determined contributions (ndcs) are important and necessary, but not sufficient preconditions to steer energy transition towards climate neutrality nor appropriate to govern energy transition(s) to meet the other objectives. indeed, if we are talking not about one, but multiple energy transitions, defining them through their respective components makes a lot of sense, since such a definition can be easily operationalized by, say, national policy makers. however, in order to enable global governance and international cooperation mechanisms on this issue, there must be an understanding of energy transition every stakeholder can identify itself with. although different stakeholders propose different measures and elements, there is indeed one common element such a definition can be based on: the characteristics of the future energy system they deem necessary and aim for are the same. all major stakeholders, some explicitly (g ; bmwi , p. ; g , p. ; mofa japan ), and some implicitly (iea a, b; ec ; irena ; national governments, e.g. the prc's government ) define sustainability, environmental safety, economic efficiency and security of supply to be the central goals and the end-state to which the process of energy transition should lead. a future energy system with these characteristics is indeed universally aspired-the sustainable development goal on energy, that is, access to affordable, reliable, sustainable and modern energy for all (un ), has been adopted by governments of countries. moreover, instead of energy transition, talking about energy transformation reflects the necessary systemic nature shifts in the energy system. sometimes both concepts are used interchangeably: in irena's report "global energy transformation-roadmap to " energy transformation is a means to achieve energy transition, which is conceptualized as the end-state itself: "the challenge that policy makers around the world face is how to accelerate the transition. fully delivering the energy transition will require a transformation in how we view and manage the energy system. transitioning in a few decades from a global fossil-fuel powered energy system, built-up over several hundred years, to one that is sustainable, will require a much greater transformation than current and planned policies (the reference case) envisage" (irena : ). as in several recent academic studies, in one if its newest reports "geopolitics of energy transformation", irena uses the term "energy transformation" intentionally instead of energy transition, to point out the broader implications a transition to low-carbon energy sources brings with it (irena ). against the above said, we suggest having an intensional definition of energy transition that is formulated as follows: a policy-driven process which involves systemic shifts towards (a) sustainable and climate-friendly, economically efficient and secure energy system(s). the measures and building blocks of such a transition will differ from country to country. yet, there should be a governance system behind these national efforts, to pave the way, facilitate, enhance and accelerate the energy transition(s). the existing energy governance landscape began emerging in the second half of the last century and has developed over time. it is sketchy and fragmented. within this landscape, there are very few multilateral institutions that tackle energy issues in a comprehensive way (see fig. ). this is the result of ( ) the different positions and roles of countries in the international energy system and ( ) the diverging national priorities in energy policies regarding the strategic quadrangle of energy. the traditional organizations such as the organization of oil exporting countries (opec), the gas exporting countries forum (gecf) or the international atomic energy agency (iaea) focus on specific energy sources, respectively oil, natural gas and nuclear energy. whereas opec and gecf are providing platforms for dialogue and cooperation among producing countries, the international energy agency (iea) was formed by the oecd countries as an organization of energy consumers and primarily in response to the first oil crisis of - . the iea has been dealing with different energy sources ever since, albeit it has always had a pillar on oil crisis management and prevention. the iea has been adjusting its role constantly to the new energy and climate realities. however, its membership structure, restricted to the oecd countries, came under increasing criticism as non-oecd countries like china and india have become powerful energy market players. in face of the changing dynamics, an association process has been currently under way with major non-oecd energy powers. in , the iea comprises member states, association countries and countries in accession. though being a display of iea's adaptability, the association process is certainly an attempt to maintain the existing order. the creation of the international renewable energy agency (irena) in meant a significant advance, both in renewable global governance as well as with regard to multilateralism (see also roehrkasten ). irena got a clearly defined mandate to "be the global voice and knowledge base for the use of renewable energy, to serve as a forum for international technological cooperation, and to advise the member states on these matters". (roehrkasten and westphal ; roehrkasten ) . the specific focus has been on renewables. irena has also been looking into the geopolitical implications of an energy transformation (irena ). as fig. shows, there are some organizations and fora that deal with specific energy sources or encompass a particular group of countries. this overview contains institutions on the global level, whereas regional organizations that specifically focus on energy (such as the latin american energy organization (olade)) or have energy in their portfolio (united nations economic commission for europe (unece), european union (eu), united nations economic and social commissions for western asia, for asia and the pacific and for latin america and the caribbean (unescwa, unescap, uneclac), etc.) are not included here. not included is also the world trade organization, which has played an important role in setting the rules for trade generally, but not in the energy sector (with an exception of energy services). the european energy charter in and the treaty in were an attempt to translate similar rules into the energy trade, transport and investment. yet, from today's perspective, it can be said that it is very doubtful whether the energy charter process can be revived and modernized in a way to provide a 'rule book' or a 'code of conduct' for international energy trade, transport and investments, despite the signed international energy charter. as fig. shows, very few existing institutions equally address energy policy objectives in an institutionalized manner. at the end of the s, there was a strong impetus to strengthen the coordination among the existing governance mechanisms and organizations. the initial idea was to better integrate the new powers such as china and india, and to have an outreach to the regions. the outreach and association process of iea as well the international platform of energy efficiency cooperation (ipeec) under the umbrella of iea resulted from initiatives of the group of eight (g ). it was the g that reacted to the fact that energy governance did neither reflect the energy landscape any longer nor the changes in global politics in general. in an increasingly multipolar world, energy governance (lesage et al. ) became a matter of steering committees and clubs, first and foremost of the g / and g . the g transformed back into an exclusive oecd-club with the crisis in and over ukraine, when russia was excluded from the process in . the group of carried on with the agenda of tackling climate change and energy security (with the primary focus on natural gas). in , the g emerged as the new 'club' to primarily address the financial crises. the g began to work on energy matters under the us presidency in , when g members declared their intent to phase out harmful and inefficient fossil based on westphal , updated fuel subsidies (van de graaf and westphal ). this new focus was also intended as an answer to the financial and economic crises as the member countries committed themselves to a resilient, sustainable and green recovery. the g is perfectly positioned to steer global energy transition. along with the g countries canada, france, germany, italy, the uk and the us, the g includes the european union (eu), argentina, australia, brazil, china, india, indonesia, mexico, russia, saudi arabia, south africa, south korea, as well as turkey. it comprises countries that are of utmost importance for a successful energy transition and includes major energy producers, consumers and key players in existing international institutions. also, in terms of climate policies, the g countries would make a huge difference, if acted together, as they account for % of global emissions (in comparison, g accounts for %). last but not least, the g includes all permanent members of the un security council, and major financiers of principal international organizations. the g has constantly stepped up its voluntary cooperation in energy-related areas such as subsidies, market transparency and price volatility, international energy collaboration, energy efficiency, energy access and renewable energies. the g summits provide countries with an opportunity to meet on an equal footing and to exchange national views and standpoints on energy topics, a major step forward being made in with the first g energy ministers meeting that took place under the turkish presidency. yet since then, every new presidency set its own priorities, which hampered continuity as an important precondition for efficient and effective energy governance. energy ministers have met each year since , except for under the german presidency. overall, though the g unites a representative group of industrialized countries and new powers that can have an impact in their respective regions, the members have very distinct and diverse policies and perspectives. this limits the role of the g when it comes to global energy governance and is also the reason for the group's focus on less controversial issues, such as energy efficiency. as a result, the g has only partly lived up to its potential as a steering committee (van de graaf and westphal ). in its current form, the g builds on the principle of voluntariness and on "soft" modes of steering, such as agenda setting, coordination among g members, information exchange and the steering of international organizations (ibid.). at the same time, the g has moved international energy governance up on its policy agenda, has rhetorically connected energy and climate policies and has enlarged its focus to sustainable development. since , the g has continued to exchange on and monitor the progress towards phasing-out of fossil fuel subsidies: in the iea, opec, oecd and the world bank published reports tracking fossil fuels subsidies (iea/opec/oecd/wb , ). in , the g endorsed a methodology for voluntary peer reviews "on inefficient fossil fuel subsidies that encourage wasteful consumption" (g , paragraph ) . since , the g has been addressing energy issues more comprehensively. at the g summit in brisbane, australia, the g endorsed the g principles on energy collaboration. the chinese presidency in continued this initiative to make energy institutions more inclusive and effective under the title "global energy architecture". the g affirmed its support for the sdg target number and pledged to increase the share of renewable energy substantially by . at the core of the g action on renewable energy is the toolkit of voluntary options, developed by irena. the following five options are presented as particularly beneficial for the g action: ( ) in-depth and country-specific analyses of renewable energy costs and reduction potentials, ( ) exchange good practice examples on enabling national policy frameworks, ( ) development of renewable energy-specific risk mitigation instruments, ( ) country-specific assessment of renewable energy technology potential and development of roadmaps and ( ) support the sustainability indicators and further actions of the global bioenergy partnership (gbep), in close cooperation with irena and iea bioenergy. in addition, g members decided to explore the potential for increased regional infrastructure connectivity and cross-border investment to enable greater levels of investments in renewable energy, and to continue the support for international cooperation, including capacity building for developing countries and encouraging the use of existing cooperation platforms. in , energy transformation has been officially put on the agenda at the ministerial meeting on "energy transitions and global environment for sustainable growth" in japan (g ). today's fragmented energy landscape increasingly amplifies the contours of a multipolar world. it is clear that in its current state, energy governance is far from being comprehensive, efficient and effective to steer a global energy transition. moreover, in the current geopolitical environment the efforts to strengthen theglobal cooperation and work on global public goods seem more and more futile. at the turn of the new decade of the s, personal ambitions of politicians determine politics. these are less directed to multilateral negotiations rather than to bilateral tit-for-tat zero-sum games. the volatility of personal relationships among the world leaders, where selfish nation-first policies dominate, increasingly compromises the stability and continuity of international relations. in the same vein, the global geopolitics around climate have changed fundamentally: since the adoption of the paris agreement in , the consensus among major powers has faded. cop in madrid in ended without a clear statement on raising the ambitions of the nationally determined contributions (ndcs), with the communiqué being watered down by the us, brazil and australia. the 'ndc explorer' shows, that the absolute majority of the countries put renewable energy first, while carbon capture, utilization and storage (ccus) technologies are hardly mentioned. even when taking into account that the ndcs have been produced under time pressure and that they may not be the best-grounded pledges, massive political and financial gaps are obvious and the ambitions are far too low (pauw et al. ). this altogether makes energy (transition) governance-albeit granular, selective and regional-more important than ever. policymakers at all levels face the herculean task of making energy systems more sustainable and climate friendly. moreover, at the same time, they have to ensure the supply of, e.g. fossil fuels, for the transitional period without perpetuating the existing energy system (westphal ) . if one looks to the horizon , in which the world aims to become carbon-neutral, the energy supply worldwide should be structured in such a way that the expected nine to ten billion people on earth have access to modern, affordable and sustainable energy supplies without further destroying the livelihoods of present and future generations (ibid.). we assume that energy transition pathways differ and depend on countries' respective preferences and imagined energy futures (see chapters in this volume). thus, we defined energy transitions as an intensional policy-driven process which involves systemic shifts towards (a) sustainable and climate-friendly, economically efficient and secure energy system(s). there is no single and simple solution to transitioning the energy system(s) in line with these paradigms, as stated by the iea in its world energy outlook of . the iea's weo has been very clearly stating that there is no silver bullet at hand, but a combination of technologies ranging from energy efficiency, renewables, fuel switch, nuclear, ccus, etc. as well as-not least-behavioural change are needed to put the world on track (see fig. ) . the systemic nature of energy transitions in general has been pointed out before, most notably in works on historical energy transformations (ex. smil ; kander et al. , etc.) . in its core, previous energy transitions have been transitions from one energy source (wood, coal, oil, electricity) and one type of energy converter (manpower, animal power, steam engine) to another. in all of these cases, major inventions of leading technologies such as the steam engine, electric lightning, etc., have kick-started processes of transition. however, all these transitions have been also accompanied by the profound and irreversible shifts on societal, ideological, political and economic levels (ibd.). in this regard, the energy transition that is taking place nowadays is no exception: it involves a shift to new, low-carbon energy sources. yet, this time, the range and speed of the transition is and needs to be different. moreover, the range of measures that will have to be deployed is enormous. as a result, the scale of socio-economic and political changes to be expected from the energy transitions happening around the world is not comparable to the historic cases. in other words, we have to think about energy transformation, in a way karl polanyi described the "great transformation"-neither national nor global energy systems are discrete elements. they are closely intertwined with politics, as well as with economic and social systems. a transition to a low-carbon economy doesn't just change the energy system. it has massive knock-on and distributional effects, causing re-allocation of resources both nationally and internationally. how to think about the new world (irena, ) and the difficult, painful, but promising transition phase? ( ) the energy transition(s) come with various structural shifts that create new patterns of energy supply and demand, investment and data flows, new infrastructure systems and new power balances. ( ) the new system will be more electrified, digitized, demand-side driven and distributed. this requires large infrastructure to adapt, to modernize or to be developed, depending on the respective countries. ( ) today's energy system rests on individual sectors (i.e. electricity, buildings, transport, industry), each characterized by a dominant mix of (fossil) fuels (goldthau et al. ). in the system of the future, the sectors (electricity, industry, heating and cooling, transport and mobility) will be coupled by the use of electricity and synthetic/decarbonized molecules and liquids. ( ) as a consequence of these changes in the system, a relocation of production and demand as well as a reconfiguration of energy spaces will take place. ( ) in the new energy world, the value is no longer generated primarily from the fossil fuel resource such as coal, oil or gas, but rather at the stage of conversion into end-user energy/services (ibid). in other words, more and more value will be created downstream of the energy supply chain and in services (e.g. lightning, heating, cooling, etc.). as a consequence, profits will be generated by the availability and use of low-carbon technologies. energy transformation does not only recalibrate energy value chains. it also (re)configures energy spaces, which are shaped by infrastructure, production chains, and industrial clusters. energy infrastructure can be viewed as an "infrastructured" geography of "long durée" that shapes spaces and even creates its own "ecology" and topography (högselius ) . this is particularly true for electricity grids and their different shapes (central, decentralized) as well as sizes (local, national, trans/continental). the spatial effects of the energy transition(s) result from technoeconomic change, e.g.in the shape of local micro grids or region-spanning super grids, such as those promoted by china's belt and road initiative. connectivity will be newly defined, knocking on existing interdependencies, alleviating old sensitivities and vulnerabilities, but also creating new ones. the interconnectedness of two critical infrastructures, the electric grid and the internet creates specific challenges and hybrid threats. if we assume that the energy transition has tremendous political, economic and social effects, the interaction with international political and geographical factor is evident (ivleva and tänzler ) . geopolitics can be understood as dynamics that stem from the interaction of geographical factors and international politics (ibid.; scholl and westphal ) . in international politics energy is (intended to be) used as a tool and means to influence political outcomes, achieve foreign policy goals and as a lever to project power (ivleva and tänzler ) . the geopolitics of energy transformation constitute a governance challenge in its own right. there is a growing body of literature on the energy transition having a geo-economic and geostrategic character (bradshaw ; scholten ; goldthau et al. ; bazilian et al. ; irena ) . importantly, the very notion of energy security will change along with the transformation of energy systems: to be more precise, in the oil-centered world of the past, national security and the issue of import dependencies were at the heart of energy security. in the new energy landscape, where electrification is a major trend, the stability of the power grid will be the defining feature of energy security. not surprisingly, energy is and will remain at the heart of national sovereignty and/or statecraft, as daniel yergin's definition of energy security as "adequate, reliable supplies of energy at reasonable prices in ways that do not jeopardize major national values and objectives" hints to (yergin ) . energy has always proven to be a major policy field, involving a strong role of the state, as it is closely related to its traditional tasks of providing prosperity, security and stability. the energy transition offers new opportunities to shape the energy system in a new vein, which is in line with national values and interests, while also providing and protecting global commons and goods. while traditional geopolitics is related to power relations, the energy transition implies power shifts and alters the political economy on the national and the international levels. it creates winners and losers (irena ; overland et al. ) . petrostates and coal-exporting countries are repositioning themselves in the international system as their major assets become de-valued (irena ). at the international level, fossil fuel producers are vulnerable to the fundamental changes caused by the energy transitions. resilience to the energy transition effects depends on the percentage of fossil fuel rents in the gdp and the diversification of their economy (irena ). if petrostates such as russia, saudi arabia or iraq, etc., are confronted with declining oil rents, their socio-economic model and political systems come under severe pressure. fossil fuel exporters are not only faced with a devaluation of their natural resources, but increasingly face fundamental challenges to their economic and social systems, since the resource wealth is part of the social contract. this in turn affects the political stability and economic growth in these countries. yet, it is fair to say that the us shale gas and tight oil revolution has already caused a landslide by creating a new situation of energy abundance, shaking up the position of energy rich countries and diminishing their respective rents. in a sense, the us shale revolution has already anticipated certain effects for the petrostates. transit countries such as ukraine, morocco or tunisia that gain rents from their midstream part in fossil fuel supply chains, will also feel the effects of energy transitions. obviously, the energy transformation will have knock-on effects along the whole fossil fuel value chain making the exporting and transit countries to losers of an energy transformation. evident winners are major importing countries, which will be able to produce more energy from renewables locally and at home or in cross-border cooperation within 'grid communities' (scholten ) , formed by political choice and not due to geological circumstances. at the same time, renewable technology leaders are emerging (irena ; goldthau et al. ) , gaining more and more political weight and a central place in the global markets. hence, energy governance has to tackle the geopolitical ramifications of energy transformation and aim for a transition that is as smooth as possible. in this respect, the notion of a 'just transition', energy justice or evenness, is key for the global energy transition, in particular with regard to the global south (see goldthau in this volume). finally, the energy transformation has profound and even disruptive structural effects. at the national level, it inherently entails structural ruptures and puts stress on the incumbent energy system. incumbent utilities like the german companies e. on and rwe lost significantly in their market capitalization and/or changed their asset base, which also split their renewable branches. in the socio-technical realm, a paradigm shift will have to take place, with the end consumer and/or the community moving into focus. consumers are becoming key actors as both, consumers and producers ("prosumers") of sustainable energy, which requires a behavioural change beyond energy saving and efficient energy use. the eu, for instance, has paid a tribute to this paradigm shift by focusing on the end consumer in its 'clean energy package for all europeans' of . in general, this paradigm shift from supply to the end consumer has three dimensions. first, consumer behaviour is critical to the success and speed of an energy transition: consumers have to take up responsibility, be empowered and become to a certain extend 'owners' of the transition. second, there is the social dimension of access, availability and affordability of (modern) energy: among others, governance measures are needed to deal with e.g. (temporary) price increases. last, but not least, structural ruptures such as a 'coal phase out' are part of the decarbonization. this requires states to mitigate social risks, e.g. ones expected from the coal phase-out negotiated in germany in (bmwi ). germany's decision to phase out coal by was achieved by a societal consensus after a long negotiation process and backed by a set of structural policies in coal regions. these policies translate into a long phase-out over almost years, depending on the age (and technology used) of the respective power plants. other countries might have the chance to leap-frog this technology, or might have to close down coal-fired power plants before their respective lifespan ends(as is likely to be the case for some countries in asia) (iea a, b) . in any case, the socio-economic dimension of the energy transformation cannot be underestimated. as mentioned above, energy transition affects societies. energy transition has a considerable effect on labor markets. germany is a case in point where the narrative of creating green jobs has not really (or only temporarily) delivered. when feed-in tariffs triggered the diffusion of pv in germany, the 'solar valley' in sachsen-anhalt boomed. yet, as china began to expand its solar panel manufacturing industry, many involved in the same sector in germany lost their green jobs. socio-technical dynamics have to be closely analysed and the respective policy measures developed: in germany, traditional energy sectors are covered by unions, primarily the respective labor union igbce (ig bergbau, chemie, energie), whereas workers in new industries such as solar and wind energy are not organized in trade unions and therefore don't have the same kind of support. this particular challenge to tackle the socio-economic effects of the energy transition is thus increasingly debated as the "just energy transition". the focus on a just transition is inextricably linked to the question of "who wins, who loses, how and why". it is imperative to ask this question both in relation to the existing distribution of energy (e.g. "who lives with the side effects of extraction, production and generation?"), and with regards to the ongoing energy transformation (e.g. "who will bear the social costs of decarbonizing energy sources and economies?") (newell and mulvaney , p. ) . this, in turn, necessitates addressing the issues of distribution and access to political power, natural, social and economic resources, and the political economy behind socio-technical energy transitions (goldthau and sovacool ) . attention has to be paid to the interrelation between a just energy transition and the speed of decarbonization, though. in the beginning, mitigating social effects can be an impediment to moving ahead with the rapid decarbonization, but a sound social consensus is needed as a stabilizing element to transform the energy system. the creation of green jobs can serve as a catalyst and is even more important than social measures to compensate for income losses and job cutbacks. these social aspects are moving to the political core of many western societies, where, i.e. resulting from such movements as "fridays for future", the energy-climate cleavage has started to influence the politics and polarize the societies. the message this chapter can't emphasize enough is that the energy transition(s) will play out differently in countries and regions, but they all will have a huge impact on all levels: the global, the regional, the national and the local. moreover, while the targets and paradigms are in place, creating the institutional framework fit to steer the transitions' pathways remains an open issue. as there is no simple and single solution (see fig. ), there is no one-size-fits-all approach to governance. instead, what is needed is a flexible multilevel architecture which is ( ) reflecting new connectivities and energy spaces, ( ) enabling, promoting and diffusing new technologies and knowhow and ( ) adapting the institutional and regulatory framework to the changes that come along with the transformation of the energy system(s) (see fig. ). there is a need for a better global and regional, and a good governance on the national and policies and cooperation mechanisms for global energy transition governance. source local level. particularly in today's world of nation-first policies and geo-economics, it is imperative to establish, maintain and improve the multilateral energy landscape. moreover, the governance task is not only to move forward with the energy transition, and to transform the system, but also to deal with the geopolitical aspects which the energy transition brings about. energy transformation comes with a cost, but the costs of doing nothing are higher, even if less immediate and more diffuse. the call on governance is evident, because it is assumed that this will make the transition(s) faster, smoother and more even. the transition period is assumed to have systemic transformational effects on political systems, economies and societies, and thus can be messy, disruptive and conflictive. furthermore, the energy transition(s) are not taking place in a vacuum but have the potential to add to the geo-economic rivalry. moreover, technology leadership and control over mineral resources can add to the struggles over political authority and power. the global environment of great power rivalry and the crises of multilateralism are clearly complicating the global energy transformation. there is less political will to work together to create and preserve global common goods than in the past. under these circumstances preserving the existing institutions such as wto, irena and un energy that build on 'altruism' and are aiming at a level-playing field is of the utmost importance. if the global consensus is shaky, it will remain important to act plurilaterally, in clubs, coalitions and alliances. the existing governance structure (figs. and ) can and has to ensure the functioning of today's energy system without perpetuating it. the format of clubs, the comprehensive institutions of iaea and iea will have a role to play. this is equally true for irena, un energy and se all, which are directed to changing the energy system(s) along the paradigms of the strategic energy quadrangle. in order to ensure that the measures undertaken (see fig. ) not only contribute to diversification, but in fact transform the system, the efforts in governing energy efficiency and renewable energy have to be stepped up. aside from the global level, new governance structures will have to be developed or adapted at the regional level. without an aspiration of being comprehensive, we recommend the following focus areas. governing energy regionalization and connectivity. the energy transition will reshape regions, but also create webs and routes within and between them (connectivity). so far they are largely un-or only partly governed. yet, the existence of large infrastructure (e.g. power grids) running across regulatory spaces will require new norms, rules and standards which deal with interoperability of systems and cross-border management of flows (scholl and westphal ; overland et al. ; balmaceda and westphal forthcoming) . energy regionalization takes place without a recognition of existing jurisdictions and polities. the question of who defines the rules of the game in the "infrastructured" space or across production and value chains is very acute. new governance schemes are necessary, also to prevent regulatory fault lines from feeding into geopolitical conflicts. this has systemic, structural and spatial implications of a transboundary nature that have repercussions on the regional and global level. among them are the global shift of investment and financial flows due to the changes in energy and technology markets; the emergence of new geographies of demand and supply; where the digitization comes with its own risks and challenges, as both energy, it and telecommunication sectors are connected by super infrastructures, which are highly critical to modern societies. the cascading effects in case of a crisis or a 'black-out' demand for specific resilience measures to be taken in smart/super grid communities. this issue is already very tangible in the eu, where electricity security and grid stability have gained utmost importance. the creation of synchronized grid communities that include turkey, and soon the baltics and ukraine, come with their own governance challenges, not least of them being connected to cyber security. a common set of global rules. one immediate blind spot to address in global energy governance is the lack of a code of conduct and/or a set of common rules. both are needed in order to create a level playing field as well as transparent and functioning markets. the more technology-driven the energy system will be, the more important will rule-setting organizations such as the wto become. patents and intellectual property rights will remain important in order to make profits from innovation, but at the same time, solutions will be needed to provide access to important technologies for developing countries. investments. one of the key challenges for a sustainable energy transition is to get the investments right and right in time. under the current price regime of low energy prices and in an era of abundance of energy sources, price signals to turn away from fossil fuels will be too weak or simply lacking. investments into production sites and infrastructure predetermine and cement path dependencies given the long lead times and lock-in effects they create. policy measures and regulatory frameworks will be key in the transition toward a sustainable global energy system. institutions will play a central role in incentivizing and realizing the big shifts in technology, as well as creating and capturing the value and creating new business models. this is also related to the question of who will finance the necessary infrastructure. therefore, 'shifting the trillions' and getting the financial and taxation framework right, is of a paramount importance. in many countries with high renewable energy and energy efficiency potential, the cost of capital is too high. new power grid infrastructure, renewable energy facilities, development of energy efficient buildings and appliances, restructuring transport sector, etc., require huge sums of infrastructure investments, great coordination efforts, and a stable regulatory framework to realize the shift. the unprecedented oil price slump triggered by the covid- pandemia in the first quarter of is burning capital which will be missing in the energy sector and for the transformation as a whole. technology-specific governance schemes and mechanisms. moreover, there are many issues around specific measures and technologies to be addressed by specific governance mechanisms. the table above is not considered comprehensive. yet, it aims to visualize the complexity of the tasks faced by the global community. the instrumental and operational level aims to grasp the multitude of the technologies, components and tools needed to bring forward energy transition, among them the deployment of low-carbon energy sources, power-to-x and synthetic fuels, but also the new approaches to power grid design (e.g. smart grids or super grids) as well as energy efficiency, sector coupling, and phase-out of fossil fuels. these elements and tools are employed altogether or in part, based on the political agenda and preferences of the respective countries-their efforts on the operational are therefore highly heterogeneous. a consumer-producer dialogue. one of the key mechanisms to ensure a successful energy transition is an enhanced and effective consumer-producer dialogue. such a dialogue is particularly important for depletion strategies and gradually phasing-out of fossil fuels. moreover, this dialogue can create new partnerships to produce, trade and transport 'de-carbonized' molecules and fuels (hydrogen and power-to-x) and coopt fossil fuel producers. the international energy forum (ief), whose primary focus is consumer-producer dialogue, is not delivering on that. it seems that it would be more fruitful to move ahead with the 'clubs' and 'coalitions of the willing' to e.g. gradually develop hydrogen markets. get the institutions right. steering energy transition on the global level requires enhanced technical and regulatory dialogue as well as a continuous exchange on best (and worst) practices among countries, regions and communities. there is no lack of targets, but the major challenge is to create effective incentives, frameworks and regulations to implement and accelerate the energy transformation. in addition, exchange and cooperation on a knowledge-and database on energy (including exchange on energy forecasts and common modelling exercises) must be developed, to provide transparency needed for an efficient energy transition governance. for these modes of inter-and transnational cooperation, the multilateralism of energy governance institutions should be kept up and preserved. coordination and coherence among the existing institutions, clubs, and coalitions of the willing must be strengthened, while governance structures where cooperation on energy transition can take place in a level-playing field and is not driven by geo-economic rivalry have to be developed. for this, countries and other relevant stakeholders have to abandon the traditional perception of the quadrangle of energy security, economic efficiency, climate and sustainable development as mutually exclusive dilemmas, and put synergies from coordinating these four elements to the forefront instead. tandems between global north and south are imperative to efficiently addressing the issues of energy poverty and just energy transition globally and to making sure that no region is left behind. with regard to the deployment of renewables, 'tandems' may be a way forward as pursued in the g with phasing-out fossil fuel subsidies. healey and barry ( ) rightfully highlight an "increasing inequality-of income, wealth and resource ownership" in general, and rising "inequality of access to safe and affordable energy" as well as "energy poverty" as major challenges. energy transition regimes must address inequalities in power and injustices across entire socio-energy systems. the issue of energy justice must be incorporated into all governance mechanisms. this can be done by paying tribute to the eight principles of energy justice: availability, affordability, due process and information, responsibility, sustainability, intra-generational and inter-generational equity (sovacool and dworkin ) . education, research and information. at the end of the day, the benefits of energy transition have to be communicated and pushed forward in the public debates: for instance, human security gains as improved air and water quality are among the 'dividends' of energy transition (goldthau et al. ) . education and information are key in addressing societies in general and in particular increasingly polarized societies. approach climate and energy security through the lens of public goods. energy transition has the potential of re-localizing the economy around human-scale enterprises rooted more closely in the communities they serve. internally, energy transition should be 'democratized' as entailing a shift towards empowerment and ownership, transforming end-users into "prosumers" in the true sense of the word. normatively, the aim should be a reconfiguration of "transition arenas" from spaces for 'coalitions of frontrunners' towards more open spaces for deliberation, dialogue and participation (barry et al. ) . for this, approaching energy and climate security through the lens of global public goods as opposed to a strategic national interest is important. we conclude that a just energy transition on all levels, but certainly on the national and the international level, is necessary to keep countries and the world on a sustainable energy transition path. it is essential for the international community to stick to the paris agreement in order to keep up the level of ambition nationally. but also vice versa, the international ambition cannot be sustained without an enduring social consensus in major countries. open access this chapter is licensed under the terms of the creative commons attribution . international license (http://creativecommons.org/licenses/by/ . /), which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license and indicate if changes were made. the images or other third party material in this chapter are included in the chapter's creative commons license, unless indicated otherwise in a credit line to the material. if material is not included in the chapter's creative commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. low carbon transitions and post-fossil fuel 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mr soe authors: nan title: preface: globalisation and global logistics date: - - journal: nan doi: . /b - - - - . - sha: doc_id: cord_uid: mr soe unknown in our daily lives, we are surrounded by many goods from all over the world. my shirt, for example, is from vietnam, my trousers are made in china, and my jacket comes from italy. my watch is swiss made, and my glasses are imported from the united states. the coffee cup on my desk is produced in france, and the coffee in it is made from blended beans from brazil and guatemala. perhaps my laptop is assembled in my own country, but its parts are imported. in the same way, many goods are produced in various regions, transported across locations, and finally consumed at other places. this complicated production-consumption system has been facilitated by the globalised logistics system wherein products are transported internationally, in addition to the international movements of people, currency, and information. the establishment of the global logistics system is the result of three major factors: technological innovation, infrastructure investment, and evolution of the institutional system. containerisation was an epoch-making event that transformed the logistics industry from a labour-intensive to a capital-intensive industry (levinson, ) . containerisation has facilitated complex cargo-handling tasks such as loading/discharging and trans-shipment of cargo to and from vessels at ports, upgraded safety standards, reduced damage to cargos, and also enabled an intermodal transport network connecting ships, railways, and trucks. vessel design technology has also evolved, resulting in larger vessels over time (rodrigue, ) . the upward trend in the sizes of containerships is mainly motivated by economies of scale, which has led to a significant reduction in average cargo transport costs. international cargo traffic flows are also supported by sophisticated transactions of commercial information and currency. notably, recent revolutions in information and communication technology (ict) have enhanced the efficiency and safety of global logistics operations. these developments include sophisticatedly digitalised operating systems such as electronic data interchange (edi) processing, radio-frequency identification (rfid) processing, and optimisation of cargo handling at automated container terminals (saragiotis, ; al-fuqaha et al., ; steenken et al., ) . regarding the institutional framework, trade obstacles due to traditional manual transactions at cross-border points have been gradually removed under the guidance of regional strategies. the liberalisation of international trade can be realised by trade facilitation and implementation of cross-border paperless trade, which includes simplifying required paperwork, modernising procedures, harmonising customs requirements, and introducing a single-window system (tijan et al., ) . reductions in time and costs of cross-border point transactions enable nations to seamlessly connect with others, which can facilitate the process of evolution into an integrated global production chain. rapid globalisation with reduced transport costs has motivated global firms to optimise their manufacturing clusters located in regions with the cheapest labour and material costs. this significantly diminishes production and operating costs. this trend is further accelerated by a business model of horizontal specialisation at a global scale (bloch, ) . firms that specialise horizontally identify a specific market to which it can offer a complete business solution, which may involve offering a wide range of components, products, and services to a narrow range of customer types (williams and aaron, ) . additionally, this business model has promoted the rapid development of manufacturing industries located in the markets of emerging economies. to keep updated, major logistics industry players have adapted to rapid globalisation. shipping liner companies have established a global hub-and-spoke shipping network (farahani et al., ) . tough competition amongst shipping companies has also encouraged mergers and acquisitions under horizontal integration since the s (notteboom et al., ) . this has led to the establishment of giant shipping liners and promoted global strategic alliances amongst shipping companies (crotti et al., ) . furthermore, the increased sizes of vessels require massive investment in port and/or canal facilities. many governments have participated in the global competition to construct large-scale hub ports to lead the global supply chain and earn benefits from saved transport costs by facilitating the movement of direct shipping services to and from hub ports. an interregional intermodal transport network has been formulated (reis et al., ) under the international development strategies of regional bodies. such efforts to improve efficiency in the global logistics system have accelerated international business activities. in summary, the globalisation of the supply chain, in line with innovation in logistics and institutional systems and massive investment in freight transport infrastructure, has enabled many firms to diversify their procurement sources, which has led to lower supply costs. end users now have more options in consumption goods, whilst prices have also significantly reduced. this has improved the quality of life for people whilst increasing tax revenues for governments through the revitalisation of economic activities. the above-mentioned causality is supported by much empirical evidence, particularly on the significant associations between international trade and global gdp growth (alcalá and ciccone, ; frankel and romer, ) and positive impacts of the liberalisation of international trade on economic efficiency (pavcnik, ; bloom et al., ) . many studies have indicated that even in the least-developed countries, export growth could stimulate economic growth (e.g. ghirmay et al., ) following two paths: increasing investments (capital accumulation) and enhancing efficiency. this has contributed to addressing poverty and other global issues, which are targeted by the sustainable development goals. the rapid development of the global logistics network has upgraded accessibility to and from landlocked regions where no seaport is available as well as remote areas located far from major markets (faye et al., ) . these improvements in accessibility have encouraged global firms to invest in such landlocked and remote areas whilst also promoting exports from those areas that could create more jobs, generate better salaries, and improve the quality of life of the people in these places. similarly, enhancement of regional connectivity amongst nations enables the development of an integrated economic market, fosters regional competitions, stimulates international trade and leads to better economic growth even in less-developed regions. nonetheless, the negative aspects of globalisation also exist. a commonly discussed issue is its damaging effect on local economies and domestic jobs. developed countries that outsource manufacturing to other regions to exploit cheaper labour costs could suffer from employment insecurity; developing countries could also be affected in their domestic employment although the impacts are still inconclusive (lee and vivarelli, ) . this may lead to political movements favouring protectionism and isolationism (stiglitz, ) . another issue relating to globalisation is the income inequality compromised for the sake of countries' economic growth. this typically indicates a 'core-periphery' structure, wherein the core contains the major wealthy and powerful countries, with countries that cannot reap the benefits of global wealth located at the periphery (hartmann et al., ) . core countries settle on a diverse set of knowledge-intensive and value-added products, and peripheral developing countries specialise in exports of simple resources and labour-intensive products to higher blocks of the hierarchy (kostoska et al., ) . this could be regarded as neocolonialism-the dark side of globalisation (rao, ) . additionally, the world system may be more vulnerable under globalisation, as supply chain disruptions could transfer to and significantly affect international trade. such system disturbances may be caused by natural disasters, trade embargoes, or disruptive demand change (sprecher et al., ) . many researchers in recent years have highlighted the resilience and vulnerability of the supply chain (elleuch et al., ) . the tremendous impacts of the covid- pandemic in are still ongoing. this book attempts to provide a reference for discussions on the above-mentioned issues from a global logistics system perspective by presenting a technical tool to investigate the international freight transport network and its related policies. part contains four chapters which cover introductory topics regarding the container shipping market, hinterlands, cross-border logistics, and container demand forecast. part presents the model and data, which are complemented with quantitative simulations and later applied to case studies in many regions. a macroscopic network modelling technique is employed to analyse cargo flows in international freight networks. the practical modelling approach enables us to examine the expected impacts of the logistics system changes in a realistic manner. as explained earlier, these logistics changes include technological innovation, infrastructure investment, and evolution of the institutional system. the proposed simulation model can assist in evaluating the policies intended to change the logistics system in terms with their impacts on accessibility, traffic volume, trade patterns, or share of transport modes. their expected influences on regional/local economic performance could also be discussed if the logistics network model is integrated with another international economic simulation model. the logistics transport network assumed in this book's model covers multiple transport modes, including maritime shipping, railway, trucks, and inland waterway transport, although maritime shipping should be highlighted since its role is dominant in international trade. part demonstrates a series of cases wherein the proposed model is customised and applied to seven regions across the world. they highlight the logistics network in developing countries since the major problems in logistics systems are observed in less-developed regions. these case studies are expected to contribute to the policy debates in each region. the unique contribution of this book is in providing a useful tool and verifying its application in various regions for the decision-making of stakeholders in logistics industries, related government authorities, and international donors concerned with global issues. we hope that our modelling approach can assist various individuals, such as supply chain and logistics professionals, university students interested in logistics and freight transport, and experts in logistics and transport planning/policy in exploring novel directions in logistics research. trade and productivity internet of things: a survey on enabling technologies, protocols, and applications specialization and its critical role in business trade induced technical change? the impact of chinese imports on innovation, it and productivity merger waves and alliance stability in container shipping resilience and vulnerability in supply chain: literature review. ifac-papersonline - hub location problems: a review of models, classification, solution techniques, and applications the challenges facing landlocked developing countries does trade cause growth? exports, investment, efficiency and economic growth in ldc: an empirical investigation international trade, development traps, and the core-periphery structure of income inequality core-periphery structure in sectoral international trade networks: a new approach to an old theory the social impact of globalization in the developing countries the box: how the shipping container made the world smaller and the world economy bigger the relationship between port choice and terminal involvement of alliance members in container shipping the drivers of port competitiveness: a critical review trade liberalization, exit, and productivity improvements: evidence from chilean plants neocolonialism" or "globalization"?: postcolonial theory and the demands of political economy rail and multi-modal transport the geography of transport systems business process management in the port sector: a literature review framework for resilience in material supply chains, with a case study from the rare earth crisis container terminal operation and operations research: a classification and literature review the overselling of globalization maritime national single window: a prerequisite for sustainable seaport business specialization as a small business strategic approach key: cord- - gyk cwx authors: morand, serge; walther, bruno a. title: the accelerated infectious disease risk in the anthropocene: more outbreaks and wider global spread date: - - journal: biorxiv doi: . / . . . sha: doc_id: cord_uid: gyk cwx the greatly accelerated economic growth during the anthropocene has resulted in astonishing improvements in many aspects of human well-being, but has also caused the acceleration of risks, such as the interlinked biodiversity and climate crisis. here, we report on another risk: the accelerated infectious disease risk associated with the number and geographic spread of human infectious disease outbreaks. using the most complete, reliable, and up-to-date database on human infectious disease outbreaks (gideon), we show that the number of disease outbreaks, the number of diseases involved in these outbreaks, and the number of countries affected have increased during the entire anthropocene. furthermore, the spatial distribution of these outbreaks is becoming more globalized in the sense that the overall modularity of the disease networks across the globe has decreased, meaning disease outbreaks have become increasingly pandemic in their nature. this decrease in modularity is correlated with the increase in air traffic. we finally show that those countries and regions which are most central within these disease networks tend to be countries with higher gdps. therefore, one cost of increased global mobility and greater economic growth is the increased risk of disease outbreaks and their faster and wider spread. we briefly discuss three different scenarios which decision-makers might follow in light of our results. the anthropocene has also been nicknamed the 'great acceleration' because various socioeconomic and earth-system related indicators experienced a continuous and often exponential growth after the second world war (steffen et al., a; mcneill and engelke, ; steffen et al., ) . while this relentless growth of the human enterprise improved human well-being around the world in many aspects (waage et al., ; barrett, ; permanyer and scholl, ; zheng and qian, ) , negative impacts have likewise increased (ipcc, ; ipbes, ) . in tandem, warnings about a climate emergency (lenton et al., ; ripple et al., ) , a sixth mass extinction (pereira et al., ; barnosky et al., ; ceballos et al., ) , increasing ocean acidification and dead zones (hoegh-guldberg et al., ; diaz and rosenberg, ; branch et al., ) , and even widespread ecosystem collapse (jackson, ; barnosky et al., ; unep, ) and transgression of safe planetary boundaries (steffen et al., b) have grown increasingly urgent. to avoid or at least dampen the anticipated or already realized changes, scientists and many others have called out for radical changes to how human economies operate and relate to human societies and their environments (unmüßig, ; simms, ; walther, ; ripple et al., ) . we here want to draw attention to another important and noteworthy feature of the anthropocene which greatly affects public health, human well-being, and economic performance. these findings are especially pertinent as the world reels from the health, social and economic impact of the current sars-cov- pandemic (el zowalaty and järhult, ; ghebreyesus and swaminathan, ; lorusso et al., ) . the increasing connectivity of human populations due to international trade and travel (guimerà et al., ; colizza et al., ; brockmann and helbing, ; gabrielli et al., ) , the rapid growth of the transport of wild and domesticated animals worldwide (rosen and smith, ; schneider, ; rohr et al., ; levitt, ) , and other factors such as the increasing encroachment of human populations on hitherto isolated wild animal populations through loss and fragmentation of wild habitats (patz et al., ; despommier et al., ; pongsiri et al., ; myers et al., ) have led to a great acceleration of infectious disease risks, e.g., the increase in emerging infectious diseases and drug-resistant microbes since (jones et al., ) and the increase in the number of disease outbreaks since (smith et al., ) . to expand the previous analysis (smith et al., ) to the beginning of the anthropocene, we investigated whether the number of disease outbreaks has increased since the second world war. in addition, we examined whether the global pattern of infectious disease outbreaks changed possibly due the increasing connectivity of human populations. in other words, have the disease outbreaks become more globalized in the sense that these outbreaks are increasingly shared by countries worldwide? to investigate these questions, we used a the most complete, reliable, and up-to-date global dataset (gideon informatics, ) which had already been used in the previous analysis (smith et al., ) . this dataset can be used to enumerated the recorded annual number of disease outbreaks. to investigate the changing global patterns of disease outbreaks, we used this dataset to calculate two measures which have been recently introduced into ecological and parasitological studies. these two measures, namely modularity and centrality, quantify the connectivity of bipartite networks. modularity is defined as the extent to which nodes (specifically, sites and species for presenceabsence matrices) in a compartment are more likely to be connected to each other than to other nodes of the network (thébault, ) . the calculation of a modularity measure is useful for global phenomena because it allows the overall level of compartmentalization (or fragmentation) into compartments (or clusters, modules, subgroups, or subsets) of an entire dataset to be quantified. high modularity in a global network means that subgroups of countries and disease outbreaks interact more strongly among themselves (that is, within a compartment) than with the other subgroups (that is, among compartments) (bordes et al., ) . centrality is defined as the degree of the connectedness of a node (e.g., a keystone species in ecological studies; jordán, ; gonzález et al., ) . in the context of our study, centrality is the degree of the connectedness of a country and those countries connected to it. we estimated the countries which are the potential centres of disease outbreaks by investigating the eigenvector centrality of a given country in a network of countries which share disease outbreaks among each other. eigenvector centrality is a generalization of degree centrality, which is the number of connections a country has to other countries in terms of sharing disease outbreaks. eigenvector centrality considers countries to be highly central if the connected countries to them through shared outbreaks are connected to many other well-connected countries (bonacich and lloyd, ; wells et al., ) . modularity and centrality analyses have been used to investigate various ecological, parasitological and epidemiological questions (e.g., tylianakis et al., ; jordán, ; gonzález et al., ; anderson and sukhdeo, ; bascompte and jordano, ; poisot et al., ; bordes et al., ; genrich et al., ) . using a widely used world dataset on infectious disease outbreaks, we here present results which demonstrate that the accelerated number of disease outbreaks and their increased global spread are two further threatening aspects of the accelerated infectious disease risk associated with the globalization process which characterizes the anthropocene. to collate the total number of infectious disease outbreaks over the years - , we extracted the relevant data from the medical database called gideon (gideon informatics, ) which contains information on the presence and occurrence of epidemics of human infectious diseases in each country as well as the number of surveys conducted in each country. the gideon data are curated as records of confirmed outbreaks, are continually updated using various sources such as who and promed, and are accessible via subscription. this dataset is generally considered to be the most complete, reliable, and up-to-date in the world and has been regularly used in previous macro-scale studies of infectious disease, epidemics, and pathogen diversity (e.g., smith et al., ; dunn et al., ; morand et al., ; morand et al., ; poisot et al., ; smith et al., ; morand, ; morand and walther, ) . each row in the gideon dataset specifies the disease 'species', the year and the country of the outbreak. the 'annual total outbreak number' is simply the annual total number of outbreaks regardless of the disease designation and including all countries. the 'annual total disease number' uses the same data for each year as the 'annual total outbreak number' but then counts only the different infectious diseases which had at least one outbreak in that respective year. the 'annual total country number' uses the same data for each year as the 'annual total outbreak number' but then counts only the different countries which had at least one outbreak in that respective year. our entire - dataset contains outbreaks of human infectious diseases in nations. in our case, we built yearly bipartite networks of presence-absence matrices which link countries with all the recorded epidemic outbreaks. we then transformed these bipartite networks where separate nodes from countries were connected with nodes of epidemic outbreaks into unipartite networks using the tnet package (opsahl, ) the calculation of modularity of bipartite networks of shared epidemic outbreaks among countries allowed us to identify modules of countries that share common epidemic outbreaks in each respective year (see introduction) (blondel et al., ; bordes et al., ) . we calculated our modularity measure of unipartite network for each year using igraph (lehoucq et al., ) . high modularity calculated in this context means that an epidemic remains relatively constrained within a few countries while low modularity means that an epidemic has spread across relatively more countries. the calculation of the eigenvector centrality of the unipartite network of each respective year allowed us to determine the number of connections a country has to other countries in terms of epidemic outbreak sharing. eigenvector centrality is a measure of the degree of the connectedness of a country and those countries connected to it. high centrality calculated in this context means that a country is connected to many countries which are also well-connected (bonacich and lloyd, ; wells et al., ) . a visual examination of the time trend of the annual modularity measure suggested a discontinuous trend over time. to detect such a discontinuity (or breakpoint) in the trend over time, we used the r package segmented (muggeo, ; muggeo, ) . this package allows the identification of one or more discontinuities using the bootstrap method; in other words, the decomposition of a relationship into one of more piece-wise linear relationships and the identification of breaking point(s). the standard errors of the breakpoint estimates were computed with the procedure of clegg et al. ( ) which is implemented in the r package segmented. finally, we used a smooth regression to visualize the patterns of changes over time (harrell, ) (e.g., for air transport, modularity, etc.). increase in global measures of mobility and gdp. the increase in measures of mobility during the anthropocene has been staggering, with growth percentages of up to % (table ) . many more impressive local and regional examples exist, see, e.g., (wilson, ; wilson, ) . for further analyses below, we only used the world bank data on flight passengers and air freight; therefore, we detail them here. since the s, the total global number of flight passengers ( increase in the number of outbreaks. since the s, the annual total outbreak number ( fig. d ), the annual total disease number (fig. e) , and the annual total country number ( fig. f ) have increased exponentially. however, for the annual total disease number, this increase has slowed since the s. while there is some annual up-and-down variation, the overall trends are well demonstrated by the smooth line regressions. furthermore, around , the trends for the three variables began a decrease or stagnation in the actual data, but not in the smooth line regressions. we also plotted all the annual centrality values for each nation within six regions. despite a large amount of variation over the investigated time period, the three north american countries had the highest mean of centrality values, followed by the three pacific countries and then the european, south american, asian and african countries (fig. ). these differences in centrality between the six regions are statistically significant (kruskal-wallis χ = . , df = , p = . e- ). our results further support the hypothesis that the anthropocene is associated with to a great acceleration of infectious disease risks. first, we showed that the number of disease outbreaks, the number of diseases involved in these outbreaks, and the number of countries affected have increased during the entire anthropocene (thus expanding on the results of previous studies which were more limited in time or space, e.g., morand et al., ; morand et al., ; smith et al., ; morand, ) . furthermore, these increases have mostly been exponential, although with some recent slowdowns (see discussion below). second, we demonstrated that the spatial distribution of these outbreaks has become more globalized in the sense that the overall modularity of the disease networks across the globe has decreased since around . in other words, clusters of disease outbreaks began to increasingly become connected with other clusters so that the fragmented nature of outbreak clusters diminished over time. before , a disease outbreak usually remained confined to one or a few closely connected countries; thereafter, disease outbreaks have become increasingly pandemic in their nature. we thus revealed a long-term, worldwide change in the biogeographic structure of human infectious diseases associated with outbreaks. we further found that this decrease in modularity is correlated with the increase in air traffic. the increase in global mobility and especially in air traffic (table ) allows an outbreak to rapidly spread across several national and continental borders within a short period of time (see also results from modelling and real-world data below). third, we demonstrated which countries and regions are most central within these disease networks. countries which are more centrally located within these disease networks tend to be also the more developed and emerging countries with significantly higher gdps. therefore, one cost of increased global mobility (which is currently tightly linked to economic growth and globalization, see discussion below) is the increased risk of disease outbreaks and their faster and wider spread (although we note that the risk per capita may be decreasing, smith et al., ) . before we discuss the implications of our results, we address possible limitations and biases. while gideon is generally acknowledged to be the most complete, reliable, and up-to-date global dataset on infectious disease outbreaks, we nevertheless should consider that ( ) there may have been some underreporting in the early part of the anthropocene, and ( ) recent outbreaks may not have been entered into gideon yet. ( ) there may have been some underreporting of infectious disease outbreaks during the early parts of the anthropocene in developing countries. however, the imposition in the s of the so- while we cannot exclude the possibility of some underreporting of disease outbreaks during the early part of the anthropocene, it is rather unlikely that the large increases of several hundreds of percent which we documented in figures d-f are entirely due to underreporting. since the overall trends are so consistent and so large over a relatively long period of time, we argue that these trends are real even if the actual numbers may be off by a few percentage points. ( ) the recent slowdowns shown in figures d-f could be real or due to the most recent outbreaks not having been entered into gideon yet. if they are real, they are not really influencing the overall decade-long trends documented here. however, if they are due to underreporting, then the documented trends would be even stronger. although it is generally acknowledged that correlation does not prove causation, the correlation between air travel and modularity specifically (fig. ) , and the relationship between increased mobility and the faster and wider spread of disease outbreaks (table , figures and ) in general make sense given theoretical models and real-world evidence (see discussion below). however, we acknowledge that other factors may be responsible, especially variables which may covary with mobility measures. further causal analyses are therefore required, but these are beyond the scope of this study. the starting point of a disease outbreak is due to a variety of local conditions or factors (morand and lajaunie, ; morand and figuié, ) . however, after emergence, the local, regional, or global spread of a disease is of course dependent on many other factors of which host mobility is usually one of the most important ones. this is of course especially true for directly transmitted human pathogens (walther and ewald, , and studies cited below), although mobility of humans as well as vectors are also important for the global spread of vector-borne diseases (tatem et al., ; brown et al., ; eritja et al., ; golnar et al., ; oliveira et al., ) . theoretical models predict that increased mobility leads to a faster and more wide-ranging spread of a disease outbreak, and, vice versa, decreased mobility slows and contains the spread of an outbreak. modelling the spread of the sars-cov- pandemic, hufnagel et al. ( ) demonstrated that two control strategies, shutting down airport connections and isolating cities, reduced the spread of the virus. drastic travel limitations also delayed a pandemic by a few weeks in a model of the global spread of influenza (colizza et al., ) . similarly, increasing levels of ( ) isolation of infectious hosts, household quarantine and related behavioral changes which reduce transmission rates and ( ) air traffic reduction increasingly slowed the global spread of influenza, although the latter control strategy required the almost complete halt of global air traffic (cooper et al., ; ferguson et al., ; flahault et al., ; hollingsworth et al., ; epstein et al., ; bajardi et al., ) . epstein et al. ( ) emphasized that a combination of both control strategies would be even more effective, a result mirrored by mao ( ) for a model at the city scale. crucially, hollingsworth et al. ( ) also showed a significant decrease in the number of countries affected if travel reductions are combined with other control strategies to reduce transmission rates. this result was confirmed by cooper et al. ( ) and flahault et al. ( ) who found that fewer cities (distributed around the world) were affected by major outbreaks if sufficiently early and significant travel and transmission reductions were implemented. in a simulated smallpox attack, even gradual and mild behavioral changes had a dramatic impact in slowing the epidemic (del valle et al., ) . another model suggested that public health policies that encourage self-quarantine by infected people can lower disease prevalence (chen et al., ) . real-world examples also demonstrate the link between increased mobility and faster disease outbreaks. real data on influenza in the usa showed that a reduction in air travel resulted in a delayed and prolonged influenza season (brownstein et al., a; brownstein et al., b) . similarly, the presence of airports and railway stations significantly advanced the arrival of influenza during the pandemic in china (cai et al., ) . global connectivity due to air traffic allows an outbreak to rapidly spread across several national and continental borders within a short period of time. for example, the ebola virus outbreak was brought into the continental usa onboard a commercial flight from liberia because the host was asymptomatic during the flight (cdc, ) . sevilla ( ) reviewed and modelled how air travel can aid the global spread of ebola, h n influenza, sars-cov- , and pneumonic plague. a systematic review of the effectiveness of travel reductions concluded that internal travel restrictions as well as international border restrictions both delay the spread of influenza epidemics (mateus et al., ) . therefore, given the staggering global increase in global mobility during the anthropocene documented in table , the increase of the number of disease outbreaks, of diseases involved in these outbreaks, and of countries affected, as well as the decrease of modularity of these disease outbreaks make sense because the mobility of humans, other living beings, and goods (which can act as carriers or vectors) all facilitate the spread of disease and species (e.g., smith and guégan, ; findlater and bogoch, ; sardain et al., ) . given the lack of any antiviral or vaccine treatment, the current sars-cov- pandemic has forced governments to drastically curtail people's mobility and introduce continent-wide social distancing and lockdowns in order to at least slow its spread by lowering transmission rates. thus, the governments' responses to this acute global health emergency actually mirror many of the recommendations which were given by the various modelling studies cited above. it should also be noted that the restriction of people's mobility (and its most extreme form, quarantine) and social distancing were already used before the advent of the germ theory of disease and are even used to some extent by other species (hart, ; tognotti, ; bashford, ) . given the link between mobility and disease outbreaks documented by our study, the key question which decision-makers and society at large should ask are which of the following three scenarios (which we outline in very broad terms only) should we aim for in the coming decades. ( ) once the current sars-cov- pandemic is over, we continue on our path of ever increasing mobility without regard to the costs in terms of the accelerated infectious disease risk. ( ) we attempt to slow down or even reverse mobility rates of infected hosts and vectors. ( ) we attempt to slow down or even reverse mobility rates of humans and other carriers and vectors (in other words, decrease many or all of the mobility measures in table ). we briefly discuss the implications of each scenario. however, this discussion is by no means exhaustive, but meant to stimulate further discussion and study which are urgently needed to come to terms with the accelerated infectious disease risk of the anthropocene. ( ) most likely, at least in the short-term, economic and political decision-makers will return to 'business-as-usual' which means increasing mobility rates even further. after all, various projections predict more immense increases of mobility within the next few decades. for example, international tourist arrivals worldwide are expected to increase by . % a year between and to reach . billion by (unwto, ) from the . billion recorded in (table ) in addition to the environmental and social costs and risks of this scenario (e.g., increasing landuse change, greenhouse gas emissions, resource use and waste production, etc.), including the risk of widespread ecosystem collapse (see introduction), we can now add the cost of an increasing infectious disease risk. while our study only focused on human infectious diseases, this cost related to increased mobility is also increasing for animal and plant disease outbreaks as well as alien species introductions (e.g., anderson et al., ; fisher et al., ; bélanger and pilling, ; sardain et al., ) . while outbreaks of animal and plant diseases may be amenable to a cost- benefit analysis (tildesley et al., ) , the current sars-cov- pandemic has clearly shown that simple cost-benefit analyses cannot be applied when the lives of millions of people are at stake (note that another emerging infectious disease, the global hiv pandemic, has claimed million lives so far). given that another pandemic becomes more likely with increasing rates of emergence and increasing global mobility, a 'business-as-usual' scenario is automatically associated with further epidemics and pandemics, possibly killing further millions of humans and devastating local and regional economies or even the global economy. if a 'business-as-usual' scenario is followed with regards to global mobility, countries and the world community should at least invest in better detection and surveillance methods to catch and contain the next pandemic as early as possible, and in better preparedness of public health facilities in case the next pandemic nevertheless gets out of hand (jain et al., ; bedford et al., ; di marco et al., ) . however, this scenario nevertheless will likely be associated with an increased number of epidemic outbreaks (some of which may become devastating pandemics), given the results of our study. ( ) consequently, the most realistic and agreeable scenario may be to slow down or even reverse the mobility rates of infected hosts and vectors. again, the current sars-cov- pandemic has demonstrated that identifying infected hosts and reducing secondary infection rates caused by these infected hosts appear to be the most successful strategies to achieve elimination of the outbreak (e.g., . the required measures, such as mass home quarantine, restrictions on travel, expanded testing and contact tracing, and additional surveillance measures, are thus mostly focused on ( ) identifying and isolating infected hosts (which means to drastically restrict their mobility) and ( ) drastic restrictions of mobility for uninfected hosts. while the latter is possible in crisis situations, it cannot be a long-term solution to the quandary of the increased infectious disease risk of the anthropocene unless we want to decrease our total global mobility (see scenario below). therefore, much improved identification and isolation infected hosts may be the way forward. already, such measures have been adopted during the current sars-cov- pandemic, e.g., body temperature checks for every air travel passenger even though they appear to be ineffective (cohen and bonifield, ) . however, if efficient and reliable health checks which can identify various diseases and which can be administered relatively timeand cost-efficiently to large numbers of passengers could be implemented, we may be able to significantly restrict the mobility of infected hosts. while such a proposal may sound like "pie in the sky" at the moment, rapid advances in diagnostic techniques, such as translational proteomics, may soon allow us to identify infected hosts using simple breathalyzer, saliva, or urine tests (athlin et al., ; nakhleh et al., ; tao et al., ; zainabadi et al., ) . furthermore, hygienic measures, such as the enforcement of handwashing and the wearing of facemasks in public transport hubs, complete and regular disinfection of important traffic hubs and vehicles (including the air and all surfaces), and much better vector control should become mandatory global standards of public health (e.g., grout and speakman, ; nicolaides et al., , reviewed in huizer et al., , especially in the most central of traffic hubs, such as the world's most connected airports (guimerà et al., ; bajardi et al., ) . such measures would certainly help to decrease the mobility of infected hosts and thus the transmission and global spread of diseases. ( ) the most sustainable scenario is, however, to decrease or even reverse global mobility rates of humans and other carriers and vectors, especially if it is part and parcel of a much larger movement towards global sustainability by reducing humanity's environmental footprint and replacing unsustainable economic growth with sustainable economic degrowth (schneider et al., ; daly and farley, ; alexander, ; czech, ; galaz, ; cosme et al., ; weiss and cattaneo, ; chiengkul, ; sandberg et al., ; schmid, ) . such a general, comprehensive and global slowdown of mobility of both uninfected and infected people and vectors would be opposed for many reasons and by many interest groups, mainly based on economic arguments based around the need for continuous economic growth which has so far almost always been positively linked with increased mobility (e.g., arvin et al., ; hakim and merkert, ; unwto, ; saidi et al., ; nasreen et al., ) . it is to some extent possible to decouple mobility from economic growth (loo and banister, ; lane, ) , but even if such a decoupling was achieved, it would not sufficiently reduce mobility to significantly decrease infectious disease risks. as the modelling results cited above and the experience with the current sars-cov- pandemic clearly show, only a huge reduction in mobility and contact rates is sufficient to achieve a slowdown or halt of a highly contagious disease outbreak which is already under way. yet, a decrease in global levels of mobility should also decrease the overall number of disease outbreaks, according to our results (which is different to just slowing and containing the spread of an outbreak, see discussion above). therefore, the many environmental benefits of economic degrowth and deglobalization would be augmented by a global health benefit, the almost certain decrease of infectious disease outbreaks. since economic degrowth and deglobalization have been advocated by many sustainability experts to deal with the currently converging environmental crises (climate change, ocean acidification, biodiversity, etc., see references above), our results further strengthen the argument for such a 'not-business-as-usual' scenario. moreover, the economic degrowth scenario would also ameliorate many of the local conditions or factors associated with the emergence of outbreaks (such as increased livestock production and contact rates with wildlife, climate change, loss and fragmentation of natural habitats caused by urbanization and agricultural intensification, etc.) thus further decreasing the likelihood of disease outbreaks. in addition, we have a growing understanding that the presence of abundant biodiversity and healthy ecosystems has an overall positive effect on human well-being and health (chivian and bernstein, ; wood et al., ; sandifer et al., ; walther et al., ; morand and lajaunie, ; mcmahon et al., ) which should count as an additional health benefit of the economic degrowth scenario. naturally, decreasing mobility is a moral and political choice which can be informed by science, but not answered by science. however, given all the current negative impacts of high mobility (greenhouse gas emissions, land-use and land-cover change and the resulting habitat loss and fragmentation due to transportation infrastructure and energy production, transport of alien species, etc.), maybe it is time to ask whether it is morally justified, for example, to move the equivalent of all the inhabitants of a small town across a continent so that a football team can be supported by its fans during an away game? is it necessary to fly halfway around the world for a weekend shopping trip? is it really most cost-efficient for supply chains to cover the entire globe when all the externalities are included? is long-term sustainability achievable with ever higher rates of mobility? the demand for ever-increasing mobility is putting many stresses on the earth system and therefore also on many aspects of human well-being and health. in this study, we documented another one: the public health risks of an increasing number of disease outbreaks and their increasingly global spread. even without the devastating current impacts of the sars-cov- pandemic, the additional disease outbreak burden associated with our highly mobile and migratory human societies is a definite cost which must be considered in its moral and ethical implications as we consider the future trajectory of the anthropocene (ehrlich and ehrlich, ; steffen et al., ; schill et al., ) . the medicine that might kill the patient: structural adjustment and its impacts on health care in bangladesh planned economic contraction: the emerging case for degrowth emerging infectious diseases of plants: pathogen pollution, climate change and agrotechnology drivers host centrality in food web networks determines parasite diversity transportation intensity, urbanization, economic growth, and co emissions in the g- countries comparison of the immuview and the binaxnow antigen tests in detection of streptococcus pneumoniae and legionella pneumophila in urine human mobility networks, travel restrictions, and the global spread of h n pandemic elimination: what new zealand's coronavirus response can teach the world. the guardian new zealand's elimination strategy for the covid- pandemic and what is required to make it work approaching a state shift in earth's biosphere food security and sociopolitical stability mutualistic networks quarantine: local and global histories a new twenty-first century science for effective epidemic response the state of the world's biodiversity for food and agriculture. fao commission on genetic resources for food and agriculture assessments fast unfolding of community hierarchies in large network eigenvector-like measures of centrality for asymmetric relations forecasting potential emergence of zoonotic diseases in south-east asia: network analysis identifies key rodent hosts habitat fragmentation alters the properties of a host-parasite network: rodents and their helminths in south-east asia impacts of ocean acidification on marine seafood the hidden geometry of complex, network-driven contagion phenomena assessing the risks of west nile virus-infected mosquitoes from transatlantic aircraft: implications for disease emergence in the united kingdom. vector-borne zoonotic dis air travel and the spread of influenza: authors' reply empirical evidence for the effect of airline travel on inter-regional influenza spread in the united states roles of different transport modes in the spatial spread of the influenza a(h n ) pandemic in mainland china cdc and texas health department confirm first ebola case diagnosed in the u accelerated modern human-induced species losses: entering the sixth mass extinction public avoidance and epidemics: insights from an economic model the degrowth movement: alternative economic practices and relevance to developing countries sustaining life: how human health depends on biodiversity estimating average annual per cent change in trend analysis no us coronavirus cases were caught by airport temperature checks. here's what has worked modeling the worldwide spread of pandemic influenza: baseline case and containment intervention the role of the airline transportation network in the prediction and predictability of global epidemics delaying the international spread of pandemic influenza assessing the degrowth discourse: a review and analysis of academic degrowth policy proposals supply shock: economic growth at the crossroads and the steady state solution ecological economics: principles and applications effects of behavioral changes in a smallpox attack model the role of ecotones in emerging infectious diseases sustainable development must account for pandemic risk spreading dead zones and consequences for marine ecosystems global drivers of human pathogen richness and prevalence can a collapse of global civilization be avoided? from sars to covid- : a previously unknown sars-cov- virus of pandemic potential infecting humans-call for a one health approach. one health controlling pandemic flu: the value of international air travel restrictions direct evidence of adult aedes albopictus dispersal by car strategies for mitigating an influenza pandemic human mobility and the global spread of infectious diseases: a focus on air travel emerging fungal threats to animal, plant and ecosystem health strategies for containing a global influenza pandemic dissecting global air traffic data to discern different types and trends of transnational human mobility global environmental governance, technology and politics: the anthropocene gap duality of interaction outcomes in a plant-frugivore multilayer network scientists are sprinting to outpace the novel coronavirus global infectious disease and epidemiology online network quantifying the potential pathways and locations of rift valley fever virus entry into the united states centrality measures and the importance of generalist species in pollination networks are we there yet? in-flight food safety and cabin crew hygiene practices the worldwide air transportation network: anomalous centrality, community structure, and cities' global roles the causal relationship between air transport and economic growth: empirical evidence from south asia regression modeling strategies: with applications to linear models, logistic and ordinal regression, and survival analysis behavioural defences in animals against pathogens and parasites: parallels with the pillars of medicine in humans urbanization and disease emergence: dynamics at the wildlife-livestock-human interface coral reefs under rapid climate change and ocean acidification will travel restrictions control the international spread of pandemic influenza? forecast and control of epidemics in a globalized world usefulness and applicability of infectious disease control measures in air travel: a review iata annual review fifth assessment report (ar ). intergovernmental panel on climate change shipping statistics and market review itf transport outlook ecological extinction and evolution in the brave new ocean planning for large epidemics and pandemics: challenges from a policy perspective spillover and pandemic properties of zoonotic viruses with high host plasticity global trends in emerging infectious diseases keystone species and food webs antibiotic and pesticide susceptibility and the anthropocene operating space stalls in africa's fertility decline partly result from disruptions in female education impacts of biodiversity on the emergence and transmission of infectious diseases the outcomes of old myths and the implications of new technologies for the sustainability of transport climate tipping points -too risky to bet against two billion and rising: the global trade in live animals in eight charts. the guardian decoupling transport from economic growth: extending the debate to include environmental and social externalities novel coronavirus (sars-cov- ) epidemic: a veterinary perspective evaluating the combined effectiveness of influenza control strategies and human preventive behavior effectiveness of travel restrictions in the rapid containment of human influenza: a systematic review ecosystem change and zoonoses in the anthropocene the great acceleration: an environmental history of the anthropocene since diversity and origins of human infectious diseases emergence of infectious diseases: risks and issues for societies biodiversity and health: linking life, ecosystems and societies confronting emerging zoonoses: the one health paradigm climate variability and outbreaks of infectious diseases in individualistic values are related to an increase in the outbreaks of infectious diseases and zoonotic diseases estimating regression models with unknown break-points segmented: an r package to fit regression models with broken-line relationships human health impacts of ecosystem alteration diagnosis and classification of diseases from subjects via pattern analysis of exhaled molecules long-run causal relationship between economic growth hand-hygiene mitigation strategies against global disease spreading through the air transportation network a quantitative risk assessment (qra) of the risk of introduction of the japanese encephalitis virus (jev) in the united states via infected mosquitoes transported in aircraft and cargo ships in the wake of structural adjustment programs -exploring the relationship between domestic policies and health outcomes in argentina and uruguay structure and evolution of weighted networks unhealthy landscapes: policy recommendations on land use change and infectious disease emergence global trends in lifespan inequality causal inference in disease ecology: investigating ecological drivers of disease emergence ongoing worldwide homogenization of human pathogens biodiversity loss affects global disease ecology mobility, vehicle fleet, energy use and emissions forecast tool (moveet) the r project for statistical computing. r foundation for statistical computing world scientists' warning of a climate emergency emerging human infectious diseases and the links to global food production summarizing the evidence on the international trade in illegal wildlife the long-run relationships between transport energy consumption, transport infrastructure, and economic growth in mena countries green growth or degrowth? assessing the normative justifications for environmental sustainability and economic growth through critical social theory exploring connections among nature, biodiversity, ecosystem services, and human health and well-being: opportunities to enhance health and biodiversity conservation global forecasts of shipping traffic and biological invasions to a more dynamic understanding of human behaviour for the anthropocene degrowth and postcapitalism: transformative geographies beyond accumulation and growth crisis or opportunity? economic degrowth for social equity and ecological sustainability. introduction to this special issue sold into extinction: the global trade in endangered species germs on a plane: the transmission and risks of airplane-borne diseases conventional thinking will not solve the climate crisis. the guardian global rise in human infectious disease outbreaks changing geographic distributions of human pathogens globalization of human infectious disease the trajectory of the anthropocene: the great acceleration planetary boundaries: guiding human development on a changing planet trajectories of the earth system in the anthropocene maritime economics a saliva-based rapid test to quantify the infectious subclinical malaria parasite reservoir global traffic and disease vector dispersal identifying compartments in presence-absence matrices and bipartite networks: insights into modularity measures the role of movement restrictions in limiting the economic impact of livestock infections lessons from the history of quarantine, from plague to influenza a anthropogenic pressure on the open ocean: the growth of ship traffic revealed by altimeter data analysis habitat modification alters the structure of tropical host-parasitoid food webs united nations, department of economic and social affairs, population division unctad, . unctad handbook of statistics . united nations conference on trade and development review of maritime transport unctad, b. unctad handbook of statistics . united nations conference on trade and development global environmental outlook geo- . united nations environment programme radical goals for sustainable development unwto tourism highlights. edition. world tourism organization (unwto) unwto, . unwto tourism highlights. edition. world tourism organization (unwto) unwto, . tourism towards . global overview. world tourism organization (unwto) the millennium development goals: a cross-sectoral analysis and principles for goal setting after the radical rebuilding of societies biodiversity and health: lessons and recommendations from an interdisciplinary conference to advise southeast asian research, society and policy pathogen survival in the external environment and the evolution of virulence annual world airport traffic forecasts - degrowth -taking stock and reviewing an emerging academic paradigm distinct spread of dna and rna viruses among mammals amid prominent role of domestic species disease ecology and the global emergence of zoonotic pathogens travel and the emergence of infectious diseases population movements and emerging diseases does biodiversity protect humans against infectious disease? air transport, freight (million ton-km) air transport maritime highways of global trade maritime logistics: a complete guide to effective shipping and port management an efficient and costeffective method for purification of small sized dnas and rnas from human urine development and poverty reduction: a global comparative perspective a pneumonia outbreak associated with a new coronavirus of probable bat origin this work was part of thefuturehealthsea project funded by the french anr (anr- -ce - - ). s.m. is supported by the thailand international cooperation agency (tica) "animal innovative health". we sincerely thank dieter stockmann from the institute of shipping economics and logistics (isl) and claire thackeray from container trades statistics (cts) for providing data about container movements, jean tournadre for providing data about ship numbers, and ting-wu chuang for providing references. traffic vehicles for transportation < to > million motor vehicles (> %) (steffen et al., a) - international tourism < to > million arrivals (> %) (steffen et al., a) table are approximations whenever numbers are given with a ~, < or > sign because these numbers were taken from graphs in steffen et al. ( a) and isl ( ). abbreviations: dwt = deadweight tonnage is a measure of how much weight a ship can carry; mt = metric ton; teu = twenty-foot equivalent unit, a standard size for . m long containers. key: cord- -bcyotwkf authors: alkire, sabina; chen, lincoln title: global health and moral values date: - - journal: lancet doi: . /s - ( ) - sha: doc_id: cord_uid: bcyotwkf nan shaped differently depending on the morals espoused. a rights-based or equity approach, for example, would be expected to differ from a utilitarian or humanitarian approach. also, an initiative is only partly justified by its moral expediency. of critical importance are factors shaped by knowledge and by institutional interests. moral soundness about why particular global programmes should be advanced may need to be balanced against the imperative of achieving consensus among people of many different moral views. yet, as we argue in the conclusion, moral clarity-as well as knowledge and institutional interests-can usefully shape what, when, and how health initiatives should best proceed. to stimulate discussion, we have selected four major schools of moral values commonly used to justify global health initiatives: humanitarianism, utilitarianism, equity, and rights. we could have analysed other schools, but these four, we believe, encompass a good range of moral positions. there are, of course, both large and important variations within each school. the appeal for charitable acts to meet pressing humanitarian needs is arguably the most common ethical basis for global health action. humanitarianism can be a form of virtue ethics but it also often a humanistic response to evident social problems. the ethos of humanitarianism is embedded in nearly all religions. in a humanitarian approach, people respond to human suffering and realise human fulfilment by acting in a virtuous manner based on compassion, empathy, or altruism. the virtues might be specific or broad. examples of specific acts are charitable tithing among baptists or zakat (charitable donations) among muslims. broadly proscribed virtues encompass such human qualities as generosity, honesty, trustworthiness, integrity, and fairness. among the wealthy, these virtues might be expressed as philanthropy, which often focuses on health. humanitarianism provides the primary ethical basis of voluntary action undertaken by non-governmental organisations (ngos), and is also an important base of public support for official foreign aid. us president george bush in announcing us$ billion in assistance for hiv/aids control described the pledge as a "work of mercy". public opinion polls in the usa consistently show that alleviating world hunger and providing drinking water are worthy of foreign aid from the usa. emphasis on voluntary generosity and self-expression (rather than on duties or obligations) gives humanitarianism a broad appeal to many social groups, corporations, and governments. contemporary appeals to people's humanitarian impulses focus on the giver: who a person becomes by acting well, and how a person realises a sense of accomplishment or fulfilment. there are dangers that those who are helped can be placed in a dependent position, treated as victims not agents. also, the underlying societal rules and structures that generate the social ills are not necessarily addressed. this approach might be more relevant to humanitarian catastrophes than structural approaches that attempt to correct the root causes of social problems. in a utilitarian framework, the value of health is determined by the subjective utility (happiness, pleasure, or desire satisfaction) that it creates for an individual. across all individuals in a society, the ideal state is one that maximises the aggregate utility. health could be valued because it generates utility directly, or because good health is instrumental to other utilitygenerating states, including opulence, or both. many contemporary health policies are based on a form of utilitarianism in which good health is valued as instrumental to maximising aggregate utility. for example, the who commission on macroeconomics and health calculated the costs and benefits of burdens of disease and argued that investing in health would generate economic growth, thereby enhancing incomes and aggregate utility. the utilitarian approach underscores important interconnections between health and other variables. it can show how improving the health of the deprived can be "in everybody's interest"-including the self-interest of people not inclined to altruism. its difficulties, however, are several. first, the instrumental valuation of health demeans it as an intrinsically valued goal in all societies. second, people's self-assessments do not www.thelancet.com vol september , rights were not granted to include this image in electronic media. please refer to the printed journal. necessarily match their observed health status. for example, the self-reported morbidity rates in the indian state of kerala, where life expectancy is - years, are significantly higher than in bihar, where life expectancy is significantly lower; and self-reported morbidity in the usa is higher still. third, it is rather difficult, even theoretically, to aggregate very different kinds of utility together into a single entity. finally, a utility-maximising approach is not directly sensitive to distributional concerns. equity is a relational concept in which ethical assessments are-at least in part-based on distributional features of one or more variable. fortunately, considerable intellectual work has recently been done on health equity and social justice. , building on the work of political philosopher john rawls, amartya sen has addressed some key features of health equity. first, he poses the question of "equity of what?" should equity be evaluated with reference to health achievement or access to health care? sen argues that equity in health should be assessed in terms of health capabilities and achievements rather than healthcare activities. after all, health care is a human activity; what people actually value is the capability to attain good health. he further notes that equitable social processes should inform evaluations of equity in the health space. in some equity domains, such as gender, completely equal distribution of health achievement could be considered unfair because women-whose lifespan in the absence of gender discrimination exceeds that of men-should, under an equity framework, enjoy longer life expectancies. an equity-based evaluation considers not only allocation of a fixed set of health resources, but also allocation of resources between health and other social objectives. equitable approaches to health have carried considerable power in mobilising support for health components of international development. striking disparities in health achievement and emotively powerful arguments of preventable suffering can animate the public and political leaders. an example is the recent call for public funds to expand antiretroviral treatment to hiv-positive people in poor countries. the disparity between the health of those with access to lifesaving drugs and the avoidable deaths among all others evokes the moral imperative to alleviate preventable human suffering caused by the inequitable access to antiretroviral drug therapy. human rights in health are embedded in several un declarations, and they have deep and wide moral bases. legal formulations were created to specify what was argued in the th century to be an inalienable moral claim grounded in the ontological dignity of human beings. human rights can be described as "things which are owed to man because of the very fact that he is man". some human rights can be expressed in the space of capabilities-for example rights to health, or to inclusion. yet rights also add to the capability perspective by invoking duties and obligations on the part of others. because each human being is recognised as an "end", human rights demand obligatory behaviour on the part of the state, firms, groups, and individuals. obligations may be "perfect" (as enshrined in law) or "imperfect" (a general duty to do what one can to help). calls for a rights-based approach to global health have recently grown. extensions of human rights to children and women both contain references to freedom from preventable suffering and freedom to exercise health choices. , the application of human rights to good health has drawn attention to the duties and obligations that people and institutions have towards human beings, viewed squarely as an "end" worthy of dignity. a human rights approach often assumes some health minimum that all people should be able to realise for human dignity. the challenge is to implement the corresponding "incomplete obligations" among communities, institutions, and states where good health depends upon resources, knowledge, technologies, and social action. these ethical schools do not track precisely to any specific health initiative. none of the schools dominates any specific health action, and several schools are often relevant to any single initiative. at present, whether the by initiative was evaluated according to aggregate utility (increasing the utility of people with hiv/aids) or distributional equity (increasing the numbers of people in developing countries who are given antiretroviral treatment), human rights (for health care), or the need www.thelancet.com vol september , rights were not granted to include this image in electronic media. please refer to the printed journal. for humanitarianism (to alleviate the suffering of those with hiv/aids), in all cases action is morally imperative. ensuring a minimal threshold of health might similarly fit well with humanitarianism and human rights, and equity and justice values will require action on behalf of the most disadvantaged. beyond moral values, the selection of global health initiatives is shaped by other, often implicit but no less valid, factors. among these are knowledge and institutions. to a large degree, ethical assessments will rest not only on the ethical perspective chosen, but also on the information selected for examination. the selection of information is shaped by political and scientific forces as well as by moral theories. paul farmer has written eloquently about the selective scrutiny of information that shapes health action. tuberculosis, especially multidrug-resistant tuberculosis, became recognised as a health crisis when it achieved rapid transmission in new york city. yet tuberculosis-before, during, and after the new york crisis-kills million people annually, most of whom are poor. because of informational selectivity, tuberculosis is a silent crisis among the world's poor, invisible to the rich and powerful. similarly, severe acute respiratory syndrome (sars) achieved front-page news because of its lethal nature and the paralysing effect it had on global commerce. yet, "sars-like" health catastrophes take place daily in thousands of rural villages in low-income countries. these health problems likewise severely affect families and communities, who are invisible to better-off and protected communities. scientific knowledge provides the basis for research and development of health technologies, such as vaccines and drugs. breakthroughs in health research raise moral challenges because they make feasible treatment for conditions that were hitherto incurablefor example, antiretroviral drugs for hiv. morally, there is a big difference between inevitable human calamity and suffering that can be prevented by modern technology. growing knowledge gaps between technological potentiality and health realities present huge ethical challenges. contention is further fuelled if the gap is accentuated by commercial interest. recent debates over affordable access to life-saving antiretroviral drugs have focused on the fairness of international regimes of intellectual property rights that are perceived to favour commerce over human health. global health, like other fields, has a cluster of institutional stakeholders. governments and intergovernmental agencies like the un and the world bank are mandated to play technical, financial, and operational roles. since health is a major component of the global economy, corporations have interests in profits as well as in protecting their public reputations. civil society organisations have many roles, ranging from the direct delivery of services to advocacy on public policies. institutions, like all actors, are endowed with certain capabilities and also seek to advance their bureaucratic, political, and financial agendas. one typical driver of organisational behaviour is to gain command over resources that can translate into more jobs, higher status, and more numerous activities. tracking of financial flows in global health initiatives can help reveal institutional winners and losers. historical studies have examined these institutional motivations in global health. the work of the rockefeller foundation overseas, for example, was often linked to corporate interests and political propagation of capitalism. in an excellent historical analysis of tuberculosis control in mid- th century, sunil amrith postulated that the conduct of tuberculosis programmes was primarily shaped by the state of knowledge and the capabilities of global institutions. field research had shown that directly observed therapy (dots) was highly effective in curing tuberculosis in home-based settings. endowed with new knowledge, yet limited by institutional capacity and scarce funding, who decided to pursue tuberculosis control through vertical programmes involving cadres of specifically tasked field workers rather than attempt to build holistic villagebased primary services. the latter approach would have been far more demanding institutionally and financially. a common usage of moral values is to mobilise public support. sometimes, however, advocates of global health do not give an accurate representation of distinct ethical schools, simply because they want everyone to agree. braveman and groskins, for example, argued that the concepts of equity and rights are essentially identical, and lead to similar strategies. their aim seems to have been advocacy for certain types of health actions rather than for clarification of distinctive moral schools. de cock argued that a public health rather than a human rights approach should frame responses to hiv/aids in africa, but again this analysis is based on a very narrow example of both ethical schools. we argue that clarity in thinking is essential, because different moral schools do indeed raise distinct considerations and it can be useful to evaluate these carefully. at the same time, the urge to seek consensus is also valid, and can be sought without either exaggerating differences, or claiming (inaccurately) that differences between moral schools do not exist. a common usage of moral values is advocacy, often to rich and powerful leaders, institutions, and nation states with the goal of mobilising resources-finance, political will, human motivations-on behalf of particular health action. but here we run into an apparent paradox: how can one use moral values as advocacy tools, when the moral schools are distinct, and when people argue passionately among them? in order to achieve the support, global health programmes also must build consensus among a diverse constituency of resource-holders as to the central value of the initiative. so when it comes to the language of why support for global health is important, we recognise, with cass sunstein, the wisdom of seeking "incompletely theorized agreements" in the moral discourse surrounding global health. in his tanner lectures in human values, sunstein argued that in some cases consensus can be achieved if participants refrain from elaborating their moral positions, because if they scrutinised these positions in depth, consensus could fracture. by contrast, he advocates an approach that "enlists silence, on certain basic questions, as a device for producing convergence despite disagreement, uncertainty, limits of time and capacity, and heterogeneity". sunstein's approach has the advantage of opening space for dialogue, exchange, and discussion, thereby promoting deliberative democracy, political accountability, and reason-giving. incompletely theorised agreements satisfy diverse constituencies who might have very different reasons, including incompatible values, for supporting a particular activity. there is a further point against requiring everyone to agree on only one ethical justification for global health. for not only might different approaches appeal to different groups, different people might also have distinct understandings of what the terms "rights", "equity", or "humanitarianism", actually mean. after all, the support base of global health initiatives is diverse, ranging from heads of state to private-sector executives to religious leaders to activists from ngos to opinion-setters and journalists. it is highly unlikely that these constituencies will share an identical understanding of ethical terms. a global health initiative can receive emphatic support from people who do not necessarily agree on the ethical foundations for their support, and in fact may very clearly disagree with one another as to why a programme should proceed-ie, its ethical or metaphysical justification. advocates of global health initiatives would thus do well to proceed with a general appeal to moral concepts such as social justice and compassion, and this generality belies prudence rather than a lack of moral rigour. yet an eclectic appeal to moral values in order to garner support of global health initiatives is not to imply that distinctions among moral values are trivial. beyond clarifying why an action is important, adopting a particular moral approach can influence health action in other deeply important ways. first is the scope of health action. an example is the programmatic implication of pursuing access to health care versus equitable distribution of health outcomes. in the former case, the programme would invest heavily in building health clinics and outposts, and perhaps in increasing the ratio of medical personnel per citizen. this sounds very appealing until one recognises that a country may have many rural health outposts, and many doctors on salary role, but if these doctors do not turn up to work, and the outposts do not have adequate pharmaceutical supplies, the population's health outcomes might remain very poor. on the contrary, to achieve an equitable distribution of health outcomes it would be necessary to make sure that the investment in health care results in better health across the population. it would also then be necessary to address broader social determinants of health, such as that raised in michael marmot's intriguing research on the under-recognised relation between socioeconomic inequality and health. second, different ethical schools (and different groups within them) may shape how global health programmes are undertaken. charitable acts might treat people as passive recipients of generosity, whereas rights-based approaches would encourage "voice" and participation to strengthen the agency of people for achieving their inherent rights. third, advocacy might use moral values to advance a global health agenda-because they are effective in advancing a global agenda. to mobilise a compassionate response, a picture of a feeble, emaciated, and large-eyed child might be used to stir pity among donors. such advertisements tend to view the poor as helpless victims, rather than people who could be empowered to care for themselves. arguably, much harm has been done by such dehumanising advocacy techniques. yet, it could be argued that such moral approaches are legitimate to use because they are more effective in evoking public support than other moral approaches. when people speak of ethics, the contribution that most readily leaps to mind is motivational: that an appeal to moral values will motivate people to support a set of actions. yet this is only one of the ways in which moral values can support global health initiatives, and is not necessarily the most powerful. discussions on whether to frame the objective of global health initiatives in terms of access to health care, or capabilities for good health, or utility maximisation, help to clarify what global health initiatives seek to accomplish. criteria such as efficiency, or equitable treatment for men and women, clarify which alternative actions to realise similar goals should be selected. consideration of how health activities contribute to or block non-health objectives such as the support of agency, or the rights to self-determination, clarify the importance of how health initiatives are carried forward. thus global health may be far easier to achieve if we pause to follow through different moral analyses and thereby clarify what, which, and how global health initiatives can best proceed. science and the health of the poor speech at the world health assembly health at the world summit on sustainable development philanthropy and health. london: king's college introduction to the principles of morals and legislation. london: the athlone press, . who commission on macroeconomics and health. macroeconomics and health: investing in health for development health: perception vs observation inequality reexamined challenging inequities in health: from ethics to action public health, ethics, and equity why health equity? the rights of man and natural law. london: geoffrey bles, the centenary press human development and human rights: human development report convention on the rights of the child vienna declaration and programme of action informational analysis of moral principles infections and inequalities: the modern plagueupdated edition with new preface rockefeller medicine men: medicine and capitalism in america plague of poverty? the world health organization, tuberculosis and international development, c - poverty, equity, human rights and health: policy and practice shadow on the continent: public health and hiv/aids in africa in the st century legal reasoning and political conflict aristotelian justice and health policy: capability and incompletely theorized agreements is inequality bad for our health key: cord- -z j izi authors: ross, allen g.p.; crowe, suzanne m.; tyndall, mark w. title: planning for the next global pandemic date: - - journal: int j infect dis doi: . /j.ijid. . . sha: doc_id: cord_uid: z j izi in order to mitigate human and financial losses as a result of future global pandemics, we must plan now. as the ebola virus pandemic declines, we must reflect on how we have mismanaged this recent international crisis and how we can better prepare for the next global pandemic. of great concern is the increasing frequency of pandemics occurring over the last few decades. clearly, the window of opportunity to act is closing. this editorial discusses many issues including priority emerging and re-emerging infectious diseases; the challenges of meeting international health regulations; the strengthening of global health systems; global pandemic funding; and the one health approach to future pandemic planning. we recommend that the global health community unites to urgently address these issues in order to avoid the next humanitarian crisis. the west african ebola virus pandemic has shown us yet again that the world is ill prepared to respond to a global health emergency. this follows similar statements that were made after the h n outbreak in that ''the world is ill prepared to respond to a severe influenza pandemic or to any similar global, sustained and threatening public health emergency''. our response to the ebola zoonotic 'spillover' was delayed and as a result , people lost their lives in nine countries. the direct financial cost of the ebola pandemic was estimated to be in the vicinity of six billion us dollars and global economic losses over billion dollars. clearly there are lessons to be learnt from the ebola outbreak. in , following the severe acute respiratory syndrome (sars) pandemic, the international health regulations (ihr) were modified. while two thirds of the world health assembly countries have failed to comply with the regulations as of , and for the one third who say they did, there are serious concerns about the reliability of their self-assessment. now, with liberia declared free of ebola and declining incidence in sierra leone and guinea, these same regulations are once again being revisited after more than a decade. is this a futile exercise and should the ihrs be abandoned if they cannot be enforced by who and fulfilled by the world health assembly (wha) member nations? the national health systems in west africa, and for most low and middle income countries (lmics), would not meet ihr standards (despite claims by some member wha nations) and it is unlikely that following the ebola pandemic much will change. many have stated that who failed to respond to the current ebola epidemic in a timely manner but even if they did, would the outcome have been really that different? there were no drugs or vaccines available to treat and prevent the disease, thus quarantine, isolation and safe burials were the primary methods utilized to halt the spread of disease and were initiated by the afflicted nations themselves. it typically takes years if not decades to develop a vaccine or drug that will have public health impact. one only has to look at the countless billions that have been spent on trying to develop a vaccine for hiv, thus far without success. moreover, weak, malnourished, immunosuppressed populations living in poverty with little or no hygiene, sanitation or running water will always be highly susceptible to new emerging or reemerging infectious diseases. at 'ground zero' of the ebola epidemic it was believed that in , hungry children living in the remote guinean village of meliandou killed and ate infected fruit bats. , thus, what can realistically be done to prevent and contain future national epidemics from becoming global pandemics? we discuss a number of issues that urgently need to be addressed in order to plan, and possibly prevent, the next global pandemic. if one looks at the history of emerging or re-emerging infectious disease pandemics globally, on average they have appeared every decade but now, worryingly, the frequency between pandemics seems to be disturbingly shorter as evident with severe acute respiratory syndrome ( in order to mitigate human and financial losses as a result of future global pandemics, we must plan now. as the ebola virus pandemic declines, we must reflect on how we have mismanaged this recent international crisis and how we can better prepare for the next global pandemic. of great concern is the increasing frequency of pandemics occurring over the last few decades. clearly, the window of opportunity to act is closing. this editorial discusses many issues including priority emerging and reemerging infectious diseases; the challenges of meeting international health regulations; the strengthening of global health systems; global pandemic funding; and the one health approach to future pandemic planning. we recommend that the global health community unites to urgently address these issues in order to avoid the next humanitarian crisis. international journal of infectious diseases j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / i j i d human/host/reservoir interaction. weak malnourished populations in lmics serve as the breeding grounds for future pandemics ( figure ). for example, in metro manila, the most densely populated city in the world, approximately six million people live in slums with no piped water or toilets. according to who, million people in urban centres have no access to safe drinking water and over million lack sanitation. the un predicts that the world's urban population will double to over six billion by and most of the increase in density will occur in lmics. population density is directly correlated with the rate of transmission of respiratory and faecal-oral pathogens (e.g. mycobacterium tuberculosis, influenza, cholera, rotavirus, helminths). between and there were emerging infectious disease (eid) origins reported globally. figure illustrates some of the most recent eid epidemics. eids are primarily zoonotic ( %), originating in wildlife populations (e.g. hiv, sars, ebola, west nile virus, lyme disease) but bacterial pathogens have become increasingly of concern due to antibiotic resistance especially in the developing world. , multidrug-resistance (mdr) to mycobacterium tuberculosis, streptococcus pneumoniae and staphylococcus aureus are a global concern and gram-negative bacteria resistance to b-lactams is widespread. drug resistance to enteropathogens has also become a major global health challenge. mdr salmonella enterica typhi and s. enterica paratyphi are common in asia and sub-saharan africa, and there are increasing reports of reduced susceptibility to fluoroquinolones. campylobacter jejuni resistance to fluoroquinolones has become a concern in southeast asia, with rates of resistance of % reported from thailand. viral pathogens (e.g. ebola, makona variant (ebov), mers-cov, h n ) are also of concern due to their high rates of nucleotide substitution, poor mutation error-correction rate ability and capacity to quickly adapt to human hosts. table displays some potentially pandemic pathogens that should be under active global surveillance. the current outbreak of mers-cov in south korea is of grave concern given the case fatality rate is over %. surveillance of zoonotic diseases is largely based on detecting illnesses in humans who often serve as the sentinel species and dead-end hosts. apart from rabies, most national surveillance systems in the world do not monitor zoonotic diseases appearing in wildlife, yet % of zoonotic eids (e.g. anthrax, nipah virus, hantavirus, type a influenza, sars, mers-cov, ebola) come from this source. , many rna viruses have emerged and dispersed globally such as chikungunya virus, west nile virus and dengue virus. these three arboviruses alone have morbidity and mortality rates that far exceed those of the combined rates of sars, ebola and mers-cov. , thus, eid discovery efforts need to be directed toward reservoirs and vectors at the human-animal interface. the integration of human, veterinary, and agricultural medicine, as proposed by the 'one health' approach, should result in earlier warning of eids and provide us with a better opportunity to respond to potential spill-over threats. , moreover, targeting surveillance to regional hotspots of eids provides an evidencebased rationale for more appropriate allocation of global resources. the outbreak of ebola once again tested the revised ihr. according to gostin and friedman ( ) ''who fell short of its leadership responsibilities, and the ihr -the governing legal framework -displayed deficiencies''. the three west african countries involved (guinea, liberia, sierra leone) in the pandemic failed to comply with the ihrs capacity-building mandate and, to date, two thirds of wha member countries have failed to comply with the same regulations. , of the one third of the wha member nations that said they did comply, there has been no evaluation to verify their claims. , like the outbreak of h n in , the response raises questions regarding the extent to which the ihr can serve as a framework for global pandemic responses. , , if the wha member nations ( ) do not take the ihr core capacity-building requirements of disease surveillance, reporting, and response seriously, then why continue to use them as an international framework? in reality wha member nations from lmics see the regulations as an enormous obligation primarily developed to protect the health and welfare of developed nations. , during the ebola outbreak, controversy arose when american and spanish nationals were preferentially chosen to receive the experimental drug zmapp over west african nationals. moreover, when foreign medical staff became infected they were flown home for what was deemed superior medical care. clearly these ethical issues, which are well known by the wha member representatives, will impact on future ihr compliance. furthermore, member nations from lmics do not have the national capacity to adhere to ihr, given they have very weak infrastructure and poorly financed health systems. lmics must be given considerable financial and capacity building assistance or they will be unable to comply. these massive inequities must be addressed if we are to plan appropriately for the next pandemic. for most countries in the developing world it is difficult to improve their health systems to a standard that is similar to that of high-income countries. moreover, as mentioned, most lmic countries will not be able to establish core ihr capabilities without considerable donor support and international assistance for training, creating the necessary laboratory infrastructure for prompt diagnosis, and the technology required for 'real-time' reporting of epidemics. point of care screening tests for use in community health posts are increasingly available for rapid diagnosis of emerging pathogens and will shorten the time from presentation to treatment. however improvements and access to diagnostic technologies will need to be supported by the capacity to interpret and act on the findings. presently limited health-care dollars are spent on running tertiary national hospitals with little, or none, spent on preventive services, disease control or epidemic preparedness. however, most countries do have offices or departments for communicable disease control with the number of staff engaged in such full-time activities varying considerably. at the district/municipal level most developing countries have medical health officers and at the community level a considerable human resource of community health workers (chws). gostin and friedman ( ) have proposed a new global health framework with robust national health systems at its foundation and an empowered who at its apex. however, who has failed to provide the necessary leadership to coordinate global health emergencies on the ground and adequately support wha member nations to develop core ihr capacities. in september , the un assumed leadership of the ebola response and created the un mission for emergency ebola response (unmeer), the first un mission to respond to public health emergencies. in contrast with ihr recommendations, security council resolutions are legally binding for member countries. we now propose a new un centre for disease control (un cdc), potentially based in new york, to serve at the apex of a new global health framework with a number of new and existing regional cdcs reporting directly to it (figure ) . a proposed structure might be: national cdc departments reporting to their regional cdcs, and provincial/district/municipal cdc departments reporting to their national cdcs with community health workers at local health centres reporting to their municipal health officers. in sum, at the apex of our proposed global health framework would sit a new un cdc with security council authority and at the foundation, chws in local health centres. chws have transformed the health-care systems of many developing nations including bangladesh, india, ethiopia, and malawi and are absolutely crucial for future global security. on october th , world bank president, dr jim yong kim, has proposed a new pandemic emergency facility (pef). as stated on their website ''the world bank group is playing a lead role in conceptualizing the facility, working in coordination with international organizations, including the who, the private sector and other development partners. pef is a global financing facility that would channel funds swiftly to governments, multilateral agencies, ngos and others, to finance efforts to contain dangerous epidemic outbreaks before they turn into pandemics. financing from the pef will be linked to strong country-level epidemic and pandemic emergency preparedness plans, thereby incentivizing recipient governments and the international community to introduce greater rigor and discipline into crisis preparedness and reduce the potential for moral hazard. the pef is expected to cover a range of response activities such as: (i) rapid deployment of a trained and ready health care work force; (ii) medical equipment, pharmaceuticals and diagnostic supplies; (iii) logistics and food supplies; and (iv) coordination and communication. the pef would if the who contingency fund ( million us dollars) and the world bank pandemic emergency facility cannot be utilised to strengthen national health systems in lmics in order to meet ihrs core capabilities, then how can this be achieved? a multi-billion us dollar international health system fund has been proposed but considerable funding from both the private and public sector will need to be secured if the fund is to be successfully launched. the g , the european union, and philanthropic organizations will need to contribute. the implementation and monitoring of such funds at the national level will have to be carefully scrutinised and audited if the core capacities of the ihrs are to be achieved and maintained. ultimately lmic nations themselves will need to allocate health care dollars toward health prevention and epidemic planning. for many lmics this is not a priority and they are ill prepared to respond to epidemics on their own soils. building national capacity is the rate limiting step for global health security. if the international community fails to support this capacitybuilding initiative then this puts the world in a precarious situation with regard to future pandemics. it is well known in management circles that 'if one fails to plan then one should plan to fail'. with regard to pandemic planning, if we fail to build national epidemic capacities in lmics then we should plan to deal with a global pandemic in the not too distant future. however, in order to build such national capacity it will take considerable international political will that at the moment seems to be lacking. instead of allocating huge resources that 'react' to pandemics, funds must be earmarked to 'prevent' pandemics. this would include building national capacities of lmics and smart surveillance of eids in identified hotspots in the tropical and subtropical world. what are the likely organisms to cause a future pandemic and where will they originate from? zoonosis from wildlife represents the most significant global health threat of our time yet little funds are spent monitoring and identifying new zoonotic pathogens originating in wildlife. clearly a 'one health' approach is the way forward. pandemic preparedness and response-lessons from the h n influenza of a retrospective and prospective analysis of the west african ebola virus disease epidemic: robust national health systems at the foundation and an empowerd who at the apex report of the ebola interim assessment panel. who reference number: a / are we ready for a global pandemic of ebola virus? an audacious goal: the elimination of schistosomiasis in our lifetime through mass drug administration bat-filled tree may have been ground zero for the ebola epidemic outbreak of ebola virus disease in guinea: where ecology meets economy global trends in emerging infectious diseases urbanisation and infectious diseases in a global world surveillance for antimicrobial drug resistance in under-resourced countries enteropathogens and chronic illness in returning travellers surveillance and control of zoonotic agents prior to disease detection in humans factors responsible for the emergence of arboviruses ecology of zoonoses: natural and unnatural histories prediction and prevention of the next pandemic zoonosis the economic value of one health in relation to the mitigation of zoonotic disease risks the revised international health regulations: a framework for global pandemic response ebola in west africa: learning the lessons global health security: the wider lessons from the west african ebola virus disease epidemic health inequalities and infectious disease epidemics: a challenge for global health security the world bank. global pandemic emergency facility key: cord- -o rt authors: brockmann, dirk title: understanding and predicting the global spread of emergent infectious diseases date: - - journal: public health forum doi: . /j.phf. . . sha: doc_id: cord_uid: o rt abstract the emergence and global spread of human infectious diseases has become one of the most serious public health threats of the st century. sophisticated computer simulations have become a key tool for understanding and predicting disease spread on a global scale. combining theoretical insights from nonlinear dynamics, stochastic processes and complex network theory these computational models are becoming increasingly important in the design of efficient mitigation and control strategies and for public health in general. the rapid spread of sars in , the h n influenza pandemic and the emergence of mers-cov in in the middle east illustrate the increasing threat of emergent infectious diseases and their global spread to public health. massive worldwide mobility in combination with exponentially growing, dense populations increase the rate at which novel pathogens emerge and amplify the speed at which they can proliferate worldwide. compared, for instance, to the th century black death pandemic that advanced at a speed of only a - km/day (noble, ) killing - % of the european population in its wake, the h n pandemic progressed a few hundred km/day on average (brockmann and helbing, ) . given that more than million passengers travel a total approx. billion km (three times the radius of our solar system!) every day on the worldwide air-transportation network (wan), this is not surprising. global mobility has not only increased in magnitude, but also in complexity (brockmann et al., ) . the wan connects more than airports by more than links yielding a complex, intricate and multi-scale network (see fig. b ). during the last decade the development and application of high-performance computational models has become an important strategic component in understanding and mitigating disease spread on a global scale (brockmann and helbing, , hufnagel et al., , colizza et al., , van den broeck et al., . the majority of these computational approaches incorporate comprehensive data on human mobility and transportation networks. although the development of parsimonious mathematical models in the context of disease dynamics has a long history (going back to daniel bernoulli who developed the first mathematical model to resolve the figure . understanding global disease dynamics using effective distance. a: effective distance from a reference node (london heathrow) is quantified by radial distance from the origin. each node in the diagram represents one of approx. airports in the worldwide air-transportation network. the tree structure represents the most probable spreading path of a potential pandemic. effective distances and most probable paths are computed from traffic flows in the complete network. b: the entire worldwide air-transportation network. more than airports are connected by more than direct connections amounting to a total of more than billlion passengers per year. c: temporal snapshots of a simulated pandemic with initial outbreak in london. in the conventional geographic representation spatio-temporal patterns are incoherent and complex. d: the identical simulation in the effective distance representation exhibits simple, concentric wave patterns which allows immediate calculations of expected arrival times at any node in the network. th century cow-pox inoculation debate (bernoulli, ) ), modern computational models account for unprecedented detail and a multitude of factors that are believed to play a role in global disease dynamics. relying on the increasing performance capabilities of modern supercomputers, agent-based simulations and complex meta-population models have been developed that are able to model the behavior of nearly one billion individuals. while early models in this context were able to reproduce the global dynamics of e.g. the sars epidemic (hufnagel et al., ) , state-of-the art models are now able to produce reliable quantitative forecasts and projections that can help policy makers develop more efficient mitigation strategies and optimize the distribution of e.g. anti-viral drugs and vaccines (van den broeck et al., ) . one of the key features that nearly all modern computational models predict is that, unlike historic pandemics that advanced in regular wave like patterns, modern diseases spread in spatially incoherent ways due to the complexity of underlying mobility networks (see fig. c ). this makes it impossible to predict e.g. epidemic arrival times based on spreading speed and geographic distance to the outbreak location. in fact, the lack of correlation of arrival times and geographic distance requires running high performance computer simulation in the first place. however, despite their increasing sophistication and accuracy, high-performance computer simulation approaches face a number of fundamental problems. first, the complex nature of spatio-temporal patterns of disease dynamics and computer generated pandemic scenarios are still poorly understood at a fundamental level. secondly, highly detailed computer simulations that account for all possible factors that may impact disease dynamics typically come with multiple unknown parameters that must be estimated or even guessed. because disease dynamical models are typically nonlinear it is often unclear how robust predictions are with respect to errors in these parameter estimates. because detailed computer simulations are typically computationally resource demanding, systematic parameter scans cannot be performed efficiently. furthermore, when all possible factors are incorporated into these models from the start, it is generically difficult to assess in simulations which parameters are central and which ones are peripheral for the dynamic outcome. these drawbacks are particularly severe in situations when predictive computer simulations are needed most: during the initial outbreak of novel pathogens with uncertain properties. in this situation, quantitative forecasts come with significant error bars because simulation parameters that define the new pathogen are not known. this dilemma can only be solved if the dynamics of global disease spread is better understood at a fundamental level, i.e. if we identify which model ingredients dominate the patterns of global spread, which ones can be neglected and what features of global spread are universal and valid for the majority of emergent pathogens. one step in this direction was the recent discovery that the patterns of global spread of sars, h n and related diseases can be understood and substantially simplified by introducing a novel type of effective distance that is based on methods borrowed from complex network-and random walk theory (brockmann and helbing, ) . conventional computer simulations that incorporated for example the wan typically use conventional geographic map representations in which the spatio-temporal dynamics of epidemic spreads exhibit the aforementioned complex, spatially incoherent structure. when conventional geographic distances are replaced by effective distances between airports, these complex patterns are mapped onto regular wave-like patterns that are reminiscent of historic spreading phenomena such as the historic black death pandemic. this allows the measurement of effective spreading speeds and the prediction of relative arrival times with a much higher fidelity and independently of disease specific parameters. this is possible because the effective distance between any two locations in the network can be computed by mobility network properties alone (see fig. a /d). one of the key implications of this approach is that even in situations when little is known about an emergent pathogen and the likelihood of global spread the most probable spreading pathways and relative arrival times at distant location can be computed. this can help during the design of mitigation strategies that are based e.g. on the implementation of travel restrictions and airport based containment actions. the network theoretic, effective distance approach provides another important feature that is derived from the observation that only from the actual outbreak location a regular wave-front is observed in the effective distance representation. one can make use of this property to solve the so-called inverse problem: given a complex spatial incidence patterns one can reconstruct the most likely initial outbreak location. this technique has been shown to work efficiently when applied to the ehec/hus outbreak in germany using a proxy of food transportation in germany as the underlying network (manitz et al., ) . given the increasing availability of data on human mobility and human interactions modern computational and network-theoretic models for disease dynamics will become a central tool for understanding and predicting disease dynamics on local, intermediate and global scales and will aid policy makers and public health research in mitigating their negative effects on society. reflexions sur les avantages de l'inculation the scaling laws of human travel the hidden geometry of complex, network-driven contagion phenomena modeling the worldwide spread of pandemic influenza: baseline case and containment interventions forecast and control of epidemics in a globalized world origin detection during foodborne disease outbreaks -a case study of the ehec/hus outbreak in germany the gleamviz computational tool, a publicly available software to explore realistic epidemic spreading scenarios at the global scale the emergence and global spread of human infectious diseases has become one of the most serious public health threats of the st century. sophisticated computer simulations have become a key tool for understanding and predicting disease spread on a global scale. combining theoretical insights from nonlinear dynamics, stochastic processes and complex network theory these computational models are becoming increasingly important in the design of efficient mitigation and control strategies and for public health in general. die entstehung und globale ausbreitung neuartiger, von mensch zu mensch übertragbarer infektionskrankheiten ist eines der größten public-health-probleme des . jahrhunderts. detaillierte, umfangreiche computersimulationen haben sich in diesem kontext zu einem wichtigen werkzeug für das bessere verständnis der ausbreitungswege und deren vorhersage entwickelt. in modernen ausbreitungssimulationen werden methoden aus der theoretischen und rechnergestützten physik, der nichtlinearen dynamik mit erkenntnissen aus der theorie komplexer netzwerke in numerischen modellen vereint um genauerer vorhersagen und potenzielle ausbreitungsszenarien ,,in silico'' zu untersuchen und damit das design effizienterer mitigations-und kontrollstrategien zu fördern und zu beschleunigen. infectious diseases = infektionskrankheiten, computer simulations = computersimulations, complex networks = komplexe netzwerke, prediction = vorhersage, disease spread = seuchenausbreitung key: cord- -z ondg r authors: jacobsen, kathryn h.; hay, m. cameron; manske, jill; waggett, caryl e. title: curricular models and learning objectives for undergraduate minors in global health date: - - journal: annals of global health doi: . /aogh. sha: doc_id: cord_uid: z ondg r background: a growing number of institutions of higher education offer undergraduate educational programs in global health. objective: to identify all undergraduate minors in global health being offered in the united states during the – academic year, categorize the curricula being used by secondary programs of study, evaluate the content of required foundational courses, and examine the types of experiential learning opportunities that are offered. methods: a working group of the consortium of universities for global health (cugh) conducted a systematic review of the websites of all accredited -year colleges and universities, identifying institutions offering general global health minors. findings: a typical global health minor consists of one introduction to global health course, one epidemiology or health research methods course, several additional required or selective courses, and one applied learning experience. within this general structure, five curricular models are currently being used for global health minors: ( ) intensive minors composed of specialty global health courses, ( ) global public health minors built on a core set of public health courses, ( ) multidisciplinary minors requiring courses in the sciences and social sciences, ( ) anthropology centric minors, and ( ) flexible minors. conclusions: cugh recommends ten undergraduate student learning objectives in global health that encompass the history and functions of global health; globalization and health; social determinants of health; environmental health; health and human rights; comparative health systems; global health agencies and organizations; the global burden of disease; global health interventions; and interdisciplinary and interprofessional perspectives. bulletin and/or the webpages for relevant departments. we minimized our risk of overlooking relevant programs by validating our searches of institutional websites with general search engine queries pertaining to global health majors, minors, concentrations, and certificates. we defined a minor as a secondary program that complements a primary area of study in a bachelor's degree program. we classified secondary programs of study requiring at least semester credit hours (or the equivalent in quarter hours, course counts, or other institutional-specific terms) as minors. curricular pathways requiring fewer than semester hours or the equivalent, such as short-term study abroad programs and certificates requiring only three courses (equivalent to semester hours or fewer), were not considered to be minors. global health concentrations embedded within minors in other disciplines (such as public health) or interdisciplinary areas (such as global studies) were included when more than half of the credits in the minor were allocated to the global health concentration. in this paper, we use use the term minor for all programs that met the inclusion criteria, even though some schools call these secondary programs certificates or use other names for them. global health is still in the process of being defined as an area of academic study, but it is generally considered to be distinct from public health, which tends to have a focus on health promotion in one community or one nation [ , ] . to be eligible for inclusion in the analysis, a minor had to be focused on global health (rather than public health, global affairs, international development, medical anthropology, population health, or other areas that overlap with global health but do not have global health as the central focus) and cover global health broadly rather than focusing on just one specialty area within global health (such as maternal and child health). most of the included programs were named global health ( ), global public health ( ) , or global health studies ( ) . other program names included community and global health; global health and health policy; global health and social medicine; public health: global health; global and comparative public health; global health and development; global health and humanitarian assistance; global health promotion; global health service; global health technologies; global health, culture, and society; global public health and epidemiology; global public health and the common good; international health; medicine, health, and society: global health; public and global health; and social justice in global health. for each institution with a global health minor that met our inclusion criteria, we acquired location, institutional enrollment, and other information from the carnegie classifications data public data file (version , released on september ) produced by the indiana university center for postsecondary research. we accessed the cur-ricular and co-curricular requirements for the minor and extracted key details about required courses (title, course level, and hosting department), the thematic areas in which students were required to select one or more courses from a list of approved courses (such as students being required to select one research methods course from a list of two or more preapproved courses), and co-curricular requirements such as field experiences, research or capstone projects, or synthesis capstone courses. since most of the minors required a course that introduced the fundamentals of global health, we also acquired the course descriptions for each required introduction to global health course from the catalog (or bulletin) or program website of each school. we applied grounded theory to the coding of each required element of the curricula of included minors, using several rounds of individual coding, group discussion, and recoding to reach consensus about the codes for each curricular element. the codes noted the disciplinary area for each course (such as biology or statistics), the type of course (such as introductory, methodological, or experiential), and the specific focus (such as environmental health or medical anthropology). related codes were grouped into categories. we then looked for patterns in the sets of categories that were required curricular components, seeking to identify themes that aligned with three or more institutions. a final set of five curricular models is presented in the results section. we used a similar process to code the course descriptions of introductory global health courses and establish interrater reliability. to ensure the comprehensiveness of our coding, we separately coded three specific content areas for each course: ( ) health and disease topics, such as environmental health, hiv/aids, reproductive health, nutrition, noncommunicable diseases, and violence; ( ) populations, agencies, and organizations, such as children, low-income countries, refugees, women, health systems, and the world health organization; and ( ) theories and themes, such as globalization, social justice, and multidisciplinarity. we then reviewed the codes, categorized them, and identified the themes that were most often expressed in the course descriptions. our search identified colleges and universities that offered minors in global health during the - academic year, including three schools for which two different programs met our definition of minors in global health (for a total of minors). all schools were nonprofit -year institutions, but they represent diversity within this sector of higher education. they were nearly equally divided between public universities and private schools. of the institutions, were doctoral universities, were master's universities, and were baccalaureate colleges (all of which were designated in the carnegie classifications as awarding more than half of their bachelor's degrees in arts and science fields rather than awarding the majority of their degrees in professional areas such as business and engineering). forty-seven of the schools had a large undergraduate enrollment (≥ , ), medium ( - ), small ( - ), and very small (< ). in total, of the schools had undergraduate admissions rates that were designated in the carnegie classifications as "more selective" (the th to th percentile of selectivity among undergraduate institutions, based on sat and act percentiles and the admission rate), as "selective" (the th to th percentile of selectivity), and as "inclusive." based on the four location classifications used by the national center for education statistics (nces), of the schools were in cities, in suburbs (that is, within urbanized areas but outside of principal cities), in towns (outside of urbanized areas), and none in rural areas. many of the schools with global health minors offered other health-related educational programs, including offering an mph degree (including with an mph concentration in global health), offering an undergraduate major in public health, offering a medical degree (md, dds, dmd, do, or dvm), and offering an undergraduate minor in public health. thirteen offered an undergraduate major in global health, and at least a dozen additional schools offered a secondary major in global health or a concentration in global health within another major, such as public health or global studies. an introduction to global health course was required by % ( / ) of the included minors. the interdisciplinary nature of global health was evident in the prefixes for the introductory courses (one of which was required by two different minors at the same institution). in addition to catalog prefixes specific to global health, public health, health science, health administration, and other health fields, these introductory courses were also offered by africana studies, anthropology, biology, international studies, kinesiology, nursing, nutrition, political science, and sociology departments as well as by interdisciplinary programs. the topical themes featured most frequently in the descriptions of introduction to global health courses included the social and environmental determinants of health; the global burden of disease, often described using terms such as epidemiology, demography, data, and methods; global health agencies and organizations; governance and comparative health systems; and interventions related to exposures, diseases, and special populations. the conceptual themes that were expressed most often in introductory global health courses (that is, the cross-cutting themes that were not consistently associated with specific exposures, diseases, and populations/ groups) included multidisciplinarity or interdisciplinarity; globalization; health disparities and inequalities; ethics, human rights, and social justice; problem solving; and the historical context for global health today. the introductory course was the only curricular component required by a strong majority of programs. about half of the current global health minors ( / ) required at least one course on epidemiology, statistics, and/or the research methods used in public health or the social sciences. other popular clusters in which courses were required for global health minors included, in decreasing frequency, courses on health, culture, and society; the biology of health and disease; health policy and economics; and environmental health and sustainability; and ethics, human rights, and social justice. thirty-eight ( %) of the global health minors required some type of capstone experience or another type of applied or experiential learning. while some of the programs mandated that all students in the minor complete the same type of capstone experience-such as all students completing a practicum or internship ( ), a research project ( ), a capstone course with an experiential component, such as service-learning or problembased learning ( ), study abroad ( ), an applied project ( ), or a reflective portfolio ( )-the most common option was to allow students to choose from a list of approved experiential learning activities ( ) . only five minors required an international experience. based on the most frequently required curricular elements, the general framework for a global health minor includes one introduction to global health course, one epidemiology or health research methods course, several additional courses exploring different domains of global health, and some type of applied learning experience ( figure ) . however, few schools strictly follow that model in its entirety. there is considerable variability in which domains of global health are emphasized and how rigid the curricula are. at some schools, every student who earns a global health minor completes the same set of five (or more) courses; at some other schools, students select their own courses for the minor from a long list of "selective" courses. based on our evaluation of the curricular structures of the global health minors, we identified five curricular models being used for global health minors ( table ). intensive global health minors are built around a series of specialty courses in global health, such as courses on global environmental health, global health policy and systems, and global health leadership. most of the universities offering this track were doctoral universities with large undergraduate enrollment. the majority of the intensive global health minors were offered by a school of public health or health professions that also offers an undergraduate major, master's degree, or graduate certificate in global health. about half ( / ) of the intensive minors required some type of capstone experience, most often a practicum. global public health minors are built on the three building blocks for undergraduate public health education that were published by the association of american colleges and universities (aac&u) and the association for prevention teaching and research (aptr) in : introductory courses in public health, epidemiology, and global health [ ] . global public health minors were offered by schools, including that include "public" in the names of their global health minors. global public health programs were often housed in departments or schools of public health at universities that did not offer global health majors. only a few ( / ) global public health minors had an experiential learning requirement. multidisciplinary global health minors require students to take courses from several departments to fulfill course requirements, including at least one natural science course (typically biology or environmental science) and at least one social science course. multidisciplinary minors were offered by schools, including six of the baccalaureate colleges and eight of the small schools. their program descriptions typically emphasized the value of learning about health from a diversity of disciplinary perspectives. most of these schools did not offer undergraduate public health majors or minors or mph degrees. multidisciplinary minors were often hosted by the interdisciplinary or interdivisional unit of a college of liberal arts and sciences rather than being overseen by one academic department. more than half ( / ) of the multidisciplinary minors required some type of a capstone experience, with students typically being allowed to choose from a variety of approved experiential learning opportunities. anthropology global health minors require several courses in anthropology, sociology, and related disciplines. this type of minor was offered by eight schools, including three with "social justice" or "social medicine" in the names of their global health minors. most of these programs required at least one course in medical anthropology or a closely related area, and several include an introductory anthropology course among the requirements for the global health minor. most of these programs were housed in anthropology departments or in social science divisions at public doctoral universities that did not offer any other baccalaureate or graduate programs in global health. experiential requirements were not common ( / ) in anthropology global health minors. a flexible global health minor built from elective courses is offered by schools. these programs typically require an introductory global health course and some sort of capstone experience related to global health (such as a research project, experiential learning activity, or seminar), but they allow students considerable flexibility in choosing the other courses they take for the minor. flexible minors are different from multidisciplinary minors because they do not have distribution requirements spanning several mandated areas of study. most flexible minors were offered at schools that do not offer a public health major or minor. flexible minors were housed in interdisciplinary units, colleges of liberal arts and sciences, special centers focused on health or global one of the major challenges for global health as an academic discipline is the lack of national or international standards for what content should be included in the curriculum. for schools that offer global public health, multidisciplinary, anthropology, and flexible global health minors, it is critical for the introductory global health course to provide a comprehensive overview of global health theory and practice that equips students with a broad knowledge foundation that they can build on when they take advanced or elective courses within the minor. our analysis of the content of introductory global health courses found that most courses cover a similar set of concepts and subject matter content. however, there was no standard set of learning objectives available to schools that were creating new global health courses or revising existing ones. in our role as members of the cugh working group tasked with developing evidence-based resources for undergraduate education in global health, we decided to use our analysis of current course content and our familiarity with existing resources for teaching and learning in global health as a foundation for a draft list of candidate learning objectives for global health survey courses in north american colleges and universities. two organizations' documents provided a starting point for prioritizing content. one is cugh, which has developed interprofessional global health competencies that span levels from "global citizen" to "advanced." [ ] the lowerlevel competencies that focus on understanding global health theories and preparing for experiential learning with host organizations that serve people with different cultural and socioeconomic backgrounds are appropriate targets for undergraduates [ ] . the other is the council on education for public health (ceph), which accredits public health degree programs. ceph has identified essential components of undergraduate public health education and created a list of foundational knowledge areas in public health [ ] [ ] . while the ceph accreditation standards do not specifically address global health, they outline areas of undergraduate study that prepare students for entry-level practice and graduate studies in various areas of the population health sciences [ ] . we also examined the competencies for global health education proposed by international groups for students and trainees in medicine, public health, and other areas [ ] . together, the educational frameworks of cugh, ceph, and international groups point toward potential priorities for undergraduate global health courses and programs. based on the categories and themes we identified in our analysis of the current content of introductory courses required by existing global health minors in - , our review of existing educational frameworks related to global health [ , , ] , and expert feedback from cugh members, we generated a preliminary list of recommended student learning objectives for an introductory global health course. this list included central global health principles, such as globalization and health equity, plus foundational knowledge areas related to the determinants of health, the major causes of morbidity and mortality, and the entities involved in funding and implementing global health interventions. after several rounds of revision and refinement, a final set of ten cugh recommended undergraduate global health student learning objectives was reviewed by members the cugh education committee and the cugh secretariat, and then endorsed by cugh ( table ) . the cugh recommended undergraduate global health student learning objectives are not meant to be an exhaustive list of all global health principles and themes. however, including these ten items alongside institutionspecific learning goals and competencies will ensure coverage of critical global health knowledge and skill areas. these learning objectives are applicable to introductory global health courses housed in diverse academic units. if the verbs used for each item (such as define, explain, compare, and evaluate) are scaled up to higher order thinking skills, these items could also form the basis for programlevel learning goals for an entire global health program, such as a certificate, minor, or major. rather than dictating the specific topics that a survey course should address-like naming the exact diseases and populations that should be examined in an introductory course-these learning objectives provide a framework for exploring a variety of global health issues. for example, although pandemics are not directly named within these ten items, the components of the emergency management cycle (prevention, preparedness, response, and recovery) align with many of the learning objectives. global health security is one of the functions of global health (learning objective # ). pandemics arise from globalization (# ) as well as from human behavior (# ) and environmental interactions (# ). the responses to pandemics, such as mobility restrictions, may raise questions about human rights (# ). pandemics like covid- place a heavy burden on medical care providers (# ) and require substantial investment in public health interventions like contact tracing (# ). case studies about the coronavirus pandemic provide opportunities to compare the epidemiological profiles of different populations (# ), examine which interventions are effective in various demographic groups (# ), and think creatively about what policies and practices might prevent another emerging infectious disease pandemic (# ). while students will benefit from exposure to a wide range of health issues, not just one, in their introductory global health courses, these learning objectives allow the flexibility to adapt courses to emerging health issues and local priorities. in many academic disciplines, a minor comprises a subset of courses from the corresponding major. for example, the american psychological association provides strong guidance about the knowledge and skill components of foundational, intermediate, advanced, and capstone courses in a psychology major, and it recommends that a minor require completion of about four foundational courses rather than being based on one introductory psychology course plus higher-level coursework [ ] . the american chemical society's educational standards list the specific subdisciplines in which coursework is required for a major in the field [ ] , and although acs has issued no standards for minors in chemistry, it is typical for minors to consist of the foundational courses plus a subset of the advanced courses from the major. however, this "minors as mini-majors" approach will not work in global health, since few schools currently offer global health majors and there is not yet consensus about what types of courses are important for a major in global health [ ] . when minors are not derived from majors, they are often designed around interdisciplinary themes. for example, public health minors offered by diverse types of institutions often consist of three foundational courses (epidemiology, u.s. public health, and global health) plus a few "selective" courses (that is, courses selected from lists of approved course options) and at least one experiential learning activity [ , ] . this structure is similar to the curricular plan used by many global health minors (and featured in figure ) . we identified five variants of this general structure that are currently being used for global health minors. these models are characterized based on whether they are built around specialty courses in global health (intensive) or public health (global public health), require taking courses in several different departments (multidisciplinary) or primarily in one department (anthropology), or are relatively unstructured (flexible). each of the five curricular models used by global health minors has its own set of curricular and programmatic strengths and weaknesses ( table ). minors that align with the intensive and global public health models may provide the most comprehensive exposure to global health principles and practices, but they require substantial institutional investments in courses specific to the minor. these resource demands make these models most suitable for large schools that already offer many courses on global health topics as part of a public health or global health major. minors that align with the multidisciplinary or flexible models may allow students the greatest freedom to individualize their studies to match personal interests and goals, but even with strong advising these loosely-structured programs may leave students with critical gaps in their understanding of global health. given the diversity in course requirements across the current minors, even when looking at minors that apply the same general type of curricular model, it would be premature to recommend a set of standard courses for global health minors. however, all courses that count toward a minor should build on the undergraduate student learning objectives introduced in the fundamentals course, and all should have health as a central theme. schools lacking the resources to offer a variety of specialized global health courses should still verify that all courses that count toward the minor engage with global health in a meaningful way. general courses in anthropology, biology, communication, economics, environmental science, government and policy, philosophy, sociology, and other areas are unlikely to provide sufficient engagement with global health themes; by contrast, health-specific courses such as medical anthropology, health communication, and environmental health are likely to engage more closely with global health principles and practices. similarly, applied learning experiences completed as part of global health minors should require students to synthesize and reflect on the global health knowledge areas and competencies spelled out in the undergraduate student global health learning objectives. many types of experiential learning opportunities may be suitable for undergraduates [ ] . experiential learning does not require international travel, and it can involve student engagement with a diversity of clinical and non-clinical professional practice areas within the governmental, nonprofit, and commercial sectors. (mentors should ensure that students do not perform beyond the scope of their training, especially in clinical settings.) schools where institutional resources are not available to offset the burden that experiential learning activities can place on students, faculty mentors, and community hosts may opt not to require applied learning experiences for all students minoring in global health, but they can still recommend experiential learning as an optional curricular component. our results imply that . % ( / ) of all -year colleges and universities offered minors in global health in - , but since some schools that award bachelor's degrees do not offer minors in any discipline, the true percentage is greater than . %. we used a systematic approach to attempt to identify all the colleges and universities offering global minors in - , but it is likely that our months-long review process missed some programs. global health is a recently launched curricular offering at many schools, and some websites might not have been updated at the time we conducted our review of their institutional webpages. the curricular trends we observed across general global health minors are unlikely to be affected by one or more programs being overlooked. our count of minors in global health intentionally omits minors in specialty fields related to global health and minors in areas such as public health, population health, and medical anthropology that overlap with global health but are distinct fields of study. if our eligibility criteria had used a broader definition of global health, there would be well over minors included in the tally. the count also intentionally excludes several new global health minors that were announced in or earlier but were not beginning enrollment until the - academic year. this analysis provides a snapshot in time of the institutions of higher education in the untied states that were offering global health minors during the - academic year along with the content they included in their introductory courses, the curricular models they were using for the remaining courses in the minor, and the types of applied learning experiences they required. it also introduces the cugh recommended undergraduate global health student learning objectives, summarizes the general framework used by the typical global health minor, and describes the models that schools use requires significant institutional resources specific to global health; courses taught by experts in focused areas of research and practice may offer depth at the expense of disciplinary or professional breadth global public health emphasizes a set of core public health courses (introductory courses in epidemiology, global health, and u.s. public health policy) for which resources are available to support instructors without specialized training in global health treats global health as a subdiscipline of public health rather than as a multidisciplinary field that overlaps public health while drawing on other academic and professional areas; the public health core leaves few credits for courses specific to global health multidisciplinary applies a liberal arts lens to global health education by requiring students to examine complex issues from the perspectives of the natural sciences, social sciences, and (sometimes) the humanities; requires limited institutional investment in courses specific to the global health minor demands that a single introductory global health course cover a wide range of global health principles and practices, because electives in supporting disciplines might only peripherally touch on topics specific to global health (such as a course in environmental science only briefly examining global environmental health concerns) allows students majoring in fields other than anthropology to deeply understand anthropological theories and methods as they apply to global health focuses narrowly on anthropological (and sometimes also sociological) approaches to global health, providing limited exposure to biological and public health perspectives flexible allows students the greatest freedom to craft their own programs of study that best align with their academic and professional interests; requires limited institutional investment in courses specific to the global health minor requires intensive advising to ensure that each student's unique set of curricular and co-curricular learning experiences provide some sort of coherent engagement with global health and enable the student to synthesize, integrate, and apply central global health principles to structure their minor curricula. we expect that the number of schools offering global health minors will increase over the next few years in response to student demand driven by the coronavirus pandemic as well as by other ongoing global challenges, such as climate change. the recommended learning objectives and curricular framework presented in this paper provide schools with tools they can use to design minors that align with disciplinary norms and with institutional goals, values, and resources. global health and public health majors and minors at universities the emergence of undergraduate majors in global health: systematic review of programs and recommendations for future directions teaching global public health in the undergraduate liberal arts: a survey of colleges an analysis of undergraduate educational programs in global health trends in public and global health education among nationally recognized undergraduate liberal arts colleges in the united states master of science (ms) and master of arts (ma) degrees in global health: applying interdisciplinary research skills to the study of globalization-related health disparities master of public health (mph) concentrations in global health in : preparing culturally competent professionals to address health disparities in the context of globalization health promotion practice from sovereignty to solidarity: a renewed concept of global health for an era of complex interdependence towards a common definition of global health curriculum guide for undergraduate public health education (version . ) identifying interprofessional global health competencies for st -century health professionals accreditation criteria: schools of public health & public health programs accreditation criteria: standalone baccalaureate programs what is population health? a review of global health competencies for postgraduate public health education. front public health apa guidelines for the undergraduate psychology major (version . ) acs guidelines and evaluation procedures for bachelor's degree programs developing an undergraduate public health introductory core course series. front public health association of american colleges and universities (aac&u)/association for prevention teaching and research (aptr) how do we teach for global health? reviewing and renewing to advance pedagogy for global health and health promotion this work was conducted by the subcommittee on master's and undergraduate degrees in global health of the consortium of universities for global health (cugh). the authors thank the members of the education committee and the cugh secretariat for their insights and support. the authors have no competing interests to declare. key: cord- -umlqh q authors: wenham, clare; kittelsen, sonja k title: cuba y seguridad sanitaria mundial: cuba’s role in global health security date: - - journal: bmj glob health doi: . /bmjgh- - sha: doc_id: cord_uid: umlqh q cuba has been largely absent in academic and policy discourse on global health security, yet cuba’s history of medical internationalism and its domestic health system have much to offer contemporary global health security debates. in this paper, we examine what we identify as key traits of cuban health security, as they play out on both international and domestic fronts. we argue that cuba demonstrates a strong health security capacity, both in terms of its health systems support and crisis response activities internationally, and its domestic disease control activities rooted in an integrated health system with a focus on universal healthcare. health security in cuba, however, also faces challenges. these concern cuba’s visibility and participation in the broader global health security architecture, the social controls exercised by the state in managing disease threats in cuban territory, and the resource constraints facing the island—in particular, the effects of the us embargo. while cuba does not frame its disease control activities within the discourse of health security, we argue that the cuban case demonstrates that it is possible to make strides to improve capacity for health security in resource-constrained settings. the successes and challenges facing health security in cuba, moreover, provide points of reflection relevant to the pursuit of health security globally and are thus worth further consideration in broader health security discussions. ► debate on global health security has focused on how we collectively respond to outbreaks, including what role and responsibility states have in supporting response efforts to health crises beyond their borders, and in strengthening domestic public health capacities to detect and contain disease risks. ► cuba's history of medical internationalism and its domestic disease prevention and control activities speak directly to these debates; yet, cuba is largely absent within global health security academic and policy discourse. cuba's international medical activities focused on routine health provision and crisis response, alongside its domestic disease control activities and universal health system demonstrate that cuba has a strong health security capacity. ► health security in cuba also faces challenges, however, particularly with respect to the trade-off between civil liberties, regime preservation and security in protecting the state and its population from diseases threats, and with respect to resource constraints, exacerbated by the us embargo. ► cuba does not frame its disease control activities within a discourse of health securitywhich impacts cuba's visibility and participation in the global health security regime. cuba demonstrates that it is possible to make strides to improve capacity for health security in resource-constrained settings facing multiple challenges, although within a particular political context where social controls exercised by the state raise questions of civil liberties. ► the successes and challenges that characterise cuba's health security activities speak to broader global health security debates and are thus worth engaging with more explicitly in contemporary health security discourse and practice. cuba has been largely absent in academic and policy discourse on global health security, yet cuba's history of medical internationalism and its domestic health system have much to offer contemporary global health security debates. in this paper, we examine what we identify as key traits of cuban health security, as they play out on both international and domestic fronts. we argue that cuba demonstrates a strong health security capacity, both in terms of its health systems support and crisis response activities internationally, and its domestic disease control activities rooted in an integrated health system with a focus on universal healthcare. health security in cuba, however, also faces challenges. these concern cuba's visibility and participation in the broader global health security architecture, the social controls exercised by the state in managing disease threats in cuban territory, and the resource constraints facing the island-in particular, the effects of the us embargo. while cuba does not frame its disease control activities within the discourse of health security, we argue that the cuban case demonstrates that it is possible to make strides to improve capacity for health security in resource-constrained settings. the successes and challenges facing health security in cuba, moreover, provide points of reflection relevant to the pursuit of health security globally and are thus worth further consideration in broader health security discussions. in the wake of this epidemic, academic and policy debate has turned to how the system for global health security can be reformed. [ ] [ ] [ ] this has included a focus on how national and global capacities can be enhanced to rapidly respond to health emergencies and how we can connect global health security activities to broader health system strengthening efforts, including the movement towards universal health coverage (uhc), as championed by who director-general tedros adhanom ghebreyesus. cuba's activities in global health security speak directly to these debates. indeed, cuba has made considerable strides in infectious disease control, comparable to that of high-income countries, doing so in a low-income setting beleaguered by a struggling economy, and facing resource and access challenges from the us embargo. these activities are embedded within a strong integrated health system, of which a key constituent part is preventative medicine (including vaccination for infectious disease) and uhc free at the point of care. through its work internationally, moreover, cuba has moved towards supporting sdg .d by assisting other countries in meeting their core capacities for surveillance and response for disease control. importantly for the global health audience, cuba demonstrates that it is possible to make strides to improve capacity for health security in resource-constrained settings facing multiple competing challenges, although this has been in a context of an authoritarian state where civil liberties have been questioned. given these achievements, it is interesting that cuba has not been referenced in broader global health security debates; yet cuba's lack of visibility in health security academic and policy discourse is noticeable. this could be attributed to cuba's isolation geopolitically, as a small island state, and given that the health security policy field has traditionally been western (us) dominated. the cuban government may not have wanted to engage in this debate, or been able to participate, based on political tensions, ideological differences and/or the us blockade of the island. alternatively, the geographical focus of health security discourse (and associated pragmatic efforts) has shifted temporally and geographically as the perception of 'next big one' has expanded from being focused solely on the threat of pandemic influenza in south-east asia to include haemorrhagic fevers in low-income and middle-income countries (lmics) in africa. cuba might have been absent from global health security narratives, similar to most of latin america, because it had not been prey to a major epidemic that has put its health system surge capacity in the spotlight. however, with the spread of zika across the caribbean and to cuba, despite the government's denial of the outbreak, this may not be an adequate explanation. we suggest a third consideration for the lack of cuban visibility in discussions of health security: that cuba does in fact demonstrate key traits which we understand to be health security, but it does so in the name of solidarity and part of a socialist project which seeks to export the strengths of the cuban regime internationally. we argue that health security is alive and well in cuba and offers insights into how we might strengthen health security globally, particularly in lmics which is vital to future preparedness efforts, although we consider these questions cautiously, recognising the particular political context in cuba and the trade-offs of civil and political liberties which come at the costs of such a strengthened health security position. to demonstrate our argument, we focus on what we consider the key traits of cuban health security, conceptualised as falling into two main categories: cuban medical engagements internationally, and cuban health provision domestically. we then consider some of the challenges for health security in cuba, notably the tension between providing complete security from the threat of disease and protecting civil rights within the state, and the impact of the us embargo on cuban health security, before reflecting on what we can learn from the cuban experience in improving health security globally. this paper uses a case study methodology to understand how cuba exhibits tendencies in global health security. the empirical material for this paper was drawn from a series of semistructured elite interviews conducted in havana in december with policymakers, medical professionals and other infectious disease control experts working in cuba. these data were subsequently transcribed, and thematic analysis was conducted to identify key trends that appeared in the qualitative material. we further undertook documentary analysis of policy documents from a range of sources, including the ministry of public health (minsap), cubacoopera (a government department responsible for medical internationalism) and the who/pan american health organization (who/paho), along with media sources both from cuba (granma) and internationally. these documents were sourced both in english and in spanish, and where necessary, translations are the authors' own. this material was triangulated against secondary literature including academic literature on health policy, international relations and cuban/latin american studies. these sources were identified through medline, google scholar and snowballing from these and international and cuban contacts. this latter step was important for two reasons: first, having undertaken interviews with policymakers from a one-party state that has worked hard to control information, we wanted to ensure that we were not solely reproducing the narrative that the cuban government wished us to voice, but that this was contextualised amid other research and findings within health and/or security analysis of the island. second, as hollander states, short-term research visits to socialist countries can be wholly misrepresentative, so we wanted to ensure that our findings were reflective of broader debates and narratives within the literature on the cuban health system. cuba's medical internationalism cuba's programme of medical internationalism has been well documented by latin-american scholars and anthropologists. [ ] [ ] [ ] [ ] medical internationalism involves sending medical brigades on missions abroad to offer routine health services, respond to crises as well as bringing medical students and patients back to cuba for education and/or treatment. we consider this to be the most apparent embodiment of cuban health security activities internationally, where the state appears to be supporting response efforts for emerging pathogens by providing human resources and technical expertise within outbreak response, and health systems capacity-building elsewhere in the world, such as the training of international medical professionals. particularly significant from the standpoint of global health security is the role that these cuban doctors, particularly the henry reeve brigade, have played in supporting responses to a number of epidemic outbreaks. brigades were deployed to el salvador, ecuador, nicaragua and honduras between and to support dengue fever response efforts. moreover, the cuban government was one of the first to respond to the ebola outbreak in west africa and its henry reeve brigade constituted the largest international bilateral support to arrive in the region. this stands in contrast to the criticism that the global community as a whole has faced for its delayed and inadequate response to the crisis. the cuban delegation, under who, was particularly involved in direct care to patients in ebola centre modi (liberia), kerry town and port loko (sierra leone) and supported the establishment of the coyah ebola treatment centre (guinea). to do so, cuban brigadistas received comprehensive training at the tropical medicine institute, instituto pedro kouri (havana), demonstrating the significant health security competency and capacity within cuba. this training included the use of personal protective equipment, biosecurity standards for patients and staff, treatment and diagnostic techniques, and risk scenario activity planning, and can now be used to launch a response to other diseases (interview, instituto de medicina tropical pedro kouri). more routinely, cuba deploys up to % of all its medical professionals to a number of non-crisis settings. this has involved medical teams totalling over health personnel, in over countries, including within the who and the g states. these cuban medical teams have tended to work in rural communities or in urban slums, areas that often have not had state medical provision prior to cuban arrival due either to an inability to recruit medical practitioners to live and work in these areas, or a lack of monetary motivation to establish provision where the local community has not been able to afford associated care costs, such as out-of-pocket payments. as routine access to health professionals facilitates the detection of diseases sooner, such activity can be considered to directly contribute to increased global health security, although notably this has not necessarily been the aim of any such brigade's mission. indeed, despite these efforts to support the development of health systems and respond to health crises, cuba does not frame these activities within the discourse of health security. rather, cuba's medical internationalism is framed as the embodiment of international solidarity and considered an extension of cuba's national health policy within the socialist framework. interviewees cited 'serving a global population' rather than protecting cuba's citizens against pathogen spread as reason for crisis interventions. recent media coverage of the closure of the mais medicos programme in brazil has focused on the political determinants of these overseas medical missions, where cuban doctors are sent to provide healthcare in exchange for oil or hard currency. political motivations have also been suggested as standing behind cuba's provision of over half of the medical professionals for mission barrio adentro in venezuela, chavez's (now failing) health and social welfare programmes focused on delivering universal healthcare across poorer neighbourhoods. such activities have spurred discussion on the motivation for this cuban international activity, whether driven by international prestige, goodwill, soft power, solidarity or economic gain. cuba's medical missions have also been criticised for violating the (labour) rights of those deployed. there is some suggestion, for example, that these doctors may not have autonomous decision-making regarding whether they want to deploy on these international missions, but rather are forced to do so by the government. recent legal proceedings in brazil, moreover, have sought to show that the cuban model of exporting physicians for economic gain violates the international labour organization's agreement on the protection of wages. this is based on the findings from the mais medicos programme that suggest that cuban medics received significantly less in wages than their international counterparts, with the majority of the wages paid directly by brazil to cuba for its doctors being retained by the cuban state. discussions about the profit-making nature of these overseas medical missions suggest that cuba's medical internationalism may be less about a notion of international solidarity or global health security, but rather functions as a form of income generation for the government within a failing economic system. in this respect, the contribution of these missions to global health security might be overegged and simply a by-product of government financing. nevertheless, we suggest that this activity could be considered part of a cuban contribution to global health security and may offer lessons for strengthening national and global rapid response capacities for disease emergence, as the deployments and training of the henry reeve brigade suggests. indeed, the global response to the - ebola epidemic was criticised as being 'hampered by a lack of trained and experienced personnel willing to deploy to the affected countries'. aside from important concerns regarding the rights bmj global health of medics deployed, cuba's medical brigades and the training they receive offer insights into how such a rapid response capacity might be achieved. moreover, the focus of cuba's medical internationalism in strengthening the provision of routine health services in resourceconstrained settings speaks to a broader vision of health security than disease containment and response alone-a focus of current debates concerning how global health security activities can be integrated in a more sustained way into broader health system strengthening and uhc aims. yet, this deployment of cuban teams has also raised concerns of taking jobs away from locally qualified physicians and healthcare workers, which raises further questions of sustainability within health systems as a cornerstone of uhc. discussions on cuban healthcare tend to focus on its government-run, integrated health system, rooted in a fundamental right to health as part of the socialist project; to provide a range of preventative and curative services free of charge to all. these services have produced worldleading health outcomes and demonstrate what is possible to accomplish in a resource-poor setting, allowing cuba to demonstrate a strong domestic health security position, although the veracity of some of these claims has been disputed. in particular, critiques have highlighted that the cuban image of a high-performing system appears to be almost exclusively based on infant mortality rates-an explicit point of focus of cuban government policy-at the cost of other health indicators, including maternal mortality, disability, disease exposure and life expectancy, and underinvestment in the social determinants of health more broadly. moreover, even this infant mortality rate has been questioned with regards to its accuracy, relative to the counterfactual and potential case-definitional differences to routine practice making cuba dramatically outperform its regional (and global) neighbours. focusing on infectious disease in particular, there are three key components to cuba's domestic health security: disease surveillance and control, cuba's biotechnology industry and universal healthcare. first, cuba has focused considerable efforts on reducing or eliminating disease threats from its territory. this has included decades of work reducing hiv/aids infection, including eradicating mother-to-child transmission of hiv, through prevention and destigmatisation campaigns, although this has come at a cost of human rights through the compulsory testing and indeed quarantining of those infected (interview, biosecurity expert). similarly, cuba eliminated malaria on the island in , and maintains this status, although through mandatory prophylaxis of those returning (or indeed arriving) in cuba from endemic regions. the country has also managed to eliminate diseases since , including measles, rubella, mumps, tetanus, meningitis b and c, and hepatitis b. (interview, ministerio de salud publica). when the threat of zika spread across the americas, cuba was quick to take proactive moves to stop the introduction of the disease within its borders. this included mass fumigation campaigns, the deployment of the military to clean civic spaces where mosquitoes may grow, and an appeal to citizens enforced by law, to support control efforts and ensure that private dwellings remained clear from mosquitoes and therefore, disease. such procedures are rooted in disease-specific action groups for health concerns; for example a dengue task force, empowered at multiple levels of governance from the municipality to the minsap and deployed in the case of a dengue outbreak with the exclusive task of bringing about the outbreak's end (interview, pan american health organization (paho)). this provides cuba with surge capacity to systematically respond to and manage health security concerns that occur within its borders. these groups work alongside the routine health service, and with civil defence units to respond to crisis events and mobilise quickly to minimise any potential threat to the population (interview, pan american health organization (paho)). more systematically, cuba has a distinct focus on rigorous point-of-entry controls. indeed, the main role of minsap's health surveillance unit is to prevent the introduction of infections to cuba (interview, ministerio de salud publica). when cuban nationals return to cuba from states that have endemic infectious diseases, they are subject to rigorous airport screening. this information is passed to their neighbourhood doctor for daily or weekly follow-up to ensure that individuals are not experiencing unusual symptoms and if they are, to facilitate rapid treatment, including if necessary, mandatory treatment and/or quarantine to avoid further disease transmission (interview, instituto de medicina tropical pedro kouri). the ability of the health system to facilitate such personalised follow-up, to ensure rapid treatment and to limit further infection is remarkable, and from a public health perspective, it far outperforms any health system in the global north, if not from a human rights perspective. these point-of-entry protocols are enforced for every flight and include airport scanners and in-airport medical professionals. if necessary, those arriving in cuba may be taken directly to a doctor and/or the tropical medicine institute, ipk (interview, instituto de medicina tropical pedro kouri). this quarantine and prophylaxis procedure at instituto de medicina tropical pedro kouri (ipk) includes all medics returning to cuba from ebola-infected or malaria-infected locations, who are subject to a mandatory days stay at ipk. second, cuba has a booming biotechnology industry, with significant investment made by the cuban state into research and drug development to ensure access to medicines should an outbreak emerge. as cuba is unable to purchase many global biomedical products, owing to the strict embargo placed on the country by usa, the bmj global health strides taken to ensure indigenous production of these medicines, treatments and future research represents demonstrable activity in maintaining cuba's health security to ensure a healthy and productive population. for example, this has included development of a vaccine for dengue fever, meningitis b, hepatitis b and many more besides. moreover, a biosecurity level laboratory (interview, ministerio de salud publica) and the development of other biomolecular diagnostic laboratories that can do diagnosis incountry mean that cuba does not have to send virus samples elsewhere (interview, ministerio de salud publica). third, cuba maintains almost uhc. uhc has been championed as a key mechanism to developing health systems resilient to disease outbreaks. cuba demonstrates how the mechanisms and processes for providing uhc to the population also provide the foundation for effective infectious disease control. cubans can seek medical advice through free and easily accessible consultations with health professionals through the consultorio (neighbourhood health clinic), established 'on every block' with a doctor and nurse in each communitywith approximately one consultorio per people. this has only been possible through significant government investment in healthcare as a priority since the revolution (although the motives for this are in part because the majority of doctors in cuba fled at that time (interview, pan american health organization (paho)). for more specialist care, patients are referred to a policlinico (polyclinic), particularly specialising in maternal and child health, chronic disease support and minor surgeries. the initial aim of this family centred programme was to decentralise hospital activities, to free up space in the system to manage the most serious of cases and to allow for surge capacity in the event of an emergency. yet the medics, and importantly nurses, who work in these consultorios and policlinicos who offer general medical provision also play a decisive role in epidemiology and disease prevention. in terms of epidemiological surveillance, the 'doctor on the corner' functions to record any epidemiological changes in the community. for example, dengue outbreaks, which occur with some frequency across cuba, are rapidly detected and within a matter of days integrated vector control activities will have begun due to the epidemiological reporting of the local consultorio. the close contact between the nuclear family and the doctor on every corner facilitates this rapid detection and response, ensuring that infections do not become major outbreaks and that infection control protocols are implemented (interview, ministerio de salud publica). this is in spite of no automated infrastructure and a paper-based surveillance system in a resource-poor setting. this infectious disease surveillance also pre-empts disease outbreaks through annual health checks on all members of the community (dispensarizacion). through this process, the consultorio preclassifies potential 'at risk' citizens based on social factors which may make them predisposed to infectious disease should it arise (interview, ministerio de salud publica; interview, pan american health organization (paho)). this preventative approach to disease control also relies on preventative care through increased vaccination coverage and health awareness among the population, reducing the chances of an outbreak taking hold in the country, the latter evidenced by the successful management of the hiv/ aids crisis on the island. thus, cuba demonstrates how the mechanisms and processes for providing uhc to the population also provide the foundation for effective infectious disease control, although this has been in a political context where the components of disease surveillance, biotechnology and universal healthcare form part of a broader narrative of regime preservation. indeed, if the goal of the cuban state is to preserve its borders and political narrative, then ensuring that its population has protection from infectious disease and access to routine healthcare functions also to reassure citizens in an effort to avoid internal sedition and lack of faith in the socialist project. nevertheless, while learnings from cuba must be considered within an instrumentalist paradigm and recognise that cuba's health security activities may not be as portable to different political and social environments, cuba's integration of community-based healthcare and disease surveillance and control activities does provide a pertinent example for broader global health security/ uhc debates as to what this might look like in practice, and how effective uhc can be for ensuring global health security. despite cuba's strong health security position, cuban health security activity is not framed as such, and this framing may well have an impact on cuban visibility within this global policy space. in turn, there are further impediments to cuban participation and recognition as a leader within the global health security architecture. for example, cuba claims to have met all the core capacity requirements for disease surveillance and control under the international health regulations (ihr) ( ), but has yet to agree to undergo a joint external evaluation (jee) to externally verify these capacities. although interviewees stated that plans were afoot for a jee in , we were unable to find evidence of this at the time of writing. this lack of clarification over the status of the jee is also mirrored in cuba's failure to report outbreak events to who, as required under the ihr ( ), including during the zika outbreak and rumoured cholera outbreaks across the island. where reports have been made, the case numbers reported have sometimes been manipulated so as not to reveal the full extent of the outbreak (interview, pan american health organization (paho)). thus, while cuba may demonstrate achievements in global health security, it also appears to be a reluctant player in the global health security regime. cuban health security activity, moreover, is not without its own challenges. as highlighted above, the ability for the state to mandate prophylaxis or quarantine for those potentially infected by a particular virus, not to mention pre-emptive activity on citizens deemed to represent risks to collective health security on the island, raises questions of civil liberties and human rights within the cuban health sector. much has been written about cuba's abuse of human rights and tight authoritarian control in other sectors, so this may not be of surprise from a broader cuban structural perspective. yet, within the health sector, there is no right to privacy in the physicianpatient relationship, no right to informed consent and no right to refuse treatment. these challenges point to an inherent tension within health security between the protection of civil liberties and public health, as encapsulated by the siracusa principles. the social control exercised by the cuban state thus raises questions of where the line between liberty and security lies and what rights governments have to restrict individual freedom in the name of public health-a debate that has also played out in other contexts, such as in the handling of patients with multidrug-resistant tuberculosis globally. a further challenge to cuba's health security is the level of underdevelopment that remains across much of the island. vast swathes of the island live in poverty, without routine access to water or sanitation services, with open sewers or water that is unable to drain because of poor civic planning (interview, pan american health organization (paho)). this can have a direct influence on susceptibility to vectorborne or waterborne disease. failure to maintain sewage systems in a civic infrastructure struggling to financially support itself has led to an increase in diarrhoeal disease and cholera. this lack of investment in the socioeconomic determinants of health, potentially as a consequence of the decisive focus on infant mortality within the health sector, poses a contradiction to so much of the success that cuba can show in terms of an exemplary health security capacity in such a resource-poor setting. it also demonstrates the inequalities across the system; while the consultorio model and thus 'health security' may work in urban areas, this may not be replicated across the system in poorer zones (interview, pan american health organization (paho)). thus, socioeconomic development and indeed, resources remain a key limitation of health security in cuba. lack of government funds means that in the event of a major outbreak there may be limitations on equipment, deployment activities elsewhere, and research and development achievements. these resource constraints are exacerbated by the us embargo, which has been almost continuously in place since . this has wide-ranging effects across areas of domestic policy, and despite having little impact on life expectancy, we propose that the embargo does have a potential impact on the health security strengths of the system. for example, the embargo on us goods means that pharmaceutical ingredients or products produced in usa or with a patent held by a us company are not available in cuba. this means that cuban access to newer international drugs is limited and may directly impact on the health security of the nation if a newly emerging pathogen appears and a drug is developed that cubans are not able to access (interview, ministerio de salud publica). this also extends to medical equipment. there have been efforts by cuban medics to circumvent this medical embargo, through sourcing medication from third party states, but this has been met with indignation and legal challenge by the usa. while it is impossible to imagine a replication of the cuban health system in other resource-poor settings owing to the uniqueness of the political situation, this is not to say that meaningful lessons cannot be ported. in particular, cuba demonstrates how a health system that is prevention-oriented and community-based contributes to reducing infectious disease threats-a key point of focus in contemporary global health security debates. here cuba provides a much needed example of how disease surveillance and control efforts can be integrated with community-based primary healthcare to provide for health security in low-income settings. cuba's medical internationalism, moreover, demonstrates the effectiveness of frequently offering national doctors for international disease control efforts, allowing for a welltrained and readily deployable medical corps to respond to disease both within cuba and abroad. the training provided to the henry reeve brigade in responding to the ebola outbreak is particularly illustrative of how national and global surge capacity to respond rapidly to health crises might be achieved. the focus on strengthening routine healthcare as well as health crisis response in cuba's medical internationalism, moreover, opens up space to reflect on how global health security activities might be integrated into longer-term health interventions. despite these activities, however, cuba remains largely at the margins of global health security policy and debate, with implications for cuba's engagement with the global health security regime, as encapsulated by the ihr ( ), and for cuba's visibility in global health security policy and practice. indeed, the us embargo, cuba's development and resource challenges, and the tight social controls exercised by the state in managing disease threats in its territory also speak to broader global health security issues. these concern global access to essential medicines and commodities, the development of sectors beyond health alone in reducing vulnerability to disease, and the trade-off between civil liberties and public health in disease control efforts. the cuban case thus offers opportunity for more in-depth reflection as to the strengths and weaknesses of contemporary health security practices, although with the caveat that lesson learning should be applied cautiously in this context given bmj global health the tensions within the cuban political system in relation to civil and political freedoms, the critiques concerning cuba's instrumentalist promotion of its health system and the trade-offs which had been decisively made for the prioritisation of disease control and infant mortality. correction notice this article has been corrected since it published online to reflect the correct author names in reference . twitter clare wenham @clarewenham microbial threats to health: emergence, detection. and response toward a common secure future: four global commissions in the wake of ebola sustainable development goals will ebola change the game? ten essential 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grip on aids. the new york times mosquito guns and heavy fines: how cuba kept zika at bay for so long an appeal to our people the cuban biotechnology industry: innovation and universal health care: pan american health organization world health organization. cuban experience with local production of medicines, technology transfer and improving access to health redefining universal health coverage in the age of global health security health systems strengthening, universal health coverage, health security and resilience disease diplomacy : international norms and global health security cuban civil society during and beyond the special period cuba en la comunidad internacional en los noventa: soberanía, derechos humanos y democracia re-examining the cuban health care system: towards a qualitative critique siracusa principles on the limitation and derogation provisions in the international covenant on civil and political rights failing siracusa: governments' obligations to find the least restrictive options for tuberculosis control an evaluation of four decades of cuban healthcare effect of the u.s. embargo and economic decline on health in cuba acknowledgements the authors thank lse latin american and caribbean centre including helen yaffe, gareth jones and alvaro mendez for their discussions during the research phase of this study. contributors cw and skk conceived, designed and undertook the research. they both wrote the final paper. competing interests none declared.patient and public involvement patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.patient consent for publication not required.ethics approval ethical approval was obtained from lse ethics committee ( ).provenance and peer review not commissioned; externally peer reviewed. key: cord- -l d rgt authors: turcotte-tremblay, anne-marie; fregonese, federica; kadio, kadidiatou; alam, nazmul; merry, lisa title: global health is more than just ‘public health somewhere else’ date: - - journal: bmj glob health doi: . /bmjgh- - sha: doc_id: cord_uid: l d rgt nan ► global health can be anywhere as it often focuses on large-scale health inequities that are rooted in transnational determinants. ► some global health initiatives and actors aim to find solutions to domestic problems. ► king and koski's definition of global health may exacerbate inequities by reserving the right to call oneself a global health researcher to those who are privileged and have access to funding that enables them to travel to other settings. ► an inadequate definition of global health based on a 'here' vs 'somewhere else' dichotomy could result in less funding for a field already characterised by limited resources. ► the decolonisation of global health requires promoting and valuing reflexivity, critical approaches, equitable partnerships and accountability. king and koski recently published a bold commentary in bmj global health that defines global health as 'public health somewhere else'. it raises important concerns about the justification, scope, efficiency and accountability of the field. we appreciate that the commentary compels us to reflect on the definition of global health, its application and how the field could be improved. we also agree that many of the issues highlighted by the authors (ie, political priorities driven by the north, expertise from the north being overvalued) do exist in some global health interventions. many of us have heard of or witnessed disastrous situations caused by seemingly wellintentioned people. however, the problems described are not unavoidable or intrinsic characteristics of global health. moreover, we believe the proposed definition of global health is not adequate to conceptualise the field. rather than prompting improvements, it could result in mistrust towards global health and be a step backwards for the field. in the following, we contend that global health is more than just 'public health somewhere else' and argue that an inadequate definition entails risks for the field. . the populations of interest in these instances can be anywhere (low, middle and high-income countries) and include anyone affected and facing health inequities due to these transnational or global issues. the solutions can also be global or transnational in nature. the coronavirus pandemic is an example of a global health problem that is affecting people everywhere, especially vulnerable groups. due to the ever-increasing movement of people across borders, viruses like covid- can spread easily and quickly around the world and affect anyone, irrespective of whether they are in the global north or south. a global health response involving most countries that includes data sharing and coordinated efforts to stop the spread, find treatments and a cure as well as protect vulnerable groups (eg, elderly, migrants, prisoners, homeless) is therefore necessary. second, we disagree with king and koski's statement that 'a person engages in global health bmj global health when they practice public health somewhere-a community, a political entity, a geographical space-that they do not call home'. to us, this is an oversimplified statement. several of our colleagues, and we as well, have received funding to engage in global health in places we call home. for example, kk has conducted research on social protection policies in burkina faso, her home country. similarly, na has conducted research on the health of migrant workers in bangladesh, where he lives. we should be applauding and valuing global health initiatives that are led by local researchers/practitioners rather than excluding them from the definition. moreover, king and koski's definition is not adequate because some global health initiatives are aimed at finding solutions to domestic problems, whether it be in a high, middle or low-income country. for example, grand challenge canada funded the adaptation and transfer of innovations from low and middle-income countries to make a difference in canada. while the innovations come from abroad, the primary focus or end goal of such initiatives is quite local. this also highlights the fact that solutions for health problems in the north and south sometimes stem from expertise in the south. according to syed et al, global health partners are increasingly seeking a mutuality of benefits across countries. third, there are many public health researchers and practitioners working 'somewhere else', in a place that 'they do not call home', whose work does not qualify as global health. they do not view themselves as part of the global health community, nor do they actively participate in global health activities. their practice and research would also not be eligible for global health funding. for example, a canadian medical student's clinical placement in a public health unit in belgium is not automatically considered training in global health simply because it is done in another country. therefore, referring to global health merely as public health 'somewhere else' is not useful. fourth, we consider that king and koski's commentary and definition discredit the field of global health and fail to recognise its added value. while it is crucial to reflect on limitations, it is also important to highlight the field's strengths, best practices and success stories. there are examples of global health research and interventions where countries and communities have worked collaboratively and shared expertise, cultural knowledge and other resources to develop appropriate and effective solutions. [ ] [ ] [ ] moreover, while global health is considered one of the multiple branches of public health, the literature does suggest there are differences among them. for example, global health tends to have a broader focus (ie, health for all worldwide), a greater emphasis on health inequities, more interdisciplinarity and more 'bridging' between cultures and communities. practitioners and researchers working in global health also face unique ethical challenges (eg, power differentials between parties) and require that some key competencies be further developed (eg, cultural safety and inclusion, partnership development). recognising global health as a field in its own right is crucial to ensure there are dedicated resources for training and forums where the global health community can exchange and share knowledge, so that best practices can be further promoted, especially among students and emerging researchers and practitioners. it is also vital that global health be recognised as a distinct field so that resources will be made available to support global health initiatives that can promote the human right to health and help meet the global pledge to 'leave no one behind'. the proposed definition by king and koski entails several risks. first, accepting the definition proposed would mean that global health initiatives led by local actors or community leaders in low or middle-income countries, or by indigenous or migrant communities in high-income countries, would not be acknowledged and considered global health. this in turn could lead to devaluing their contribution as global health actors and limiting their access to resources to support their work, despite there being significant needs. therefore, rather than moving us 'towards an eventual decolonisation of global health', the definition by king and koski might actually reinforce the problems they highlight in their article, including inefficiency, lack of accountability and uncritical faith in western expertise, because only 'foreigners' would be acknowledged as doing global health. second, the definition may exacerbate inequities by reserving the right to call oneself a global health researcher, and the related expertise, exclusively to those who are privileged and have access to funding that allows them to travel and practise or conduct research in other settings that they do not call home. third, the definition would limit the scope of problems and solutions considered, possibly neglecting global and transnational issues. fourth, if global health is conceptualised as public health elsewhere, what interest would countries and communities have in investing in global health? this could result in less funding for a field that already faces the challenge of limited resources. lastly, the definition and commentary imply that working somewhere else is somewhat problematic and negative. we are concerned that this view is divisive and dangerous. it could contribute to ethnocentrism and ultimately limit the sharing of knowledge and expertise across groups. a 'here' versus 'somewhere else' dichotomy seems counterproductive. we live in a globalised world, and more than ever we are interconnected and interdependent. everyone in high, middle and low-income settings has a vested interest in attaining health for all and reducing health inequities. concerns over pandemics (covid- !), global warming, environmental degradation bmj global health and potential misuse of technological advances (the easy spread of fake news!) affect us all. protecting the most vulnerable is beneficial for everyone-for our economic, social, mental and physical well-being. as a burkinabé saying goes, 'we are together'. currently, global health may not be perfectly practised, but we need inclusive definitions, frameworks and training programmes that set the standards towards which we should all strive. we can have transparent discussions and be critical of global health academic programmes, research and practices, while sharing an adequate definition. we should condemn bad practices, rather than condemn the whole field. true partnerships across disciplines and geographic boundaries, which have resulted in meaningful projects, exist and can be further promoted. we need to promote the strengths and best practices of the field and value success stories while learning from failures. ultimately, the decolonisation of global health requires training programmes that teach reflexivity, critical approaches, equitable partnerships and accountability. such training programmes, and all global health initiatives more broadly, should include participatory approaches and ensure there are benefits for all stakeholders involved. resources should also be expended equitably. these are all good practices that are attainable. this is the morally 'right way' to do global health, and also a more effective way to achieve 'health for all'. contributors amtt conceived the main idea presented. all authors contributed to the conception and writing of the commentary. funding we thank the quebec population health research network for its contribution to the financing of this initiative. moreover, amtt received a training bursary from the canadian institutes of health research (cihr). lm was supported by a research scholar junior award from the fonds de recherche du québec-santé (frqs). competing interests none declared. patient consent for publication not required. provenance and peer review not commissioned; internally peer reviewed. open access this is an open access article distributed in accordance with the creative commons attribution non commercial (cc by-nc . ) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. see: http:// creativecommons. org/ licenses/ by-nc/ . /. anne-marie turcotte-tremblay http:// orcid. org/ - - - defining global health as public health somewhere else towards a common definition of global health rethinking the 'global' in global health: a dialectic approach developed-developing country partnerships: benefits to developed countries? reverse innovation" could save lives. why aren't we embracing it? in: the new yorker the global health research capacity strengthening (ghr-caps) program: trainees' experiences and perspectives the what works working grouplevine r. millions saved. proven successes in global health emergence and robustness of a community discussion network on mercury contamination and health in the brazilian amazon ngo-researcher partnerships in global health research: benefits, challenges, and approaches that promote success lessons from developing, implementing and sustaining a participatory partnership for children's surgical care in tanzania public health and global health definitions beyond procedural ethics: foregrounding questions of justice in global health research ethics training for students l'évaluation qualitative, informatisée, participative et inter-organisationnelle (equipo) key: cord- -j w u authors: gaupp, franziska title: extreme events in a globalized food system date: - - journal: one earth doi: . /j.oneear. . . sha: doc_id: cord_uid: j w u our food systems are complex and globally interdependent and are presently struggling to feed the world’s population. as population grows and the world becomes increasingly unstable and subject to shocks, it is imperative that we acknowledge the systemic nature of our food system and enhance its resilience. after the prevalence of undernourishment had declined over the last decades, since , the number of people who suffer from hunger is increasing again. today, more than million people in the world are hungry, and around billion people do not have regular access to nutritious and sufficient food. a growing and more affluent population will further increase the global demand for food and create stresses on land, for example, through deforestation. additionally, food production and agricultural productivity are further affected by an increasingly changing and variable climate, including extreme events, which further undermine the resilience of our systems. we are facing increased frequency, intensity, and duration of climate and extreme weather events, such as heat waves, droughts, and floods. increased temperatures have contributed to land degradation and desertification in many parts of the world. erratic precipitation patterns and unpredictable rainy seasons increase uncertainty about planting times and can lead to crop failure. changing land conditions through human actions on the regional scale, such as deforestation and urban development, can further accentuate these negative impacts at a local level. given that extreme events are expected to further increase through the st century, we need to increase the stability of the global food system. increases in global temperatures will affect processes involved in land degradation (such as vegetation loss or soil erosion) and food security (through crop losses and instabilities in the food supply). a . c global warming is projected to lead to high risks of food-supply instabilities, including periodic food shocks across regions and spikes in food pricing, and our current trajectory has us on course to significantly exceed this threshold. although climate and climate extremes affect our ability to produce food, food and nutrition security is more than just agricultural productivity. today's food system is globalized and consists of highly interdependent social, technical, financial, economic, and environmental subsystems. it is characterized by increasingly complex trade networks, an increasingly efficient supply chain with market power located in fewer and fewer hands, and increased coordination across interdependent sectors via information technology. between and , trade connections for wheat and rice doubled and trade flows increased by % and % respectively. furthermore, market power along the global food supply chains is consolidating. the three largest seed suppliers increased their combined market share from % in the s to % in . in the uk, the three largest supermarkets hold a market share of %. although these emergent network structures of commodity supply chains increase gains in economic efficiency, they lead to systemic instability susceptible to shocks. trade networks are more interconnected and interdependent than ever, and research has shown that they can be intrinsically more fragile than if each network worked independently because they create pathways along which damaging events can spread globally and rapidly. it is true that these trade networks could, for instance, help connect local producers to global markets and increase their incomes, but there is a risk that increasing network densities and complexities might lead to food insecurity in one part of the system as a result of the food system's inherent response to a shock rather than as a result of the initial shock itself. furthermore, local events might trigger consequential failures in other parts of the system through path dependencies and strong correlations and thus lead to amplification of the initial shock through cascading effects. a shock in the integrated global food supply chains can lead to ripple effects in political and social systems. the droughts in wheat-producing countries such as china, russia, and ukraine, for instance, led to major crop failures, pushing up food prices in the global markets. this in turn contributed to deep civil unrest in egypt, the world's largest wheat importer, as people were facing food shortages and helped the revolution to spread across the country. although it has been shown that global economic integration continues to strengthen our resilience to smaller shocks through trade adjustments, the current network structure and functional relations create higher vulnerabilities to so-called systemic risks. given how interconnected the food system is globally, taking a systems approach is vital to help us ensure food security. doing so requires an understanding of the systemic characteristics and vulnerabilities of the global interconnected food system. although one extreme event and the consequent crop losses in a single production region can be buffered by highyielding harvests in other places, grain storage, and trade, multiple-breadbasket failure is a growing reason for concern. correlated or compound climate and ll weather events (a combination of correlated climate drivers that surpass the coping capacity of the underlying systems) on both local and global scales could trigger systemic risks in the global food system. locally, non-linear dependencies between heat and drought conditions have been shown to have severe consequences for crop production in specific breadbasket regions, such as the mediterranean. on a global scale, largescale atmospheric circulation patterns, such as el niñ o-southern oscillation or rossby waves, can cause simultaneous extreme heat and rainfall events in different parts of the world. in summer , simultaneous heat extremes in the northern hemisphere were associated with amplified rossby waves, resulting in reduced crop production in central north america, eastern europe, and eastern asia. because those regions include important areas of crop production, such teleconnections have the potential to cause multiple, simultaneous breadbasket failures, posing a risk to global food security. if climate extremes are additionally co-occurring with other hazards, the systemic vulnerability of our global food system becomes apparent. this can currently be observed in east africa and yemen, where the population is fighting against a desert locust upsurge while experiencing conflicts, climate extremes, and coronavirus disease (covid- ), all of which further constrain surveillance and control operations in the locust crisis. the combination of those multiple hazards has led to warnings that in the second half of , million people will experience acute food insecurity. the climate-agri-food system is characterized by dynamic interactions across spatial and temporal scales, ranging from global to local and from shocks such as heat waves to long-term stressors such as biodiversity loss. nonlinear dynamics in the climate system can lead to rapid and irreversible changes if the system surpasses a certain threshold. one of those so-called climate ''tipping points'' that might have major consequences for europe's climate and lead to significant losses of crop yields is the weakening and potential collapse of the atlantic meridional overturning circulation (amoc). greenland melting and arctic warming are driving an influx of fresh water with lower salinity and density into the north atlantic, which is weakening the overturning circulation, an important part of global heat and salt transport by the ocean. if amoc weakened and even collapsed in the coming decade as a consequence of further warming, europe's seasonality would strongly increase and lead to harsher winters and hotter and drier summers. this is projected to reduce global agricultural productivity and to increase food prices. not all shocks to the globalized food system are directly linked to agricultural productivity or climate. the complexity and inter-connectedness and vulnerability of our globalized food system have become painfully evident in recent weeks after the emergence of a different type of shock to the system: a global pandemic. having started as a health crisis, covid- quickly trickled through the political, social, economic, technological, and financial systems. in the food system, lockdown measures and trade and business interruptions all over the world led to cascading effects that are projected to trigger food crises in many parts of the world. although harvests have been successful and food reserves are available, interruptions to global food supply chains have led to food shortages in many places. products cannot be moved from farms to markets, processing plants, or ports. food is rotting in fields because transport disruptions have made it impossible to move food from the farm to the consumer. at the same time, many people have lost their income, and food has become unaffordable to them. the world food programme has warned that by the end of the year, million additional people could face famine. in the fight against covid- , borders have been closed, and a lack of local production has led to price spikes in some places. in south sudan, for example, wheat and cassava prices have increased by % and %, respectively, since february. in the coming months, planting, harvesting, and transporting food are likely to further face logistical barriers, which will again exacerbate food shortages and drive up prices. a lack of food access and the related grievance could then lead to further cascading effects, such as food riots and collective violence. besides compound shocks, non-linear dynamics, and cascading events, the complexity of the global food system entails feedback loops that further amplify initial shocks. as a consequence of covid- , the fear of food shortages and price spikes due to global trade interruptions has led to export restrictions on food in several countries. at the time of writing, countries have active, binding export restrictions on food, as shown by the international food policy research institute's food policy tracker. russia, the world's biggest wheat exporter, announced in april that it will halt exports until july, when farmers will start to bring in grain from the new harvest. other wheat suppliers, such as kazakhstan and ukraine, have also capped sales. importers such as egypt, on the other hand, are hoarding crops in fear of shortages, creating feedback loops that will further drive up prices. especially in lowincome countries, this might make food unaffordable for large parts of the population and increase the threats of food insecurity. the visible and measurable systemic characteristics of the global food system are complemented by hidden links and consequences that become visible only after a shock has hit the system. the current pandemic has revealed structural weaknesses in our food system. little storage and just-in-time supply chains have increased economic efficiency but led to systemic instability. just how vulnerable and easy to disrupt the supply chains in some parts of the world are has become evident in the last several weeks. further food-system interdependences that were previously ignored but are becoming apparent now include the role of schools in providing nutritious food to children. the world food programme estimates that globally, million school children miss out on meals that they would normally receive in schools because classes are shut down. if we want to make the global food system resilient to future shocks, we need to pay attention to both quantifiable and uncertain systemic risks and foodsystem interdependencies. to address the challenges of a globally interconnected, complex food system that is projected to be hit by more frequent and severe extreme events, we need to take a systems approach and one earth , june , ll acknowledge the systemic characteristics of the global food system (figure ) . we need better food-system models that can account for systemic risk characteristics and increase our understanding of non-linear dynamics, tipping points, feedbacks, dependence structures, and adaptive behaviors. we need transdisciplinary approaches that bring together different disciplines as well as other forms of expertise, such as knowledge of local practitioners. quantitative and qualitative methods need to be combined, and different model types need to be integrated to link climate hazards with technological and civilizational risks. artificial intelligence and new machine-learning tools can improve our understanding of the food system's complexity but must be complemented by qualitative assessment, such as perceptions, social concerns, or socio-economic impacts. robust data and statistics that are accurate, timely, disaggregated, and accessible are needed for monitoring and early warning systems. systemic risk and systemic opportunities need to be incorporated into the design of food-related policies. effective governance needs to consider the interconnectedness among different parts of the global food system. a network perspective that pays attention to the ll interdependent actors and nodes is required. one solution could be a systemic-risk transaction tax as suggested for the financial markets. individual actors (such as large trading companies or retailers) that increase systemic risks in the network will be taxed proportionally to their marginal contribution to the overall systemic risks. the tax can be seen as insurance for the public against costs arising from cascading failure. additionally, we need global collaboration to work toward better management of trade barriers to ensure that food value chains function even in moments of crises to prevent price spikes and provide ''all people, at all times, [with] physical, social and economic access to sufficient, safe and nutritious food that meets their dietary needs and food preferences for a healthy and active life.'' more shocks are likely to hit our global food system in the future, unleashing the potential for systemic risks to cascade through the system and to lead to major impacts and system breakdowns. these include projected increases in simultaneous climate extremes in breadbasket regions, crop pests, and other, unexpected shocks. if we want to avoid major threats to food security, we need to take a systems perspective in analyzing, managing, and governing the global food system. the state of food security and nutrition in the world: safeguarding against economic slowdowns and downturns special report on climate change and land (intergovernmental panel on climate change globally networked risks and how to respond amplified rossby waves enhance risk of concurrent heatwaves in major breadbasket regions fao makes gains in the fight against desert locusts in east africa and yemen but threat of a food security crisis remains, fao news article running amoc in the farming economy soaring prices, rotting crops: coronavirus triggers global food crisis covid- food trade policy tracker coronavirus: rationing based on health, equity and decency now neededfood system expert, the conversation global monitoring of school meals during covid- school closures modelling food security: bridging the gap between the micro and the macro scale governance of systemic risks for disaster prevention and mitigation united nations office for disaster risk reduction elimination of systemic risk in financial networks by means of a systemic risk transaction tax global strategic framework for food security and nutrition the author would like to thank the editor and michael obersteiner for valuable suggestions and comments in the development and improvement of the manuscript. the author's work is supported by the receipt project (grant agreement ) and by eit climate-kic's ''forging resilient regions deep demonstration.'' key: cord- -ji suirn authors: ciupa, kristin; zalik, anna title: enhancing corporate standing, shifting blame: an examination of canada's extractive sector transparency measures act date: - - journal: extr ind soc doi: . /j.exis. . . sha: doc_id: cord_uid: ji suirn canada's extractive sector transparency measures act (estma) is the culmination of a series of proposals and consultations with government, industry and civil society organizations to address conflict over canadian extractive industry. created in the context of a global call for extractive industry accountability, as well as increasing scrutiny of canadian mining activities for alleged human rights and environmental abuses, the estma aims to deter corruption via financial reporting requirements for canadian extractive firms operating in canada and abroad. by mandating that firms publicly disclose payments to various levels of government, however, the estma is constructed atop global corruption discourse that identifies host states in the global south as the source of social pathologies that facilitate corruption, largely excluding a critical analysis of extractive firms in the global north. drawing on interviews, document analysis of material related to the estma and case studies of extractive firm financial reporting, this paper argues that under the estma's financial reporting processes, corporate risk management trumps meaningful social regulation. while the act does mandate disclosures useful to the advocacy community, limited oversight, a lack of standardized reporting and excluded activities under the act mean that the estma offers limited leverage to substantively address the human and ecological cost of canada's extractive industry. as has resulted from transparency policies more broadly, however, the estma provides firms a means to counter broader critique and, in complying with audit culture, promotes investment security. in late the former harper government enacted canada's extractive sector transparency measures act (estma). the act came into effect on june , four months prior to the election of a liberal majority government under prime minister justin trudeau. the estma fulfilled the commitment made by the canadian government to implement the extractive industries transparency initiative (eiti) at home. canada was among the global proponents of eiti implementation in 'host states' of the global south and had served on the eiti board from its inception. the estma also made canada compliant with key terms of the european union (eu) transparency directive issued in (modified in ) and the us dodd frank act and consumer protection act. the ngo publish what you pay canada (pwyp) advocated strongly for the estma, and convoked and facilitated the multi-stakeholder resource revenue transparency working group (rrtwg) whose negotiations significantly contributed to the legislation. in , the estma completed its first round of implementation and reporting by canadian extractive sector firms operating domestically and internationally. within the context of domestic legislation, the estma may be viewed as a major step forward, requiring firms listed on a stock exchange in canada, or which conduct business in canada that meets a particular minimum threshold, (thus incorporating some firms that are not publicly traded), to publicly disclose payments to various levels of government (guidance, ) . in principle international policies entailing global transparency practice are directed at reshaping relations between the northern extractive industry and so-called 'host states' in the global south as well as controversial industries at home. discussed in various articles in this special issue, the key global example is the extractive industries transparency initiative implemented by domestic governments in varied jurisdictions. while the canadian government had been an eiti supporter since , it has never implemented it incountry. nevertheless, given that the estma's reporting requirements are mandatory, the legislation is viewed by some as more stringent than the voluntary dynamics undergirding the eiti. in the case of the eiti, domestic implementing legislation may be rudimentary and thus neither obligatory nor enforceable at the firm level. in canada and elsewhere the content of twenty-first century extractive sector transparency legislation, with its emphasis on reporting and formal financial procedures, responds to public calls for greater accountability on the part of polluting and frequently violent industry. yet is also offers measures of security to both the firm and state as a form of industrial audita topic that received important critical attention at the turn of the millennium from scholars from business to anthropology (power (power , strathern strathern , a . critiques of audit influenced analyses of various practices -in accounting, public management and education, and has been revisited in recent work, including on the extractive sector (kemp et al. ; welker ; shore and wright ; gilbert and zalik, ) . as michael power emphasized, audit practice operates primarily as a form of social reassurance regarding largely under-regulated, and potentially high-risk, industrial and institutional processes. in addition to audit and risk management, however, the estma and eiti also are constructed atop global corruption discourse (haufler, ) , itself a function of a broader context of global systemic racism. herein, critical race theory draws attention to how an investment in white supremacy entails justifying the overall impoverishment of indigenous and racialized peoples through racist tropes. scholars such as doshi and ranganathan ( ) and bratsis ( ) discuss the roots of corruption discourse in modernization theory and orientalist and racist depictions of global south governance. the eiti discourse of corporate 'home' state (global north) and operational 'host' state (typically global south), which characterized the initiative at its inception, set up an uneven application between extractive sites in the south and sites of corporate headquarters in the north, as bracking ( ) delineates. the so-called 'host states' of the global south or non-west are thus identified as the source of social pathologies that facilitate corruption, a problem to be remedied by revenue transparency confirming the amounts firms pay to government institutions. the broader international financial architecture that historically favoured massive wealth transfers from less to more industrialized sites or to unnamed 'beneficial owners' are left external to interrogation. while elites globally have benefited from wealth transfers, financial accumulation has tended to accrue in the north or in offshore havens that protect funds these elites control (palan, ; osuoka and zalik, ) . although practices of insider trading and nepotism in the global north received increased scrutiny after the financial crisis, the term 'corruption' is not typically applied to refer to these practices. rather, 'corruption' is largely reserved for practices that occur in the non-west and zones 'overseas' (gillies, ) , a notable discrepancy given that the oil and gas sector is an essentially global industry. the duplicity in this position has not gone unnoticed even by mainstream policy makers. clare short, former eiti chair and one time uk minister for international development implied as much when calling on the us, uk and canada to pass domestic legislation and implement the eiti at home in . on the basis of interviews and primary documents related to the estma, this paper views the estma as an expression of 'audit culture transparency' (gilbert and zalik, ) . above we placed our analysis of estma in conversation with some literatures on extractive sector transparency and the eiti, as well as the re-regulation of the us and eu financial sectors following the financial crisis. as discussed further below, we offer a critical view on how transparency and anticorruption discourse pathologize states and southern bureaucracies and indigenous governments, subjecting them to imperial relations. the pathologizing of social and political relations in these spaces -and their economic and ecological role as capital and nature exporter -intersects with global logics of racism and white supremacy. the next section examines the estma in the context of (section ) canadian domestic and international calls for greater oversight of canada's oil, gas and mining sectors given the canadian industry's complicity with growing human rights abuses. subsequently the paper reviews (section ) the emergence of the estma legislation in relationship to broader transparency discourse and eiti scholarship, and the role played by both civil society and the business sector in shaping it. our particular focus of attention is the estma legislation and guidance documents. through this analysis we draw parallels with attributes of 'audit culture', including how anti-corruption discourse largely upholds the power of global capital, and serves to manage risk on the part of financial institutions. on this basis we then consider (section ) actual reporting under the estma to date, including both affirmations of its role in lifting the veil on corporate actions, as well as a less optimistic account of how information gaps could render the estma a hollow example of transparency without substantive disclosure. as is typically the case in the corporate world, boards of directors and ceos may overlap across firms engaged in activities that are and are not covered by the estma; notably extraction and production on which the estma mandates disclosure of payments, and exploration and processing activities which are not covered under the estma. while the estma, importantly, legally mandates reporting by firms, it also creates various loopholes that make disclosures either less useful to communities and civil society, or revocable. we attend to three examples -(i) that of goldcorp/ tahoe's/pan american silver -which publish what you pay canada has featured among its case studies, as well as (ii) that of de beers/anglo american, including de beers' use of reporting under another jurisdiction to fulfill estma requirements. we end with reflections on (iii) africa oil corporation, part of the broader lundin group of companies that includes within it firms engaged in both exploration and development. the specific projects that prompt our attention to these firms are the el escobal mine in guatemala, the victor mine in northern ontario and africa oil's recent acquisition of assets in nigeria and guyana in joint ventures. in the past decade, the global relations of canada's extractive industry have come under increasing scrutiny. with the rise in value of the canadian dollar in the first decade of the millennium, canada's foreign direct investment in the global south increased. due to rising commodity prices, the mining industry, which has long been significantly traded on the canadian stock exchange, became a particularly profitable arm of canadian capital (deneault and sacher ; zalik ) . while canadian mining activity increased internationally in this period, its presence in latin america became particularly problematic. canadian civil society organizations, among them mining watch, rights action and kairos paid particular attention to human rights abuses associated with the activities of canadian mining firms. attention to questionable security practices, destruction of three formal interviews ( - . hours) with key informants were conducted: one with a government representative and two with civil society representatives. in addition, the paper draws on notes from discussions with civil society and academic researchers over a two year period. primary document (footnote continued) analysis draws on transcripts of formal legislative debates as recorded in the canadian senate and house of commons hansard. communities, use of paramilitary forces and divide and rule tactics by canadian firms increased while resisance at mining sites was met with aggression and outright repression. film maker steven schnoor provided footage of the destruction of communities by security contracted by a canadian mining company in guatemala; in response the canadian ambassador claimed this film was based on false testimony by actors. following a legal suit, the ambassador retracted. activist scholars deneault et al. ( ) documented practices of canadian mining firms in the african context in their book noir canada and were subsequently faced with a slapp (strategic lawsuit against public participation) suit by barrick gold. among others, scholars such as north et al. ( ) , campbell ( ) , nolin and stephens ( ), imai ( , , deonandan and dougherty ( ) , gutierrez-haces ( ) , macdonald ( ) and weisbart ( ) have documented the practices of canadian extractive firms, as have gordon and webber ( ) in their account of canadian imperialism in latin america. in the context of increasing attention to canadian firms abroad, violations of first nation rights in canada garnered increasing attention. in , the band council of the ki first nation was jailed for refusing to allow mineral prospecting on their territory (kuyek, ) . in , the canadian government under prime minister harper described ngos challenging resource extraction in western canada as 'enemies of the state' (zalik, ) . in new brunswick the community of elsipogtog had a direct stand-off with the rcmp over a fracking company's access to their territory, while in alberta, various first nations, including the athabasca chipewyan first nation, launched legal suits again firms and government for violations of their territorial rights. nation-wide movements against major pipeline projects also emerged in this context. these successfully halted a number of projects including the enbridge northern gateway and energy east pipelines. significantly, a major global movement against tar sands extraction in alberta and its implications for climate change and indigenous rights had a real effect on the presence of transnational industry at home (haluza delay and carter, ) . assisted by a major drop in oil prices, this ultimately prompted the exodus of major transnational operators from northern alberta, including shell. most recently, mining giant teck indicated that its cancellation of a proposed tar sands project was due to canada's unclear approach to questions of climate and indigenous rights. over this period various regulatory proposals sought to address conflict over canadian extractive industry. the first major initiative was the extractive sector roundtable. intended to bring about substantive monitoring of human and ecological rights associated with canadian extractive industry, various advocates felt that the process was thwarted and minimized through the creation of the 'devonshire initiative'. the initiative was named for the address of the munk centre at the university of toronto where it was to be housed. the munk centre is financed by a major endowment from barrick gold, at the time canada's largest mining company, of which peter munk, now deceased, was founder and former ceo. the initiative resulted in the creation of an 'extractive sector counsellor' in charged with the receipt of complaints from affected communities concerning the mining industry. ultimately, in and after considerable criticism from civil societynotably the canadian network on corporate accountability, government and the mediathe office of the extractive sector corporate social responsibility counsellor (herein csr counsellor) was left vacant after counsellor marketa evans' resignation. counsellor evans had accepted only six complaints in the years the office was open and of these, five were closed without resolution (saunders, ) . in a new csr counsellor was appointed, a former rio tinto executive, but ultimately the critique of this office led to its permanent closure in may . overlapping with this initiative, from canada's national contact point for implementing the oecd guidelines for multinationals, chaired by global affairs canada and co-chaired by natural resources canada in partnership with five other ministries, also accepted complaints regarding canadian extractive firms, but its own procedures were critiqued as providing insufficient protection to those who lodge a complaint (above ground/mining watch canada/oecd watch, ). over these years, legislative initiatives such as john mckay's private member bills (discussed below) aimed to address the gap in extractive sector regulation, human rights and transparency but were not passedaccording to various commentators, due to private sector interference. as coumans ( ) describes, the devonshire initiative and the csr roundtables in canada were dominated by industry and the former harper government. the dissolution of the office of the csr counsellor prompted further advocacy by legal and human rights and academic advocates, including a petition calling for the establishment of an ombudsperson for the extractive sector. the trudeau government announced in january that a canadian ombudsperson for responsible enterprise (core) would be established; an ombudsperson was hired in april who had previously worked as a lobbyist for the oil industry. the ngo community resigned from the government advisory board for core en masse in august . key concerns are that the office is insufficiently independent from industry, would not have powers to compel evidence from corporations or investigate but rather only 'review' cases, that the anonymity of complainants from affected communities abroad could not be guaranteed, and significantly that core would accept from companies complaints against human rights defenders , muzzling criticism and putting community members at risk (dwyer, ) . the broader regulatory context in canada underlines our argument concerning the estma's role in legitimating and offering security for industry, rather than substantively reforming its activities. given that transparency discourse elides the role of powerful states in shaping discussions of 'corruption' and in constituting the eiti (bracking, ) , it is perhaps unsurprising that the academic literature on the eiti has centered on eiti implementation as a global and domestic governance issue and institutional problem, largely involving policy elites (haufler, ; furstenberg, ; arond et al., ) . within accounts of procedural transparency mason ( ) and gupta ( ) importantly called for, and convened, greater interrogation of the political economic implications of the discourse (gupta and mason, ). recent studies in extractive industries and society have assessed the effect of eiti adoption on gdp and the role of the eiti in reducing corruption. the results of this research are mixed. interestingly some results point to the importance of a higher degree of perceived corruption in a particular state as a factor associated with eiti compliance, given the initiative's role in attracting investment to a country's mining sector (magno and gatmaytan, ) . other texts have also discussed the eiti as part of a broader set of global anti-corruption institutions (gillies, ) . in a more critical direction, Öge's ( ) work on 'transparent autocracies' points at the ways in which civil society's whistleblowing functions have been weakened even with eiti implementation. much of the more critical recent literature on the eiti assesses its ability to enact greater accountability from implementing states, those in which oil and gas extraction occurs. these studies measure the extent to which the costs and resources associated with the initiative bring about better accountability performance among implementing states than existed prior to eiti implementation (sovacool et al., ) . despite the eiti's initiation by elites, social accountability theory argues that it can and has been used to build stakeholder (civil society and local community) power in the global south. significantly for our analysis herein, however, the autocratic nature of host states in the global south remains the central problematic (akonnor and ohemeng, this issue; Öge, ) , disregarding global power relations and historical and contemporary transnational wealth transfers that extractive industries have entailed. while the accountability-oriented literature importantly identifies the problems of secrecy (florini, ) that undergird industrial payments to governments and affected communities, these discussions are meant to further secure and regulate processes of financialization and audit in which the eiti is embedded, rather than critique or displace them. our approach in contrast, critiques the unequal application of corruption discourse (laufer, ) , as it is embedded in broader orientalist and racist depictions of southern states and indigenous peoples generally. we consider, rather, the functional role that estma plays in corporate audit practice as a means to reduce risk for the firm, what may be understood as 'audit culture transparency' (gilbert and zalik, ) , a practice that draws attention away from industrial violence and obscures calls by colonized peoples for substantive reparations for wealth extracted from their lands. as per the watts and zalik ( ) paper in this issue, the time taken by advocates to review corporate disclosures reduces capacity available for systemic critique of global industrial systems. our research suggests that various aspects of the estma are congruent with audit culture transparency. first of all, while the estma mandates reporting by firms, there is little or no oversight by canadian government bodies responsible for collecting the data. thus, ultimately, reporting or assessment in the estma seeks to achieve a further end, but without clear oversight and due to corporate exclusions, much information is protected and confidential. blocking access to data may be understood as a form of 'legal enclosure' (szablowski, ) . second, there is limited or no standardization of reporting among firms, making it difficult to evaluate results in divergent spatial and national contexts, or to make comparisons between the kinds of payments that firms make to national or local governments. through the estma, as apparent in its treatment in scholarship and ngo practice to date, public discontent with profit-driven, rights-violating, and environmentally harmful extraction is translated into legal and regulatory frameworks that produce highly technical information. while incorporating a number of contested interests and actors, these processes do not address the underlying concerns regarding social violations and wealth extraction that prompted industrial regulatory initiatives; arguably these are funneled into transparency regulations and voluntary codes of conduct for industry, protecting the interests of industry. the estma was introduced to the house of commons on october , as part of omnibus bill c- under the title economic action plan act , no. , before it received royal assent less than two months later on december , . the estma paralleled the cardin lugar provision of the dodd frank act (section ) which was subsequently repealed under the trump presidency ( global witness, ) . section directed the us security and exchange commission to require oil and gas industry disclosure of payments to us and foreign governments. as discussed above, among canada's precursors to the estma were private member's bills introduced by liberal mp john mckay. these were narrowly defeated in (bill c- ) and (bill c- ). the changes from these earlier proposals were double edged: they increased the scope of reporting requirements to payments made to all governments not only abroad, but also in canada. however a major difference between the aforementioned bills and the estma legislation was that reporting oversight and reporting requirements to the public were scaled back under the estma. omnibus bills, defined by the house of commons as those which seek to amend, repeal or enact several related, but separate, initiatives have been around since (dodek, ) . since , however, budget bills have become longer and more complex. under the harper government in particular, 'omnibudget bills' (omnibus budget implementation bills) grew exponentially to an average of . pages between and , from an average of . pages between and (ibid). using a practice referred to as "tacking", seemingly unrelated provisions are included upon the logic that they are loosely connected to the budget; a practice sanctioned by speakers in the house of commons. the increase in the size and scope of omnibus bills, however, makes it difficult for mps to properly scrutinize a bill's content, and therefore to consider and debate before enacting laws proposed by government. this, dodek ( ) argues, undermines the democratic process whereby elected citizens' representatives consider different viewpoints when proposing, debating and enacting laws. bill c- and the estma embedded within it are illustrative of this practice. the bill was a -page document proposing wide-ranging legal reforms. these included, for example, legislation restricting the ability of refugee claimants to access social assistance, to the establishment of the canadian high arctic research station, and the reform of canada's intellectual property laws. with debates in the canadian house of commons pivoting on the bill's proposed cuts to social assistance, the estma received scant attention. critique of the massive omnibudget was a frequent topic of debate from opposition party mps, but a motion to decline the bill a third reading because it "amends dozens of unrelated acts without adequate parliamentary debate and oversight" was defeated - , with conservative representatives almost unilaterally responsible for its defeat (parliament of canada, ). mckay noted that "…the irony is quite resplendent. that bill demanded of the extractive sector accountability and transparency and was put in an omnibus bill…which has no accountability and no transparency." (house of commons, ) . the proposed estma, found under division , part of bill c- , received the most attention from the standing senate committee on energy, the environment and natural resources. these consultations occurred prior to the bill coming before the senate. hearing from representatives of the canadian association of petroleum producers (capp), the assembly of first nations, mining association of canada (mac), and publish what you pay -canada (pwyp), these debates centred around the issues of reporting requirements, the role of aboriginal governments, and canadian alignment with international transparency standards and legislation. quite explicitly these legislative proceedings illustrate that while extractive entities are responsible for reporting under the act, the purpose of the legislation is to hold governments to account for money transferred to them from such entities. mark pearson, director general, external relations, of the ministry of natural resources canada stated that "…the purpose of this legislation… is to hold the governments to account for the money. oftentimes you have industry working in countries abroad; the resource gets developed, the taxes, royalties and so forth have been paid to the government; the money does not seem to go back into the economy; the people are questioning what happened to the money; and then the industry can get the blame for it. this way, it's out there; the information is provided publicly; citizens in those countries can hold their governments to account: what happened to the money? where did it go? it provides that element of transparency." (senate of canada, ). canadian and foreign companies operating within canada must report transfers to the canadian government under the act. however, as per doshi and ranganathan ( ) and bratsis'( ) positions above, canadian state officials promoting the estma were most concerned with monitoring transfers to foreign governments by canadian companies as a means of deterring corruption. in principle, such reporting would enable citizens in foreign countries to hold their governments to account for transfers such as taxes and royalties paid by canadian extractive companies to governments which did not accrue to broader public accounts (ibid). the focus of the estma in effect, is to monitor and undo elements of the resource curse associated with undemocratic governance regimes in the global south. the senate committee proceedings also demonstrate that private, corporate interests were generally supportive of the way the estma was taking shape, as a piece of legislation that could advance their k. ciupa and a. zalik the extractive industries and society xxx (xxxx) xxx-xxx interests. arguing that the estma goes 'hand in hand with the corruption of foreign public officials act', ben chalmers of the mac stated that the act could be used as a tool for canadian extractive companies to use against foreign governments when being asked by them for a bribe. such companies could cite the requirement to report these illicit transfers under the act. as stated by chalmers, "it provides an opportunity for us to say, ''we can pay you that money, but we're going to have to report it, so if you want us to report it, then let's have a conversation, but i don't think you want us to report that, so let's move on and do business above board.''" (senate of canada, ). further, reporting under estma could increase extractive companies' standing within communities: "…(as) it provides a mechanism for us to credibly and independently communicate the benefits that mining can bring to communities and countries where we operate, wherever that might be in the world." (ibid). in this way, estma deters corruption via reporting, rather than regulating and monitoring extractive industry's human rights and socio-ecological practices. this purpose diverges from, and fails to address, the original concerns that prompted the creation of transparency legislation: public discontent with profitdriven, rights-violating, and environmentally-harmful extraction. estma's congruence with audit practice is also revealed in these debates. first, while the estma mandates reporting by firms, there is no direct enforcement mechanism to ensure that the reporting requirements are achieved. rather, the obligation is on entities to report, and it is up to the minister of natural resources of canada (nrcan) to then deem whether the reports are accurate and appropriate (estma, article ). while an independent audit of an estma report can be requested by nrcan (estma, article ), the ministry website indicates that such verification compliance will only be conducted if there are multiple errors or data anomalies in a report, or if a company fails to report, for example, a joint venture (nrcan, ). as such, nrcan uses a 'risk-based approach', where companies found to be at higher risk of non-compliance may be asked for further verification, rather than systematic oversight of each report. accordingly, the purpose of the estma is to act as a deterrent against corruption, explained ekaterina ohandjanian from justice canada (senate of canada, ), with little guaranteed oversight, where reporting operates as a form of social reassurance in an under-regulated industry. the limitations of this form of industrial audit on increasing accountability were succinctly articulated by senator ringuette in these debates: you may have serious evidence that the money spent within canada by the extraction company or outside of canada is being used in a corrupt manner, but this entire piece of proposed legislation has no policing. there's no way you can go elsewhere in the world to see if canadian company x is providing any kind of funding to a government entity" (ibid). still, representatives from nrcan, pwyp and the mac agreed on the merit of the reporting scheme to deter corruption overall. chalmers of the mac noted that 'making sure this information sees the light of day' is a 'business imperative' since it is more difficult for companies to communicate the benefit of resource extraction to communities when money is misspent by governments. for pearson from nrcan, and woodside from pwyp, the merit of the reporting scheme lies in "making this information public…to provide to those who want to hold governments to account the information they need to do so" (pearson, senate of canada, ). both noted that it is civil society organizations that are committed to seeing this information disclosed by companies operating in their countries (woodside, ibid), and that such organizations would be monitoring disclosures and holding their governments to account (pearson, bid). nrcan considers requests by parties to further examine a report if there are 'reasonable grounds to believe that the report merits further scrutiny', according to their website (nrcan, ), though there is no formal legal recourse by third parties themselves. the penalties imposed for non-disclosure however are minimal for larger firms (estma, article ( )). as we discuss in specific examples below, the estma also lacks systematized reporting requirements for firms which undermines the ability of civil society organizations to monitor and hold governments accountable based on company disclosures. the precise content for inclusion in estma reports is not spelled out in the act, but instead outlined in the guidance document first published by the ministry of natural resources in in which industry was highly influential (interview ). to align with similar legislation in the us and uk, outlining reporting requirements in accompanying rules, such as the estma guidance, makes the content easier to amend in future (senate of canada, ). pwyp canada expressed concern that the lack of detail could limit the ability of citizens, communities, journalists and parliamentarians to interpret information project-by-project, particularly since the regulations give the governor in council the power to grant exemptions on reporting: "citizens, communities, journalists and parliamentarians cannot use this information to hold their governments to account if they cannot access disaggregated payment information on a project-level basis. …our perspective is that the legislation needs to be strengthened to reference the type of disaggregation that will be required and to include a main date to require project-level reporting" (ibid). ultimately, pwyp was successful in bringing about project based disaggregation. as we discuss below, however, the project level information is not disaggregated by community requiring analysts to compare and make assumptions about firm reporting disclosed on a governmental and project level basis; a tedious undertaking. the final version of the legislation also increased discretionary powers for exemptions to standardized reporting through the inclusion of a substitution provision (estma, article ). this provision enables the minister of nrcan to accept reports employed in another jurisdiction as acceptable substitutes for those set out in section of the act (estma, article ( )), so long as the entity provides a copy to the minister within the other jurisdiction's specified reporting period (estma, article ( )). this amendment reflects concerns expressed in the oral testimony of the capp (senate of canada, a), and a written report submitted by sections of the canadian bar association, wherein both argue that preparing a second report to fulfill reporting requirements under the estma would create an administrative burden for companies already filing a report in a foreign jurisdiction (cba, ) . in particular, the capp noted that there are frequently confidentiality clauses between extractive companies and foreign governments concerning payments to state institutions; therefore stringent reporting conditions could force reporting entities to choose between complying with canadian or foreign legislation (senate of canada, a). consequently the standardization clause incorporated industry's preferences while also creating paid work for legal counsel. although standardization exceptions on extractive company reporting across different jurisdictions lessen the administrative burden for business entities, they make evaluating the results for civil society organizations more difficult. this dilutes the pretext that such legislation empowers civil society organizations to access and interpret information disclosed by companies as a means of exacting government accountability. missing in the debates in the house and senate on the bill, and in the legislation itself, are provisions for civil society organizations to hold extractive entities themselves to account. a number of exclusions from the estma are also notable. the pipeline and processing sectors are not subject to the estma, an exclusion these sectors sought early in the negotiations in the rrtwg that led to the legislation. yet given their much larger spatial and indeed material footprint in canada, pipeline projects have been domestically highly controversial in recent years, particularly in their economic relationships with communities -including indigenous impact benefit agreements -along the extension of their operations. further, only extractive and not exploratory firms are subject to estma's terms. this author's interview, key informant, . the extractive industries and society xxx (xxxx) xxx-xxx may facilitate partnerships between firms engaging in each of exploration and extraction, which allows the former to conceal problematic cash transfers associated with securing a contract under the category of exploration, a possibility we discuss further below in relation to africa oil corporation. transparency in various forms of impact benefit agreements, for instance, could be highly controversial in the context of broader divide and rule policies pursued by the oil and gas industry (caine and krogman, ; zalik, ; pasternak, ) . exploring particular firms and data to further explore the above mentioned attributes of the estma, we turn to a number of examples of current estma reporting. an exploration of examples of canadian extractive firms (including tahoe resources, debeers and africa oil corporation), and their relationship to the estma reporting requirements, reveals the contradictions we have discussed above concerning estma reporting as audit culture transparency. it is also suggestive for the way in which the marker of corruption is employed in the global south while the absence of full disclosure by firms is protected as corporate exclusion. this section situates these examples within the context of three aspects of audit culture transparency outlined above: little or no oversight by canadian government bodies responsible for collecting data; limited standardization of reporting among firms; and the failure of transparency regulations to address underlying societal concerns about human rights violations and environmental degradation. although estma reporting is meant to achieve increased transparency and accountability, there is no direct enforcement mechanism to ensure that reporting mandates are met. rather, natural resources canada only mandates an independent audit when a report is submitted with numerous unrectified errors, and the reporting entity is thus deemed to be at higher risk of non-compliance. this means that in the vast majority of cases, reporting becomes an end in itself; a concern echoed in senate committee debates on the proposed estma. during the senate committee debates, both the government and publish what you pay anticipated that civil society organizations would play a key role in reviewing corporate reporting made public under the estma. civil society oversight was anticipated to hold foreign governments to account, rather than the extractive firms themselves. in practice, however, public use of estma reports is constrained by a series of exclusions, blocked access to data, and exceptions to standardized reporting requirements, as well as by the often shifting and overlapping ownership structure of extractive activities. first, the exclusion of pipeline, processing and exploratory firms under the estma means that only the extractive subsector of oil, gas and mineral production is subject to reporting requirements. what is notable is that the exclusion of these activities from the estma allows firms to divide up potentially controversial activities into excluded sector companies in order to shield them from scrutiny. for example, africa oil corporation -part of the lundin group of companies -has recently acquired major offshore holdings in nigeria and guyana including both production and exploratory leases. offshore holdings in both countries have been under considerable scrutiny for issues of tax avoidance and corruption. the manner in which sectoral activities are divided, however, has protected them from further analysis under the estma since exploration is exempt. in addition, africa oil corporation's acquisition involves the purchase of a petrobras stake in the project, but was initially facilitated by a consortium headed by private oil trading firm vitol whose dealings in nigeria and elsewhere have been the subject of scrutiny for non-disclosure (somo forthcoming). as vitol is a private firm that is not headquartered in canada, the business dealings that preceded and led up to the acquisition are unlikely to be subject to estma reporting. in guyana, africa oil corporation's partnership with eco atlantic, an exploratory firm headquartered in the us, similarly indicates that payments made around acquisition will not be subject to estma. yet, a review of board and management structure reveals the close connection between these firms. the ceo of africa oil corporation, keith hill, sits on the eco atlantic board as an independent director but as a non-canadian firm eco atlantic is not subject to estma, and with changes to section of the dodd frank act is not subject to disclosure in the us either (ostfeld, ) . the africa oil corporation case is thus suggestive of the narrow role of estma in strengthening global financial transparency in extractive industry. in addition to those activities excluded under the estma, reports from extractive firms normally subject to the estma may become publicly unavailable under specific exclusions. reporting by tahoe resources is an example of this. tahoe resources was founded by former goldcorp ceo kevin mcarthur and is headquartered in reno nevada (pwyp, ); its canadian entity is registered to its lawyer's office mcmillan llp. tahoe is subject to estma reporting requirements, and its and reports are publicly available. tahoe's solely-owned guatemalan subsidiary, minera san rafael, operated a highly contentious project in guatemala, the el escobal mine, which was previously owned by goldcorp. in , claims were brought against the el escobal project to british columbia (b.c.) courts in a civil case by guatemalan protesters seriously injured when the firm's security shot unarmed community protesters at its gates in (weisbart, ) . the el escobal project has also been the subject of a publish what you pay ( ) case study, which notably had to be rereleased following complaints from the firm that the initial pwyp report did not use language they consider acceptable to describe charges against them. a retraction published by pwyp states that its reporting should have used the term 'alleged' to describe that the firm's security shot protesters. following a b.c. court of appeal's decision which found that canada was the preferred forum to hear the claims of guatemalan protesters given the risks posed to plaintiffs if the case were tried in guatemala, and the subsequent refusal in june by the supreme court of canada to hear tahoe's appeal of that decision, the path was cleared to try the case in canada. from this time, tahoe's estma reports would no longer be available on estma's public database given that they were subject to legal proceedings. although the legal proceedings pertain to guatemala, no tahoe report is available for on any of its operations. in , tahoe resources announced that it was to be acquired by vancouver based pan american silver (canadian press, ) . after the pwyp case study of el escobal was completed, and in the midst of the lawsuit delineated above, the pan american silver/tahoe acquisition was completed in february , making pan american silver the world's largest silver mining firm. on july , , pan american silver reached a settlement with the guatemalan plaintiffs, though the mine remains closed pending a consultation process with the local xinka community. pan american silver estma reporting is available for through , and as of july the pan american silver report indicates payments to the guatemalan government (taxes) and the municipality of san rafael las flores (royalties). the el escobal mine (earth works, ) and pan american silver (environmental justice atlas, ) are subject to considerable ongoing criticism from civil society (moore, ) ; estma reporting does not address these crucial concerns. second, public access to data is limited by the manner in which financial transfers are reported, which can make their interpretation difficult. for example, according to pwyp's ( ) study of the el escobal project, two types of royalties were paid: statutory royalties to the guatemalan government and the san flores municipality, and voluntary royalties paid to both the government and affected communities in the area of the mine. the voluntary royalty paid to municipalities ranges from percent split between three communities and . percent owed to one of them. the voluntary royalty is not required on sales of silver at a price lower than $ /ounce. pwyp explains that since the company does not disclose the voluntary royalty paid, pwyp cannot ascertain how much of the royalty payment disclosed in the estma report was paid due to the voluntary, as opposed to the statutory, royalty. important here is that the dispute over the el escobal mine revolves considerably around the exclusion of the indigenous xinka, who have consistently opposed its development, from the consultation process (earthworks, ). the affected municipalities, in a form sharing parallels with dynamics around industry relationships with indigenous band councils and indigenous hereditary chiefs in canada through impact benefit agreements (caine and krogman, ; scott, ) , have received this voluntary royalty in principle as part of the company's 'support' to communities, providing a superficial means for a firm to claim a 'social license to operate'. as per the canadian context, the acceptance of the royalty has also created the conditions for divide and rule, with communities ousting leadership that had accepted these payments (maritimes-canada breaking the silence network et al., ) , and fewer mayors accepting the payment than tahoe had publicly announced. as a recent legal case in canada demonstrates (axmann and cassidy, ) , payments for community development subject to legal privilege have been used to argue against affected communities (in this case an indigenous community's) claims for damages from resource projects. this, along with other forms of excluded data, can be understood as a form of what szablowki ( ) calls 'legal enclosure'. that is, blocking access to data on (in this case voluntary) royalties closes off potential spaces of legal recourse, and inhibits residents of extractive territories from seeking justice from resource firms. third, due to estma's substitution provisions, there is limited standardization of reporting requirements among firms. as discussed above, this enables companies operating in multiple jurisdictions to file reports in other formats, if approved by the minister. a lack of standardization makes it difficult to evaluate results in divergent spatial and national contexts, or to make comparisons between the kinds of payments that firms make to national or local governments. the case of the de beers victor mine near attawapiskat is suggestive of the implications for reporting in varied jurisdictions. de beers' estma reports consist of filings that anglo american -debeers' majority ownermade elsewhere. the cover letters to the report indicate that it was prepared for the united kingdom, and one assumes this reporting was required by the uk to comply with the eu transparency directive. the estma cover letter does not specify where the uk reporting is posted or available and thus cross-referencing of the data is not straightforward and requires the user have specialized knowledge of estma and other legislative guidelines and reporting locations. as the victor mine was closed in may , payments arising from clean-up or remediation concerns may be excluded from reporting. again such exceptions to reporting requirements lessen the administrative burden on extractive firms, but undermine the ability of civil society organizations to monitor and hold governments accountable based on company disclosures. lastly, estma reporting produces highly technical information, but does not address the underlying concerns regarding social violations and wealth extraction. this is consonant with a gramscian understanding of civil society's role in undergirding elite hegemony, wherein the development of transparency regulations and codes over the extractive industry serve as private initiatives to garner ongoing consent (cox, ) . mac, indeed, identified estma reporting as a means to enhance extractive company standing in local communities. division between communities is a frequent outcome of extractive sector activity, where blame is shifted away from firms and to neighboring settlements. some scholarship suggests that attawapiskat has benefited more than surrounding communities from the victor mine's presence (whitelaw et al., ) , and the payments themselvesdisclosed as of when estma's application to indigenous government took effecthave the potential to lead to intra-community conflict given the significant discrepancy in amounts paid to some communities over others. no explanation is available in the reported information for this variance. while it likely arises from the relative assessment of 'impact' associated with various first nations impact benefit agreements, this is not specified. similarly the el escobal case indicates that estma reporting could increase conflict amongst local communities affected by extraction where there are internal tensions over royalty payments. in this way, the estma may serve the interests of extractive firms by increasing their reputation in contrast to a perceived deficit of transparency in local community governance. this does little to protect the interests of local communities, while deepening intra-community tensions. the challenges civil society faces in navigating this data obscure more fundamental controversies over physical and ecological violence. both the debeers' victor mine and tahoe resources' el escobal project raise questions around the estma's ability to address socioenvironmental justice particularly around private security contracting and ecological disclosure. the victor mine has been highly contentious given its siting at an indigenous community which has faced a major drinking water crisis. it is a quintessential example of disputes over questions of environmental justice in ontario's ring of fire region. the victor mine is the subject of a legal case in ontario for mercury contamination, brought by the wildlands leagueformerly canadian parks and wilderness. the case has been in ontario provincial courts since and concerns the mine's failure to report data on mercury monitoring. in both the victor mine and el escobal cases, estma reporting has not assisted in identifying or addressing human rights and environmental violations. rather, legal proceedings on these violations served to diminish estma reporting requirements. while the scope of the estma is arguably confined to financial transparency, this legislation was created in the context of a call to end human rights abuses by canadian extractive companies. the fact that the legislation, guidance document and reporting requirements contain little that could be used to monitor, or advocate for, human rights and environmental protections is indicative of the way in which the final product was reshaped to protectand was in fact strongly supported bythe interests of industry. the relations described in the aforementioned examples of firms required to report on the estma are not exceptional. they offer an example of a number of the broader financial, judicial, and environmental regulatory structures excluded under the legislation and guidance provisions but which should be central to any form of substantive transparency. they are suggestive for the estma as a form of broader audit culture within the extractive industry where highly technical information is produced with little guaranteed oversight, and limited standardization of reporting. rather, reporting serves as a form of social reassurance in an under-regulated industry, while the drawbacks of this reporting structure inhibit civil society organizations from holding reporting firms accountable. see p. of the disclosure complaint filed by shin imai for the justice and corporate accountability project at https://justice-project.org/wp-content/ uploads/ / /final-bcsc-disclosure-complaint-re-tahoe-may- - .pdf. the extractive industries and society xxx (xxxx) xxx-xxx as we conclude this paper, the role of systemic racism in the broader socio-economic system is receiving long overdue attention in mainstream media. this attention sheds light on how the broader contours of corruption discourse operate in a form that 'blames the victim' for an industrial system that has accumulated capital through the oppression of racialized peoples. the global extractive industry is a long standing profiteer of this system (rodney, (rodney, / . our analysis of legislative debates and specific reporting examples herein indicates that the estma in canada offers some terrain to critique and gain access to the inner workings of financial capitalism which protect corporate privacy. yet the broader systemic violence upon which the industry is built remains shielded from view, with scrutiny of minutiae drawing attention away from a broader context of substantive injustice wherein the wealth extracted from specific landsnotably those of indigenous peoples -entails the overall impoverishment of those who reside there. the canadian implementation of estma shares attributes with the global implementation of eiti, in particular where more stringent requirements than those of the eiti have been implemented through civil society pressures, as per the example of nigeria. these create space for further research on corporate activity that by necessity requires detective work. but despite the ways in which access to such corporate information may 'lift the veil' on secrecy, corporate disclosure most pertinent to the work of human rights advocates is not proffered through this legislation. as argued by bratsis ( ) with regard to anticorruption discourse generally, the broader context of transparency discourse can serve to justify northern intervention into economic activities of global south governments and indigenous nations by suggesting mismanagement of funds. on the basis of the above analysis we see that estma's terms prompt reporting by firms that may indeed be useful to the advocacy community and thus broader struggles for equality. yet the patchy additional documentation it makes available to those affected by extractive sector activities requires inordinate analysis from corporate monitors, producing information that is just as notable for its absences as for what it reveals (weisbart ; see also watts and zalik, this issue). above we identified key limitations to the estma that may render it an example of 'audit culture transparency' (gilbert and zalik )where limited oversight by government bodies means that reporting becomes an end in itself, and where financial requirements for corporate risk management trump substantive social regulation and disclosure. in the context of particular examples of estma reporting, the problems entail: i) the exclusion of extractive adjacent activities from estma mandated reporting; ii) the employ of financial categories that act as obstacles and exclusion to public access and interpretation of data; iii) limited standardization across international reporting jurisdictions and between parent/subsidiary firms; and iv) the production of technical data that distracts attention from more fundamental questions of human and environmental rights violations and systemic injustice. ultimately, the estma offers limited leverage to substantively address the ecological and human cost of extractive industry. including more systematized disclosure of information that is publicly available in estma reportingsuch as the frequently changing ownership structure among firms, and overlapping relationships between board and managementis a key area wherein the value of actual estma data for substantive transparency might be improved. such reporting would begin to respond to civil society demands for clear beneficial ownership information, although given the centrality of secrecy to global corporate management (bracking, ) , much more is required. the panama papers disclosures demonstrated the extent to which offshore havens employ ownership systems to exploit taxation and regulation. beneficial ownership disclosure is a demand of the publish what you pay coalition internationally and in canada (johnson, ) , an issue on which the canadian government is now making legislative overtures (lim, ) . nevertheless, the trudeau government's lobbying scandal over prosecution of the firm snc lavalin and controversial purchase of the transmountain pipeline demonstrate the extent to which corporate elites remain central to state decision-making post-harper (lukacs ), a long-standing critique among political economists (sklair, ; strange, ) . indeed, the most significant gaps in the estma data are privileged materials that firms are not required to disclose. in the context of proposed and implemented canadian and alberta government bailouts of the broader mining, oil and gas and pipeline sectors (riley, ) , the dilution of environmental monitoring (weber, ) , ontario's declaring mining essential during the covid- pandemic, and ceo stock sell-offs prior to the covid lockdown, calls for substantive corporate disclosure are eclipsed by global corporate profiteering and its attendant racist inequalities (amin, (amin, / . returning to the questions of systemic racism as a feature in the repression of racialized and indigenous peoples and of nature exporting (southern) states, we recall once more that corruption (and transparency as an antidote) may serve as a pathologizing trope and distraction. the time has come to seek substantive reparations (nwajiaku et al., ) , from the industrial/economic actors who have profited from global structural injustice. canada is back maldevelopment: anatomy of a global failure ngos as innovators in extractive industry governance. insights from the eiti process in colombia and peru first nation ordered to produce private agreements with industry -update on blueberry river first nations treaty infringement proceedings hiding conflict over industry returns: 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piece. all errors are ours. key: cord- -r aq egw authors: griffith, david a. title: human capital in the supply chain of global firms date: - - journal: organizational dynamics doi: . /j.orgdyn. . . sha: doc_id: cord_uid: r aq egw nan supply chain of global firms the common thought is that corporate globalization cannot exist (in a practical sense) in a world filled with differences. this is both true and not true. the great difficulty for many firms is that most managers are more apt to focus on differences than similarities. the true test is of the manager's perspective. it is the manager's perspective that allows for global success. john k. ryans, jr., applied management sciences institute world is flat: a brief history of the twenty-first century'' that he awoke to the revelation one day that the traditional barriers of international trade had somehow passed, resulting in a world where relatively frictionless commerce on a global basis was taking hold. while new to friedman, the issue of the movement toward a global economy is not new to those senior executives engaged in global competition. however, the fundamental elements of friedman's book speak to all of those in the economy, when we look to the issue of why this change has come upon us-whether the breaking down of physical barriers, such as the berlin wall, or the ''opening of the windows,'' via the introduction of the windows operating system, which has placed us on a course for global workflow management. through these changes and the continued evolution toward the opening of world markets and the reduction of trade barrierssuch as through the efforts of nations in the world trade organization -the world has indeed become flat. the flatteners that friedman speaks of, such as open sourcing, outsourcing, offshoring, in-forming, etc., have transformed commerce. however, friedman argues that these flatteners have led to a ''leveling of the playing field.'' unfortunately, this is an oversimplification of global business (much as the foundation economic theories of international trade oversimplify the complex nature of global commerce). while managers would agree that the ''levelers'' friedman speaks of have clearly led to the globalization of markets, thus intensifying competition on a global basis, they have no more leveled the playing field than the internet leveled the playing field between well entrenched firms and online startups. simply stated, the levelers have increased the inter-connectiveness of the global market, reducing the barriers a firm faces when operating (whether selling or sourcing) throughout the world. the newly formed hypercompetitive global competitive environment has increased the importance of how firms compete (e.g., placing firms such as haier group, samsung electronics co. and whirlpool corporation in more intense competitive environments). understanding resource configurations leading to competitive advantage has become heightened. however, today's hypercompetitive global environment necessitates that firms acquire and retain the human capital capable of effectively developing marketing and management strategies capitalizing on resource advantages in the new global environment. nowhere is this more notable than in the operations of the firm's global supply chain. in this article, it is argued that the human capital a firm employs in its global supply chain allows the firm to take advantage of the global flatteners. this is to argue that friedman's hypothesis that the flatteners have created a level playing field overstates the nature of the global business environment. rather than these flatteners leveling the playing field, they have set the stage for firms to compete more fiercely, thereby enhancing the competitive advantage of those firms embodying the human capital capable of leveraging this newly charged environment. the focus here is on the human capital necessary for firms to operate aggressively in the global marketplace, taking advantage of the flatteners to maximize value delivered to a wide variety of firm stakeholders. to this aim, we ( ) address the importance of human capital for global supply chain competitiveness, ( ) delineate dimensions of human capital that firms need to accumulate within the firm's global supply chain to compete in this new environment, and ( ) discuss how the explicated human capital dimensions advance global supply chain strategies for success in a dynamic global business environment. firms are globally competitive when they possess and configure the appropriate unique combinations of tangible and intangible resources within their global supply chain. it is through the development and leveraging of unique combinations of heterogeneous and imperfectly mobile resources in the firm's global supply chain that it is able to achieve and sustain competitive positions resulting in above normal returns. for example, the ability of wal-mart stores to connect with consumers throughout the world is derived from the supply chain people wal-mart employs, who are able to deliver superior value to these customers. it is through the interface of wal-mart's management and marketing personnel that wal-mart has been able to engage global consumers (via its global supply chain) at a fundamental level. though global sourcing programs demand higher quality goods, lower prices and more integrated supply chain coordination, wal-mart has led the retail sector in the delivery of value. however, resource configurations (i.e., capabilities) are only foundations of competitive advantage when they are able to be continually modified to maintain competitiveness within the dynamic environment. hence, it is through the firm's ability to develop and maintain dynamic capabilities within the global supply chain that it competes. this argument, while well founded, often proceeds without consideration of the fundamental unit of analysis-i.e., the human capital employed by the firm, which embodies the firm's capabilities. human resources are one of a firm's most common means to build and maintain dynamic capabilities. this fact is more important today, when firms compete in hypercompetitive global markets, where a firm's employees are challenged to work within a global supply chain environment. therefore, it is important for senior managers to not only understand how to motivate supply chain personnel to accumulate capital, but also to understand themselves the types of capital most useful to the firm in working in the flat world. here it is argued that a meta-element of competitive advantage in the flattened world is the cognitive approach (or perspective) that one has to world business dynamics. inherent within the argument of the importance of human capital employed in the firm's global supply chain is the mindset of the supply chain personnel employed in the strategic decision-making element of the firm, as well as its tactical implementation. the issue of global mindsets is not new. rather, the global mindset of an individual has been well addressed in the business press. a global mindset refers to an individual's perspective on the world, and therefore, places cognitive constraints on his/her manner of relating to the world around him/ her. while the press (both business and academic) enumerates a number of mindsets, for the purpose of this discussion we will speak of three ( ) domestic, ( ) international and ( ) global, and we will relate these mindsets to issues concerning understanding the complexities of the global economy (e.g., the flatteners) friedman addresses (see fig. ). supply chain personnel with a domestic mindset have primary business experience and interest in their domestic market. given the lack of interest or experience in foreign markets, these individuals have been primarily unaware or uninterested in the dynamically changing global environment. these individuals, when challenged in a hypercompetitive global business context, are ill-equipped to effectively compete with their global counterparts. first, these individuals often do not perceive the flatteners friedman speaks of as influencing their firm's competitive position (this conclusion is typically based upon a limited scope of the firm's operations). second, when these individuals are placed into this context they often rely upon extant patterns of behavior/strategies in the administration of their tasks (i.e., to expand beyond their domestic operations, they often consider the most appropriate strategy to be the standardized strategy). for example, a canadian marketing manager in charge of the customer service department of an international maintenance, repair and operating supplier, when charged with responsibility for the firm's u.s. operations, immediately extended existing policies used in canada to the u.s. unfortunately, national differences in the supply chain personnel now under her control were overlooked, resulting in a series of initiative failures in the u.s. market that had been effective in the firm's canadian operations (a consequence not foreseen due to the domestic mindset of this manager). the ineffectiveness of the strategy resulted in a figure relationship of mindset to perceptions of hurdles to global business lengthening of the cycle time of the firm. as this example illustrates, those individuals having a domestic mindset are cognitively restricted to a relatively rigid self-reference criterion, in which their limited experiences and interest shade not only their perspectives of what is appropriate, but more importantly, what is possible (and thus places constraints on organizations engaged in the global environment). supply chain personnel with an international mindset have some limited business experience or interest in markets outside of their domestic market. these individuals have become sensitized to the complexities of unique aspects of international markets and are relatively well versed in the need for adaptation of business due to the inherent variations across markets. as such, these individuals, while understanding the flatteners increasing global competitiveness of the firm, in some respect have become hypersensitive to the inherent differences across markets, thereby limiting their ability to fully capitalize on these flatteners. thus, these individuals face the paradox of understanding the need to leverage the flatteners available to their firm but also understanding that in order to leverage these flatteners, the firm must overcome the hurdles of operating across vast market differences. for instance, while an individual in a global supply chain may see that offshore outsourcing provides the firm with unique locational advantages (e.g., cost and productivity), concerns over the costs related to control and coordination issues with such an operation spanning cultural, geographic and time differences may cognitively outweigh the perceived advantages of this strategy. for that reason, the cognitive frame employed by those with an international mindset places the firm at a strategic disadvantage in relation to maximizing global supply chain operations. supply chain personnel with a global mindset have multiple business experiences and interests in international settings. given the experience of these individuals, they are often more capable of sensing both the advantages and disadvantages of global operations. such personnel, while perceiving the uniqueness of each market in which their firm operates, also senses opportunities for leveraging the firm's operations. for example, m company was challenged when operating in india in relation to its dish scrubber product (a product consisting of a liquid soap fill-able handle and an attached sponge scrubber). local content laws required m to use locally produced sponges. supply chain personnel sensitive to the local requirements and the ability to leverage existing products decided to offer the product to the market without the sponge, thereby capitalizing on economies of scale and minimizing the need to contract with local manufacturers. supply chain personnel with global mindsets are able to focus on leveraged opportunities in the global marketplace, putting aside inherent differences (overlooking complexities) to focus on opportunities. it is argued that global supply chain personnel with global mindsets are more sensitive to the opportunities offered in the global marketplace resulting from the flatteners of the global economy. further, it is argued that it is the supply chain personnel's lack of a global mindset that is a constraint on the firm's capabilities, both embodied by and developed/ maintained by, the human capital of the firm. the cognitive constraint imposed on the organization sets forth its path for recognizing and leveraging the flatteners friedman identifies. this is not to indicate, however, that simply by developing global mindsets within the firm's global supply chain personnel that the firm can achieve competitive positioning in the hypercompetitive global marketplace, but rather that senior executives must recognize the constraint that such cognitive frames have on the organization (and its ability to develop dynamic capabilities). furthermore, it is argued that the perspective of the supply chain personnel is leveraged by the specific human capital that the individual possesses which determines the strategic path of the firm. the perspective of supply chain personnel plays a critical role in the foresight that the individual has in developing effective global strategy. however, this perspective must be leveraged through a series of skill sets that enable the individual to excel in both strategic assessment and continual management skills. here, strategic assessment skills relate to the competencies of supply chain personnel to effectively determine appropriate courses of action in a globally competitive marketplace. alternatively, continual skills relate to the set of competencies that allow the individual to effectively manage existing and future initiatives of the firm, its global supply chain, and in its competitive environment. these skills directly relate to two fundamental sets of human capital, i.e., analytical capital and social capital. although ebbs and flows have come to pass related to the primacy of analytical capital and social capital (as both have had prominence in the business environment at different times), the seminal issue is that differing balances of capital are needed for different positions within a firm's global supply chain. for example, for those whose primary responsibility is in managing the global supply chain relationships of the firm, a more developed set of social capital than analytical capital is appropriate. for an operations manager within the firm's global supply chain, social capital becomes somewhat less important than analytical capital. within the context of a flatter world marketplace, characterized by an emphasis on informing, outsourcing, off-shoring and global workflow, an individual's set of human capital (analytical and social) becomes increasingly important. overall, while there are many dimensions of human capital, some appear specifically important for successful global business in a flat world (see fig. ). analytical capital (e.g., critical thinking) reflects an individual's abilities to conceptualize a problem, isolate its components, organize information for decision-making, establish criteria for evaluation, and draw appropriate conclusions. analytical capital structures the manner in which the individual applies bases of knowledge and can be viewed in relation to tacit knowledge, experiential framing, prioritization of problems, learning and unlearning. tacit knowledge is an intellectual and cognitive process that is neither expressed nor declared openly, but rather implied or simply understood. from a cognitive standpoint, tacit knowledge results from the reduction of abstract concepts to a structure reflective of the environment that allows individuals to learn. tacit knowledge appears in the form of complicated, multicondition rules for accomplishing specific tasks within a given set of parameters. tactic knowledge bypasses in-depth analysis, and moves rapidly to a plausible solution when a familiar pattern is recognized. as such, tacit knowledge is often used during the decision-making process to determine the appropriateness of the solution, or to determine information requirements necessary for a decision. more importantly, tacit knowledge is important for supply chain personnel to adapt to changing environmental conditions, as it provides the foundational reference from which individuals can extrapolate concepts. for example, a global supply chain manager's tacit knowledge of effectively coordinating geographically disperse and diverse supply chain units can enhance not only the effectiveness of decision-making regarding outsourcing and offshoring decisions, but can also increase the effectiveness of strategic adaptations to policies. take the case of japanese electronics specialist matsushita electric industrial co. historically, matsushita maintained armslength relations with its supply chain partners, conducting the majority of innovation and high-tech component manufacturing. however, to take advantage of locational supply economies while simultaneously retaining its tacit knowledge, matsushita engaged in training and assisting an elite set of foreign suppliers, thus transferring elements of the firm's tacit knowledge while leveraging flat world economics. the concept of tacit knowledge is also related to another type of analytical capital referred to as experience framing. experience framing relates to an individual's ability to apply past experiences to different problems and their related solutions. through repeated exposures and extrapolation episodes an individual's experiences, problems, and their related solutions become hierarchically organized. this results in developing a more expansive knowledge structure, allowing for foreshadowing of effects. experiential framing is important for decision-making as those with greater experiential framing abilities are able to more effectively organize information around implicit principles and abstractions that enhances their ability to make appropriate decisions. further, breadth of experiential framing, derived from a breadth of experiences and extrapolation episodes, plays an important role in the decision-making process. this is because functional experience (i.e., that experience related to the specific job tasks of the individual) tends to narrow cognitive processing. lack of breadth of experiential framing has resulted in the inability to replicate successes from one market to the next. for example, although carrefour has had tremendous success throughout western markets, the narrow experiential framing of western market operations hindered its ability to effectively deliver value to the japanese marketplace. this mistake ultimately resulted in the sale of eight of its stores to japanese retailer aeon, co. carrefour's four-year presence in japan lost the french retailer between and million euros. however, the failure in japan may have provided carrefour the experience to broaden its framing for success in other eastern markets. while experience and knowledge are critical analytical capital elements, supply chain personnel must also be able to prioritize problems (i.e., an individual's ability to identify and rank those issues related to the achievement of the firm's goals). supply chain personnel rely upon their experiences and their understanding of the organization's goals to develop a ranking of issues presented to them (reduced cycle time, inventory control problems, product delivery delays, etc.) in order to determine the ordering of actions to be taken by them-selves or by others working in the firm's global supply chain. the ranking is typically completed under a risk management perspective, with global supply chain personnel assessing the risk associated with each course of action. those issues containing relatively little risk are usually ranked lower in priority, while those higher in risk to the organization typically are ranked higher. the flat world has increased the speed at which information flows as well as the information available to global supply chain personnel (in-forming). for that reason, the importance of an individual's ability to prioritize problems is increased in a flat world. it is only when these individuals can quickly and effectively sort through global issues in an effective manner that the manager can respond in an appropriate timeframe for the organization. learning refers to the process through which supply chain personnel acquire a dominant logic upon which to operate. this conceptualization explicitly addresses the feedback component necessary for learning, as well as allowing for a general enough definition to include stimulus-response, cognitive and behavioral theories. an individual's ability to learn, or his or her ability to develop consistent logic, is critical for effective performance under global environmental conditions. with such great emphasis placed on the learning organization, the ability of supply chain personnel to learn is becoming paramount. through learning, supply chain personnel are better able to effectively adapt to changing conditions. for example, in june , nike inc. noticed significant problems in inventory excesses and shortages. nike was able to identify the problem as a glitch in its i supply chain forecasting implementation system. the reliance on the system has become a pivotal learning experience for nike's global supply chain personnel, setting forth new protocols to minimize the probability of future replications (e.g., nike stopped using i 's demand planner for short-and mediumrange athletic footwear planning). as the world flattens, the ability of global supply chain personnel to learn is challenged, as they are often faced with extremely divergent worldviews. supply chain personnel emerging from linear thinking societies are often confronted with learning nonlinear thinking in order to enhance the firm's overall operations. the ability of global supply chain personnel to quickly learn divergence cognitive processes (both in terms of value chain members and customers) becomes central to effective strategic planning. while learning is important to minimize future mistakes, we cannot dismiss the importance of unlearning (i.e., the process through which a manager, or organization, relinquishes dominant logic or protocols for completing a task and acquires new logic or protocols). as in learning, global supply chain personnel vary in their ability to relinquish logic that was previously successful when presented new problems to solve. while learning enhances an individual's logic and thus allows him/her to become a more efficient and effective decisionmaker, existing logic creates a barrier to solving many of the complex problems of the global marketplace, thus stifling innovation. the importance of unlearning is heightened in a global business context, as global supply chain personnel must be able to make micro-level adaptations given contextual conditions. furthermore, supply chain personnel are challenged continually in the global marketplace to unlearn the effective strategies of the past in the assessment of the future. for example, although avon products inc.'s supply chain operations in the united states have been extremely successful, avon needed to unlearn this system and learn a new system to operate in the chinese market (inclusive of increasing the speed and flexibility in the supply chain via flattening of the supply chain structure). through unlearning and learning avon has been able to overcome many of the challenges that have caused other firms to fail in the chinese market. however, only through continued unlearning and learning will avon be able to repli-cate the supply chain success it has had in the united states. social capital reflects an individual's abilities, personality traits, character traits, interpersonal abilities, work ethic, and attitudes. social capital is founded in an individual's inherent nature. however, this is not to suggest that social capital cannot be nurtured. rather, through specific development programs and social capital elements (e.g., intuition, self-confidence, ability to deal with ambiguity, ability to work under pressure and flexibility), the personnel associated with the global supply chain can be enhanced. intuition is a sense of certainty relating to an issue, decision, or course of action without specific knowledge as to how one came to a conclusion. it is the essence of knowing without necessarily being able to explain how the knowledge was ascertained. while a consensus has not been reached relating to either the conceptualization or definition of intuition, here we define intuition as a feeling of knowing on the basis of inadequate information and without conscious awareness of rational processing. at the conscious level, intuition aids in the recognition of patterns. at the subconscious level, intuition is used to access cumulative experience and expertise. as such, intuition can be viewed as the end product of an implicit learning experience. intuition can be one of the most useful skills for achieving desired results. in a global business environment where adequate information is lacking and change is continuous, intuitive skills enable a firm to maintain progress toward accepted goals in an environment of unfolding situations. for example, market research indicated that the u.s. market was not prepared to accept another home video game system in the s (after the fall of the market in ). however, the intuition of minoru arakawa about the viability of such a market proved correct, resulting in one of the largest rebirths of a global industry. furthermore, individuals having greater intuition can more effectively interact with others, thus enhancing the effectiveness of global supply chain activities. similarly, self-confidence is a necessary capital element for global supply chain personnel. self-confidence refers to an individual's degree of perceived probability of success at a task. self-confidence is a summary judgment of performance capability that is induced by the assimilation and integration of multiple performance determinants. one aspect of self-confidence's importance stems from its relationship to performance outcomes. those global supply chain personnel possessing self-confidence tend to achieve higher performance, while those low in selfconfidence often experience self-discouragement, resulting in lower achievement. as global competition increases with the flattening of the world, self-confident managers are better able to maintain extant relationships and reconfigure and formulate global supply chain activities in turbulent and uncertain environmental conditions. for example, only when supply chain personnel are confident in their partner firm's abilities are they able to effectively communicate to partners their own firm's strengths. an example is the recent alliance between united parcel service of america, inc. (ups) and hong kong disney. ups will be responsible for the delivery of disney's magical memories around the world by bringing its express delivery services to the park. the success of this alliance hinges to a significant degree on the brand reputation of ups, which is derived, in part, from the self-confidence in supply chain excellence of ups' global supply chain personnel. further, the ability to deal with ambiguity, often referred to as ambiguity tolerance, is concerned with the degree to which supply chain personnel can hold back their need for complete information relating to their environment. supply chain personnel high in ambiguity tolerance are more comfortable handling situations in which complete information is unavailable. alternatively, those supply chain personnel who have a low level of ambiguity tolerance avoid the uncertainty and opaqueness of a situation by oversimplifying the content and thus forming a realityinadequate approach. the ability of supply chain personnel to deal with ambiguity has been a common variable used to differentiate individuals in the workplace. nowhere is ambiguity higher than in an increasingly dynamic, flatter global business environment. for example, uncertainties about the role of government in the chinese economy have firms both selling to and buying from china operating in environments constantly in flux. only supply chain personnel possessing a certain degree of ambiguity tolerance are able to work under the stress of such conditions and develop effective business strategies. while being able to deal with uncertainty allows supply chain personnel to cope with global operations, they must do so under the increasing pressure of the flat world. pressure is the aggregate of all changes, challenges or demands placed upon managers. in business, pressure is commonly experienced through demands on time or attention, dealing with people, task overload, organizational changes, etc. stress is the biological and psychological response to pressure. the ability of supply chain personnel to effectively employ coping strategies to minimize stress enhances the firm's effectiveness. the ability to function under pressure is believed to be a key determinant of successful supply chain personnel engaged in global business. those individuals who are able to employ effective coping strategies are better able to maintain focus and problem-solve effectively. the importance of this skill has been heightened in the flat world, where interconnectivity of global supply chain personnel and customers are constantly in flux. for example, the movement toward virtual workflow necessitates that global supply chain personnel be able to effectively operate under multiple timeframes simultaneously. thus, supply chain managers for dell computer corp. must be able to adapt to conceptualizing the worldwide supply chain flow of parts to assembly facilities, and to individual customer shipments simultaneously. they must be able to understand how slight cycle time disturbances in a component part can result in substantial delivery delays. not only the ability to work under pressure becomes a paramount capital element, but also the ability to be flexible in the flat world. flexibility, from a cognitive perspective, refers to an individual's awareness that in any given situation numerous options and alternatives are available. it implies not only the awareness of alternative options, but also a willingness to change one's behavior based upon an assessment of the alternatives. this results in linking the cognitive to the behavioral dimension. in a firm setting, flexibility is viewed by many as a key skill for an effective workforce. flexibility allows global supply chain personnel to assess a wide range of information and consider a number of alternatives prior to making a decision. this allows the supply chain manager to select the most appropriate solution for the given problem, as well as effectively interact with a wide range of individuals. the upside is increasing both their ability to manage in a global workforce as well as effectively contribute to the creation of market offerings capable of meeting a diversity of consumer needs. inflexible managers restrict their alternatives to those previously employed and thus limit their ability to effectively develop optimum solutions for newly encountered problems. for example, the increased potential for a global pandemic raises substantial concerns related to disruptions in the firm's supply chain. outbreaks of severe acute respiratory syndrome (sars) and avian influenza have forced global supply chain personnel to act quickly in adapting their supply chain tactics to minimize inventory disruptions. for example, motorola inc. was required to reshuffle production schedules when it temporarily suspended production at its singapore facility when workers there were quarantined for sars exposure. through the employment of flexible global supply chain personnel, firms can continue to develop effective strategies and tactics to be competitive in an increasingly flat world. the fact that the ''world is flat'' places firms, and more importantly the human capital charged with the development and maintenance of the capabilities of firms, at the nexus of global hyper-competition. as human capital is central to the effectiveness of global supply chain strategy development and implementation, the strategic implications offered here relate specifically to developing and retaining the firm's human capital to maximize global supply chain efficiency and effectiveness. step one: as sess tasks o f supply chain personnel in order for the firm to discern its appropriate amount and distribution of human capital, it is necessary for the firm to explicate all of the tasks it needs to perform in its supply chain operations and decompose those tasks into specific jobs. this multi-stage process involves the firm identifying the tasks that it needs to perform in delivering value. the first stage is delineating the functions of the global supply chain. this involves exploring the functional elements both internal and external to the firm's operations. for example, the sorting and matching function could be held internal to the firm or external to the firm, or the customer relationship development function of the firm's global supply chain. next, the firm must identify the tasks to be performed within each function. for example, in relation to sorting and matching, if it is held internal to the firm, the determination of the most efficient location as to where this specific function resides in the global supply chain operations should be identified. similarly, attention must be given to which tasks would be required in customer relationship development (e.g., handling complaint behavior, customer research, etc.). next, the firm should map the tasks into jobs. the breadth of tasks incorporated in jobs will vary by any number of criteria, e.g., size of firm, size of supply chain department, union requirements, or country standards. once tasks have been mapped into jobs, the firm should work to develop job descriptions and job specifications. through this multistage process, the firm cannot only gain a better understanding of its current operations, but it can also gain an understanding of potential areas that need help. step two: assess hu man capital and t he mindset of managers a firm's supply chain personnel vary in their level of analytical and social capital. that is to say, a senior supply chain analyst's human capital distribution may not be similar to a manager of reverse logistics, a warehouse manager or a manager of supply chain relationships. for example, a senior supply chain analyst may possess a high degree of analytical capital, he/she may not possess a high degree of social capital. conversely, a manager of supply chain relationships may possess a higher degree of social capital than analytical capital. thus, it is necessary to first gain an initial understanding of the distribution of capital elements possessed by supply chain personnel as well as individual mindsets (which set cognitive constraints on perceptions of global business). the assessments of human capital and mindset can be conducted in a number of ways. for example, objective assessment via measurement protocols, such as psychological testing of analytical and social capital, as well as mindsets, can be employed. psychological testing has become a common method of employee evaluation within professional development programs. through such assessment, senior managers are better able to structure programs to develop personnel to become more efficient in their present jobs or to offer the employee jobs that would better suit their set of capital. as an alternative to psychological testing, experiential assessment methods, such as scenario exposure or post hoc review of the manager's past behaviors, can be used to assess human capital levels. step three: matchi ng job t asks to h um a n cap i ta l le v el s in order for a firm's supply chain personnel to be able to effectively operate in a flat world, the embodied human capital of these individuals needs to appropriately match the tasks embedded within the job. only when the human capital and mindset of supply chain personnel is matched to the job tasks can a firm realistically expect success in the global marketplace. for example, supply chain personnel in jobs with task responsibility for production efficiency require higher degrees of analytical and social capital in order to effectively monitor operations and manage those involved within production. furthermore, these managers must also possess a global mindset. alternatively, those tasked with customer service roles would require greater social than analytical capital. key to this process is a developmental approach -in that the firm is striving to not only enhance its global supply chain efficiency, but also provide a more ideal work environment for employees by better understanding each employee's skill set and mental perspective. step four: assessing the effectiveness o f the supply chai n p er sonne l and deve lopment p lann ing assessment of the effectiveness of supply chain personnel in their specific jobs should occur periodically. the firm may wish to employ both objective and subjective assessment methods. for example, a firm may wish to query individuals at periodic intervals regarding their perception of their effectiveness and how they believe it could be improved (thus potentially leading to human capital development planning). furthermore, by independently assessing supply chain personnel effectiveness, differences may be observed, suggesting opportunities for developing human capital elements. however, it is important to indicate that a self-assessment at the firm level of task mapping is also required at this point. the effectiveness of supply chain personnel may be due to the firm's misalignment of tasks necessary in the job and the requisite capital and mindset of the supply chain manager. thus, it is important to not view (or present) this exercise as an evaluation tool, but rather as a mechanism aimed at professional development of employees by more appropriately crafting their jobs. the goal is to provide for a more fulfilling work experience while simultaneously working toward enhancing the overall effectiveness of the global supply chain. friedman's contention that we are operating in a flatter world is correct. however, it is argued here that firms challenged with operating in this environment must recognize that the levelers have not made the playing field equal for each firm. the playing field has been leveled by increasing the need to focus on the human capital (and constraining managerial mindsets) of the supply chain personnel that the firm employs. this article has argued that human capital is the foundation for business success in the flat world. through the embodiment of human capital in the firm's global supply chain the firm is able to compete. however, it is argued that global competitiveness is constrained by the mindsets that supply chain personnel operate under, as well as the degree of analytical and social capital possessed. it is argued that through a four-step assessment procedure, firms can assess and appropriately match supply chain personnel to specific jobs, thereby increasing their global competitiveness. it is argued here the importance of the individual is key to effective supply chain operations. finally, it is recognized that the capital dimensions enumerated here are but a few of the human capital dimensions that can lead to competitive advantage. however, it is hoped that this discussion can serve as a starting point to recognizing the interaction between mindset, human capital and global competitiveness in an increasingly competitive global marketplace. firm resources and sustained competitive advantage dynamic capabilities: what are they?'' strategic management journal a resource perspective of global dynamic capabilities direct and moderating effects of human capital on strategy and performance in professional service firms: a resource-based perspective managerial perspective, as indicated by the concept of mindset, is essential for effective global operation. several books and articles examine this concept analytical and social capital identified come from a rich research tradition in organizational behavior integrating left and right brian management skills social learning theory strategic decision making: the influence of ceo experience and use of tacit knowledge intolerance for ambiguity as a personality variable the nature of expertise expertise and problem categorization: the role of expert processing in organizational sense-making a cybernetic theory of stress, coping, and well-being in organizations the importance of unlearning griffith is an associate professor of marketing and supply chain management in the eli broad graduate school of management at michigan state university. griffith has published extensively on global business issues, with a recent focus on human capital within firms key: cord- - e akcjf authors: liu, peilong; guo, yan; qian, xu; tang, shenglan; li, zhihui; chen, lincoln title: china's distinctive engagement in global health date: - - journal: lancet doi: . /s - ( ) -x sha: doc_id: cord_uid: e akcjf china has made rapid progress in four key domains of global health. china's health aid deploys medical teams, constructs facilities, donates drugs and equipment, trains personnel, and supports malaria control mainly in africa and asia. prompted by the severe acute respiratory syndrome (sars) outbreak in , china has prioritised the control of cross-border transmission of infectious diseases and other health-related risks. in governance, china has joined un and related international bodies and has begun to contribute to pooled multilateral funds. china is both a knowledge producer and sharer, offering lessons based on its health accomplishments, traditional chinese medicine, and research and development investment in drug discovery. global health capacity is being developed in medical universities in china, which also train foreign medical students. china's approach to global health is distinctive; different from other countries; and based on its unique history, comparative strength, and policies driven by several governmental ministries. the scope and depth of china's global engagement are likely to grow and reshape the contours of global health. in only three decades, china's global engagement has accelerated from closed autarky to open engagement; from relative isolation to integration into the world system; from a low-income to a middle-income country; and from an aid recipient to an aid donor. as a global demographic and economic giant, china's prominence in global health should not be surprising. with % of the world's population, china weighs heavily in all global health metrics, such as life expectancy, disease burden, and health systems. as the world's largest trading nation, its movement of goods and services is associated with transfer of health technologies, diseases, and risk factors. in health knowledge and strategies, china has a rich history of traditional medicine and has pioneered many health-care innovations. china's ascendency has generated many questions and some concerns. a common assumption is that china uses foreign aid to secure energy and natural resources and to expand export markets. , china's claim of aid with "no strings attached", is considered by some to encourage corruption, weaken accountability, or ignore human rights. the international press has reported delayed and muddled notifi cation of infectious outbreaks, and much news of exported contaminated chinese manufactured products. china is sometimes perceived as working alone and insuffi ciently cooperating with other countries. in this review, we attempt to address the following questions: what is china's role in global health? is china's engagement distinctive or similar to other countries? what does the evidence illuminate of china's global health engagement? china, similar to most countries, has no single offi cial source of data for global health because of the multiplicity of governmental stakeholders, the absence of a national strategy on global health, and the unclear borderline between aid and trade investments. a study by nyu's wagner school has estimated china's foreign aid to africa, latin america, and southeast asia from to . strange and coauthors estimated all previous estimates of chinese development fi nance to africa. the state council of the chinese government, the highest body of state administration, published white papers summ arising china's overall foreign aid in and . none of the above estimations disaggregated or separately reported health aid. , we thus have resorted to an extensive search of data from multiple chinese sources-the state council, the ministries of health, commerce, education, foreign aff airs, and science and technology. reports from provincial governments, chinese embassies abroad, and the press were searched. altogether, we obtained data from sources- from various websites, from statistical yearbooks, from regular reports, and from newspapers. data sourced came from groups of organisations, including sources from the ministry of commerce, from the health ministry (national health and family planning commission), and from ministry of education. the overwhelming proportion of these data sources are in chinese ( %), with less than % in english. all data sources are shown in the appendix. interviews were done with dozens of former offi cials, medical team members, and key provincial authorities to collect fi rst-hand information. not surprisingly, the data quality is mixed, often incomplete, and the fragments need to be matched and fi tted together. the chinese government is essentially the only source of information, without other sources of independent verifi cation. reports of classifi cation and nomenclature often do not follow international standards. a common limitation is the mixing of stock data versus fl ow data. our compiled data, nevertheless, generate what we believe to be the most robust estimation possible. matching and piecing together the fragments allows inconsistencies to be double checked for consistency. most inconsistencies relate to exact numbers, but estimation of the general order of magnitude is believed to be reasonably robust. all data sources for this review are shown in the appendix in both original chinese and translated english. after introducing a framework, we present sections on china's work in health aid, health security, health governance, and knowledge exchange. china's participation in global health has deep historical roots, not only just in recent years. in the fi rst millennium, knowledge of medical cures were transmitted by the silk road that facilitated exchange between china, india, the middle east, and europe. in the th century, some chinese health crises such as the manchurian plague epidemic captured the attention of neighbouring countries of the international community. china has historically been the origin of many infectious epidemics and a source of key health innovations of breakthroughs such as the barefoot doctor (a term that emerged in the s and s, which refers to farmers who received minimal basic medical and paramedical training and worked in rural china to promote basic hygiene, preventive health care, family planning, and treat common illnesses. the name comes from southern farmers, who would often work barefoot in the rice paddies), and artemisinin, an eff ective antimalaria drug developed from plant-based chinese traditional medicine. , because there is no universal consensus for the defi nition of global health, some approaches focus on transnational health risks, which lie beyond the reach of national governments, whereas other approaches stress the global commitment and responsibility to address health inequities and to support health. we have adopted a framework of global health as characterised by health and related transnational fl ows of diseases, people, money, knowledge, technologies, and ethical values. [ ] [ ] [ ] four domains capture these globalisation processes (fi gure ). first, health aid aims to advance global health equity. it is the traditional area of offi cial development assistance (oda) coordinated by organisation for economic cooperation and development (oecd) countries. second, global health security should be ensured by management of interdependence in global health and mutual protection against shared and transferred risks, such as epidemic diseases. third, health governance is needed for global stewardship to set ground rules as mediated by health diplomacy. fourth, knowledge exchange is needed, which includes the sharing of lessons and knowledge production, ownership, and application worldwide. knowledge centrally aff ects all four pillars of global health, and global health governance is recognised to be central to all four domains (fi gure ). on the basis of this framework, china's modern timeline might be demarcated by fi ve landmarks. first, in , china sent its fi rst overseas medical team to algeria, followed years later by the donation of its fi rst hospital in tanzania. the explicitly articulated purpose of china's health aid was to further political solidarity as part of china's foreign policy. second was china's economic openings after , which launched the dramatic transformation of china from a low-income to a middle-income country, leading to china qualifying as an aid recipient followed by increasingly becoming an aid donor. third, starting from , china has hosted a series of forums on china-africa cooperation, with each forum announcing yet another major aid pledge-eg, hospital construction, malaria control, and high education scholarships ( - ); training of health workers and artemisinin drug donation ( - ); and brightness action (eye care) campaign ( - ). , fourth, global engagement greatly accelerated after when china entered the world trade organization (wto), an event that marked china's joining almost all international bodies. finally, and perhaps most dramatically, the severe acute repiratory syndrome (sars) epidemic underscored both china's neglect of its health sector and the reality that china's global trade cannot be done without mutual health protection. in recent years, the state council has published two white papers in april, , and july, , summarising china's foreign aid by volume and type. the white paper reports foreign aid of us$ · billion accumulated up to and including in three categories: grants of $ · billion; concessional loans of $ · billion; and interest-free loans of $ · billion. this amount is fairly close to another estimate of china's foreign aid at $ · billion cumulative from to , reaching $ · billion annually by . , the aid increased signifi cantly during the period of - , reaching an average of $ · billion per year, of which the grants accounted for · %. figure shows that african countries received % of all aid, with asia receiving about a third ( %) and latin america receiving around %, before the end of . the share for african countries increased to · % during the past years, whereas latin america received relatively less. another estimate computed china aid to africa in , at $ · billion in comparison with japan at $ · billion and usa at $ · billion. chinese aid in health is provided in fi ve categories: medical teams, construction of hospitals, donation of drugs and equipment, training of health personnel, and malaria control. the largest share of health aid is spent on medical teams and donated facilities. the fi nancial value of chinese in-kind health aid is diffi cult to estimate. crudely, from to , we estimated the value of chinese medical teams in africa to be about $ million annually, with donated facilities at a similar amount. total health aid to africa annually has been estimated at about $ million. understanding of the type of health support off ered rather than the precise volume of funding might be more important. diff erent from most oecd donors, china does not off er general sectoral support, albeit small cash grants given to several countries in recent years. its health aid uses a project approach. the in-kind provision in the fi ve categories is based on chinese competencies. health seems to constitute only a small proportion of the total chinese aid. health aid is mainly in donation form, whereas most of china's overall foreign aid is off ered as either concessional or interest-free loans. since , under the protocol on the dispatch of medical teams signed between the government of china and the recipient countries, about chinese medical workers have been sent to about countries to provide services to an estimated million people. at the end of , chinese medical workers were working in medical centres in countries. of the countries are in africa, and the remaining seven are mainly small countries-four in asia, one in europe, one in south america, and one in oceania. the table shows african countries in according to medical teams, aided facilities, and malaria control programmes, along with the chinese provinces twinned to each country. figure shows china health aid to africa with countries shaded according to density of medical team coverage and demarcated by aided facilities and malaria control. the distribution shows wide coverage of nearly all african countries with a higher density of medical teams in western and eastern africa regions. the largest and most powerful african countries such as south africa, nigeria, and kenya do not have chinese medical teams. chinese selection of hosting countries is based on country request and the joint decision by china's ministries of health, foreign aff airs, and fi nance. the medical teams are overseen by the chinese embassy economic and commercial counsellor's offi ces. medical teams are fi nanced by the health aid budget in the health ministry (except the basic salaries), which is responsible for dispatching medical teams. selected countries are twinned to specifi c chinese provinces with public hospitals and local medical schools responsible for staffi ng, supervising, and partially funding the medical teams. some practical criteria such as willingness and workload are used to match chinese provinces and recipient countries in the twinning arrangement. the number of members in medical teams ranges from a half dozen people to nearly , usually working out of chinese donated hospitals and clinics. most workers are clinicians, and most teams include a leader and a translator. public health skills are usually not included. medical teams mainly provide clinical services, especially for specialties in short supply-eg, surgery, gynaecology, and obstetrics. the average duration of an overseas assignment is years, with team members receiving housing and food plus enhanced salaries. over the period of - , these medical teams working in countries had provided about million medical consultations and treatments. panel describes some of these medical teams in southern sudan and the democratic republic of the congo. since , china has constructed more than a hundred health facilities overseas with its health aid. china accelerated its assistance in the construction of hospitals and clinics-from to , china has supported about construction projects of health facilities. most of these facilities are donated, and only a few are built as part of large infrastructure projects funded by chinese loans. african countries were the recipients of more than three-quarters of the donated facilities. although most countries have received at least one facility, some have received up to . these facilities are mostly so-called turnkey operations, for which chinese construction fi rms build the facility for transfer to local authorities. malaria control has recently been prioritised. control programmes are undertaken through anti-malaria centres, featuring artemisinin based on chinese traditional medicine. panel describes an ambitious chinese programme of malaria eradication with mass drug administration with artemisinin on the comoros islands. the question of whether health aid is mainly driven by china's commercial interest is not easy to investigate. much depends upon interpretation of underlying motivation. for example, chinese aid to africa might be viewed as either helping the world's poorest countries or building friendship with the origin of much of the world's energy and natural resources and potential export markets. a comprehensive analysis of this question would need access to data not currently available. as a preliminary fi rst step, we attempted to examine correlations between health aid and commercial economic indicators. regression analysis of african countries with variables of health aid (medical teams, donated facilities, malaria control) and economic interests (petroleum imports, china's foreign investment, and china's imports and exports) yielded no signifi cant pattern. figure shows four scatter-plots of china health aid and african trade. in the four diagrams, individual african countries are plotted according to health and commercial indicators. the scatter-plots did not show any association between medical aid and economic interests. spearman's rank correlation and t test analysis for the period of - showed no signifi cant fi ndings of correlations. these preliminary analyses should not be interpreted as conclusive. a core component of global health is mutual health protection against international transfer of health risks, which shows health interdependence. transborder movement of infectious diseases, contaminated goods and products, air pollution, and globally pooled co are prime examples. for china, the sars epidemic was a crisis with serious economic and political consequences. both disease control and international cooperation were delayed. chinese errors made in the early stage of sars have been acknowledged and have generated strong corrective measures, both domestically and internationally. domestic measures include major re-investment in the public health system via the chinese center for disease control and prevention (cdc), including development of the world's largest real-time electronic surveillance system. international eff orts include active participation and leadership in many international forums that foster cooperation in compliance of disease reporting and control, as shown by the initiation of the un resolution on enhancement of capacity-building in global public health in , and the joint international pledging conference on avian and human pandemic infl uenza with china, the european commission, and the world bank held in beijing in . [ ] [ ] [ ] subsequent management of infectious outbreaks such as avian infl uenza a h n virus shows that china recognises the importance of strict adherence to the international health regulations. in the sars outbreak, china needed days between fi rst case detection and report to who and another days for joint teams to investigate the outbreak. for h n one decade later, less than half the days lapsed between fi rst case and report to who and the initiation of joint investigations. [ ] [ ] [ ] infections can move in several directions. china has been the destination of cross-border infectious transmissions. in , a polio epidemic was imported from pakistan into china's xinjiang province. after making arduous eff orts and expending large resources. similarly, china has been threatened by the import of dengue fever, malaria, and several other transmissible diseases. , cross-border risks can also accompany the import and export of commodities. as the world's largest exporter of manufactured products, china, of course, transfers health risk overseas. news reports have been plentiful of contamination in chinese exports of toothpaste, lead paint, milk products, and heparin. [ ] [ ] [ ] [ ] these safety concerns are not limited to exporters. china has also been a destination in the dumping of contaminated chemicals from richer to poorer countries; these safety hazards are of equal concern to the chinese public. these concerns might be why china has upgraded its state food and drug administration (sfda) to the status of a ministry with larger budget, increased staff , and stronger regulatory powers. environmental pollution also moves across national boundaries. air pollutants in china have been cited as causing acid rain damage to forests in korea and japan. , china is today the world's largest emitter of carbon dioxide, contributing substantially to global climate change. to tackle air pollution, china's state council released an action plan setting a -year road map for air pollution control. its implementation deserves tracking for monitoring and evaluation of control eff ect. health governance sets ground rules for global stewardship of diverse activities. across the board, china has become an active member of the world system, opening with china's economic reform and accelerating after its entry into the wto in every aspect-eg, political (un), fi nancial (world bank, international monetary fund), economic (wto), and military (arm control and data underscore the participation of china in global governance. china's receipt of net offi cial development assistance and offi cial aid peaked at about $ million in , had steadily decreased to a third of that amount by , and is already disappearing as china increasingly becomes an aid donor rather than an aid recipient. from to , china's receipt and contribution to who were equal at about $ million. by - , china's assessed contribution to who had increased to $ million, while who funding to china had remained at baseline. in parallel with this increase in funding, the number of chinese staff members in who has expanded. whereas in , there were only chinese offi cials working in who, that number had tripled to by , although chinese staff in who are still under-represented. additionally, based on the newly released white paper, china allocated $ million to support the global fund and other international organisations in - . global health participation by china has been mainly governmental. in non-governmental stakeholders, growth in the international participation of some academic universities, business, and industry has occurred. china has very few non-governmental organisations (ngos) and thus the chinese are mostly absent from global civil society forums. a few international ngos work in china, but few have achieved offi cial registration from the chinese government. it will take substantial time, if ever, before china's civil society becomes active in global health. knowledge is both local and global, and its production, ownership, exchange, and application have global dimensions. china has much to share with and much to learn from the rest of the world. in medicine, strategy, and implementation, china has had some spectacular accomplishments, worthy contributions to the world's knowledge pool. chinese traditional medicine off ers many health-enhancing technologies-ranging from ephedrine to acu puncture. [ ] [ ] [ ] in the s, village health workers were fi eld tested, and later re-engineered as the barefoot doctor. china's three-tier rural health system was established soon after the founding of the people's republic. the alma ata movement for primary health care took great encouragement from china in showing what barefoot doctors could do at the community level. the three decades after the founding of the people's republic in witnessed some of the steepest advances of mortality control in human history. china's management of common infectious diseases, maternal-child health, tropical disease control, malaria and schistosomiasis containment, mass social hygiene campaigns, and recent achievement of near-universal health coverage are worthy of documentation as valuable lessons. physicians, two nurses, two chefs, two translators, and one medical engineer from shaanxi province constituted china's th medical team to sudan in - . the th chinese team from hebei province to the democratic republic of the congo arrived in , consisting of a team leader, physicians (including one in chinese traditional medicine), two nurses, one french translator, and one chef. for both teams, their primary role was to provide clinical care to patients. an ancillary function was to mentor, train, and improve the skill of local health workers. medical teams were self-suffi cient, bringing all their own supplies, equipment, and medicines. in response to questionnaires, team members commented positively on their experiences. higher salaries, fi nancial subsidies, and allowances from both central government and employers (about a six-fold increase) operated as important incentives. reported constraints included language barriers, unaccustomed disease profi les, poor facilities and equipment, unstable water and electricity supply, and homesickness. if the opportunity were off ered, nearly all would be willing to serve again. , panel : traditional chinese medicine to eradicate malaria? malaria eradication in some countries had been successful with dichlorodiphenyltrichloroethane, and hopes have focused on new vaccines. but a professor of chinese traditional medicine from guangzhou university of chinese medicine is leading an unprecedented eff ort to eradicate malaria on the comoros islands with traditional chinese medicine. starting in on moheli island where % of the residents were carriers of plasmodium falciparum, disease prevalence has dropped to · % in months with mass administration of artemisinin and piperaquine, donated by china's ministry of commerce. years later, the chinese team extended this programme to anjouan, an island of , reducing the prevalence of p falciparum carriers from % to · %. last year, the eff orts were expanded to the residents of grande comore, the country's largest island. the project goal is malaria eradication in the people of the comoros by . panel describes an innovative grant by uk government's department for international develop ment (dfid) to foster research by, and capacity building for chinese universities and other institutions to disseminate and share chinese lessons with other countries. for the future, china aspires to be a worldwide knowledge leader and it has fast growing research and development investments in biomedicine. chakma reported china's biomedical research and development at $ · billion in , in comparison with usa ($ billion), europe ($ billion), and japan ($ billion). the absolute size of these fi gures might undervalue chinese investments because the lower salaries, cost of infrastructure, and cost of operations in china might not be captured fully by purchasing power parity-adjusted values. strikingly, china's investments since have increased annually at % in comparison, for example, to − % for the usa. china, moreover, houses laboratories for most of the major pharmaceutical companies. it has advanced genetic research capacity as shown by its genetic sequencing of the h n virus within days of isolation and identifi cation. china is also a growing producer and exporter of generic products. china aspires to be a powerhouse in the discovery and production of new drugs and vaccines in global health. china's medical universities are increasingly undertaking research and education in global health. in the past year, several new multidisciplinary centres of china supports government offi cials, technical professionals, and young people from developing countries to participate in training and education programmes in china. in - , the government provided scholarships for such programmes, of which many were health related. china's medical universities also train foreign medical students. according to the data from the china education yearbook, in - , china trained foreign medical students, who constitute % of all foreign students in . for that year, the ministry of education reported almost foreign medical students studying modern medicine and studying traditional chinese medicine. , by , china had extended authorisation to medical schools to admit foreign students who will study medicine in english. figure shows the rapid increase of foreign medical students and scholarships in china in - . although foreign interest in traditional medicine is high, most foreign students register for modern medicine. about % of the foreign medical students receive chinese government scholarships that might be regarded as part of china's foreign health aid. chinese medical schools charge foreign students higher than chinese tuition fees, and the schools acknowledge foreign students as a source of school revenue. in , many of the students came from neighbouring asian countries, such as india, japan, pakistan, south korea, and southeast asia. our most salient fi nding is china's distinctive mode of engagement in global health. china's health aid volume is small, but the mode is distinctive, driven by china's health capabilities and national experiences. unlike many other traditional donors, china's in-kind aid focuses more on some important aspects of the health system. china's overall global engagement follows a very diff erent path from developed countries partly because it has no colonial experience nor did it participate in shaping the american-led post-world war world order. china was inward-looking until it expanded into the global economy in . over the ensuing three decades, china has had large shifts from a low-income to a middle-income country, and from aid recipient increasingly to aid donor. the spread of its foreign aid throughout the breadth of africa presumably refl ects both eff orts to solidify friendship politically, promote mutually benefi cial economic gains, and compete with taiwan for political friendship. china's health aid is embedded in the dynamic shifting of foreign and economic policies. the opening in marked a shift from economic development serving foreign policy to foreign policy serving economic development because china's association, for example, with africa, has developed from a political one in the s to a broader economic-based and trade-based engagement. , these are all defi ning characteristics of china's engagement in global health. china's global health work, unfortunately, does not seem to rank highly in government agencies. health has been assigned a lower position than political and commercial aff airs. taking advantage of both domestic and international resources and accessing both domestic and international markets is china's explicit national development strategy. these powerful economic motives drive much of china's global engagement, including its engagement in africa, to the point where the dividing line between trade and aid become blurred and hard to demarcate. health aid is only a very small adjunct to these much larger and more powerful forces. china's overseas forces include several government agencies. as a result, improved interministerial coordination is a necessary development for the evolution of a coherent overall engagement in global health. formulation of a china global health strategy could help bring coherent policy and harmonised action, because it would compel the articulation of specifi c health and humanitarian objectives in chinese governmental policies. an explicit china global health strategy would provide a stronger context for ngos and private sector overseas participation. china's bilateral approach diff ers substantially from its multilateral approach. although china's bilateralism takes an independent approach, china's multilateral strategy is full participation, joining as a regular member and complying with its responsibilities and privileges in un bodies such as who. the records show that china respects and complies with rules governing multilateral institutions in all aff airs-health, trade, migration, environment, and other aspects of global governance. china has increased its contribution to multilateral funding pools, such as the global fund from $ million per year in , to $ million per year in . how important china will become as a major donor to these pooled funds is uncertain. some see the early actions as symbolic gestures of cofunding, whereas others hope that the size of the chinese economy will propel it to become a fi nancial leader of multilateral funds. the new development bank being established by brics countries aims to compete with the world bank and international monetary fund, which is one example of how china has debatably played a leadership role. most important is the avoidance of over-simplifi cation. no country's international engagement is free from political or economic motives-eg, europe colonialism, us millennium development accounts, or sweden-vietnam partnership during the american war. and no single modality of foreign aid has proven to be more eff ective or more sustainable. , although china's health aid is generally appreciated by recipient offi cial statements, there are indeed complaints about the scale of china's intrusion, access to natural resources, and the trade market in africa. but energy resource-based trade structure with africa does not occur only in china; it occurs with all major african trading partners. the most fundamental improvement is to increase the capacity for independent development, to which all partners in africa should contribute. china's global health engagement is diffi cult to attribute to one motivation factor. chinese driving forces are undoubtedly several and complex-political, economic, social, and humanitarian. china's approach has been characterised as pragmatic that "combines the utilitarian logic of reaping material benefi t, the realist objective of expanding its global power and infl uence, the neo-liberalist interest in pursuing absolute gains from international cooperation, and the constructivist attempt to become a responsible stakeholder in the system". china's global health engagement will probably grow substantially with expanding budgets, more projects, and more staff sent abroad. china will pursue its own distinctive approach, not copying the developed world model; chinese government policy and indigenous professional capacity will be key. the fi rst generation of chinese professionals with experience and foreign language fl uency is emerging along with stronger global health institutions. given this trajectory, one should assume global health will likely be re-shaped by china's participation, with its structures and processes increasingly accommodating chinese characteristics. pl led and coordinated the authors' group. all authors participated in study design, data collection, analysis, interpretation, and paper writing and editing. lc and zl produced the fi rst draft. we declare no competing interests. emory global health institute. case study: can global sanitation contribute to china's prosperity? atlanta, e-mory global health institute china's global hunt for energy council on foreign relations will china change international development as we know it? china's foreign aid activities in africa, latin america, and southeast asia china's development fi nance to africa: a media-based approach to data collection information offi ce of the state council white paper on china's foreign aid, the people's republic of china passage to china the great manchurian plague of - : the geopolitics of an epidemic disease the barefoot doctors of the people's republic of china artemisinin (qinghaosu): a new type of antimalarial drug making sense of global health governance: a policy perspective towards a common defi nition of global health health professionals for a new century global health governance at a crossroads chinese medical cooperation in africa aid within the wider china-africa partnership: a view from the beijing summit the fi fth ministerial conference of the forum on china-africa cooperation beijing action plan china's engagement with global health diplomacy: was sars a watershed? shifting paradigm: how the brics are reshaping global health and development chinese development aid in africa: what, where, why, and how much? china to strengthen cooperation with africa on health key players in global health: how brazil, russia, india, china, and south africa are infl uencing the game characteristics of china-africa health collaboration: the case of democratic republic of congo the experience of chinese physicians in the national health diplomacy programme deployed to sudan fighting malaria china engages global health governance: processes and dilemmas china information system for disease control and prevention (cisdcp) permanent mission of the people's republic of china to the un. statement by chinese permanent representative wang guangya at the th session of the un introducing a draft resolution entitled "enhancing capacity building in global public health who. international pledging conference on avian and human pandemic infl uenza china's health diplomacy: sharing experience and expertise infl uenza a virus subtype h n joint mission on human infection with avian infl uenza a (h n ) virus timeline: sars virus controlling the polio outbreak in china xinjiang remains polio-free china tightens quarantine for malaria, dengue china regions on alert for malaria, dengue fever elements of a sustainable trade strategy for china made in china melamine in milk products in china: examining the factors that led to deliberate use of the contaminant contaminated heparin seized by fda toxic exports: the transfer of hazardous wastes from rich to poor countries china upgrades drug safety agency-people's congress: move aims to raise quality of food and drug supply trend of acid rain and neutralization by yellow sand in east asia-a numerical study air pollution from china reaches japan, other parts of asia world carbon dioxide emissions data by country: china speeds ahead of the rest ministry of environmental protection, the people's republic of china. the state council issues action plan on prevention and control of air pollution introducing ten measures to improve air quality data: net offi cial development assistance and offi cial aid received (current us$) who. financial and auditing reports from world health assembly, from wha to wha who. human resources: annual report chinese materia medica: chemistry, pharmacology and applications chinese acupuncture and moxibustion asian medicine. the new face of traditional chinese medicine health service delivery in china: a literature review mortality in china global health support programme supports shared international development objectives uk global health support programme (ghsp) asia's ascent-global trends in biomedical r&d expenditures duke kunshan university, and the leading chinese universities launch new global health consortium liberal education meets chinese tradition china consortium of universities for global health established in beijing ministry of education of people's republic of china. china education yearbook . beijing: people's education press ministry of education of people's republic of china. brief statistics of international students in china new list of chinese medical institutions admitting international students for academic year ministry of education of people's republic of china. interim provisions to control the quality of foreign students' undergraduate education (english class) in china beyond borders: potential gaps in the international system of public health surveillance china: foreign policy serves domestic development china's priorities in africa: enhancing engagements collection of important documents since third plenary session emerging economics to launch development five metaphors about global-health policy development assistance for health: critiques and proposals for change the great escape: health, wealth, and the origins of inequality china and global health governance we thank haomin yang, yang li, and jing bai for their work on data collection, data analysis, and research assistance. key: cord- -e ajbl s authors: mcinnes, colin title: who's next? changing authority in global health governance after ebola date: - - journal: int aff doi: . / - . sha: doc_id: cord_uid: e ajbl s the world health organization (who) occupies a central place in the system of global health governance and plays a key role in the control of epidemics and pandemics. the ebola crisis in west africa, however, saw widespread and sustained criticism of its performance, leading many to call for its reform and even replacement. this article moves on from initial analyses of the who's ‘failure’, to argue that the crisis has led to a shift in its authority as a global governor. it argues that the who's traditional basis of authority was largely expert and delegated; that it provided technical advice and normative guidance, and that its authority was ‘on loan’ from member states, who exerted considerable influence over the who. its actions during the west african ebola outbreak remained consistent with this, but it was unable to cope with what the outbreak required. the criticisms both of the who and the wider system of global health governance, however, have opened up a space where the balance of authority is shifting to one based more heavily on capacity—the ability to act in a crisis. if such a shift is realized, it will create different expectations of the who which, if they are not fulfilled, may lead to trust in the organisation declining and its legitimacy being compromised. with the model of expert and delegated authority. the who, however, became the focus for criticism of the handling of the west african ebola outbreak. this was not simply because it failed to provide sufficiently prompt warning of the developing crisis and to coordinate international response; as the lead governor in global health, it was also implicated in the system's apparent failure to provide an adequate response. beginning in , reforms at the who have attempted to address the issue of an operational capacity to act in major health crises, thereby potentially changing the who's authority to one more heavily based on capacity. these reforms are still under way, and the article suggests two 'litmus tests' to identify whether such changes have been embedded in the governance architecture and accepted by both governors and governed. in the terms used by avant, finnemore and sell, the who is a global health governor because it possesses the authority to exercise power over borders for the purposes of affecting policy. in this sense, authority is separate from legitimacy, in that authority creates the basis for deference to a governor's wishes. legitimacy, however, is created through the establishment of trust in a governor, trust here being understood as governors meeting the expectations of the governed in terms of their behaviour on specific issues. the importance of authority is that it establishes the parameters of a governor's actions-not only what they can or cannot do, but the expectations of what they should do given the nature of the authority accorded them. as avant, finnemore and sell state: 'governors cannot do just anything they want; their actions must be seen by the governed (and others) to accord with whatever authorizes them to act.' authority creates expectations of the governor which, when they are not fulfilled, leads to a lack of trust, potentially undermining legitimacy. in their framework, several different types of authority exist for global governors, each suggesting different parameters of action. for the purposes of this article, three are particularly significant: delegated authority, where states have 'loaned' to a governor the ability to act in certain areas; expert authority, based on the governor's technical expertise; and capacity-based authority, based on the governor's ability to undertake effective action. these different forms of authority are not mutually exclusive, and a governor may possess multiple authorities; but when it does so, it runs the risk of conflict between different expectations of behaviour. this may result in a variety of outcomes, ranging from institutional paralysis to the prioritization of one form of authority over another or others. these outcomes in turn affect the legitimacy of governors, potentially creating pressure for change in either a governor's authority, or in who the governors are. the significance of this framework is that it enables debates on global health governance and institutions such as the who to be recast, moving away from questions of the relationship with states and effects on sovereignty towards a richer understanding based on different relationships between global health governors and governed. more specifically, it establishes a means of understanding how the nature of the who may be changing. the article argues that the nature of the who's authority, which had traditionally been of the expert and delegated type, explains the organization's actions (though not its failures) during the ebola outbreak, from the distribution of technical guidance to the care exercised over declaring an emergency. the wider expectation of action during the crisis created a tension, which undermined trust in the who and threatened its legitimacy. it is important at this stage to note two key points. first, this expectation of action did not arise particularly from who member states-the traditional source of the who's authority. rather, it arose from a wider community, including civil society, ngos, charities and the media, which increasingly takes an interest in global health and provides additional sources of authority and legitimacy. the article therefore differentiates between who member states, which comprise the who's world health assembly and provide its funding, and the 'global community', which includes not only who member states but these additional interested bodies. second, the article does not suggest that, for the who, capacity-based authority has replaced expert and delegated authority; rather, it suggests that the ebola crisis has shifted the balance between these elements to place greater emphasis on the former at the expense of the latter two, and that the balance may shift back again once the immediacy of the crisis recedes. the article's theoretical basis lies in social constructivism. in particular, it is based on the idea that the social world does not exist independently of observation, but rather that the material and ideational worlds are mutually constitutive. this is important for the analysis below because it suggests that what is said both reveals and constructs understandings of the social world. the analysis therefore does not suppose an independent reality against which the who's performance can be judged and lessons learned; rather, it uses the criticisms and explanations of the who's actions to reveal understandings of its role and the nature of its authority. the article begins by outlining the ebola crisis and articulating the criticisms made of the who. it moves on to examine how the who explained its performance, and also how it suggested reforms capable of evolving its authority and thereby re-establishing trust in the organization. although these reforms have been endorsed by the who's member states, what fidler refers to as 'political elasticity' may lead to pressures to return to a more traditional form of expert and delegated authority. the article therefore identifies two possible litmus tests for the shift away from expert and delegated and towards capacity-based authority. the outbreak of ebola in west africa was the most severe on record. by the beginning of june , the who estimated that there had been , cases and , deaths, more than in all of the previous outbreaks of the disease combined. almost all of these were in the three west african states of guinea, liberia and sierra leone. the outbreak was subsequently traced back as far as the death of a two-year-old in meliandou, guinea, in early december , though the investigators concluded that this was probably not the originating case. in march , hospital staff in guinea began to notice unusual cases of a fatal disease in the south-east of the country. this was confirmed as ebola by guinean health officials and reported by the who on march. earlier that same week, msf had established its first ebola clinic in west africa, beginning a major commitment by the charity to the region. over the following weeks, the disease began to spread to the two neighbouring west african states of liberia and sierra leone, and to major cities (including capitals) in all three countries; this is unusual for ebola, which is normally confined to rural regions, and therefore triggered increased concerns over its possible spread through the populations of the countries affected. at a geneva press conference in april, the who described the outbreak as 'one of the fidler, 'the ebola outbreak and the future of global health security'. this chronology is constructed using a variety of sources and triangulating where possible. key in september, with numbers of deaths still rising, the un security council passed resolution , declaring the outbreak a threat to international peace and security, and the general assembly authorized the secretary general's request for the establishment of the un mission for emergency ebola relief (unmeer). msf's earlier warning that the disease was out of control in west africa appeared to be supported by an estimate from the us centers for disease control and prevention (cdc) at the end of september that by january the number of cases in liberia and sierra leone might exceed . million. on september, cdc named thomas edward duncan as the first case of ebola identified within the united states, quickly followed by two further cases involving medical workers treating duncan. this led to concerns over the ability of the united states to contain the disease-concerns echoed in europe when a nursing assistant, maria teresa romero ramos, was also diagnosed as having caught the disease while working at a hospital in spain. with the disease spreading-albeit slowly-to europe and north america, and established methods of control appearing to fail, the affected countries.' by this time, world leaders were queueing up to express their concern, offer aid and, in a limited number of cases, dispatch troops to assist in the aid effort-although not without criticism that words were not always matched by deeds. at the end of , rates of new infection were slowing, and in january the outbreak appeared to be in decline. even so, by september , small numbers of cases were still presenting in both sierra leone and guinea. the who describes its role in respect of this disease as to prevent ebola outbreaks by maintaining surveillance for ebola virus disease and supporting at-risk countries to develop preparedness plans ... when an outbreak is detected who responds by supporting surveillance, community engagement, case management, laboratory services, contact tracing, infection control, logistical support and training and assistance with safe burial practices. this passage reveals an understanding of the who as a body offering technical support rather than being operationally engaged, an understanding which was regularly articulated by margaret chan during the crisis, along with statements that governments, not the who, had first responsibility for taking care of patients. nor were chan and her colleagues in the who secretariat alone in this view of the organization. kelley lee, in a leading textbook on the who, describes its core functions as providing leadership; shaping the research agenda and stimulating the exchange of knowledge; setting norms and standards; articulating ethical and evidence-based policy options; providing technical support; and monitoring the health situation and trends. the operational ability to act in a crisis is noticeable by its omission. the recent ebola outbreak in west africa, however, led to 'blistering' criticism of the who. ebola was 'the hurricane katrina for the world health margaret chan, 'who director-general's speech to the regional committee for the western pacific', oct. , http://who.int/dg/speeches/ /regional-committee-western-pacific/en/, accessed sept. . see also jeremy j. farrar organization-its moment of failure'. as msf's bart janssen bluntly commented: 'lives are being lost because the response is too slow.' (in stark contrast, the performance of msf was widely praised, not least for its prompt action. ) the new york times' use of the term 'debacle' and its description of the who's performance as 'anemic' were typical. critics blamed poor leadership and weak management. director-general margaret chan was seen as initially dismissive of the problem and then keen to pass blame onto national authorities or the global community, while individuals in the who's africa regional office (afro) were also identified, individually or collectively, as demonstrating little competence and appearing more concerned with reputational risk and trade protection than saving lives. critics also identified organizational failings. leadership in the response. for example, even though the who had publicized the outbreak in march , and in april described it as 'one of the most challenging' outbreaks of the disease ever faced, in subsequent weeks it did little to raise concerns as the numbers of cases increased and the disease spread into neighbouring states. as chan and senior colleagues at the who subsequently admitted: the initial response was slow and insufficient, we were not aggressive in alerting the world, our surge capacity was limited, we did not work effectively in coordination with other partners, there were shortcomings in risk communications, and there was confusion of roles and responsibilities at the three levels of the organization. particular criticism focused on the who's unwillingness to declare a pheic and thereby galvanize a global response. using leaked documents, the associated press reported that the who was aware of the rapidly worsening situation over the summer of , but resisted calling a pheic for political and economic reasons; in particular, concern about the risks of harming relations with the affected countries, not least because of the possible impact of any such declaration on their fragile economies. the ap reported msf's international president joanne liu telling margaret chan at a meeting in geneva in july to 'step up to the plate' and demonstrate greater leadership. in april chan, together with other senior who officials, publicly spoke of having to learn 'lessons in humility', admitting that they 'had not coped' with the ebola outbreak and needed to take 'serious note of the criticisms of the organization'. msf's early warnings of an impending disaster appeared to stand in stark contrast to the who's caution. if the who's authority was based on its 'expert' status, then it was roundly criticized for failing in this, with the result that trust in the organization was compromised and its legitimacy questioned. the who's emphasis upon expert authority during the crisis was reflected in the stocking report's analysis of its performance during the west african ebola outbreak. the report suggests that the culture at the who was not conducive to risk-taking and prompt action: 'who does not have a culture of rapid decision-making and tends to adopt a reactive, rather than a proactive, approach to emergencies.' this again reflects the organization's role as provider of expert technical advice, a role in which it is more important to be correct than prompt, and in which its normative power arises in no small part from the quality of the advice it provides. as the stocking report continues, however: 'when a health emergency occurs, there must be an ability to shift into rapid decision-making and action.' it is here that the organization fell short: 'who has a technical, normative culture, not one that is accustomed to dealing with such large-scale, long-term and multicountry emergency responses occurring at the same time or that is well-suited to challenging its member states.' indeed, the who was praised by regional governments in west africa for the quality of its technical support, while its reluctance to act independently was noted in criticisms from ngos that it was too close to governments. nor did the who have the finances or capacity to mount a major operation in west africa. not least, its core budget had been progressively cut in real terms since , while the somewhat byzantine method by which it is funded-less than a quarter of its budget is under the organization's control, the remainder being spent on programmes specified by member states-meant that it had insufficient financial discretion to fund a crisis response. moreover, the ebola outbreak was not the only major health crisis the who was managing within this limited budget. in addition to the four other grade emergencies it was involved in during the summer of , the who had declared only the second pheic in its history over the major outbreak of polio in syria in april ( just a few days after publicly identifying the outbreak of ebola in guinea). on the basis of the stocking report, then, the problem may be seen (using avant, finnemore and sell's framework) as not simply one of a failure to implement its expert authority, but also one of whether it should have a capacity-based authority equipping it to exercise a more operational role in such large-scale crises. the who offered its own account of its actions, notably in a series of documents prepared for the special session of the who's executive board on ebola in january , and then for the may world health assembly. these reveal an understanding of its authority as primarily expert and delegated. this is seen most clearly in its emphasis on protocol-based action, following established guidelines for action based either on public health methodologies or on established procedures, rather than on seizing the initiative and acting in a decisive manner. the who narrative explains the delays in identifying the outbreak in terms of initially incorrect diagnoses by local medics, unfamiliar with the disease-not least because ebola had not appeared previously in west africa. in particular, in other words, the who was following established protocols based on a technical understanding of the problem. the who's explanation continues by pointing out that it was only in the second half of june that it became clear that this episode was more serious than previous outbreaks. indeed, for a short time previously, cases in guinea (at that time the most seriously affected state) had been falling, in line with the pattern from previous outbreaks, suggesting that the worst might be over. the who responded by calling a grade emergency in july, followed by the declaration of a pheic in august. it also attempted to mobilize and coordinate the international response by publishing a 'roadmap' in late august. the who argued that it played a key role in mobilizing and coordinating the response within west africa-especially the technical response-at local, national and international levels. this included publishing technical guidance documents, hosting a series of meetings on the ethical use and clinical testing of non-registered vaccines and blood products for treating ebola, and developing improved diagnostic tools. moreover, it played a major role in expanding clinical, public health and laboratory services in the three most badly affected countries, with more than who staff members and , technical experts deployed by april across more than field sites in guinea, liberia and sierra leone, as well as smaller numbers in neighbouring countries. this represented the largest emergency operation in the organization's history. finally, the who played a key role in preparedness planning to prevent the further spread of the outbreak, including sending assessment missions to other at-risk countries, while also introducing temporary restrictions under the terms of the ihrs. what is striking in the who's account, most of which originated in the geneva secretariat, is its close fit with an understanding of the who as believing the nature of its authority to be expert and delegated. the who presents a narrative that it did act, by providing advice and guidance. indeed, the stocking report argues that in some areas it was praised for what it did, not least in providing advice to other states in the region on preventing the spread of the outbreak and its work in protocols for fast-tracking vaccine trials and diagnostic tests. but these documents also reveal a growing sense within the organization of a shift being required towards a greater emphasis on capacity, not least in proposals put to the executive board in january to develop an operational capacity for major health crises. this suggests not only that the who was capable of evolving, but that multiple conceptions of authority were coexisting within the organization. whereas for some the problem was the who's inability to implement its expert authority in providing timely warning of crisis, the organization itself, in reporting both to the executive board and to the world health assembly, was arguing for a shift in the balance of its authority. in so doing, it was not only commenting on the shortcomings of its performance during the west african ebola outbreak, but also (more implicitly) reflecting two broad narratives, both of which had been developing to the point of orthodoxy since the new millennium. the first was that, in the words of a british cross-departmental white paper, 'health is global'. in particular, outbreaks of infectious diseases such as pandemic influenza, sars and ebola are likely to spread further and more quickly because of the manner in which globalization has increased the number and intensity of transnational interactions. the second was that infectious disease outbreaks were likely to be more common because of changes in both the social and the natural worlds. these included urbanization and environmental change, leading to fears of increased vulnerability to (sometimes novel) zoonotic diseases. in this respect, at risk from infectious disease, but also to the thought that global health governance needed to change in response. the west african ebola outbreak appeared to demonstrate the inability of global health governors to act to preserve global health security. this opened up a space where not only could the argument for an increased operational capacity be made, but a more fundamental shift in the nature of the who's authority could be envisaged. shifting the balance of the who's authority from the expert and delegated model to a capacity-based model, however, has not been a straightforward matter of the organization asking and the global community providing. the picture is more complex. avant, finnemore and sell point out that multiple authorities can lead to tensions in global governors; in the case under consideration here, the present article suggests that tensions appear to have been in existence between a global health governor (the who) and its member states for at least a decade prior to the west african ebola outbreak. in the wake of the more proactive leadership role played by the who during the sars crisis, david fidler argued that global health had reached a post-westphalian moment, where international organizations such as the who could override narrow state interests and act for the global good in health crises. this suggested that the crisis had seen a shift for the who away from delegated authority. the response by member states, however, despite initially praising the who for its handling of the crisis, was to express concern that it had exceeded its mandate. moreover, although the subsequent revisions to the ihrs (concluded in ) enhanced the who's ability to act in crises, they also limited its role to offering technical assistance. similarly, after the h n ('swine flu') pandemic, concerns were raised over the who acting outside the protocols implied by delegated authority. further, in the aftermath of that pandemic, proposals from the who that it be given a more operational role in health emergencies and a crisis budget of us$ million had been turned down by member states. that were of far greater consequence than a vision of a toothless united nations bureaucracy would have us assume'. furthermore, there are suggestions that member states' concerns over the more interventionist approach of the who director-general during the sars crisis, gro harlem brundtland, led to the appointment of successive directors-general who were much less likely to adopt a similar approach to future crises and were of a more technocratic nature, reinforcing the model of delegated and expert authority. this suggests that for much of the decade previous to the west africa ebola outbreak, at the same time as a consensus was developing that new risks required new forms of global health governance, member states continued to hold a view that the who's authority should remain primarily delegated and expert. in this respect, member states do not appear to be unitary actors with a shared understanding of global health governance, but more complex political entities where competing views may be held simultaneously. the implication of the ebola crisis is that a tipping point was reached, where capacity-based authority assumed greater significance for the global community, but where an adherence to expert and delegated authority also persisted (not least in the eyes of member states). meet the new boss, same as the old boss? unsurprisingly, perceptions of the who's weak performance during the west african ebola outbreak led to calls for its reform. as lee and pang note, reform of the who is a perennial subject of discussion within the global health community. indeed, at the time of the ebola outbreak the who was already in the midst of a reform process, begun by the director-general in following the global economic downturn of and reduced contributions to the who's budget. initially focusing on finance, by early its scope had expanded to three 'themes' of governance, management and programmatic reform. african ebola outbreak provided the space for the who to present a case for an additional area of reform. at the special session of the executive board in january , called to discuss the ebola outbreak, the who presented a series of proposals addressing operational issues, specifically its ability to respond to large-scale health emergencies. arguing that 'global responses to recent emergencies and disasters demonstrate that the world is not adequately prepared to respond to the full range of emergencies with public health implications', the who proposed what has been described as 'the most sweeping changes ... since its founding in ' to take on that role for itself and thereby shift the nature of its authority to a much greater emphasis on capacity. the organization's key recommendations were: • that it be granted a clear and extended mandate as the global leader in responses to public health emergencies; • that it be restructured to allow it to support emergency responses as well as exercising its traditional roles of normative and technical guidance; • that it establish both a standing and surge capacity for emergency response; • that an emergency fund be created for operational responses (identified elsewhere as c.us$ million), to which it would have prompt and guaranteed access in times of crisis. in addition, new funds should be provided to support day-today activities in preparing for large-scale emergencies, including an expansion of core staff. these proposals were approved by the who's executive board and then by member states at the world health assembly in may . they were also in general endorsed by the stocking report, which noted that although this role was already present in the who's mandate, the organization lacked both the capacity and the decision-making culture to exercise it, suggesting that the nature of its authority had not traditionally enabled this element of its mandate to be fulfilled. these proposals were radical both in granting the who a major operational capacity, and in permitting it to be exercised with some independence from member states. in particular, establishing a contingency fund with pre-approved access appears to be a crucial step in granting the who a degree of operational independence. this suggests not only a shift to a greater emphasis on capacitybased authority, but a recognition that a global governor such as the who can exploit exogenous shocks and changes in the expectations of the governed, even when it is heavily criticized and its legitimacy is in doubt. indeed, the very fact that its legitimacy was in doubt may have contributed to its ability to make this shift by exploiting a developing space. if, as this article has suggested, multiple forms of authority coexist and create tensions between the who and its member states, then it is not so much the case that one form of authority has replaced others as that the balance has shifted and may, by inference, shift back again as these tensions develop. two issue areas may act as litmus tests for the extent to which the basis of the who's authority has shifted to a greater priority on capacity. first, in an era of continued austerity, will the funding be made available on a continuing basis, not only to conduct emergency operations, but to create a new core capacity to prepare for such action? the who's budget has been cut since the financial crash to the point where it 'is supposed to work miracles on a budget equal to that of a university hospital in geneva'. moreover, its control over this budget is limited: as noted above, over three-quarters of it is restricted to purposes and programmes specified by contributing states. this clearly suggests that not only has delegated authority held sway over the who's budget, but that a shift to capacity-based authority requires additional funding. if such funding is not forthcoming, then either trust in the organization will falter, or its authority will shift back to an emphasis upon the expert and delegated model. second, how will the ihrs be revised and will reforms to them be fully implemented? the ihrs, which provide the framework for the who to undertake global infectious disease surveillance and response, were last revised in following the sars epidemic. problems in implementing them suggested an emphasis on delegated authority. three main problems are commonly identified with the current ihrs. first, per cent of the signatories have failed to meet their agreed targets in terms of national surveillance and reporting capacity, despite the regulations coming into force in . this per cent includes many of the states most at risk from the emergence of new diseases or outbreaks of existing diseases. the reasons for non-compliance vary, but key among them is a lack of financial means to put the mandatory surveillance infrastructure in place. until this deficit is addressed, the ihrs are severely weakened. second, mechanisms for reporting compliance with the ihrs are unsatisfactory-little more than a self-assessment questionnaire with no independent verification. a more robust method of ensuring compliance is therefore required. and third, signatories breach the regulations when it suits their national interests-for example, in by imposing travel restrictions to and from west africa without who approval, or failing to inform the who promptly of ebola cases-without meaningful penalty and frequently without censure. some signatories remain resistant to the idea that the who should have a right to undertake surveillance of events within a state, while others prioritize their own national interests, fearful of economic or trade consequences if they report disease outbreaks. reporting on the who's handling of the ebola crisis, margaret chan complained that for the who to act effectively, 'the international health regulations need more teeth'. whether or not the ihrs acquire 'more teeth' would therefore appear to offer a litmus test of a shift in the balance of authority from delegated to capacity-based. this article has argued that the west african ebola crisis saw a shift in the nature of the who's authority from one which was largely expert and delegated to one based more heavily on capacity. it suggests that the who's actions during reflected a continuing understanding that its authority was expert and delegated, but that criticism both of the organization and of the more general response opened up a space whereby the who could shift the balance of its authority to one based more heavily on capacity. in making this argument the article moves beyond initial analyses, which focused upon the failings of particular individuals or structures, to one that examines the changing nature of global health governance and in particular the relationship between the key global health 'governor' and the global health community. it does not pretend that the who is a unitary actor, or that the governed-including the who's member states-have a homogeneous or coherent view of its authority. rather, the article has argued that multiple forms of authority coexist and what the west african ebola outbreak demonstrated was a shift in the balance between these, one which remains contested and in which tensions are therefore likely to persist. the article has suggested two possible 'litmus tests' to identify the extent of this shift, based respectively on budget and on the reform of the ihrs. however, if this shift has occurred and is embedded in global health governance, then it also implies changed and heightened expectations of the who. if the organization fails to deliver on these expectations, then, according to the analytical framework used, trust in the who and its legitimacy may be compromised. there is another issue that has received little attention during the west african ebola crisis and its aftermath. we will probably never know how many died of ebola during the - outbreak, but the number is almost certainly well over , . this was a tragedy. in the previous year, the who estimated that around , children died of diarrhoeal disease, an easily preventable and treatable condition. and will die from it in . this is only one of a series of chronic and endemic diseases which continue to lead to much larger numbers of preventable deaths every year than those seen during the west african ebola crisis. the danger is that in moving to a capacity-based authority targeted at major outbreaks or other emergency events, chronic disease and endemic conditions will be accorded lower priority. routledge handbook of global health security youde, global health governance global change and health health and globalisation global politics of health who governs the globe? sars: political pathology of the first post-westphalian pathogen managing global health security: the world health organization and disease outbreak control dutiful actors, rogue agents or both? staffing, voting rules and slack in the who and wto european council parliamentary assembly, the handling of the h n pandemic report on the evaluation of the management of h n influenza; hannrieder and kreuder-sonnen, 'who decides?'; desham who and the pandemic flu "conspiracies the warnings the world did not heed political considerations'. the recommendations are reprinted as an annex to the stocking report prominent among the critics was the eu: see european council parliamentary assembly, the handling of the h n pandemic; european parliament, report on the evaluation of the management of h n influenza. although, as kittelsen argues, many of the latter report's arguments were questionable, it does reflect a predisposition towards delegated authority rather than capacity: sonja kittelsen, 'the eu and the securitization of pandemic influenza interview with former senior who official won't get fooled again', who's next ebola and who reform: who cares?'. clift's arguments drew on a previous chatham house report, what's the world health organization for? a useful survey of who reform in the period immediately prior to the west african ebola outbreak is andrew cassels, ilona kickbusch, michaela told and ioana ghiga, how should the who reform? global health working paper no. (geneva: graduate institute of geneva global health programme who reform', paper a / for th world health assembly reforming who: the art of the possible ensuring who's capacity critics say ebola crisis was who's big failure ebola virus disease outbreak and follow-up to the special session of the executive board on ebola: outcome of drafting group', paper a /a/conf./ for th world health assembly ebola: ending the current outbreak, strengthening global preparedness and ensuring who capacity to prepare for and respond to future large-scale outbreaks and emergencies with health consequences global health security'. details of the who's budget can be found at its programme budget portal youde, global health governance ebola: what lesson for the international health regulations? revising the international health regulations: call for a review conference key: cord- -dvdx ggv authors: briggs, andrew m.; shiffman, jeremy; shawar, yusra ribhi; Åkesson, kristina; ali, nuzhat; woolf, anthony d. title: global health policy in the st century: challenges and opportunities to arrest the global disability burden from musculoskeletal health conditions date: - - journal: best pract res clin rheumatol doi: . /j.berh. . sha: doc_id: cord_uid: dvdx ggv the profound burden of disease associated with musculoskeletal health conditions is well established. despite the unequivocal disability burden and personal and societal consequences, relative to other non-communicable diseases (ncds), system-level responses for musculoskeletal conditions that are commensurate with their burden have been lacking nationally and globally. health policy priorities and responses in the st century have evolved significantly from the th century, with health systems now challenged by an increasing prevalence and impact of ncds and an unprecedented rate of global population ageing. further, health policy priorities are now strongly aligned to the sustainable development goals. with this background, what are the challenges and opportunities available to influence global health policy to support high-value care for musculoskeletal health conditions and persistent pain? this paper explores these issues by considering the current global health policy landscape, the role of global health networks, and progress and opportunities since the – bone and joint decade for health policy to support improved musculoskeletal health and high-value musculoskeletal health care. summary of system-level (macro) and organisation-level (meso) factors that influence msk health. adapted from briggs et al. [ ] and woolf et al. [ ] . health system level determinants of musculoskeletal health what could be changed to deliver sustainable, high-value care the macro level considers the functionality and scope of health systems, health policy, infrastructure and resource allocation, and socioeconomic factors. health systems and their governance through health policy play a critical role in the planning and delivery of msk health care. health care systems in developed nations are usually oriented towards acute care services and respond to mortality risk rather than longterm morbidity associated with msk conditions and their co-morbidities, which hinders opportunities for service development in ambulatory and primary care e arguably, the setting where msk health care is most needed. given that the msk conditions are less frequently associated with mortality, health systems and policy tend to be less responsive to these conditions and place lower importance on the development of policies and programmes to address them. this contributes to a general lack of population awareness concerning the burden and impact associated with msk conditions. further, access to msk health care is variable according to geography, ethnicity and socioeconomic status, creating unhelpful care disparities [ e ] . the impact of impaired msk health on function, mobility, quality of life, mental health and economic prosperity of the individual and their society should be communicated at a societal level e governments, employers, educators and to communities. the inaccurate perception that pain and disability are an inevitable part of ageing or due to tissue-level wear and tear' should be addressed. given that populations are ageing and becoming more obese and less active, the impacts on the msk system will be profound [ ] . primary prevention initiatives for chronic diseases should include messages about preventing impairments in the msk system. mass media campaigns for back pain, for example, are known to be effective in this regard [ e ] and potentially transferable to low and middle income settings [ ] . msk health should be explicitly included in polices and frameworks that address non-communicable diseases, chronic diseases or lifecourse and ageing [ , ] . developing system capacity (governance, resourcing, infrastructure) to support msk health care delivery in community or ambulatory care settings in urban and rural locations is important for health system sustainability. operationally, this is likely to be achieved by implementing evidence-based models of care at the community level [ , ] . encourage multidisciplinary stakeholders (including funders, insurers, policy makers, educators, consumers and carers) to co-design and co-implement models of care [ ] . meso the meso level considers health services, the volume and competencies of the clinical workforce, health professional and student/ trainee education, service delivery systems and clinical infrastructure. despite the identified burden of disease, the delivery of msk care from practitioners and health systems often inadequately aligns with best available evidence for what works [ e ]. this may be attributed, in part, to deficiencies in knowledge and skills of health professionals, but it is also largely influenced by funding and service models that inadequately support effective co-care. access to, and delivery of, care is further complicated by the chronicity of msk conditions and the high prevalence of comorbid conditions, particularly mental health conditions. development of knowledge and skills among health professionals to manage msk health conditions using a best practice, person-centred approach is required [ , ] to ensure that people receive the right treatment, at the right time, by the right person. as msk problems are so common, health professionals and community health workers at the first point of contact need approprite competencies (e.g. for osteoarthritis care [ ] ). in high-income countries, this is required amongst family physicians [ ] , and in low income countries by community health workers [ ] . professional bodies representing msk health should support curriculum development and delivery for junior health professionals. develop capacity of the non-medical health workforce to contribute to the management of msk health conditions in an interdisciplinary, inter-professional and non-hierarchical manner [ e ] . further, it is important, where feasible, to work towards achieving a this paper highlights why we need to address health policy to ensure that all health systems are fit for the purpose of providing high-value care for msk conditions and it covers health promotion, prevention, management, rehabilitation and palliation. we consider the current global health landscape, including opportunities and challenges for reform, and the role of global health networks. we also consider what has been achieved through the bone and joint decade and beyond. we also address the gaps and priorities in the context of influencing global health policy and health systems reform. [ , ] . undertake more health services research relating to the implementation of best practice models of care that incorporates program evaluation, health economic evaluation and consumer-centred outcomes [ , ] . encourage employers to support older employees with msk health conditions to maintain productive employment and promote safe workplaces. improve referral networks and pathways between providers, especially between those in primary and secondary care (e.g. between family physicians, hospital-and primary-care based allied health practitioners, rehabilitation services and medical specialists). the global health policy landscape: challenges and opportunities the global health policy landscape has evolved from the th century into the st century, reflecting dramatic changes in population health over this period. although the burden of disease associated with msk conditions has remained high over time, evidenced for example by low back pain being the leading cause of global disability since global burden of disease (gbd) study measurements commenced in [ ] , it was not prioritised as a global health priority in the th century. whereas priorities for the th century largely focussed on communicable diseases such as hiv, nutritional deficiency disorders, maternal and child health and injury and trauma associated with war, the issues impacting human health in the st century have evolved, creating new and complex challenges for health systems at all stages of maturity [ ] . health systems in the st century face new and complex challenges such as rapid population ageing, increasing disability attributed to non-communicable diseases (ncds) and multimorbidity of ncds, antimicrobial resistance, rapid transfer of pathogens through travel and migration that have the potential to create pandemics (e.g. coronavirus disease covid- pandemic), climate change and natural disasters [ , ] . for low and middle-income countries (lmics), these contemporary challenges are being experienced along with ongoing challenges of communicable diseases, thus creating an increased burden and complexity of challenges for these nations. the issues of ageing and behavioural determinants leading to increased morbidity from ncds are of particular relevance to msk health and are the focus of this paper. we acknowledge, however, that injury from falls, violence, war, workplace incidents and road trauma are highly relevant to msk health and the global burden of injury [ ] . population ageing is advancing at rates not previously seen in human history [ ] . this is particularly apparent in lmics due to reductions in mortality at younger ages and fewer deaths from infectious diseases. most older people now live in lmics and this distribution is expected to continue [ ] . life expectancy has increased in most countries (expectancy has risen by about years since ; from years in to years in [ ] ), with the age-standardised global mortality rate declining by % from to [ ] . the implications of extended longevity include unprecedented demand on health and social care services and the need to dramatically realign health systems to respond to changing health needs, which include the delivery of care over extended periods to manage long-term health conditions and the establishment of long-term care systems [ , ] . while some countries have made considerable advances in this area, such as japan and korea, much system reform is needed in many others, especially in lmics [ ] . it is estimated that by , the number of people aged and over globally will comprise about % of the world's population [ ] . with a total population estimate of . billion by (an increase of % from estimates), people aged over years will comprise more than . billion persons, or more than double the current number, with most living in lmics [ ] . the prevalence of age-related msk conditions will undoubtedly continue to rise placing increased demand on surgical, pharmaceutical and rehabilitative care interventions. systems and regulations to prioritise delivery of high-value msk care will become more imperative and urgent across the globe [ , ] . for high-income economies, overcoming unhelpful commercial influence over access to, and delivery of high-value msk care will be important [ ] . conversely, in lmics, building system capacity to deliver basic, effective msk pain care remains a priority [ ] . the e decade of healthy ageing is therefore a timely and appropriate opportunity to leverage global efforts to support healthy ageing and it explicitly includes msk health [ , ] . in this context, the optimisation of the msk system to maintain a person's intrinsic capacity will become increasingly important, creating opportunities to realign health systems to better support functional ability through improved prevention and management of msk conditions. this is evidenced by the fact that msk function and mobility are key components of the who integrated care for older people approach [ ] and are a focus of the who rehabilitation agenda [ , ] . health-adjusted life expectancy (hale), or healthy life expectancy', which quantifies years expected to live in good health, increased between and , although by a smaller magnitude than total life expectancydfrom years in to years in [ ] . the gap between life expectancy and hale points to a period of living in poorer health. notably, the gap has increased by a larger magnitude for people in lmics and is largely related to the burden of ncds. ncds account for the majority of the current total burden of disease (now %; an increase of % from to ) [ ] and the majority of the current total disability burden (now %; an increase of % from to ) [ ] . critically, the disability burden is largely attributed to msk pain conditions [ ] and persistent pain more generally [ ] . health system challenges are further exacerbated by a rise in ncd multimorbidity prevalence, commonly featuring msk pain conditions [ e ]. when considering msk pain as an index condition, up to % of adults aged e years have a concurrent chronic health condition [ ] . a prevalent msk health condition concurrent with other chronic conditions is associated with poorer health (higher ratings of pain, psychological distress and work interference) and significantly greater health costs (up to times higher) compared to those without multimorbidity [ , ] . multimorbidity with ageing is now the norm [ , ] , not the exception, suggesting that integrated care approaches that explicitly include msk health are essential, rather than the usual siloed, disease-specific care [ ] . there is a strong argument and opportunity, therefore, to strengthen health systems to respond to the increasing burden of ncds, particularly multimorbidity of ncds, and to integrate msk conditions within this agenda as an equal priority with other ncds [ , , , e ] . the sustainable development agenda: implications for global health policy global health system reform and health priorities for the next decade will largely be responsive to the agenda for sustainable development. this agenda is framed by the interdependent sustainable development goals (sdgs), providing a -year global blueprint ( e ) that aims to deliver a better and more sustainable future for all, including health. the sdgs replace the eight millennium development goals (mdgs) of e . three of the eight mdgs included a focus on health: child mortality (mdg ), maternal health (mdg ) and communicable diseases (mdg ). while the progress towards the targets for these health-related mdgs was encouraging, many fell short of targets [ ] . the health goal for the sustainable development agenda (sdg ) aims to "ensure healthy lives and promote well-being for all at all ages" and is intentionally linked with the other goals. indeed, a recent analysis confirmed the highly synergistic relationship between the sdgs, as illustrated in fig. [ ] . several of the other sdgs have direct relevance to supporting the health sdg (sdg ), and the health sdg synergistically supports the non-health sdgs [ , ] . brolan et al. [ ] highlight the importance of the non-health sdgs in promoting the social determinants of health such as nutrition (sdg ), education (sdg ), gender (sdg ), water and sanitation (sdg ), employment (sdg ), reducing inequalities (sdg ), housing (sdg ) and healthy environments (sdgs e ). they further highlight the importance of sdgs and to support health system strengthening through good governance and multi-stakeholder partnerships for health, strong data and information systems, and equitable access to quality health care services and associated entitlements. sdg (decent work and economic growth) aims to "achieve full and productive employment and decent work for all women and men, including for young people and persons with disabilities, and equal pay for work of equal value". a healthy population is a prerequisite for development and underpins economic growth [ ] . sdg is, therefore, particularly relevant to people with msk conditions in the context that msk conditions are the main contributor to loss of productive life years and the disability employment gap [ , ] . the health goal (sdg ) has targets, which include four implementation targets ( a- d; box ). the sdg targets present both challenges (to address) and opportunities (to lever) to improve msk health. target . , focusing on universal health coverage (uhc), is the unifying target for all the other health targets and arguably relevant to other sdgs [ ] . the who defines uhc as "all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship" world health organisation, https://www. who.int/health_financing/universal_coverage_definition/en/. uhc is relevant to achieving msk health gains and provides an opportunity to do so, for example through providing access to important promotive and rehabilitative services and medicines that are relevant to msk health through essential packages of care. however, although sdg target . appropriately aims to reduce mortality attributed to ncds (predominantly cancer, diabetes, respiratory disease and cardiovascular disease), there remains an under-emphasis on reducing disability associated with ncds, despite unequivocal data highlighting the growing global burden of disability [ ] . the apparent mismatch between the target and global health estimates limits the opportunity to strengthen health systems in the area of greatest need; that is, to respond to the burden of disability which is largely attributed to msk conditions [ ] . considering the sustainable development agenda and evidence of global health trends, national governments and intergovernmental organisations are increasingly cognizant of the urgency to reform and realign health systems to respond to contemporary health challenges, particularly those in relation to ageing and ncds [ , ] . the historical approach to health care is no longer fit for the purpose, and health systems in many countries remain ill-equipped to manage trajectories for ncds and ageing [ , e ] . while there is absolutely a need for episodic and curative care for communicable diseases and responding to natural disasters and health emergencies (such as the covid- pandemic) and for tertiary hospitals to deal with complex case management and maintain standards of maternal and child health, a system that overemphasises episodic curative health care grounded in a biomedical approach cannot meet contemporary and evolving health needs [ , , ] . rather, what is needed is a strong primary health care system that is accessible through uhc that supports promotive, preventive, rehabilitative and palliative care through integrated care delivery and is bolstered by a long-term care system [ , ] . the box targets for sdg : ensure healthy lives and promote wellbeing for all at all ages' (reproduced from https://www.who.int/sdg/targets/en/). . by , reduce the global maternal mortality ratio to less than per live births. . by , end preventable deaths of newborns and children under years of age, with all countries aiming to reduce neonatal mortality to at least as low as per live births and under- mortality to at least as low as per live births. . by , end the epidemics of aids, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases. . by , reduce premature mortality from non-communicable diseases by one-third through prevention and treatment and promote mental health and well-being. . strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol. . by , halve the number of global deaths and injuries from road traffic accidents. . by , ensure universal access to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes. . achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all. . by , substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water and soil pollution and contamination. .a strengthen the implementation of the who framework convention on tobacco control in all countries, as appropriate. .b support the research and development of vaccines and medicines for the communicable and non-communicable diseases that primarily affect developing countries, provide access to affordable essential medicines and vaccines, in accordance with the doha declaration on the trips agreement and public health, which affirms the right of developing countries to use to the full the provisions in the agreement on trade-related aspects of intellectual property rights regarding flexibilities to protect public health, and, in particular, provide access to medicines for all. .c substantially increase health financing and the recruitment, development, training and retention of the health workforce in developing countries, especially in least developed countries and small island developing states. .d strengthen the capacity of all countries, particularly developing countries, for early warning, risk reduction and management of national and global health risks. necessary realignment of health systems to address these challenges presents opportunities to better address the burden of long-term and high-burden msk conditions. achieving system-wide reform demands both global cooperation and national effort in responsive health policy [ , ] . globally, the declaration of astana catalysed recommitment to the declaration of alma-ata to strengthen people-centred primary health care systems that are "high quality, safe, comprehensive, integrated, accessible, available, and affordable for everyone and everywhere" [ ] , consistent with the concept of uhc. the astana declaration is highly relevant to the contemporary health need, particularly in addressing multimorbidity from ncds and supporting healthy ageing [ , , ] , and is therefore relevant to optimising msk health. examples of other relevant global initiatives supporting system reform for ncds and ageing include the who integrated care for older people (icope) approach as a component of the global strategy and action plan on ageing and health [ ] , the who rehabilitation agenda [ ] and who best buys' for ncd prevention and control [ ] . all these initiatives offer direct and indirect opportunities to support msk health care. however, the horizon for improvement in msk health through national health policy for ncds remains challenging [ , ] . linked to sdg . , global performance and monitoring targets for ncds are principally aligned with mortality reduction for cancer, diabetes, respiratory conditions and cardiovascular disease, leaving less flexibility for prioritisation of msk health, thereby offering fewer opportunities for governments to support necessary reform efforts for msk health care [ ] . the who package of essential noncommunicable disease interventions for primary health care in low resource settings is also focussed on heart disease, stroke, cardiovascular risk, diabetes, cancer, asthma and chronic obstructive pulmonary disease [ ] and policy initiatives in lmics have historically overlooked msk health [ ] . in a recent systematic analysis of health policies focusing on integrated prevention or management of ndcs among member states of the organisation for economic co-operation and development, most countries had policies with targets for cancer ( %), cardiovascular disease ( %), diabetes ( %), respiratory disease ( %) and mental health ( %), while only % of countries had policies with an explicit focus on msk health and/or pain [ ] . nonetheless, many of the proposed activities across the policies were relevant to improving msk function, potentially offering opportunity for improvement. further, several nations are developing national and sub-national responses to the burden of msk conditions through the development of strategic frameworks and models of care [ , e ] . for example, the australian commonwealth government has commissioned national strategic action plans for a range of ncds, including arthritis, osteoporosis and pain management, and resourcing to support implementation of the actions plans has commenced [ e ] . other examples include a strategic framework for the prevention of msk health conditions across the life course by public health england (box ) [ ] and the ongoing development of a national pain strategy in canada. the ncd health policy and strategy landscape for lmics remains less clear. there are a number of contemporary whole-of-system opportunities to positively influence global health policy and improve msk health outcomes, including: consistent and unequivocal data on burden of disease for msk conditions [ ] . unsustainable health expenditure on msk conditions that eclipses other ncds (e.g. $usd . billion for msk health care in the us in ) [ ] and the costs of work loss and reduced productivity attributed to msk conditions [ ] , promotion of global initiatives that prioritise functional ability (e.g. icope [ ] ) evolution of national health policy and strategic action plans that prioritise msk conditions within the ncd area [ , e ] . recommendations from the who independent high-level commission on ncds that efforts to address premature mortality and disability attributed to ncds must be rapidly accelerated [ ] , and widespread promotion of initiatives to support delivery of high-value msk care, such as 'choosing wisely' [ ] . the global community (consumers, clinicians, researchers, policy makers and industry) concerned with msk conditions constitutes a global health networkda web of "individuals and organisations linked by a shared concern to address a condition that affects or potentially affects a sizeable portion of the world's population" (p. ) [ ] . over the past quarter century global health networks have proliferated and now exist for most major health conditions, including msk conditions (e.g. through the global alliance for musculoskeletal health (g-musc): https://gmusc.com/, and others). many, such as the global polio eradication initiative, are governed by formal institutions. others are characterised by informal ties, such as an emerging network concerned with the provision of surgical care in lmics [ ] . the global health network concerned with msk conditions is of this informal kind. differences in the effectiveness of global health networks may be one reason for the considerable variance that exists in the amount of attention and resources global health conditions receive. for example, hiv attracts considerable global attention, resources and priority in health policy and programs relative to msk conditions, despite the burden of disease of msk conditions being far higher. evidence concerning the global health network that addresses msk conditions suggests that it also faces challenges in each of these areas. an opportunity exists, therefore, to optimise the effectiveness of the global health network for msk health by considering and responding to each of these challenges. the first two challenges, problem definition and positioning, pertain to framing'. framing is a process of constructing meaning that enables individuals to organise experience, to simplify and make sense of the world around them, and to justify and facilitate collective action [ , ] . problem definition pertains to a challenge internal to the networkdhow members understand the problem and its solutions. problems and solutions can be conceptualised in many ways. for instance, those involved with population and reproductive health policy have disagreed on whether individual rights or social consequences provide the primary rationale for addressing these issues, and on the centrality of family planning provision in this agenda [ ] . in msk health and pain care, for example, there has been a historical lack of consensus about the classification of chronic primary pain as a condition in its own right, requiring a unique icd classification [ ] . a key challenge for global health networks is that they often become embroiled in conflict over problem specification and solutions, hampering their ability to act collectively. if problem definition is largely an internal framing matter, positioning is an external framing concerndhow the network portrays the issue to external audiences [ e ]. any given issue can be portrayed in multiple ways, and only some may resonate with the external actors whose resources are needed to make progress in addressing a problem. for example, hiv/aids has been portrayed as a public health problem, a development issue, a humanitarian crisis and a threat to security [ ] . some positionings resonate more than others, and different positionings appeal to different audiences. a key positioning challenge for msk health is that most msk conditions are chronic and impact function, while other ncds are more closely associated with mortality than morbidity. there is also a public perception that msk health conditions are an inevitable consequence of ageing. finance ministers, for instance, might be more likely to respond to portrayals that emphasise the economic costs of a health problem than health ministers, who might pay more attention to ones that focus on public health benefits, losses and mortality. the external positionings networks usually mirror the problem definitions they create. coalition-building pertains to the recruitment of allies beyond core proponents. many global health networks are insular; they consist largely of individuals and organisations within the health sector and with a specific focus on the issue. research indicates that those networks that build coalitions that reach beyond like-minded actors and that extend beyond the health sectorda task that necessitates engagement in the politics of the issue, not just its technical dimensionsdare more likely to achieve their objectives [ ] . since msk health is highly relevant beyond ageing and co-morbidity of ncds, creating stronger alliances in areas of education, work health and safety, child and adolescent health, road traffic injury and trauma, building and infrastructure and sports may be effective in coalitionbuilding and increasing global attention. governance pertains to the establishment of institutions to facilitate collective action. provan and kenis [ ] identify three primary modes of network governance: . shared: where most or all network members interact on a relatively equal basis to make decisions; . lead organisation: where all major network-level activities and key decisions are coordinated through and by a single participating member; and . network administrative organisation: where a separate entity is set up specifically to govern the network and its activities. it is not that one mode is better than others; the question is whether the mode is congruent with characteristics of the network. for instance, a small network whose members trust one another and agree upon goals may be destroyed if a single individual or organisation with a particular agenda comes to dominate it. a large network whose members lack trust in one another and who disagree on goals may need a lead organisation to bring about effective collective action [ ] . what has been achieved from the bone and joint decade and where are the gaps in influencing global health policy and system reform? positively influencing global health policy and system reform requires attention to the challenges of problem definition, positioning, coalition-building and governance. how well the msk health community address these challenges will likely shape its capacity to generate attention and resources for msk conditions during the sdg agenda and beyond. here, we reflect on how these challenges resonate with the global msk health community, actions that have been taken to date in addressing these challenges and future priorities to enable positive global action on msk health. in , clinicians, researchers and patients from a spectrum of international and national organisations that were all relevant to msk health came together in recognition of the lack of priority for msk health and msk science to consider how this could be collectively changed [ ] . the following priorities were identified: raise awareness of the impact of msk disorders; enable patients to more effectively participate in their own care, provide accessible cost-effective prevention and treatment, and increase knowledge through research. the vision for improving msk health globally was consistent with ensuring high-value evidencebased accessible uhc for people with, or at risk of, msk conditions. broad adoption of this internal framing by the global msk health community was required, although a range of challenges existed and continue to be relevant. historically, a challenge has been how to define the problem of msk health impairment and possible solutions in a way that the whole msk health community, or global network, understands and supports the need for collective action at a global scale. the first challenge is to agree on what are msk conditions. there is a wide range of problems that affect the msk system including sprains and strains; traumatic injuries; osteoporosis and fragility fractures; back pain and other regional or generalised pain problems; osteoarthritis; and inflammatory diseases of joints and other msk structures such as rheumatoid arthritis, ankylosing spondylitis, gout, and systemic lupus erythematosus. this broad suite of more than conditions makes defining msk health challenging and msk health may mean different things to different groups. the second challenge is that, despite the commonality between these conditions in the resultant pain and impact on physical function, there are wide differences in which professionals manage them. this varies by the stage of the care pathway and by differences in health systems. for example, inflammatory conditions are usually managed by rheumatologists; trauma and advanced structural deformity by orthopaedic surgeons; regional pain problems by physiotherapists, chiropractors and pain medicine specialists; and osteoporosis by a wide range of specialties; and most interface with family physicians. in lmics, workforce configurations differ according to setting. although the management of these conditions is ideally through integrated care pathways, there is commonly a lack of integrated working between the different professional groups and health care settings and a lack of understanding of each other's capabilities in interprofessional care. there is also often competition between different professions in some health systems where there is an activity-based or fee for service funding model, which may not encourage high-value care interventions [ ] . the third challenge is harnessing a global network to influence global policy and drive reform. stakeholders do not always recognise the importance and power of collective action at the global policy level. they may not appreciate how collective action is relevant to their context, which is usually at a local or national level and often specific to their professional or patient community. the bone and joint decade e initiative focused on collective action at the global and national levels [ ] . a who scientific group meeting was held concurrent to the launch of the decade to define the global impact of msk conditions, collating data from all global regions [ ] . the decade intentionally enabled organisations from international and national clinical, research and patient communities to come together and work as an alliance to deliver the shared goals of the decade. champions were identified within the different stakeholder groups and nationally to develop the collective approach. a person-focused appraoch provided a unifying goal for the stakeholders to encourage joint action and was facilitated at the local level through national action networks. through sharing experiences, opportunities for global action could be addressed by the msk global network. it was recognised that the lack of priority and policies related to msk health was due to absence of awareness among policy makers, non-expert health workers and public about: the impact of msk conditions (epidemiology, costs, etc.); what can be achieved through prevention and treatment; and how to implement evidence to optimise prevention and management of msk conditions. to provide this evidence and to support advocacy, the bone and joint monitor project was initiated as a flagship initiative of the decade [ ] . the project focused on identifying the burden of disease by working with the who and the gbd study group. concurrently, it considered what could be achieved through the implementation of current evidence, what was being achieved, where were the gaps and how can they could be closed (fig. ) . all activities to provide the evidence for advocacy were undertaken in a collaborative way, bringing together experts and organisations from the wider msk health community so there was a shared understanding of the problems and solutions and a common narrative. the work stream is ongoing. a major step in promoting global attention to msk health was recognising at the start of the decade that the burden of msk disorders on individuals and society needed to be better characterised and communicated. critical promotion was achieved through collaboration with the who and the gbd study and working with experts in all diseases across the globe. to ensure wide relevance, this has included all disorders that can affect msk health. from a conviction of the unrecognised burden, this coalition has provided independent evidence that msk conditions are the greatest cause of disability in most parts of the world, which is influencing priorities at the policy level [ ] . this theme of work has continued since the decade concluded in through a range of global initiatives in addition to the ongoing activities of g-musc; for example through the lancet series on low back pain [ ] , dedicated reports on msk burden of disease [ , e , ] and advocacy initiatives from international organisations such as the fragility fracture network [ ] , international osteoporosis foundation [ ] and the international association for the study of pain. . evolve a robust and consistent web of evidence concerning the costs to society from msk health conditions in terms of health and social care and lost productivity. while summative health estimates are important to measure relative disease burden and set priorities, measuring and communicating the economic impact is necessary to achieve greater investment in msk health. msk conditions are amongst the greatest causes of work loss through absenteeism and presenteeism as most work-related activities are dependent on good msk function. with ageing populations and extended working lives in many countries, these costs will grow significantly unless more is done to prevent and control msk conditions. the increasing magnitude of cost related to lost productivity has resulted in greater priority for msk health in countries where the state bears a large part of the cost of people unable to work, such as in the united kingdom (uk) where policies are being developed to address this [ ] . . address misconceptions about msk health. the barriers to prioritising msk health are the inaccurate concepts that msk conditions are inevitable consequences of ageing or of certain occupations and that little can be done to prevent or treat them. communicating evidence about high-value interventions that health systems and services can implement, including disinvestment in care that is ineffective remains important. an early project of the bone and joint decade was the european action towards better musculoskeletal health' [ ] . this project developed a common policy to prevent and control a spectrum of msk conditions, reviewing the evidence base and identifying what actions the public, people with msk conditions, clinicians and policy makers could take. simple messages were developed for the whole population, for those at risk, for those with early disease and for those with established conditions. these messages were elaborated with more specific recommendations for the different msk conditions to meet all stakeholders' needs. costeffective health interventions for msk conditions were also developed for lmics as part of the disease control priorities in developing countries' report e an initiative of the world bank, who and national institutes of health [ ] . . support health systems to deliver high value care. an ongoing challenge is that guidelines and recommendations often do not get implemented in practice. the "european action towards better musculoskeletal health" project suggested ways to improve implementation. models of care for msk conditions have and continue to influence health system governance and service delivery for msk conditions [ , ] and a framework to support development, implementation and evaluation of models of care has been created and globally supported [ ] . standards of care for various msk conditions have also been developed to support consistent delivery of high-value care [ e ]. national strategies have been developed to prioritise msk health, most recently in australia [ e ] and england [ ] . box provides an overview of the approach taken by public health england in this regard. the approach of the bone and joint decade and subsequently of g-musc in supporting collective and incremental action has enabled the msk health community to define the problem and identify jointly agreed solutions, with efforts and outcomes focused mainly at the micro and meso levels. the emergence and acceptance of models of care have been instrumental in influencing reform at the system level. a continued effort towards influencing policy makers at the national and global levels through health system strengthening approaches is essential [ , ] . positioning the case (external framing) and coalition building to influence policy makers, there is a need for them to be empathetic to the importance of msk health through evidence or personal experience. there is also a need to identify what issues are relevant and important to them and how prioritising msk health will enable them to achieve their goals, such as reducing work absenteeism or increasing physical activity. supporting policy makers to explicitly integrate msk health into policies for ncds more generally remains an important priority [ ] . to further strengthen the case for action, there is a need to identify, engage and develop partnerships with stakeholders/alliances external to health where there is a potential benefit of improving msk outcomes, such as manufacturing, construction, logistics and other sectors where msk function is essential for people to remain in work. action on external framing has been pursued since the launch of the decade and increasingly since the transition of the decade to g-musc, with a range of successful cross-sectoral partnerships established. while health policy makers are the obvious primary external stakeholders to influence, there are competing priorities with health conditions which have a higher mortality burden, are part of the growing burden of diseases associated with unhealthy lifestyles, such as diabetes and heart disease, or which garner a lot of public support, such as mental health and dementia. the necessary attention to, and resourcing for the covid- pandemic will undoubtedly have an impact on health services for people with msk conditions. the evidence of the burden of msk conditions supported by evidencebased policies that support high-value care which will prevent msk problems has gained traction. developing a whole system collaborative and partnership to prevent musculoskeletal health conditions and improve musculoskeletal health across the life course in england. this case study summarises the experience in england of developing and implementing a public health approach to the prevention of and intervention in, msk conditions across the life course. it highlights key elements of the approach, the essential role of galvanising and supporting partnerships, achievements and future aspirations. a more detailed commentary has been published previously [ ] . england, like many other countries, does not have a specific government policy purely focussed on msk health, despite msk conditions imposing the greatest burden of disease, with lower back and neck pain the leading causes of disability in england from to [ ] . the estimated msk prevalence of chronic back pain in adults in / was . % [ ] . a systematic review of the prevalence of chronic pain in the uk indicates a pooled prevalence of % (the majority of which is likely from msk aetiology), with evidence of an increasing prevalence over time [ ] . msk conditions are costly for the uk health services, with over % of the uk population consulting their general practitioner about an msk condition each year and the national health service (nhs) spending an estimated £ billion each year on treating them [ ] . further, approximately . million working days were lost in as a result of an msk condition [ ] . in the last couple of years, there has been a recognition of the importance of maintaining good msk health in work and health policy e prevention green paper-advancing our health [ ] , the nhs year long term plan [ ] , government's ageing society grand challenge [ ] and the development of public health england's year msk strategic framework [ ] . driving system change for msk health: lessons from england's experience a whole system approach that starts with the development of robust partnerships and collaborations to deliver a shared vision for population health is essential. public health england provided system leadership, bringing together a coalition of willing and committed stakeholders from across national and local governments, the nhs, third sector, professional bodies, and arthritis and musculoskeletal alliance to "improve the musculoskeletal health of the population in england across the life-course, supporting people to live with good lifelong msk health and freedom from pain and disability" [ ] . partnerships inevitably bring with them new and diverse capability, capacity and additional resources to support the vision to be realised. this is sustained through continuous joint prioritisation, candid conversations and monitoring of impact. after a gradual build-up of five years of activity based on incremental action, in the uk government published a number of documents that supported the case for increased attention to the msk health of the population: -the green paper advancing our health: prevention in the s' [ ] , which offers the next opportunity to further galvanise a shift of focus from cure to prevention. -health is everyone's business: proposals to reduce ill health-related job loss [ ] . system-wide implementation of osteoarthritis care programmes and secondary fracture prevention are notable examples [ , ] . the policy agenda in global health may differ from national priorities and this needs to be monitored and influenced to arrive at a consistent approach in external framing. the msk health community, largely through the bone and joint decade and subsequently g-musc, has positioned msk health in the global agenda of ageing, pain management, rehabilitation, road safety and care of the injured, interprofessional care, workplace health, workforce development and other areas where there is a recognised problem that the msk health community can help solve. the relevance of addressing msk health is not often spontaneously recognised by policy makers and the non-msk clinical community but these opportunities have been proactively identified and the case framed to show relevance. for example, g-musc has worked with the who on the who strategy for noncommunicable diseases; who europe action plan for ncds; the who decade of action for road safety; who global alliance for the care of the injured; who partners working in disability and rehabilitation; who global disability action plan e ; who icd revision through msk topic advisory group; who world report on ageing and health; who global strategy and action plan on ageing and health including the who integrated care of older people approach, and the who rehabilitation agenda. -the nhs year plan, which makes reference to workforce capability to implement frontline msk support, the scaling up of evidence-based interventions, such as escape pain, and digital platforms to deliver information to patients [ ] . -ageing society grand challenge, with a mission to "ensure that people can enjoy at least extra healthy, independent years of life by " [ ] . taken together with the secretary of state's prevention vision [ ] , prevention of msk conditions and other ncds is now seen as everyone's responsibility. integration with other health improvement policy areas major amenable risk factors of msk conditions are shared with many other ncds and therefore, public health england has taken the approach of embedding msk health in its work across multiple teams, such as the mental health, obesity, life course, inequalities, physical activity, healthy places, work and health. data and surveillance must be used to understand msk conditions in the population, monitor them over time and continuously drive improvement in health for people with msk conditions. public health england works in partnership with versus arthritis and other organisations to increase the quality and availability of data concerning msk conditions and the health and care services needed to address them [ ] . the year strategic msk prevention framework [ ] , along with plans to design a holistic adult health check in [ ] that may incorporate a functional capability element, followed up with tailored lifestyle advice and interventions will support population msk health in england. on the horizon are innovative ways of providing personalised care and health interventions using artificial intelligence and wearable devices. care. phe provides government local government, the nhs, parliament, industry and the public with evidence-based, professional, scientific expertise and support. phe exists to protect and improve the nation's health and wellbeing and reduce health inequalities. . articulate evidence-based arguments that clearly demonstrate how attention to msk health can achieve objectives of increasing healthy life years and control of other ncds through enabling mobility and physical activity. here, building coalitions with other disease groups will be essential. . shift global health targets to also address morbidity. the who approach to prevention and management of ncds prioritises those conditions associated with high mortality and common risk factors, consistent with sdg [ ] . this is not intended to de-prioritise other ncds, such as msk health, but in reality member states will respond to the given priorities and do not therefore engage the wider community, leaving out the importance of msk health from their discussions and plans. the priority of mental health, for example, often inadequately considers the bidirectional association between msk pain and mental health, leading to non-integrated solutions. . develop economic arguments for health to be seen as an investment into a productive workforce and a healthy independent ageing population. finance and employment ministries need to be aware of the costs of poor msk health and the return on investment of optimising it. this framing of the case has supported making msk health a priority in england (box ). addressing the challenge a current challenge is to know how best to work together as an msk health community, so we can take full advantage of the current and emerging opportunities to influence global and national health policy. policy makers prefer a consistent message, and the msk health community needs a way of developing and communicating a collective position that is supported by robust evidence. however, the implementation of such positions will most likely mean different things for the different stakeholders. there needs to be clarity as to: what is best done by g-musc; what is best done by individual stakeholders with the support of other stakeholders through g-musc, and what is done by single stakeholder groups with an awareness by others. the bone and joint decade e initiative subsequently g-musc has brought together champions for change from the msk health community who have led the campaign for msk health as a global priority, identifying opportunities and co-ordinating responses, working as committed individuals not formally representing organisations but coming from the wide spectrum of msk stakeholders and understanding issues of high, middle-and low-income countries. importantly, the programme of activities has been undertaken collaboratively with the wider msk health community, with the key partners being national networks and the major professional, scientific and patient organisations to ensure a person-centred and interprofessional approach. . now that the burden of disease and importance of msk health is clearly recognised, with many national and sub-national governments developing action plans, it is timely to consider changing the way the global campaign and global msk network is governed. . the global msk health community needs to decide its future and governance model to work collaboratively. different governance models have been described above and the power of social media to connect individuals, organisations and networks should be leveraged. the burden of disease of msk health is well established and likely to increase, along with other ncds. health policy is a critical component of health system strengthening to respond to the burden of msk diseases and persistent pain. the priorities for health systems in the st century have evolved from the th century, particularly in the context of challenges associated with ageing and ncds and also, currently, the covid pandemic. in this context, there are opportunities and challenges to optimise global and national health policy responses to address msk health and persistent pain and improve outcomes for people at risk of or living with msk health impairment. the sustainable development agenda represents an important contextual backdrop to health policy evolution in the next decade and this must be considered in the advocacy for msk health. unified and collective action from the global msk network will be important in influencing system-level change at scale. reflecting on the successes of other global networks, the achievements of the e bone and joint decade and unfinished business from that period should also help to inform the priorities, actions and governance of the global msk health community in the next decade. recommended foci for research practice and policy are outlined in box . with the necessary and dramatic shift of health priorities and resources to acute health care in the context of the covid- global pandemic, the msk health community needs to ensure it is well placed to i) argue the case for the importance of msk health for economic recovery (external framing); and ii) develop policies and service strategies to ensure people with msk health conditions can access care in circumstances where services are no longer provided due to the pandemic and post-pandemic. continued efforts to influence global health policy are needed in order to improve service delivery for msk health care, particularly in lmics. health policy foci around ageing and prevention and management of ncds present opportunities to positively influence msk health care. in particular, msk health should form a component of essential care packages in uhc arrangements [ ] . communicating the relevance and importance of msk health to global health policy and system reform efforts, such as the declaration of astana, rehabilitation and subsequent iterations of the who global action plan for the prevention and control of noncommunicable diseases, will be important. integrated care approaches for ncds should explicitly include optimisation of msk health, particularly in the context of multimorbidity. as national health policies evolve in response to changing health needs, particularly for ncds, msk health should be explicitly included as an equal priority with other ncds and in the context of multimorbidity and integrated care pathways [ ] . global health targets must evolve beyond just mortality reduction from specific ncds to also include arresting the trajectory of global disability, largely attributed to msk health and persistent pain conditions. harnessing the potential of the global msk health network by effectively confronting problem definition, positioning, coalition-building and governance will enable positive action in global health policy for msk health. continued efforts to measure the economic impacts of msk health impairment on health systems (e.g. proportion of health expendutire) and society (e.g. work productivity) remain important while msk clinical trials networks have a critical role in establishing evidence for interventions and implementation feasibility. health policy and systems research similarly has a critical role in continually evaluating options 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prevention in the s e consultation document. london: department of health and social care the nhs long term plan. london: nhs policy paper. the grand challenges. london: department for business, energy and industrial strategy department for work and pensions and department of health and social care. health is everyone's business: proposals to reduce ill health-related job loss: london coordinator-based systems for secondary prevention in fragility fracture patients generation of political priority for global health initiatives: a framework and case study of maternal mortality flipping the pain care model: a sociopsychobiological approach to high-value chronic pain care development of a core capability framework for qualified health professionals to optimise care for people with osteoarthritis: an oarsi initiative global low back pain prevalence and years lived with disability from to : estimates from the global burden of disease study no external funding was acquired to support this work. the authors declare no conflicts of interest. key: cord- -j r nq authors: hernando-amado, sara; coque, teresa m.; baquero, fernando; martínez, josé l. title: antibiotic resistance: moving from individual health norms to social norms in one health and global health date: - - journal: front microbiol doi: . /fmicb. . sha: doc_id: cord_uid: j r nq antibiotic resistance is a problem for human health, and consequently, its study had been traditionally focused toward its impact for the success of treating human infections in individual patients (individual health). nevertheless, antibiotic-resistant bacteria and antibiotic resistance genes are not confined only to the infected patients. it is now generally accepted that the problem goes beyond humans, hospitals, or long-term facility settings and that it should be considered simultaneously in human-connected animals, farms, food, water, and natural ecosystems. in this regard, the health of humans, animals, and local antibiotic-resistance–polluted environments should influence the health of the whole interconnected local ecosystem (one health). in addition, antibiotic resistance is also a global problem; any resistant microorganism (and its antibiotic resistance genes) could be distributed worldwide. consequently, antibiotic resistance is a pandemic that requires global health solutions. social norms, imposing individual and group behavior that favor global human health and in accordance with the increasingly collective awareness of the lack of human alienation from nature, will positively influence these solutions. in this regard, the problem of antibiotic resistance should be understood within the framework of socioeconomic and ecological efforts to ensure the sustainability of human development and the associated human–natural ecosystem interactions. the problem of antibiotic resistance (ar) has been traditionally addressed by focusing on humanlinked environments, typically health care facilities. nevertheless, it is now generally accepted that most ecosystems may contribute to the selection and spread of ar (aminov, ; martinez et al., ; davies and davies, ; martinez, ; berendonk et al., ; larsson et al., ) . a key conceptual point is that, based on cultural, humanitarian, and economic reasons, we have historically preserved the health of individual humans and farming animals. to that purpose, the same families of antimicrobial agents have been used. as a consequence, their positive (healing) and negative (selection of ar, therapeutic failure) effects have influenced the common health of humans and animals in particular locations (one health). the concept one health, first used in early twentieth century, expands the integrative thinking about human and animal medicine, including for the first time ecology, public health, and societal aspects (zinsstag et al., ) . in the case of ar, the one health perspective focuses on the risk assessment of emergence, transmission, and maintenance of ar at the interface between humans, animals, and any other linked (local) environment (robinson et al., ; jean, ) . consequently, the application of one health approaches demands integrative surveillance tools and interventions based on multidisciplinary approaches that include ecological and sociodemographic factors, besides more classic epidemiological models. global health is based on a broad collaborative and transnational approach to establish "health for all humans." in this case, it focuses ar at a general (global) scale, considering that the selection and global spread of antibiotic-resistant bacteria (arbs) and antibiotic resistance genes (args) are a problem that influences the health of human societies with disparate social and economic structures and is linked to many societal and ecological factors (chokshi et al., ) . interventions to reduce ar burden in a global world certainly require common and integrated policy responses of countries, international organizations, and other actors (stakeholders included). its goal is the equitable access to health and minimizing health risks all over the globe. besides its objective aspects (i.e., how travelers, migrating birds, or international commerce may contribute to ar spread), it has important international political aspects. it focuses in how countries and international organizations address the elements connecting and potentially spreading ar among humans, animals, and natural ecosystems at the earth scale (wernli et al., ) . in summary, the problems and the potential solutions concerning ar are not confined to particular regions, but have a global dimension: a problem for all humans, animals, and natural ecosystems, which should be solved with interventions aiming to improve health for all of them koplan et al., ; laxminarayan et al., ) . in the context of ar, a healthy environment would be an environment where ar is low or can be controlled by human interventions (hernando-amado et al., ; andersson et al., ) . of course, the global health concept of "health of an environment" (iavarone and pasetto, ; pérez and pierce wise, ; bind, ; van bruggen et al., ) or, in general, planetary health (lerner and berg, ) , has an unavoidable anthropogenic flavor. in practice, we consider "healthy environments" or "healthy ecosystems" those that minimize their current or their potential harm for the human individual or the society, in our case for ar. in other words, we adopt a selfish strategy, which should be necessarily implemented by the international (global) institutions. selfishness (kangas, ) applies mainly to individuals, but also to societal groups. however, these groups have not enough possibilities to act alone in the case of infectious diseases in general and ar in particular, which may expand worldwide. therefore, individual selfishness for health should be integrated in local one health and also in global health actions. the goal of controlling ar is a highly complex one, and its dimension has been compared to climate change or biodiversity loss, problems where individual actions are not enough for providing a solution, and consequently, individual freedom is confronted with collective responsibility (looker and hallett, ) . the construction of human societies reflects the tension between individual freedom and social rules/laws. the implementation of different social rules/laws for regulating human activities within a society is mainly based on moral (as kant's categorical imperative (kant, ) or religious-based brotherhood (matthew : - ) statements), social stability (as anticrime laws; schiavone, ) , organizative (type of government and how it is formed, group identity), and efficacy (as antitrust laws; ricardo, ) arguments. however, these arguments mainly apply for establishing the socioeconomic organization as well as the individual welfare within a society. the situation concerning human health is somehow different. there are individual diseases, such as cancer or stroke, and social diseases, such as transmissible infections. for the firsts, social norms (as consciousness of the importance of the control of cholesterol, excess sugar uptake, or hypertension levels) are well established, and even laws (non-smoking regulations) had been implemented in occasions. however, the main impact of these regulations is at the individual health level (wikler, ) , because the associated diseases are not physically transmissible. a different situation happens in the case of infectious diseases in general and of ar in particular. for these diseases, everything that happens in a single person affects any one around. further, the fact that an arg emerging in a given geographic area can spread worldwide implies that neither individual norms nor country-based norms have been sufficient until now to counteract the worldwide spread of ar. one important aspect of laws in democratic societies is that they must be well accepted by the community, so that the acceptation of social norms usually comes first than their implementations as rules/laws. actually, the efficiency of democracy for responding to social crisis (as current ar or covid- crises), in opposition to other more autocratic regimens where decisions are implemented top-down, had been the subject of debate from the early beginning of democratic revolutions (tocqueville, ; hobbes, ; rousseau, ; spinoza, ) . in this regard, it is important to remark that one health aspects of ar can be tackled in the basis of countrylevel regulations that are linked to the socioeconomic and cultural aspects of each country (chandler, ; chokshi et al., ) . however, because global earth governance does not exist, global health control of ar is based on recommendations, rather than in rules/laws. consequently, the acceptance of social norms, starting within individuals or small organizations and expanding throughout the whole society (figure ) , is fundamental to provide global solutions to the ar problem (nyborg et al., ; chandler, ) . the acceptance by the community of these social norms, considering that the way of promoting these norms might differ in different parts of the world (cislaghi and heise, ; cislaghi and heise, ) , largely depends on the transfer to the society of the knowledge required to understand the mechanisms and the impact for human health of the emergence and transmission of ar, an information that is discussed below. figure | how the interactions among individual health, one health, global health, and social norms influences antibiotic resistance. the right panel shows the different levels of dissemination of antibiotic resistance. in the left panel, the different types of norms (from individual to global norms) that can impact antibiotic resistance at each level are shown. these norms influence all levels of transmission: the individual promotes (red arrows) his own individual health, but doing it also promotes the health of the group, and the health of the group promotes global health of the human society at large. at each level, there is a positive action (red broken lines) on antibiotic resistance. such dynamics largely depends on social norms (blue arrows) rewarding the individual or the groups whose behavior promotes health. below the left panel, the basic social norm, progress and development, has consequences on the whole ecobiology of the planet (lower panel with bullet points), influencing the undesirable open circulation of antimicrobial resistant bacteria (with their mobile genetic elements) and antibiotic resistance genes. the classic definition of ar is based only on the clinical outcome of the infected patient. an organism is considered resistant when the chances for the successful treatment of the infection it produces are low . this definition, which is the most relevant in clinical settings, presents some limitations for studies based on one health approaches that include the analysis of non-infective organisms, which lack a clinical definition of resistance, as well as analysis of the distribution of args, in several occasions, using non-culture-based methods . even in the case of animal medicine, antibiotic concentration breakpoints defining resistance are still absent for some veterinary-specific antimicrobials and poorly defined for different types of animals with disparate weights, which would influence the availability of the drug inside animal body (toutain et al., ; sweeney et al., ) . to analyze ar beyond clinical settings, the term resistome, understood as the set of genetic elements that can confer ar, irrespectively of the level of resistance achieved, in a given organism/microbiome was coined (d'costa et al., ; wright, ; perry et al., ) . ar acquisition is the consequence of either mutation (or recombination) or recruitment of args through horizontal gene transfer (hgt), transformation included. ar mutations are generally confined to their original genomes, propagating vertically and not spreading among bacterial populations, although some few exceptions of horizontal transfer of chromosomal regions containing ar mutations have been described (coffey et al., ; ferrandiz et al., ; novais et al., ; nichol et al., ) . the set of mutations that confer ar can be dubbed as the mutational resistome. current wholegenome-sequencing methods of analysis can allow defining the mutational resistome in an isolated microorganism (cabot et al., ; lopez-causape et al., ) . however, they are not robust enough yet for determining the mutational resistome in metagenomes. consequently, the impact of these analyses in one health studies is still limited and will not be further discussed in the present review. concerning their relevance for acquiring ar, args can be divided in two categories. the first one comprises the genes forming the intrinsic resistome (fajardo et al., ) , which includes those that are naturally present in the chromosomes of all (or most) members of a given bacterial species and have not been acquired recently as the consequence of antibiotic selective pressure. despite that these genes contribute to ar of bacterial pathogens, they are responsible just for the basal level of ar, which is taken into consideration when antibiotics are developed. in this regard, unless these genes, or the elements regulating their expression mutate, they are not a risk for acquiring resistance and have been considered as phylogenetic markers . further, it has been discussed that these genes may contribute to the resilience of microbiomes to antibiotic injury (ruppe et al., b) , hence constituting stabilizing element of microbial populations when confronted with antibiotics more than a risk for ar acquisition by pathogens. the second category, dubbed as the mobilome, is formed by args located in mobile genetic elements (mges) that can be transferred both vertically and horizontally, hence allowing ar dissemination among different bacteria (frost et al., ; siefert, ; jorgensen et al., ; lange et al., ; martinez et al., ) . while the analysis of the resistome of microbiota from different ecosystems has shown that args are ubiquitously present in any studied habitat (d'costa et al., ; walsh, ; jana et al., ; lanza et al., ; chen et al., b) , the impact of each one of these args for human health is different. indeed, it has been stated that the general resistome of a microbiome is linked to phylogeny and to biogeography, indicating that most args are intrinsic and do not move among bacteria (pehrsson et al., ) . however, some args escape to this rule and are shared by different ecosystems and organisms (forsberg et al., ; fondi et al., ) . these mobile args, frequently present in plasmids (tamminen et al., ; pehrsson et al., ) , are the ones that are of special concern for human health. although not belonging to the antibiotic resistome, genes frequently associated with resistance to other antimicrobials, such as heavy metals or biocides, as well as the genes of the mges backbones, eventually involved in the transmission and selection of args among microbial populations, the mobilome at large, are also relevant to track the emergence and dissemination of ar among different habitats martinez et al., ; baquero et al., ) . hgt processes are recognized as the main mechanisms for transmission of genetic information (baquero, ) . from the ecological point of view, hgt should be understood as a cooperative mechanism that allows the exploitation of common goods as args by different members within bacterial communities. in fact, some studies suggest that the ecological consequences of hgt events in ar evolution are contingent on the cooperation of complex bacterial communities, besides the acquisition of individual adaptive traits (smillie et al., ) . however, the understanding of the ecological causes and consequences of args transmission among organisms and microbiomes is still limited from the one health and global health perspectives. hgt-mediated ar is a hierarchical process (figure ) in which args are recruited by gene-capture systems as integrons and afterward integrated in mges as plasmids, insertion conjugative elements, or bacteriophages (frost et al., ; garcia-aljaro et al., ; gillings et al., ; botelho and schulenburg, ) , which afterward are acquired by specific bacterial clones. selection at each of these levels will also select for all the elements involved in ar spread. for instance, the acquisition of an arg by a clone may promote the expansion of the latter (and of all the genetic elements it contains, other args included) in antibiotic-rich environments, such as hospitals or farms schaufler et al., ) , and vice versa, the introduction of an arg in an already successful clone may increase the chances of this resistance gene for its dissemination even in environments without antibiotics, unless the associated fitness costs are high. in this sense, if arg acquisition reduces the fitness, and this implies a decreased capability for infecting humans (see below), the burden for human health might eventually be lower. nevertheless, it is relevant to highlight that ar transmission cannot be understood just by analyzing the genetic mechanisms involved and the consequences of such acquisition for the bacterial physiology. indeed, as discussed below, there are ecological and socioeconomic elements that strongly influence ar dissemination. the evolution of ar comprises the emergence, the transmission, and the persistence of arbs (martinez et al., ; baquero et al., ) . concerning human health, selection of arbs/args is particularly relevant at the individual health level, whereas transmission is a main element to be taken into consideration at the one health and global health levels (figure ) . indeed, unless ar is transmitted, it will be just an individual problem that would not affect the community at large. it is generally accepted that non-clinical ecosystems are often primary sources of args (davies, ) . as above stated, after their capture and integration in mges (figure ), args and their bacterial hosts can contaminate different ecosystems, which might then be involved in their global spread (martinez, ; fondi et al., ; gillings, ; gillings et al., ) . this means that nearly any ecosystem on earth, along with the humandriven changes produced in it, may modulate evolution of ar. importantly, the huge escalation and worldwide expansion of a limited set of animals, plants, and their derived products, including foods, due to the anthropogenic selection of a few breeds and cultivars for mass production in livestock and agricultural industries (okeke and edelman, ; zhu et al., ) of economic interest have collapsed the variability and biodiversity of animals and plants (seddon et al., ) . because these organisms harbor particular host-adapted bacteria, which are frequently under antibiotic challenge, this situation, together with the ecological similarities of human habitats, might favor ar spread (martiny et al., ; manyi-loh et al., ) . indeed, while in underdeveloped areas of the world food animals are very diverse, intensive farming, common in developed countries, ensures a "shared-stable" environment where only the most productive types prevail (kim et al., ) . the common genetic origin of these types and the process of microbiota acquisition from nearby animals in intensive farming should homogenize also their microbiomes with consequences for ar dissemination. actually, it has been shown that the loss of microbial diversity figure | genetic, ecological, and socioeconomic elements mediating the transmission of antibiotic resistance. args are ubiquitously present in any studied microbiome (a). however, only a few of them are transferred to human/animal pathogens, hence constituting a health problem. the genetics events implied include the acquisition of args by gene-recruiting genetic elements such as integrons (b); the integration of these elements in mges as plasmids, bacteriophages, or frontiers in microbiology | www.frontiersin.org figure | continued insertion conjugative elements (c); and the acquisition of these elements by specific bacterial clones (d). these arbs can share these elements among the members of gene-sharing communities (e) and also move among different ecosystems, including humans, animals (particularly relevant farm animals), and natural ecosystems (with a particular relevance for water bodies). the connection of these ecosystems, as well as the reduced diversity of animals, plants, and in general habitats as the consequence of human activities, allows the different microbiomes to be in contact, favoring args transmission among the microorganism they encompass (f). this transmission is facilitated at the global scale by travel, animal migration, trade of goods, and eventually by meteorological phenomena, climate change included (g), hence producing a global health problem (h). while most studies on the dissemination of args focus on mges (davies, ; muniesa et al., ; lanza et al., ; garcia-aljaro et al., ) , recent works suggest that the contribution of natural transformation (orange arrow), allowing the direct uptake of args by natural competent microorganisms, may have been underestimated (domingues et al., ; blokesch, ) . further, competence can occur due to interbacterial predation (veening and blokesch, ) , a biological interaction that may facilitate the acquisition of beneficial adaptive traits by predator bacterial species (cooper et al., ; veening and blokesch, ) . other hgt mechanisms, such as dna packing in extracellular vesicles (ecv) or transference of dna through intercellular nanotubes, also seem to be relevant in nature (dubey and ben-yehuda, ; fulsundar et al., ) . while the biotic conditions that may enhance hgt have been studied in detail, less is known concerning abiotic modulation of args transfer. under contemporary conditions, at least microorganisms are affected by a freeze-and-thaw cycle, at least are agitated by sand, and at least are subjected to conditions suitable for electrotransformation every year (kotnik and weaver, ) . may favor ar spread (chen et al., a) . note that, beyond the transmission of particular ar spreading clones, ar is expected to spread in farms by the modification (eventually homogenization) of animals' microbiota. notwithstanding, even farm workers are subject to microbiome acquisition from animals, leading to microbiome coalescence sun et al., ) . it is to be noticed, and the recent covid- crisis exemplifies it, that besides economic development, cultural habits are relevant in the use of animals for food, a feature that has not been analyzed in detail, particularly with respect to their role as vectors potentially involved in ar dissemination. despite that the homogenization of hosts may help in ar transmission, the spread of arbs has some constraints, because the differential capability of each bacterial clone for colonizing different hosts may modulate their dissemination. indeed, while some species and clones are able to colonize/infect different animal species, humankind included, several others present some degree of host specificity (price et al., ; sheppard et al., ) . further, it has been shown that the capacity to colonize a new host is frequently associated with a reduction in the capacity for colonizing the former one. the same happens for mobile args; they are encoded in mges that present different degrees of host specificity, which defines the formation of gene-exchange communities, where the interchange of genetic material among members is facilitated (skippington and ragan, ) . conversely, the incorporation of different replicons and modules within plasmid backbones, a feature increasingly reported (douarre et al., ) , would enable arg replication in different clonal/species background and thus modify the community network of args. actually, the risk for humans of animal-based ar seems to be linked in most cases to shuttle, generalist clones able to colonize humans and particular animals (price et al., ; sheppard et al., ) . the understanding of the elements driving the transfer of ar among animals, humans included (figure ) , requires the comprehensive survey of the clones and args that are moving among them (european food safety authority et al., ). tools to track the global epidemiology of antimicrobial-resistant microorganisms such as bigsdb (jolley et al., ) or comprehensive databases of args, ideally providing information of their mobility (zankari et al., ; alcock et al., ) , are fundamental for studying ar transmission at a global level. it is worth mentioning that, because humans constitute a single biological species, the human-associated organisms spread easily among all individuals. in fact, more prominent differences in humans' microbiome composition can be observed between individuals than among ethnic groups, even though, as expected, the resemblance in microbiotas is higher among those groups that are geographically clustered (deschasaux et al., ; gaulke and sharpton, ) . some groups of human population are, however, more prone to acquire arbs, due either to socioeconomic or to cultural factors. in lmics (low-to medium-income countries) and brics (brazil, russia, india, china, and south africa) countries, the combination of wide access to antibiotics, weak health care structures, and poor sanitation defines certainly a dangerous landscape. moreover, the progressive aging of the western population might favor the establishment and further expansion of an elderly reservoir of arbs and args, an issue that deserves further studies. the hypothesis that the microbiome of elder people might be a reservoir of ar is based not only on their cumulative history of antibiotic exposure and contacts with health care centers, but also on the rampant use of antibiotics of this population more prone to suffer from acute, chronic, or recurrent infections. significant worldwide advances in the organization of medical care of the elderly people lead to frequent hospitalizations, but health care centers may also facilitate the selection and further amplification of ar in the community. in addition, this may subsequently favor the entry of high-risk clones and of args in the hospital setting (hujer et al., ) . as stated above, there is a global increasing permeability of the natural biological barriers that have historically prevented bacterial dissemination through different ecosystems. besides local spread of ar in environments shared by animals and humans, which has to be addressed under a one health approach, ar can disseminate worldwide (figure ) by economic corridors that promote the global interchange of goods and trade or human travelers or by natural bridges, such as animal migration paths or natural phenomena such as air and water movements (okeke and edelman, ; baquero et al., ; allen et al., ; overdevest et al., ; kluytmans et al., ; fondi et al., ) . the result is the appearance of similar arbs and args in different geographic areas. as the consequence, ar is a global health problem in the sense that an arb that emerges in a given place can rapidly spread worldwide. indeed, multidrugresistant bacteria, similar to those encountered in clinical settings, have been detected in human isolated populations that were not previously in contact with antibiotic, as well as in wildlife (clemente et al., ) . this indicates that pollution with args is present even in places where antibiotic concentrations are low (kümmerer, ) and might involve mechanisms of transmission that do not require selection. for instance, migrating birds can carry enteropathogenic bacteria resistant to different antibiotics (middleton and ambrose, ; poeta et al., ) , and international travelers, even those not receiving antibiotic treatments, also contribute to ar transfer among different geographic regions (murray et al., ; reuland et al., ) . in the group of long travelers are refugee people, in which dissemination of multidrug-resistant strains is favored by the poor sanitary conditions and overcrowding camps that refugees confront (maltezou, ) . a final issue concerning ar is its stability in the absence of selection. it has been proposed that the acquisition of ar reduces bacterial competitiveness in the absence of antibiotics (fitness costs) (andersson and hughes, ; martinez et al., ) ; certainly, a wishful proposition such as, if true, the reduction in the use of drugs or eventually antibiotic-cycling strategies should decrease ar (beardmore et al., ) . nevertheless, eliminating the use of an antibiotic does not produce a full decline of ar (sundqvist et al., ) . in fact, different studies have shown that ar not always reduces fitness but also can even increase bacterial competitiveness (andersson and hughes, ; schaufler et al., ) . in addition, compensatory mutations or physiological changes that restore fitness can be selected in resistant bacteria (andersson, ; schulz zur wiesch et al., ; olivares et al., ) . it is a fact, however, that although arbs are found nearly everywhere, including wild animals, natural ecosystems, or people from isolated populations without contact with antibiotics, among others (durso et al., ; clemente et al., ; alonso et al., ; fitzpatrick and walsh, ; power et al., ) , ar prevalence is consistently lower when antibiotics are absent, which suggests that pollution may impact ar, a feature that is discussed below. pollution of natural ecosystems is associated with activities that have driven relevant economic transition, in principle favoring human welfare, such as mining, industry, intensive land use, or intensive farming, among others. notwithstanding, globalization of health services, as well as the shift toward intensive farming, besides their positive contribution to human wellbeing, has rendered an increasing pollution by compounds with pharmacological properties of natural ecosystems, particularly water bodies, which may disrupt the stability of these ecosystems (oldenkamp et al., ) . among them, antibiotics are considered the most relevant cause of ar selection. despite regulations for reducing their use (van boeckel et al., ) , a substantial increase in global antibiotic consumption has occurred in the last years, and an even greater increase is forecasted in the next years (klein et al., ) . however, antibiotics are not the unique pollutants that can prime the selection and spread of ar. in this regard, it is important to highlight that heavy metals are one of the most abundant pollutants worldwide (panagos et al., ) . their abundance results from anthropogenic-related activities, such as mining, industry, agriculture, farming, or aquaculture and even for therapeutic use in ancient times. importantly, they may persist in nature for long periods of time. further, likely because metal pollution occurred before the use of antibiotics, heavy metal resistance genes were incorporated to mge backbones before args (mindlin et al., ; staehlin et al., ) . this means that heavy metals may coselect for mges and the args they harbor (partridge and hall, ; staehlin et al., ; zhao et al., a) . even more, the presence of heavy metals, as well as of biocides or sublethal antibiotic concentrations (jutkina et al., ; zhang et al., ) , may stimulate hgt, as well as modify the dynamics of antibiotics, such as tetracyclines, in natural ecosystems (hsu et al., ) . coselection may also occur when a single resistance mechanism, such as an efflux pump, confers resistance to both heavy metals and antibiotics (cross-resistance) (pal et al., ) . although most published works analyze the effect of different pollutants on their capacity to select arbs or args, it is important to highlight that args should also be considered pollutants themselves. actually, a recent work indicates a close relationship between the abundance of args and fecal pollution (karkman et al., ) . in this respect, it is worth mentioning that, differing to classic pollutants, args/arbs are not expected to disappear along time and space, but rather, their abundance may even increase as the consequence of selection and transmission (martinez, ) . while the direct selection of ar by antibiotics or the coselection mediated by other pollutants, as the aforementioned heavy metals, has been discussed (wales and davies, ) , the effect of other types of human interventions on the dissemination of args and arbs through natural ecosystems has been analyzed in less detail. as an example, it has been proposed that wastewater treatment plants, where commensals, arbs, args, and antibiotics coexist, could act as bioreactors favoring the selection and transmission of args between different organisms (rizzo et al., ; su et al., ; manaia et al., ) , although evidences supporting this statement are scarce (munck et al., ; azuma et al., ) . in addition to the aforementioned pollutants with a direct effect in ar selection, it is worth noting that there are other abundant contaminants, such as sepiolite (present in cat litters or used as a dietary coadjuvant in animal feed) or microplastics, present in almost all aquatic ecosystems, which can favor the transmission of args or mges between bacterial species (rodriguez-beltran et al., ; kotnik and weaver, ; arias-andres et al., ) , hence amplifying the ar problem at a global scale. finally, the possible effect of climate change on the spread of ar is worth mentioning. indeed, it modifies the biogeography of vectors (such as flies, fleas or birds) involved in the spread of infectious diseases (fuller et al., ; beugnet and chalvet-monfray, ) . in addition, the increase of local temperatures seems to correlate with an increased ar abundance in common pathogens (macfadden et al., ) . besides, climate change is affecting ocean currents (martinez-urtaza et al., ) , which may allow the intercontinental distribution of arbs and args (martinez, a,b) . although this phenomenon might contribute to the globalization of ar, further research is needed to clearly demonstrate a cause-effect relationship. it is relevant to mention that increased pollution and climate change are the unwanted consequences of human development. it would then be worth discussing how human development in general may impact (positively and negatively) ar, a feature that is analyzed below. human development is a necessity of our human behavior, although different models of development have been and are proposed, each one producing different impacts in the structure of human societies and on the preservation and stability of natural ecosystems (fenech et al., ; farley and voinov, ; seddon et al., ) . nevertheless, even for different socioeconomic models, there are some social norms that tend to be widely accepted, in particular those aiming to improve individual well-being. this implies the establishment of a society of welfare, understood as a right of any human on earth, a feature that depends on the economic development, and can be particularly relevant in the case of transmissible infectious diseases in general and of ar in particular. a continuously repeated mantra in worldwide ar policies is that the abusive consumption of antibiotics for the treatment or prevention of infections in humans and animals constitutes the major driver of ar. however, we should keep in mind that antibiotics constitute an important example of human progress supporting individual and global human health. in fact, the origin of the massive production of antimicrobials was a consequence of the needs resulting from world war ii in the s. this was followed by many decades of human progress, most importantly by the common understanding of equal human rights, which was followed by the economic and social development (including medicine and food industry) of densely populated regions in the planet, including india and china. these countries are currently among the leaders in the production and consumption of antimicrobial agents. notwithstanding, as in any area of economy, progress bears a cost that, in this case, is antibiotic pollution of the environment, globally accelerating the process of the emergence, the transmission, and the persistence of arbs (martinez et al., ; baquero et al., ) . the non-controlled use of antibiotics is facilitated in lmics with disparate economic growth by different factors. heterogeneous regulation of antibiotic sales and prescriptions (often weak or missing) and the increase of online on-bulk sales in recent years contribute to their overuse (mainous et al., ). most of live-saving medicines represent out-of-pocket costs in most lmics, which led to an exacerbated use of cheap (usually old and less effective) antibiotics, phasing out their efficacy and increasing the demands and prices for the most expensive ones, eventually resulting in treatment unavailability (newton et al., ) . further, the cost of treating ar infections is much higher than that of treating susceptible ones, which is increasing the cost of health services (wozniak et al., ) . conversely, the growing economic capability of lmics in the brics category triggers the access of the population to health services and last-resort antibiotics. these countries also face a sudden high demand for meat and thus a prompt industrialization of animal production that has favored the misuse of antibiotics for growth promotion facilitated by their online availability (mainous et al., ). in addition, counterfeit or substandard antibiotics recently become a serious global problem (gostin et al., ) , which is exacerbated in lmics, where they represent up to a third of the available drugs. noteworthy, % of all reports received by the who global surveillance and monitoring system on substandard and falsified medicines worldwide come from africa, and most of them correspond to antimalarials and antibiotics (newton et al., ; gostin et al., ; hamilton et al., ; petersen et al., ) . despite this situation, it is important to highlight that human consumption of antibiotics is an unavoidable need to preserve human health. in fact, most health problems dealing with infections in lmics are still caused by a poor access to antibiotics, not by an excessive use of them. proof of this is the fact that the distribution of antibiotics has reduced endemic illnesses and children mortality in sub-saharan africa (keenan et al., ) . this means that, while a global decline in the use of antibiotics would be desirable to diminish the problem of ar, there are still several parts in the globe where antibiotic use should still increase to correctly fight infections. in fact, our primary goal should not be to reduce the use of antibiotics, but to ensure the effective therapy of infectious diseases for the long term. this does not mean that ar is not a relevant problem in lmics; it means that reducing antibiotic use is not enough to solve the problem. indeed, the current high morbidity and mortality due to infectious diseases (malaria, tuberculosis, low respiratory infections, sepsis, and diarrhea) in lmics will be worsened in the absence or low efficiency of therapeutic treatments. further, ar has economic consequences. according to world bank, . million people could fall into extreme poverty by because of ar, most of them from lmics (jonas and world bank group team, ) . consequently, besides a global health problem, ar has an important economic impact (rudholm, ) , hence constituting a global development problem, endangering not only the achievements toward the millennium development goals but also the sustainable development goals (van der heijden et al., ). world bank estimates that ar could impact the gross domestic product from to . %, which is even higher than what is estimated for the climate change (jonas and world bank group team, ) . these economic foresights are linked to the threads of increased poverty, food sustainability, global health deterioration (associated with both food safety and affordability to health care), and environment protection. all these issues are also impacted by the overuse and misuse of antibiotics, its lack of effectiveness, and the affordability to medicines and health care (van der heijden et al., ) . when talking about reducing antibiotic consumption, it is important to remind that up to two-thirds of overall antibiotic usage is for animal husbandry (done et al., ) . further, recent work states that the use of antibiotics in crops, particularly in lmics, might have been largely underestimated (taylor and reeder, ) . despite that evidences on the presence of common args distributed among animals and humans were published decades ago wegener et al., ; aarestrup, ; aarestrup et al., ) , and although the use of antibiotics as growth promoters has been banned in different countries (cox and ricci, ) , they are still allowed in many others (mathew et al., ) . of relevance is the fast increase of antibiotic consumption for animal food production in china ( % in ) and other brics countries . as stated previously, in these countries, increased income has produced a fast increase in meat products demand, due to changes in diet of their population. in addition, the increasing international competitiveness in meat production of these countries has fostered the rampant development of their industrial farming. together with the fact that legislation on antibiotics use remains weak, this situation increases the risk of emergence of ar linked to animal production. nevertheless, the problem is not restricted only to lmics, because antibiotics consumption rose as well in the highincome countries as the united states ( %) , where approximately % of the antimicrobials purchased in were applied in livestock production as non-therapeutic administration (done et al., ) . the development of intensive methods of fish production has also contributed to the rise in the use of antimicrobials and the selection of resistance determinants that can be shared among fish and human bacterial pathogens (cabello et al., ) . economic development has facilitated as well more global transport, waste disposal, and tourism, favoring ar spread within and between different geographical areas (ruppe et al., a; ruppe and chappuis, ) . however, economic growth can also reduce the ar burden, especially when it enables the development of regulations and infrastructures that might reduce the risks of infection and ar spread. this is particularly relevant in the case of public health interventions on food, water, and sewage. because ar pathogens are mainly introduced in natural ecosystems through the release of human/animal stools (karkman et al., ) , the best way of reducing this impact is through the use of wastewater treatment plants, which are still absent in several places worldwide. indeed, it has been described that drinking water is a relevant vehicle for the spread of arbs in different countries (walsh et al., ; fernando et al., ) and that raw wastewater irrigation used for urban agriculture may increase the abundance of mobile args in the irrigated soil (bougnom et al., ) . notably, the analysis of args in wastewaters has shown that the prevalence of args in the environment in each country might be linked to socioeconomic aspects mainly related to economic development, as general sanitation, particularly the availability of drinking and wastewater treatments, malnutrition, number of physicians and health workers, human overcrowding, or external debt grace period (hendriksen et al., ) . the field of ar has mainly focused in the mechanisms of selection; the main driver for the increased burden of ar would be then the use of antibiotics itself. however, these results indicate that transmission, even in the absence of direct human-to-human contact, might be, at least, equally relevant. in this situation, an important element to reduce the ar burden will be to break the transmission bridges among different ecosystems that could be reservoirs of args. even when wastewater-treatment plants are available, the presence of arbs in drinking, fresh, and coastal waters, as well as in sediments nearby industrial and urban discharges, has been described in several countries (ma et al., ; leonard et al., ) . as in the case of fecal contamination markers, a reduction in the amount of args to non-detectable levels would be extremely difficult even when advanced water treatment procedures are applied. a standard definition of polluting arb/arg markers, as well as their acceptable levels, is then needed. this would be required not only for potable water, but also for water reutilization, as well as for land application and release of sewage effluents, because in all cases the reused water/sewage may carry arbs and args, together with pollutants, such as antibiotics, metals, biocides, or microplastics, which, as above stated, may select for ar (baquero et al., ; moura et al., ; yang et al., ; zhu et al., ; larsson et al., ; imran et al., ; wang et al., ) and may even induce hgt. the examples discussed above justify that human health in general and ar in particular are closely interlinked with economic development (sharma, ) . economic differences are also found at individual level, because there is a positive relationship between economic status and health (tipper, ) . in addition, social behavior might also impact ar, a feature discussed in the following section. different socioeconomic factors can modulate the spread of infective bacteria in general and of ar in particular. among them, the increasing crowding of humans and foodborne animal populations favors transmission at the local level (one health), whereas trade of goods and human travel (figure ) favor worldwide transmission (global health) (laxminarayan et al., ; hernando-amado et al., ) . besides these global changes in social behavior, linked to economic development, more specific socioeconomic factors (income, education, life expectancy at birth, health care structure, governance quality), sociocultural aspects (inequalities, uncertainty avoidance, integration of individuals into primary groups, gender biases, cultural long-term orientation), and personality dimension highly influence antibiotic use and ar transmission (gaygısız et al., ) . for instance, although the governance quality seems to be the most important factor associated with a proper antibiotic use, western countries with distinct national culture patterns show different levels of antibiotics consumption (kenyon and manoharan-basil, ) . a better understanding of human social responses facing ailments, especially epidemics and antibiotic use, requires then a more detailed analysis of the differences between collectivistic (individuals living integrated into primary groups) and individually long-term oriented societies (oriented to future individual rewards) (hofstede, ; gaygısız et al., ; kenyon and manoharan-basil, ) . consistent with the sociological elements of ar, many of the aspects influencing ar reviewed above depend on social norms (figure ) . in the classic view of the psychoanalyst erich fromm presented in his book "escape from freedom" (fromm, ) , human individual behavior is oriented to avoid being excluded from a higher social group. indeed, not following social common rules can be eventually considered as a mental disorder; a sociopathology. a social norm is defined as a predominant behavioral pattern within a group, supported by a shared understanding of acceptable actions and sustained through social interactions within that group (nyborg et al., ) . in democratic societies, laws usually derive from already accepted social norms; otherwise, they would be changed, and in that sense, the establishment of accepted social norms for fighting ar is a prerequisite to implement the global approaches, based on worldwide rules, which are required for tackling this relevant problem. interestingly, the ar problem is a bottom-up process, where small emergent changes (in some type of individual patients, in some groups, in some locations) cumulatively escalate to gain a global dimension. frequently, that occurs by crossing tipping points, that is, points where the local ar incidence becomes significant enough to cause a larger, eventually global, health problem. because of that, the implementation of solutions should be adapted to the control of critical tipping points in the small groups of individuals to disrupt the bottom-up processes. however, as ar spread can occur everywhere and at any time, global surveillance and mechanisms of control should be implemented to prevent a top-down process of global ar expansion. individual selfishness for ar is the cornerstone of social norms. this concept was coined and developed by one of us over a decade ago (baquero, ) . let us imagine that each individual is aware that each consumption of an antibiotic increases the personal risk of himself/herself or for his/her closer relatives (frequently exchanging microorganisms) of dying because of an antibiotic-resistant infection. the situation is analogous to the consumption of cholesterol-rich or highly salted food, or drinks with excess of sugar, concerning individual health. however, in the case of ar, it requires the understanding of the impact of individual actions at the global level. in this respect, anti-ar social actions should resemble more antitobacco and even general pollution/ecological campaigns. at the individual level, there is inertia that precludes changing habits, until a tipping point is crossed and health is compromised. the conclusions of studies mainly based on long-term cohort analysis, such as the framingham program for the influence of diet or smoking on personal cardiovascular disease (mahmood et al., ) , have become social norms that are naturally imposed by the ensemble of individuals. this creates a kind of societal culture, leading to appropriate individual behaviors, in occasions without the need of specific laws (diet), in occasion favoring the implementation of such laws (antismoking). however, we lack similar studies on issues such as these dealing with personalfamiliar risks that have successfully shifted social norms, driven by groups of individuals and based on the promotion of individual behaviors in the case of ar. despite that quantitative models on how individual antibiotic use may impact ar at the population level are still absent, it is worth mentioning that a reduced antibiotic consumption has also begun to occur in a number of countries just as a result of a change in individual behavior (edgar et al., ) , and some tools and indicators to address these changes have been suggested (ploy et al., ) . the "tragedy of the commons" metaphor, first proposed in the xix century (lloyd, ) and later on discussed in (hardin, ) , has been used for addressing the sociology of ar, by showing how individual selfishness promotes antibiotic use, increases resistance, and influences the health of the community by impairing antibiotic efficacy (baquero and campos, ; foster and grundmann, ) . ensuring the prestige of individuals that follow the social rules is needed to counteract the tragedy of the commons. nevertheless, it is important noticing that the tension between individual freedom and social rules that is inherent to the construction of democratic societies (tocqueville, ; hobbes, ; rousseau, ; spinoza, ) also applies here. one example of this situation is vaccination, considered in the last century as one of the most important advances to fight infectious diseases and now being the focus of antivaccination campaigns (megget, ) , a movement that has been considered by the who as one of the top global health threats of . it is commonly accepted that social norms are mainly created by learning and education, a rational path that promotes health (chen and fu, ) . also, the increasing activities of "personalized medicine, " including antibiotic stewardship, follow the same trend (gould and lawes, ) . however, the antivaccination movement is an example of how the narrative, as well as the use of decentralized, social information channels such as the internet search, blogs, and applications to facilitate communication such as twitter, facebook or whatsapp, is of particular relevance in the construction of social norms, not necessarily based on scientific and rational grounds (jacobson et al., ; scott and mars, ) . the impact of social norms goes beyond human societies as human activities alter natural ecosystems; consequently, humans cannot be aliens of nature. we should then shape a socioecological system, linking the individuals, the groups, and the entire society, as well as natural ecosystems, also potentially damaged by ar, in a common multilevel adaptive system based on social norms and policies at the individual, local (one health), and global (global health) scale (levin et al., ) . the recent crisis of covid- illustrates the influence of social norms in the individual behavior. each one of the individuals, protecting himself/herself, also protects the others. a person not wearing on face mask is frowned upon, and on the contrary, somebody attaching to the rules increases reputation. the individual adopts the right behavior being influenced by the judgment. of others. in addition, different political regimes (democracy or autocracy), as well as their organization (centralized, federal), together with the capacity of the health services to support the norms and their efficacy to communicate the chosen policy to the citizenry, may shape the individual responses to social norms (greer et al., ; häyry, ; kavanagh and singh, ) . notwithstanding, two reasons that have been proposed to explain the low prevalence of covid- in japan were related with social norms more than with biological issues. these reasons, which are not common to other countries, were the socially accepted use of face masks and the mandatory vaccination of all the population against tuberculosis, which might protect from sars-cov- infection (iwasaki and grubaugh, ) , a feature that is still to be confirmed. the loss of social prestige of individuals taking antibiotics without prescription, as well as the pharmacies delivering these drugs or do not respect environmental protection, or the overconsumption of antibiotics in hospitals or in farms, or even in certain countries, is progressively constituting a "social norm, " converted in rules able to reduce ar emergence and spread. of course, family and school education, as well as governmental campaigns, including the use of social media (grajales et al., ) reinforces such social norms, which could allow the support of the society for the implementation of different interventions, some of them described below. controlling resistance not only requires establishing local interventions, which could be relatively easily implemented, but would also require global interventions that every country should follow, despite their disparate regulatory systems. local and global interventions are necessarily intertwined; for example, the use of a new drug to treat a single individual depends on regulations at the county level (one health approach), but the worldwide prevalence and transmission of resistance to this drug, as well as the regulations of its use, should be established internationally (global health approach). three main interventions to tackle ar have been historically considered: first, reduction of the antibiotic selective pressure by decreasing antimicrobials use; second, reduction of transmission of arbs using improved hygienic procedures that prevent spread; third, development of novel antimicrobials with limited capacity to select arbs or the design of new treatment strategies based on use of non-antibiotic-based approaches or, more recently, on the exploitation of trade-offs associated with ar evolution (imamovic and sommer, ; gonzales et al., ; barbosa et al., ; imamovic et al., ) . these interventions have been basically limited to local initiatives, applied mainly to hospitals and, more recently, to farms. however, ar has emerged and spread globally, in bacteria from different environments, so the health and dynamics of the global microbiosphere could be affected by antibiotics. in a sense, ar is affecting the planetary health (lerner and berg, ) , and the needed interventions for tackling this problem cannot be restricted to hospital settings (figure ) . the proposed reduction in the use of antibiotics (blaskovich, ) must be compensated with alternative approaches for fighting infectious diseases. in this regard, strategies based on improving the capability of the immune system for counteracting infections (levin et al., ; traven and naderer, ) or the use of non-antibiotic approaches to prevent them, such as vaccines (jansen and anderson, ) , may help to reduce the burden of ar infections. indeed, vaccination against haemophilus influenzae and streptococcus pneumoniae has been demonstrated to be an effective intervention for reducing ar (jansen and anderson, ) . however, while vaccination has been extremely useful to prevent viral infections, it has been less promising in the case of bacterial ones. recent approaches, including reverse vaccinology, may help in filling this gap (delany et al., ; ni et al., ) . moreover, vaccination should not be restricted to humans, because veterinary vaccination can also contribute to animal wealth and farm productivity (francis, ) . besides, the use of vaccines in animal production reduces the use of antibiotics at farms/fisheries, hence reducing the selection pressure toward ar. other strategies to reduce antibiotic selective pressure include the use of bacteriophages (a revitalized strategy in recent years) (viertel et al., ; forti et al., ) , not only in clinical settings, but also in natural ecosystems (zhao et al., b) , as well as the use of biodegradable antibiotics (chin et al., ) or adsorbents, able to reduce selective pressure on commensal microbiome (de gunzburg et al., . besides reducing the chances of selecting arbs, the use of antibiotics adsorbents may preserve the microbiomes, reducing the risks of infections (chapman et al., ) . importantly, the procedures for removing antibiotics should not be limited to clinical settings, but their implementation in wastewater treatment plants would reduce selection of ar in non-clinical ecosystems (tian et al., ) . concerning the development of new antimicrobials (hunter, ) , while there is a basic economic issue related to the incentives to pharmaceutical companies (sciarretta et al., ; theuretzbacher et al., ) , the focus is on the possibility of developing novel compounds with low capacity for selecting ar (ling et al., ; chin et al., ) . for this purpose, multitarget (li et al., ) or antiresistance drugs, such as membrane microdomain disassemblers (garcia-fernandez et al., ) , are also promising. furthermore, antimicrobial peptides, with a dual role as immunomodulators and antimicrobials, may also help fight infections (hancock et al., ) . in fact, some works figure | local and global intervention strategies to tackle ar and knowledge gaps that could help improve existing ones. most interventions for reducing antibiotic resistance are based on impairing the selection of arbs/args, which is just the first event in ar spread. our main goal, as for any other infectious disease, figure | continued would be reducing transmission. this does not mean that selective pressure is not relevant for transmission. indeed, without positive selection, hgt events are not fixed, allowing the enrichment of some args that are consequently more prone to diversification, both because they are more abundant and more frequently subjected to selection (davies, ; martinez, a,b; salverda et al., ) and because they can explore different landscapes when present as merodiploids in multicopy plasmids (rodriguez-beltran et al., ) . therefore, reducing the selective pressure, either due to antibiotics or by other coselecting agents as heavy metals, still stands as a major intervention against ar emergence and transmission. to address this issue, we need to know more on the amount of pollutants, their selective concentrations, and their mechanisms of coselection and cross-selection in different ecosystems. this is a general example illustrating the gaps in knowledge in the ar field that need to be filled as well as strategies that may help in tackling this problem. the figure includes several other examples of the gaps of knowledge (red) that require further studies and the interventions (blue) that may help to tackle ar. have shown that arb frequently present collateral sensitivity to antimicrobial peptides (lázár et al., ) and that, importantly, some antimicrobial peptides present limited resistance or crossresistance (kintses et al., ; spohn et al., ) . from a conservative point of view, based on the use of the drugs we already have, it would be desirable to fight ar using evolution-based strategies for developing new drugs or treatment strategies. regarding this, the exploitation of the evolutionary trade-offs associated with the acquisition of ar, as collateral sensitivity, could allow the rational design of treatments based on the alternation or the combination of pairs of drugs (imamovic and sommer, ; gonzales et al., ; barbosa et al., ; imamovic et al., ) . in addition to interventions that reduce the selective pressure of antibiotics or that implement new therapeutic approaches, reducing transmission is also relevant to fight infections. the development of drugs or conditions (as certain wastewater treatments) able to reduce mutagenesis or to inhibit plasmid conjugation may also help in reducing the spread of resistance (thi et al., ; alam et al., ; lin et al., ; lopatkin et al., ; valencia et al., ; kudo et al., ) . besides specific drugs to reduce the dissemination of the genetic elements involved in ar, socioeconomic interventions to break the bridges that allow transmission between individuals and, most importantly (and less addressed), between resistance entities (hernando-amado et al., ) are needed (figure ) . more efficient animal management, not only allowing less antibiotics use but also reducing animal crowding (and hence ar transmission), as well as improved sanitation procedures, including the universalization of water treatment, will certainly help in this task (berendonk et al., ; manaia, ; hernando-amado et al., ) . notably, wastewater treatment plants are usually communal facilities where the residues of the total population of a city are treated. hospitals are the hotspots of ar in a city; hence, on-site hospital (and eventually onfarm) wastewater treatment may help to reduce the pollution of communal wastewater by antibiotics and arbs (cahill et al., ; paulus et al., ) , hence reducing ar transmission. concerning trade of goods, it is relevant to remark that, although there are strict regulations to control the entrance of animals or plants from sites with zoonotic of plant epidemic diseases (brown and bevins, ) , there are no regulations on the exchange of goods from geographic regions with a high ar prevalence, a feature that might be taken into consideration for reducing the worldwide spread of ar. once arbs are selected and disseminated, interventions based on the ecological and evolutionary (eco-evo) aspects of ar lehtinen et al., ) should be applied to restore (and select for) susceptibility of bacterial populations, as well as to preserve drug-susceptible microbiomes in humans and in animals . eco-evo strategies include the development of drugs specifically targeting arbs. for that, drugs activated by mechanisms of resistance, vaccines targeting high-risk disseminating resistance clones or the resistance mechanisms themselves (kim et al., ; ni et al., ) , or drugs targeting metabolic paths that can be specifically modified in arbs ) might be useful. the use of bacteriovores such as bdellovibrio to eliminate pathogens without the need for antibiotics has been proposed; although its utility for treating infections is debatable, it might be useful in natural ecosystems (shatzkes et al., ) . more recent work suggests that some earthworms may favor the degradation of antibiotics and the elimination of arbs (wikler, ) , a feature that might be in agreement with the finding that arbs are less virulent (and hence might be specifically eliminated when the worm is present) in a caenorhabditis elegans virulence model ruiz-diez et al., ; paulander et al., ; olivares et al., ) . however, the information on the potential use of worms for reducing ar in the field is still preliminary and requires further confirmation. noteworthy, ar is less prone to be acquired by complex microbiomes (mahnert et al., ; wood, ) , a feature that supports the possibility of interventions on the microbiota to reduce ar. among them, fecal transplantation (chapman et al., ; pamer, ) or the use of probiotics able to outcompete arbs (keith and pamer, ) has been proposed as strategies for recovering susceptible microbiomes. the recent crisis of covid- (garrett, ) resembles the pandemic expansion of args and clearly shows that pandemic outbreaks cannot be solved by just applying local solutions. further, unless all population is controlled, and comprehensive public-health protocols are applied to the bulk of the population, such global pandemics will be hardly controlled. the case of covid- is rather peculiar, because we are dealing with a novel virus. very strict interventions have been applied, mainly trying to control something that is a novel, unknown, disease; we have been learning along the pandemic and still ignore what will come further. ar is already a very well-known pandemic affecting humans, animals, and natural ecosystems (anderson, ; verhoef, ) . in this case, we have tools that might predict the outcome, and likely because the degree of uncertainty is lower than in the case of covid- , we have not applied clear, common, and comprehensive procedures to reduce the spread of ar. it is true that we know the evolution of antibiotics consumption and ar prevalence in several countries, and also interventions, mostly based on social norms, have been applied. social norms have reduced the unnecessary prescription of antibiotics, or pharmacy sales without prescription, and the use of antibiotics for fattening animals has been banned in several countries, being still allowed in several others. nevertheless, these actions are not general, and more aggressive, global actions are still needed. coming back to the covid- example, while the aim of health services worldwide is to detect any possible source of sars-cov- , surveillance of infections (eventually by arbs) is not universal. in other words, it does not apply to all citizens in all countries. the reasons can be just political such as the inclusion of immigrants in public health services (scotto et al., ) or the consequence of limited financial resources and technical capacity that countries such as those belonging to the lmic category can face (gandra et al., ) . the problem is not only on citizens, because different non-human reservoirs, such as wastewater, drinking water, or freshwater, may jointly contribute to ar dissemination (hendriksen et al., ) . in this regard, it is important to highlight that low quality of water is regularly associated to poverty. universalization of health services, sanitization, access to clean water, and in general reduction of poverty are relevant step-forward elements for reduction of the burden of infectious diseases in general and of ar in particular. the time has come to tackle ar, and this cannot be done just by taking actions at the individual or even country level, but by taking convergent actions across the globe. as stated by john donne ( ) in his poem, "no man is an island, " written after his recovery from an infectious disease (likely typhus): "no man is an iland, intire of itselfe; every man is a peece of the continent, a part of the maine; if a clod bee washed away by the sea, europe is the lesse, as well as if a promontorie were, as well as if a manor of thy friends or of thine owne were; any mans death diminishes me, because i am involved in mankinde; and therefore never send to know for whom the bell tolls; it tolls for thee." this reflection on how infectious diseases in general should be faced by the society was published at , but the idea behind still applies nowadays, especially for ar. all authors have contributed to the concept of the review and in its writing. jm was supported by grants from the instituto de salud carlos iii [spanish network for research on infectious diseases (rd / / )], from the spanish ministry of economy and competitivity (bio - -r) and from the autonomous community of madrid (b /bmd- ). work in tc and fb laboratory was supported by grants funded by the joint programming initiative in antimicrobial resistance (jpiamr third call, starcs, jpiamr -ac / ), the instituto de salud carlos iii of spain/ministry of economy and competitiveness and the european development regional fund "a way to achieve europe" (erdf) for co-founding the spanish r&d national plan estatal de i + d + i - (pi / ), ciberesp (ciber in epidemiology and public health; cb / / ), the regional government of madrid (ingemics-b /bmd- ) and the fundación ramón areces. the funders did not have any role neither in the design, nor in the writing of the current review. association between decreased susceptibility to a new antibiotic for 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this paper describes a conceptual framework for the health implications of globalisation. the framework is developed by first identifying the main determinants of population health and the main features of the globalisation process. the resulting conceptual model explicitly visualises that globalisation affects the institutional, economic, social-cultural and ecological determinants of population health, and that the globalisation process mainly operates at the contextual level, while influencing health through its more distal and proximal determinants. the developed framework provides valuable insights in how to organise the complexity involved in studying the health effects resulting from globalisation. it could, therefore, give a meaningful contribution to further empirical research by serving as a 'think-model' and provides a basis for the development of future scenarios on health. good health for all populations has become an accepted international goal and we can state that there have been broad gains in life expectancy over the past century. but health inequalities between rich and poor persist, while the prospects for future health depend increasingly on the relative new processes of globalisation. in the past globalisation has often been seen as a more or less economic process. nowadays it is increasingly perceived as a more comprehensive phenomenon, which is shaped by a multitude of factors and events that are reshaping our society rapidly. this paper describes a conceptual framework for the effects of globalisation on population health. the framework has two functions: serving as 'think-model', and providing a basis for the development of future scenarios on health. two recent and comprehensive frameworks concerning globalisation and health are the ones developed by woodward et al. [ ] , and by labonte and togerson [ ] . the effects that are identified by woodward et al. [ ] as most critical for health are mainly mediated by economic factors. labonte and torgerson [ ] primarily focus on the effects of economic globalisation and international governance. in our view, however, the pathways from globalisation to health are more complex. therefore, a conceptual framework for the health effects of the globalisation process requires a more holistic approach and should be rooted in a broad conception of both population health and globalisation. the presented framework is developed in the following three steps: ) defining the concept of population health and identifying its main determinants, ) defining the concept of globalisation and identifying its main features and ) constructing the conceptual model for globalisation and population health. as the world around us is becoming progressively interconnected and complex, human health is increasingly perceived as the integrated outcome of its ecological, social-cultural, economic and institutional determinants. therefore, it can be seen as an important high-level integrating index that reflects the state-and, in the long term, the sustainability-of our natural and socio-economic environments [ ] . this paper primarily focuses on the physical aspects of population health like mortality and physical morbidity. our identification of the most important factors influencing health is primarily based on a comprehensive analysis of a diverse selection of existing health models (see huynen et al [ ] for more details). we argue that the nature of the determinants and their level of causality can be combined into a basic framework that conceptualises the complex multi-causality of population health. in order to differentiate between health determinants of different nature, we will make the traditional distinction between social-cultural, economic, environmental and institutional factors. these factors operate at different hierarchical levels of causality, because they have different positions in the causal chain. the chain of events leading to a certain health outcome includes both proximal and distal causes; proximal factors act directly to cause disease or health gains, and distal determinants are further back in the causal chain and act via (a number of) intermediary causes [ ] . in addition, we also distinguish contextual determinants. these can be seen as the macro-level conditions shaping the distal and proximal health determinants; they form the context in which the distal and proximal factors operate and develop. subsequently, a further analysis of the selected health models and an intensive literature study resulted in a wide-ranging overview of the health determinants that can be fitted within this framework ( figure and table ). we must keep in mind, however, that determinants within and between different domains and levels interact along complex and dynamic pathways to 'produce' health at the population level. additionally, health in itself can also influence its multi-level, multi-nature determinants; for example, ill health can have a negative impact on economic development. there is more and more agreement on the fact that globalisation is an extremely complex phenomenon; it is the interactive co-evolution of multiple technological, cultural, economic, institutional, social and environmental trends at all conceivable spatiotemporal scales. hence, rennen and martens [ ] define contemporary globalisation as an intensification of cross-national cultural, economic, political, social and technological interactions that lead to the establishment of transnational structures and the global integration of cultural, economic, environmental, political and social processes on global, supranational, national, regional and local levels. although somewhat complex, this definition is in line with the view on globalisation in terms of deterritorialisation and explicitly acknowledges the multiple dimensions involved. however, the identification of all possible health effects of the globalisation process goes far beyond the current capacity of our mental ability to capture the dynamics of our global system; due to our ignorance and interdeterminacy of the global system that may be out of reach forever [ ] . in order to focus our conceptual framework, we distinguish-with the broader definition of globalisation in mind-the following important features of the globalisation process: (the need for) new global governance structures, global markets, global communication and diffusion of information, global mobility, cross-cultural interaction, and global environmental changes (table ) (see huynen et al. [ ] for more details). we have identified (the need for) global governance structures, global markets, global communication and the diffusion of information, global mobility, cross-cultural interaction, and global environmental changes as important features of globalisation. based on figure and table , it can be concluded that these features all operate at the contextual level of health determination and influence distal factors such as health(-related) policies, economic development, trade, social interactions, knowledge, and the provision of ecosystem goods and services. in turn, these changes in distal factors have the potential to affect the proximal health determinants and, consequently, health. our conceptual framework for globalisation and health links the above-mentioned features of the globalisation process with the identified health determinants. this exercise results in figure . figure , subsequently, shows that within the developed framework, several links between the specific features of globalisation and health can be derived. these important links between globalisation and health are discussed in the following sections. it is important to note that figure primarily focuses on the relationships in the direction from globalisation to health. this does not mean, however, that globalisation is an autonomous process: globalisation is influenced by many developments at the other levels, although these associations are not included in the figure for reasons of simplification. in addition, the only feedback that is included in figure concerns the institutional response. one also has to keep in mind that determinants within the distal level and within the proximal level also interact with each other, adding complexity to our model (see huynen [ ] [ ] [ ] [ ] . below, the implications of the globalisation process on these distal determinants will be discussed in more detail. global governance structures are gaining more and more importance in formulating health(-related) policies (figure ; arrow ). according to dodgson et al. [ ] , the most important organisations in global health governance are the world health organization (who) and the world bank (wb). the latter plays an important role in the field of global health governance as it acknowledges the importance of good health for economic development and focuses on reaching the millennium development goals [ ] . the wb also influenced health(-related) policies together with the international monetary funds (imf) through the structural adjustment programmes (saps) (e.g. see hong [ ] ). in order to give a more central role to pro-poor growth considerations in providing assistance to low-income countries, the imf and wb introduced the poverty reduction strategy approach in [ ] . in addition, the policies of the world trade organization (wto) are also increasingly influencing population health [ , [ ] [ ] [ ] . fidler [ ] argues that 'from the international legal perspective, the centre of power for global health governance has shifted from who to the wto'. opinions differ with regard to whether the wto agreements provide sufficient possibilities to protect the population from the adverse (health) effects of free trade or not multi-nature and multi-level framework for population health figure multi-nature and multi-level framework for population health. new global governance structure globalisation influences the interdependence among nations as well as the nation state's sovereignty leading to (a need for) new global governance structures. global markets globalisation is characterised by worldwide changes in economic infrastructures and the emergence of global markets and a global trading system. globalisation makes the sharing of information and the exchange of experiences around common problems possible. global mobility global mobility is characterised by a major increase in the extensity, intensity and velocity of movement and by a wide variety in 'types' of mobility. globalising cultural flows result in interactions between global and local cultural elements. global environmental threats to ecosystems include global climate change, loss of biodiversity, global ozone depletion and the global decline in natural areas. conceptual framework for globalisation and population health another important development is the growing number of public-private partnerships for health, as governments increasingly attract private sector companies to undertake tasks that were formerly the responsibility of the public sector. at the global level, public-private partnerships are more and more perceived as a possible new form of global governance [ ] and could have important implications for health polices, but also for health-related policies. opinions differ with regard to the economic benefits of economic globalisation (figure ; arrow ). on the one side, 'optimists' argue that global markets facilitate economic growth and economic security, which would benefit health. they base themselves on the results of several studies that argue that inequities between and within countries have decreased due to globalisation (e.g. see frankel [ ] , ben david [ ] , dollar and kraay [ ] ). additionally, it is argued that although other nations or households might become richer, absolute poverty is reduced and that this is beneficial for the health of the poor [ ] . on the other side, 'pessimists' are worried about the health effects of the exclusion of nations and persons from the global market. they argue that the risk of exclusion from the growth dynamics of economic globalisation is significant in the developing world [ ] . in fact, notwithstanding some spectacular growth rates in the 's, especially in east asia, incomes per capita declined in almost countries during the same period [ ] . many worry about what will happen to the countries that cannot participate in the global market as successful as others. due to the establishment of global markets and a global trading system, there has been a continuing increase in world trade (figure ; arrow ). according to the wto, total trade multiplied by a factor between and [ ] . today all countries trade internationally and they trade significant proportions of their national income; around percent of world output is being traded. the array of products being traded is wide-ranging; from primary commodities to manufactured goods. besides goods, services are increasingly being traded as well [ ] . in addition to legal trade transactions, illegal drug trade is also globalising, as it circumvents national and international authority and takes advantage of the global finance systems, new information technologies and transportation. due to the changes in the infrastructures of transportation and communication, human migration has increased at unprecedented rates ( figure ; arrow ) [ ] . according to held et al. [ ] tourism is one of the most obvious forms of cultural globalisation and it illustrates the increasing time-space compression of current societies. however, travel for business and pleasure constitutes only a fraction of total human movement. other examples of people migrating are missionaries, merchant marines, students, pilgrims, militaries, migrant workers and peace corps workers [ , ] . besides these forms of voluntary migration, resettlement by refugees is also an important issue. however, since the late s, the concerns regarding the economic, political, social and environmental consequences of migration has been growing and many governments are moving towards more restrictive immigration policies [ ] . the tragic terrorist attacks in new york and washington d.c. in september fuelled the already ongoing discussions on the link between globalisation and conflicts. globalisation can decrease the risk on tensions and conflicts, as societies become more and more dependent on each other due the worldwide increase in global communication, global mobility and cross-cultural interactions ( figure ; arrow ). others argue that the resistance to globalisation has resulted in religious fundamentalism and to worldwide tensions and intolerance [ ] . in addition, the intralevel relationships at the distal level play a very important role, because many developments in other distal factors that have been associated with the globalisation process are also believed to increase the risk on conflicts. in other words, the globalisation-induced risk on conflict is often mediated by changes in other factors at the distal level [ ] . cultural globalisation (global communication, global mobility, cross-cultural interaction) can also influence cultural norms and values about social solidarity and social equity (figure ; arrow ) . it is feared that the selfinterested individualism of the marketplace spills over into cultural norms and values resulting in increasing social exclusion and social inequity. exclusion involves disintegration from common cultural processes, lack of participation in social activities, alienation from decisionmaking and civic participation and barriers to employment and material sources [ ] . alternatively, a socially integrated individual has many social connections, in the form of both intimate social contacts as well as more distal connections [ ] . on the other hand, however, the geographical scale of social networks is increasing due to global communications and global media. the women's movement, the peace movement, organized religion and the environmental movement are good examples of such transnational social networks. besides these more formal networks, informal social networks are also gaining importance, as like-minded people are now able to interact at distance through, for example, the internet. in addition, the global diffusion of radio and television plays an important role in establishing such global networks [ ] . the digital divide between poor and rich, however, can result in social exclusion from the global civil society. the knowledge capital within a population is increasingly affected by developments in global communication and global mobility (figure : arrow ). the term 'globalisation of education' suggests getting education into every nook and cranny of the globe. millions of people now acquire part of their knowledge from transworld textbooks, due to the supraterritoriality in publishing. because of new technologies, most colleges and universities are able to work together with academics from different countries, students have ample opportunities to study abroad and 'virtual campuses' have been developed. the diffusion of new technologies has enabled researchers to gather and process data in no time resulting in increased amounts of empirical data [ ] . new technologies have even broadened the character of literacy. scholte [ ] argues that 'in many line of work the ability to use computer applications has become as important as the ability to read and write with pen and paper. in addition, television, film and computer graphics have greatly enlarged the visual dimensions of communication. many people today 'read' the globalised world without a book'. overall, it is expected that the above-discussed developments will also improve health training and health education (e.g. see feachem [ ] and lee [ ] ). global environmental changes can have profound effects on the provision of ecosystem goods and services to mankind ( figure ; arrow ) . the intergovernmental panel on climate change (ipcc) [ ] concludes that it is expected that climate change can result in significant ecosystem disruptions and threatens substantial damage to the earth's natural systems. in addition, several authors have addressed the link between biodiversity and ecosystem functioning and it is agued that maintaining a certain level of biodiversity is necessary for the proper provision of ecosystem goods and services [ ] [ ] [ ] [ ] . however, it is still unclear which ecosystem functions are primarily important to sustain our physical health. basically, the following types of 'health functions' can be distinguished. first, ecosystems provide us with basic human needs like food, clean air, clean water and clean soils. second, they prevent the spread of diseases through biological control. finally, ecosystems provide us with medical and genetic resources, which are necessary to prevent or cure diseases [ ] . figure shows that the impact of globalisation on each proximal health determinant is mediated by changes in several distal factors (figure ; arrows - ). the most important relationships will be discussed in more detail below. it is important to note that health policies and health-related policies can have an influence on all proximal factors (figure ; arrow ). health services are increasingly influenced by globalisation-induced changes in health care policy (figure ; arrow ), economic development and trade ( figure : arrow ), and knowledge ( figure ; arrow ), but also by migration ( : arrow ). although the who aims to assist governments to strengthen health services, government involvement in health care policies has been decreasing and, subsequently, medical institutions are more and more confronted with the neoliberal economic model. health is increasingly perceived as a private good leaving the law of the market to determine whose health is profitable for investment and whose health is not [ ] . according to collins [ ] populations of transitional economies are no longer protected by a centralized health sector that provides universal access to everyone and some groups are even denied the most basic medical services. the u.s. and several latin american countries have witnessed a decline in the accessibility of health care following the privatisation of health services [ ] . the increasing trade in health services can have profound implications for provision of proper health care. although it is perceived as to improve the consumer's choice, some developments are believed to have long-term dangers, such as establishing a two-tier health system, movement of health professionals from the public sector to the private sector, inequitable access to health care and the undermining of national health systems [ , ] . the illegal trading of drugs and the provision of access to controlled drugs via the internet are potential health risks [ ] . in addition, the globalisation process can also result in a 'brain-drain' in the health sector as a result of labour migration from developing to developed regions. however, increased economic growth is generally believed to enhance improvements in health care. increased (technological) knowledge resulting from the diffusion of information can further improve the treatment and prevention of all kinds of illnesses and diseases. the central mechanism that links personal affiliations to health is 'social support,' the transfer from one person to another of instrumental, emotional and informational assistance [ ] . social networks and social integration are closely related to social support [ ] and, as a result, globalisation-induced changes in social cohesion, integration and interaction can influence the degree of social support in a population (figure ; arrow ). this link is, for example, demonstrated by reeves [ ] , who discussed that social interactions through the internet influenced the coping ability of hiv-positive individuals through promoting empowerment, augmenting social support and facilitating helping others. alternatively, social exclusion is negatively associated with social support. another important factor in the social environment is violence, which often is the result of the complex interplay of many factors (figure ; arrows , and ). the who [ ] argues that globalisation gives rise to obstacles as well as benefits for violence prevention. it induces changes in protective factors like social cohesion and solidarity, knowledge and education levels, and global violence prevention activities such as the implementation of international law and treaties designed to reduce violence (e.g. social protection). on the other hand, it also influences important risk factors associated with violence such as social exclusion, income inequality, collective conflict, and trade in alcohol, drugs or firearms. due to the widespread flow of people, information and ideas, lifestyles also spread throughout the world. it is already widely acknowledged and demonstrated that several modern behavioural factors such as an unhealthy diet, physical inactivity, smoking, alcohol misuse and the use of illicit drugs are having a profound impact on human health [ ] [ ] [ ] [ ] (table ) . individuals respond to the range of healthy as well as unhealthy lifestyle options and choices available in a community [ ] , which are in turn determined by global trade (figure ; arrow ), economic development (figure ; arrow ) and social interactions ( figure ; arrow ). although the major chronic diseases are not transmittable via an infectious agent, the behaviours that predispose to these diseases can be communicated by advertising, product marketing and social interactions [ ] . global trade and marketing developments drive, for example, the nutrition transition towards diets with high proportions of salt, saturated fat and sugars [ , ] . another example is the worldwide spread of tobacco consumption as transnational tobacco companies take advantage of the potential for growth in developing countries [ , ] . additionally, the scale of cigarette smuggling poses a considerable global threat to the efforts to control tobacco consumption [ ] . illegal trade in illicit drugs poses similar problems. at the same time, the alcohol industry is almost as globalised as the tobacco industry [ ] . however, health education can play a role in promoting healthy lifestyles by improving an individual's knowledge about the health effects of different lifestyle options (figure ; arrow ). besides health education, (global) policies can also directly discourage unhealthy behaviour by means of economic incentives (e.g. charging excise on tobacco) or other legislation (figure ; arrow ). the spread of infectious diseases is probably one of the most mentioned health effects of globalisation and past disease outbreaks have been linked to factors that are related to the globalisation process (see e.g. newcomb [ ] ). the recent outbreak of the severe acute respiratory syndrome (sars) demonstrates the potential of new infectious diseases to spread rapidly in today's world, increasing the risk of a global pandemic. the combination of movement of goods ( figure ; arrow ) and people ( figure ; arrow ), and profound changes affecting ecosystem goods and services (figure ; arrow ) all contribute to increased risk of disease spread [ ] . for example, the globalisation of food production, trade and consumption has been associated with the increased spread and transmission of food born diseases [ , ] . diseases like hiv/aids or hepatitis b can also spread through trade in infected biological products (e.g. blood) [ ] . enhanced knowledge and new technologies will improve the surveillance of infectious diseases and monitoring of antibiotic resistance [ , ] (figure ; arrow ). globalisation potentially increases the speed of responses in some cases. wilson [ ] states that responding to disease emergence requires a global perspective-both conceptually and geographically-as the current global situation favours the outbreak and rapid spread of infectious disease. as a result, the policies and actions undertaking by the who are becoming increasingly important in controlling infectious diseases at a global level (figure ; arrow ). for instance, the who played a critical role in controlling sars by means of global alerts, geographically specific travel advisories and monitoring [ ] . food trade has become an increasingly important factor with regard to food security worldwide (figure ; arrow ). at present, however, the developed countries usually subsidise their agricultural sectors. current liberalisation policies are expected to have profound implications on food trade and, subsequently food security [ ] . some argue that the resulting free trade will create access to better and cheaper food supplies via food imports and can excess energy intake results, together with physical activity, in obesity. obesity is an increasing health problem and has several co-morbidities such as non-insulin dependent diabetes and cardiovascular diseases [ ] . the nutritional quality of the diet (e.g. fruit and vegetable intake, saturated versus unsaturated fats) is also very important for good health. inactivity physical inactivity has been linked to obesity, coronary hearth disease, hypertension, strokes, diabetes, colon cancer, breast cancer and osteoporotic fractures [ ] . tobacco is predicted to be the leading health risk factor by [ ] . it causes, for example, cancer of the trachea, bronchus and lung [ ] , and cardiovascular diseases. alcohol use the consumption of alcoholic beverages increases to risk on liver cirrhosis, raised blood pressure, heart disease, stroke, pancreatitis and cancers of the oropharnix, larynx, oesophagus, stomach, liver and rectum [ ] . the role of alcohol consumption in non-communicable disease epidemiology is, however, complex. for example, small amounts of alcohol reduce the risk on cardiovascular diseases, while drinking larger amounts is an important cause of these very same diseases [ ] . according to the world health report [ ] , , % of the total disease burden is attributable to illicit drugs (heroin and cocaine). opiate users can have overall mortality rate up to percent higher than those in the general population of the same age, due to not only overdoses but also to accidents, suicides, aids and other infectious diseases [ ] . stimulate more efficient use of the world's resources as well as the production of food in regions that are more suitable to do so [ , ] . free trade permits food consumption to grow faster than domestic food production in countries where there are constraints on increasing the latter. accelerated economic growth can also contribute to food security (figure ; arrow ) [ ] . others, however, argue that the forces of globalisation in fact endanger food security (e.g. see lang [ ] ) and that countries should strive to become more self-sufficient [ ] . for many countries the increasing dependence on food imports goes hand in hand with a higher vulnerability to shocks arising in global markets, which can affect import capacity and access to food imports [ ] . many food insecure countries are not able to earn enough with exporting goods in order to pay for the needed food imports [ ] . at the global level, there are increasing international efforts to achieve widespread food security ( figure ; arrow ). for instance, the right to adequate food is directly addressed in the international covenant on economic, social and cultural rights. in , the world food summit reaffirmed the right of everyone to have access to safe and nutritious food. in case of extreme foodinsecurity and insufficient import capacity, food aid may be provided in order to supplement the scarce food imports. globalisation can affect food security by enhancing the knowledge of foreign nations about the usefulness of food aid (figure ; arrow ) [ ] . besides food trade, one can also deal with the mismatch between demand and supply by increasing food production in food-short regions. the globalisation process can increase food security by facilitating the worldwide implementation of better technologies and improved knowledge (e.g. irrigation technologies, research on genetically modified food) ( figure ; arrow ). at the same time, the natural resource base for food production is increasingly threatened (figure ; arrow ). finally conflicts are, of course, a threat to food security and it is expected that food security in sub-saharan africa, for example, will not increase without the establishment of political instability (figure ; arrow ) [ ] . the effects of globalisation are also raising concerns over water security. the current globalisation process is accompanied by privatisation policies affecting the provision of water [ ] (figure ; arrow ). governments and international financial institutions promote privatisation, as they believe it will promote market competition and efficiency. however, others are less optimistic about the effects of privatisation. in fact, some cases show that prices and inequalities in access even rise [ ] . it is also argued that water, with vital importance socially, culturally, and ecologically, 'cannot be protected by purely market forces' [ ] . on a global scale, there are increasing efforts to set up global guidelines or policies with regard to fresh water ( figure ; arrow ), however none of the international declarations and conference statements requires states to actual meet individual's water requirements [ ] . the virtual trade of water is also believed to be of increasing importance (figure ; arrow ). the water that is used in the production process of a commodity is called the 'virtual water' contained in that commodity. therefore, the increasing global trade of commodities is accompanied by an increasing global trade in virtual water. the global volume of virtual water embedded in crop and livestock products traded between nations is estimated to be billion cubic metres per year [ ] . in addition, the globalisation process can increase water security by facilitating the worldwide implementation of better technologies and improved knowledge ( figure ; arrow ). at the same time, the natural resource base is increasingly threatened as, for example, global climate change and deforestation profoundly affect our ecosystems ability to provide us with sufficient and adequate fresh water (figure ; arrow ). globalisation is causing profound and complex changes in the very nature of our society, bringing new opportunities as well as risks. in addition, the effects of globalisation are causing a growing concern for our health, and the intergenerational equity implied by 'sustainable development' forces us to think about the right of future generations to a healthy environment and a healthy life. despite some empirical research efforts indicating the links between the globalisation process and specific health impacts, the present weakness in empirical evidence on the multiple links between globalisation and health is still a problem [ ] . the described conceptual framework could give a meaningful contribution to further empirical research by serving as a well-structured 'think-model' or 'concept map'. it clearly demonstrates that an interdisciplinary approach towards globalisation and health is required, which draws upon the knowledge from relevant fields such as, for example, medicine, epidemiology, sociology, political sciences, (health) education, environmental sciences and economics. in addition, the exploration of possible future health impacts of different globalisation pathways by means of scenarios analysis could provide a useful contribution to the ongoing discussions on globalisation and health [ ] . scenarios can be described as 'plausible but simplified descriptions of how the future may develop, according to a coherent and internally consistent set of assumptions about key driving forces and relationships' [ ] . recent research showed, however, that the health dimension is largely missing in existing global scenarios [ ] . the developed framework for globalisation and population health has contributed to the understanding of future health implications and the model is, therefore, considered to be a useful tool to structure future scenario studies on the health implications of the globalisation process. to conclude, the framework provides valuable insights in how to organise the complexity involved in studying the health effects resulting from globalisation. we claim that our approach has several beneficial characteristics. first, it is embedded in a holistic approach towards globalisation; in this paper we perceive globalisation as an overarching process in which simultaneously many different processes take place in many societal domains. in addition, the conceptual framework is embedded in a holistic approach towards population health. as a result, our model explicitly visualises that globalisation affects the institutional, economic, social-cultural and ecological determinants of population health and that the globalisation process mainly operates at the contextual level, while influencing health through the more distal and proximal determinants. globalization and health: a framework for analysis and action 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fao: food and international trade. rome, food and agricultural organisation of the united nations fao: the state of food insecurity in the world . rome, food and agricultural organisation of the united nations food security: does it conflict with globalisation? development fao: trade reforms and food security: conceptualizing the linkages. rome, food and agricultural organisation of the united nations united states department of agriculture the world's water - : the biennial report on freshwater resources cochabamba! water war in bolivia. cambridge the world's water - : the biennial report on freshwater resources presented at aqua: european citizenship through water the problem of the future: sustainability science and scenario analysis a future without health: health dimension in global scenario studies we would like to thank all colleagues at the international centre for integrative studies (icis) and the netherlands environmental assessment agency (mnp-rivm) for the fruitful discussions leading to this paper. this work is financially supported by mnp-rivm within the project 'population & health'. the author(s) declare that they have no competing interests.publish with bio med central and every scientist can read your work free of charge key: cord- - sgr xx authors: zhou, zibanai title: critical shifts in the global tourism industry: perspectives from africa date: - - journal: geojournal doi: . /s - - -y sha: doc_id: cord_uid: sgr xx the study investigates critical shifts impacting the international tourism space in contemporary times. furthermore, the current study examines tourism policies and product development challenges faced by tourist regions as a consequence of market dynamics. drawing upon a sample of thirty tourism experts in southern africa, the critical shifts were identified and key among them include brics, terrorism, ageing population, and trophy hunting, are increasingly framing a new narrative for the future growth trajectory of the international tourism industry’s value chain in the context of africa. a conclusion is reached that to attain long term sustainable development of the sunrise multi-trillion dollar industry, it is critical that tourism operators re-set and deploy sharpened strategies which are in synch with the realities obtaining in the broader operating environment. policy recommendations and managerial implications are proffered. globally, tourism contributes significantly to the national economies in terms of employment creation and revenue generation (musavengane et al. ; unwto a, b) . understanding travel motivations and shifts in the global tourism marketplace is critical for unpacking future travel patterns and consumption perspectives, and also for tourist destinations to leverage on tourism spin-offs. anton et al. ( ) observed that growing competition in the tourism landscape has resulted in destinations increasingly becoming concerned with balancing tourists with attracting new visitors. while it is true that tourism is sensitive to violent events, political instabilities, disasters and calamities as well as economic meltdown (alvarez and campos ; woyo ; dieke ), it could be argued that tourism is also highly responsive to dynamics in the tourism market place. hapairai et al. ( ) state that political crises often lead to a decline in visitorship and public and private tourism organisations should constantly adjust policies, and product offerings in tandem with market dynamics. however, research examining the fundamental shifts in the international tourism landscape is limited. primary source markets such as the united kingdom (uk); european union, (eu) and north america consider emerging tourist destinations like africa as offering alternative authentic touristic experiences as compared to over trodden traditional z. zhou (&) tourism and hospitality management department, midlands state university, p. bag , gweru, zimbabwe e-mail: zhouz@staff.msu.ac.zw destinations. based on this, understanding the implications of the global tourism market place fundamental shifts on emerging tourist regions such as africa is critical for the formulation of destination-specific management strategies. the current study is informed by dieke ( ) who opined that in africa while there is a general disappointment with the economic returns from the tourism sector, there is insufficient knowledge of the market mix of international tourism, the market-driven nature of the sector, and the inability of governments to react to market changes or market signals. this is the research gap addressed by the current study. the current study therefore seeks to update and respond to these three issues at regional level in relation to africa's tourism industry in view of tourism dynamics in the marketplace. in addition, this study seeks to also make a contribution to the disproportionate in extant literature on the burgeoning of literature on western and mature tourism markets at the expense of africa (rogerson and visser a, b) . the other major contribution of the current study is on the geographical ecology of tourism literature that largely remains dominated by western writers. the current study therefore ties well with mkono ( ) 's call for more african voices on tourism issues. ''a sizeable proportion of tourism research on africa has been conducted by outsiders.'' (mkono , p. ) . ''… locals' opinions are often not meaningfully represented in tourism studies.' ' mkono , p. ) . ''if tourism studies are to reflect a more balanced representation, then the lens for viewing needs to be adjusted and diversified by having more page space for africans in scholarly works (mkono ) . henceforth, the study would give a fresh african narrative in the current global tourism discourse. in addition, naude and saayman ( ) and kester ( ) observed that observed that the economic dimensions of tourism to africa, and specifically the determinants of the demand for africa as a tourist destination, are neglected in the economic research literature. it is on the strength of naude and saayman ( ) 's observed scholarly literature gap pertaining to africa's tourism industry that the current study seeks to address. furthermore, christie and crompton ( ) bemoaned the lack of appropriate empirical research on tourism to africa that undoubtedly contributes to the 'limited policy guidance to the sector in relation to tourism market dynamics. in this respect, rogerson and visser ( ) argued that the imperative exists for strengthening the tempo of critical research on geopolitical developments, development debates, and global economic crises. in the past decades, there is an expanding body of critical work on tourism in southern africa, though still, very little is known with regard to the critical shifts in the global tourism sector. another context underpinning this study is trophy hunting, a controversial phenomenon which has been the subject of extensive but inconclusive research from a variety of angles (batavia et al. ; batara et al. ; mkono ) . to add on, scott et al. ( ) noted that one of the limitation of the tourism literature in africa is that studies have tended to examine the travel and tourism industry only in terms of one element of the tourism system, usually at a nation state level, or tourism sub-sector level, rather than conducting the broader tourism system (see, donaldson and ferreira ; mbaiwa and stronza ; buscher ; kavita and saarinen ; tichaawa ; hoogendorn and fitchett ) . research investigating these shifts have done so from a developed country context (see, giraldi ; debyser ; maria-irina ; weston et al. a ) leaving a theoretical gap in the context of africa, as an emerging destination. understanding such global shifts is critical not only for destination managers, but also for institutional investors and public sector because it helps in terms of forecasting travel patterns, weighing investment opportunities, and budgeting. furthermore, the constructs of terrorism, brics, trophy hunting and an ageing population are yet to be measured and applied simultaneously with the interconnectedness of nation states in the context of an emerging tourist region like africa. though there is an emerging stream of literature focusing on factors shaping international tourism future trends at the global level (unwto a, b; oecd a), there is a general absence of literature regarding the specific lynchpin variables which pertains exclusively to emerging tourist regions like africa. furthermore, the tourism related challenges and opportunities spawned by such fundamental variables in emerging tourist destination contexts like africa remains mostly unknown. the international tourism landscape is not only dynamic, but fraught with an environment that is constantly changing in a very unpredictable manner (badulesani and rusu ; kyyra and rantala ; unctd ) . whilst the unwto and practitioners acknowledge the centrality of the market dynamics in the global tourism space, there has not been a corresponding sufficient academic gaze in the current literature discourse dedicated to interrogating and unpacking such issues within the frame of africa. the tourism industry is considered a key growth sector in southern africa economy. safety and security are regarded as primary ingredients for tourism growth and destination competitiveness (donalsdson and ferreira ; correia et al. ; langfield et al. ) ; however tourism demand and factors impacting on it remain under-researched areas (visser and rogerson ) . since this study deals with the global dynamics in the areas of terrorism, brics, trophy hunting, and ageing population; it differs conceptually and contextually from other previous tourism development studies in tourism. this paper is therefore theoretically situated in the international tourism futures literature. the research was inspired by the fact that the contemporary international tourism sector has matured since the s. it has grown from being an exclusive preserve of advanced societies to becoming a multi-party phenomenon in which the emerging markets are now actively participating (unwto a, b) . another motivating factor was that the industry has been traditionally dominated by the most advanced economies, especially the g countries, in the global north at the expense of intermediate economies, however emerging markets are encouragingly catching up (bhatia ; cooper et al. ) . document analysis, archival information and expert opinions were employed to solicit for information that enriched the international tourism discourse from africa's perspective. the study highlights the critical shifts that undergird tourism future development and growth trajectories. the aim of this study is to enhance and build on ( ) christie and crompton ( ) 's observation that there is lack of appropriate empirical research on tourism to africa, which undoubtedly contributes to the limited policy guidance to the sector; ( ) naude and saayman ( ) 's assertion that there is a neglect of the economic dimension of tourism to africa; and ( ) rogerson and visser ( ) in which they opined the existence of an imperative for strengthening the tempo of critical research on geopolitical developments, development debates and global economic crises; and ( ) dieke ( ) who stated that in africa there is not only insufficient knowledge of the market mix of international tourism, but also the market-driven nature of the sector as well as the inability of governments to react to market changes or market signals. the objective of this study is to understand the fundamental global shifts in the international tourism landscape with special focus on africa. to achieve this objective, data were collected from tourism experts drawn from southern africa region. specifically, this study seeks to answer the following research questions: ( ) why should emerging tourist regions like africa be concerned with dynamics on the broader international tourism landscape? of these factors, which ones significantly predict the future growth trajectories of the tourism industry in african context? which specific tourism market shifts have impacted on africa's tourism sector? ( ) what challenges and opportunities do emerging tourist destinations face in the advent of these global shifts? what challenges and implications do these shifts pose on africa's tourism product offering, marketing strategies and planning for her tourism sector. in addressing these research questions, this study advances the understanding of the long term consequences of the global shifts on africa's travel and tourism landscape. this study also adds to the debate focusing on travel motivations, trophy hunting (baker ) crises (steiner ; al-shorman et al. ) , and mitigation strategies from a context-specific emerging tourist destination. the results of the survey can meaningfully inform the formulation of marketing messages aimed at repositioning africa, thus making it even a more appealing tourist destination in spite of headwinds in the marketplace. in what way can africa better prepare and anticipate the impacts of these shifts on custom, turn over, sales, investment etc. the remaining sections are structured as follows: the next section briefly reviews key themes in relevant existing studies highlighting the sector's economic significance at global level. this is followed by a brief description of the data and the empirical methodology. the analyses section provides a discussion of the empirical results using the content analysis highlighting the multi-faceted nature of tourism market dynamics. the final section provides overall conclusion and recommendations. current state of tourism research in africa: a regional and international context several studies have examined variables impacting international tourism at global level in different regional contexts, for example, tourism senior market (naude and saayman ; alen et al. ) ; brics (pop ; abdou and adawy ) using a number of relationships including data panel analysis, time series, arrivals and receipts; direction flows and distribution. however, studies examining the constructs of brics, terrorism, senior tourism market (ageing population demography), and trophy hunting controversy, from the african region perspective are limited. for example, existing studies have only investigated international tourism trends from advanced societies' contexts; cases in point include maria-irina ( ) , debyser ( ) , weston et al. ( a) among others. likewise, rogerson and visser ( ) argued for the continued need to understand the market dynamics fuelling tourism development trajectories in different tourist destination contexts. additionally, previous studies that focused on tourism development in african tourist destinations have not only been restricted to a specific country or sub-region of continental africa, but also limited in scope as they largely focused on specific segments and certain clusters of the tourism sector such as mega events, wildlife (saarinen ) , tourism and poverty alleviation (spenceley and meyer ) , urban tourism (rogerson ) , ecotourism (mbaiwa ) among others. while these studies provide in-depth analyses and insight into africa's tourism, there has not been an attempt to engage in other evolving issues with the potential to change the complexion of the region's tourism sector. on the international scale, there has been a sustained research on issues influencing the unpredictable dynamics of the international tourism ecosystem that hogged the global limelight, ranging from the september , terrorist attacks on the us, tsunami; sars epidemic in asia (gaetano ; schuurman ; qui et al. ; zeng et al. ; bongkosh ; tang et al. ) ; asian financial crisis, the current covid- virus, ebola outbreak in western africa (song and lin ; wang ; gossling et al. ; al-tawfiqef et al. ; maphanga and henama ; kongoley ) ; political conflicts in the middle east; icelandic ashes, the disappearance of malaysian airplane (al-shorman et al. ; steiner ; benediktsson et al. ; heimisdottir et al. ; weng ; fan et al. ); cites's trophy hunting ban, as well as climate change induced extreme weather patterns like hurricanes, cyclones and heat waves njerekai and mabika ; baker ; pandy ; moore ) . whilst acknowledging the diverse and richness of the current international tourism body of literature, the current study argues that very little attempts have been made to explore the policy and product development implications of the constructs of brics, terrorism, ageing population and trophy hunting in the context of africa. perspectives on these evolving issues from emerging tourist destinations contexts seem neglected in the academic gaze, yet in contemporary times these are the issues increasingly influencing dynamics in the tourism space. none the less studies offering a regional perspective from emerging tourist destination context are limited; with existing studies only investigating specific segments of the tourism industry in africa, for example, township tourism (boyens ); conference tourism (donaldson ) ; communities and trans-frontier parks (ferreira ) , and green guest houses (hoogendorn et al. ) , with very little attempt to relate these to market shifts. though there is a substantial research on tourism, the tourism marketplace, remains dynamic. debyser ( ) analysed the challenges and policy responses to the tourism sector by the eu, whilst tolkach et al. ( ) explored current and emerging tourism trends in the asia pacific region through a content analysis. tolkach et al. ( ) study found that economic growth, favourable political environment and improved infrastructure were sustaining continual growth of the sector in the region. furthermore, maria-irina ( ) examined tourism in the new member states of the european union in which the focus was on the importance of tourism, factors and trends that affect the industry within the eu community. still, weston et al. ( b) provided an overview of the current state of affairs in european tourism, considering the latest developments, identifying future challenges and emerging opportunities. the study established that changes in tourist behaviour and generational issues were significant challenges. even though there is a burgeoning tourism studies in the african contexts for the past decades, for example, ferreira ( ) , donaldson and ferreira ( ) , ferreira et al. ( ) , booyens and visser ( ) , rogerson ( ), zhou ( , scholtz and slabbert ( ) and tichaawa ( ) ; still these researches apart from being disproportionately too low to tourism researches in europe and the americas, they have been consistently oblivious of the quartet of brics, trophy hunting, ageing population and terrorism as critical shifts in the tourism landscape, hence leaving a theoretical gap in emerging tourist regions like africa. to put the issue into perspective, studies examining dynamics in the international tourism industry since in the context of africa are limited. a case in point is the study by signe ( ) who examined africa's tourism potential, renewed trends, key drivers, opportunities and strategies. the study found that there was huge potential due to the continent's richness in natural resources and cultural heritage; and that west african countries had introduced a visa policy to enable free movement of people across member states. furthermore, the study established that tourism was important to africa as it was driving economic growth and job creation, infrastructure development, generating foreign exchange. globalisation was the key driver of tourism. challenges of poor infrastructure and weak institutions were cited, whilst opportunities were that africa was the best candidate for investment. similarly, diakite et al. ( )'s study was country-specific. they examined tourism trends, opportunities and challenges in guinea in which it was established that ebola was a major challenge. in addition, jaensson ( ) examined potential for tourism development in sub-saharan africa in cooperation with sweden. the study results showed that the sector is important in poverty reduction, foreign exchange earnings, employment and economic growth. still, zhou ( ) analysed recent trends and future prospects of tourism in southern africa sub-region. the study's focus was on tourism development and growth at sub-regional level, and the study found that the need for economic diversity, job creation, foreign currency generation were factors motivating southern africa countries to develop the tourism sector. hosting of mega events, establishment of nature parks and aggressive marketing campaigns were identified as key elements allowing for the resurgence of tourist arrivals in the sub-region. dieke ( ) examined a production-nexus of tourism in sub-saharan africa. dieke ( ) analysed tourism issues and prospects in africa. the study focused on the current state of tourism to and within africa, highlighting key themes and issues that confront the industry across the continent. the results of the study showed that human resources have had consequences for the sector, resulting in the further marginalisation of africa in the global pleasure periphery. taken together, these studies revealed that understanding the dynamics in the international tourism arena is critical for destination managers because it helps in terms of forecasting travel patterns, demand for tourism products, growth projections and investing in new product development, investment into new markets, trends among a host of others. furthermore, from the analysis of previous studies it seems researches making a direct application of these critical shifts to a particular or specific emerging tourism region like africa are lacking. though there is an emerging stream of literature focusing on various facets of africa's tourism industry, (see , there is a general paucity of literature regarding how the dynamics obtaining on the broader international tourism arena would mean for africa's tourism industry and how the continent should respond to such critical shifts at operational and policy making level, tactically and strategically. it is a compelling case to investigate how such dynamics inform tourism policy formulation, inform investment options into product development, inform investment into new markets, and inform re-calibration of marketing strategies; which in the context of africa remain mostly unknown. alvarez and campos ( ) and woyo ( ) posit that tourism is sensitive to political, economic, ecological, technological, legal and socio-economic environment. however, research examining such critical shifts in the broader global tourism environment and their attendant implications to emerging tourist regions like africa is limited. overview of international tourism and its socioeconomic significance the post world war two (wwii), boom factors chiefly the advent of jet engine, political peace and economic stability, dual family income, inclusive tours, coupled with icts and education, generally laid the ground work for the growth and development of the tourism industry (bhatia ; boniface and cooper ; lockwood and medlick ) . however, whilst these factors are still relevant, the tourism industry has mutated as new variables evolve, presenting a new set of opportunities and challenges for the tourism industry requiring a different approach from tourist destinations. international tourist arrivals world-wide grew over . billion in , . billion in and most likely the threshold of . billion travellers is now likely to be exceeded in advance of (oecd ). globally, international travel receipts reached $ . billion in , and globally expenditures on travel have more than tripled since the turn of the century, rising to . trillion in (unwto b (unwto , . tourism is crucial to the global economy, and is regarded as a trillion dollar industry, contributing immensely to gdp, as well as employing one in every people (unwto a, b) . tourism contributes to the world economy gdp directly and indirectly through provision of full time jobs, it has a multiplier effect on down and upstream economic sub-sectors (wttc ; zhou ; musavengane ; mbaiwa et al. ; saarinen et al. ; nyahunzvi ) . the recent developments in the broader global economic environment underpinned by the emergence of brics, an ageing population demographic, calls for cites reform cum ban on trophy hunting, and the scourge of terrorism are collectively recognised by the academia, tourism fraternity and policy makers as shaping the global tourism growth agenda and its development trajectory dynamics in the twenty-first century. despite the severity and weight of these evolving issues, the global tourism industry is poised to grow in stature. while this is the case, there seems to be limited academic rigour on such phenomena, given that the available scholarship on global tourism industry dimension has not adequately explored the extent to which individual factors like the brics, population demographics, trophy hunting debate are shaping and influencing the global tourism industry growth trajectory. the tourism industry is one of the fastest growing sectors of the global economy, and the sector is a benefactor of the globalisation process. in there were million international tourists arrivals, in there were billion tourists, in it is envisaged that . billion international tourists would engage in touristic activities, and further still in the figure is forecast to hit the . billion (unwto (unwto , a . however, despite these impressive aggregate arrivals figure, the sector has to grapple with a milieu of opportunities and threats born out of the ever evolving tourism market place. on the employment front, tourism is extremely labour intensive and a significant source of direct, indirect and induced employment. it is among the world's top creators of jobs requiring varying degrees of skills and allow for quick entry into the workforce for youths, women and migrant workers and the untwo indicated that the tourism sector provided million jobs in (wttc ; oecd b; unwto a, b) . with over . billion people world-wide crossing international borders each year, tourism is increasingly becoming a major source of growth, employment and income for many countries including many of the world's developing countries. tourism has the potential to contribute to all of the sustainable development goals (sdgs) found within the agenda for sustainable development, including sdg on inclusive and sustainable economic growth, sdg on cities and human settlements, sdg on sustainable consumption and production. this underlines the need to rightly place tourism as one of the key pillars of socio-economic development. the world bank ( ) and unwto ( a, b) posit that tourism will be one of the main drivers of economic growth in africa over the next decade. an increasing number of countries, for example, south africa, kenya and rwanda henceforth, have made tourism a central pillar of their economic development and reform program, and have made significant economic strides using tourism as a plank to boost their economies. page ( ) and coulibary ( ) concurred that tourism is an escalator of development. however, in order for africa to reap tourism benefits, the region has to align its tourism offerings to marketplace dynamics. despite africa's documented perennial challenges, curtailing the growth and expansion of the tourism industry, that encompasses infrastructure underdevelopment, access issues, lack of direct flights, little appropriate promotional marketing strategies and investment budgets, portrayal of africa as a land of war, disease, poverty, hunger, anguish and desperation by foreign mainstream media, million tourists visited the region in the region, generating $ . billion worth of revenue (diakite et al. ). henceforth, tourism is a powerful vehicle for economic growth and job creation all over the world. tourism's main comparative advantage over other sectors is that visitor expenditures have a ''flowthrough'' or catalytic effect across the economy in terms of product and employment creation (christie et al. ; schubert et al. ) . given the multisectoral nature of tourism, its success is dependent upon the external and internal dynamics on the environment. the potential for tourism growth in africa is significant, anchored not only on the region's abundant pristine wildlife coupled with expansive beaches, but also on its cultural heritage. continental africa is poised to realise $ billion in revenue from billion people travelling internationally. at first glance, it may appear that its smooth sailing for africa, however, on closer inspection, such a bright future projection is made without taking into account the critical shifts panning out in the tourism market place. africa's adaptive capacity in relation to the risks and opportunities posed by market dynamics will ensure the success of its tourism sector. the fact that the brics, ageing population, terrorism and trophy hunting issues are taking root in the marketplace it is about time that emerging tourist destinations tourism starts a serious conversation to establish the implications of these dynamics on the tourism system. it is no doubt that africa has had an impressive average growth rate of her travel and tourism, which trends have continued into the twenty-first century, bolstered by a period of impressive economic growth and improvements in political stability and opportunities across the continent. the african development bank (afdb) indicated that in , africa recorded . million visitors, contributed . million jobs directly and generated $ . billion international tourism receipts (afdb , p. ). looking into the future, there is substantial room for growth in africa's travel and tourism market, particularly in light of current sectoral growth patterns, as international tourists are increasingly interested in developing countries as travel destinations, provide the region properly align its tourism sector to dynamics obtaining in the marketplace. tourism is a major global economic sector that is undergoing tremendous growth in emerging economies and is often touted as salient for the development and poverty alleviation in developing countries (scott et al. ) . tourism has been embraced largely due to its employment and foreign currency generative capacity, as it continues to make a substantial contribution to the economies of many countries around the world (zhou ; mkono et al. ) . with the exception of , each year, the tourism industry has outrun projected international tourist arrivals riding on the back of liberalisation of the aerospace, globalisation, and rising income levels. it is forecast that if the current momentum is maintained, international tourist arrivals are expected to reach . billion by (unwto ). tourism is an important economic sector to many african economies in terms of its contribution to gross domestic product (gdp), employment and trade (unctd ). at a time when the region is building its productive capacities, consolidating regional integration and pursuing economic diversification, tourism in africa continues to grow. apart from stimulating employment creation and enticing investment, tourism also contributes towards the preservation of ecosystems and biodiversity. at continental level, the african union's agenda recognise tourism's importance in driving africa's socio-economic development and structural transformation through job creation. the economic development in africa report ( ) reported that tourism can be an engine for inclusive growth and economic development and that it can complement development strategies aimed at fostering economic diversification and structural transformation within the right policy context. however, conspicuously missing in the report is any reference to terrorism, ageing population, trophy hunting, and brics, and the extent to which they threaten the envisaged economic gains. to achieve this africa must be cognisant of changes taking place in the global tourism market place. tourism marketplace dynamics provide greater scope for the region to boost international travel into africa, leveraging on africa's comparative advantage of its renowned tourism resource base. market dynamics will inevitably alter the competitiveness of tourist destinations as well as the suitability of major tourism market segments. it is evident that all tourist destinations will need to adapt to market dynamics, whether to minimise risks or to capitalise on new opportunities associated with the constructs of brics, terrorism, trophy hunting and ageing population. data were gathered through document analysis, combing archival information and expert opinions canvassed from key informants drawn from the broad travel and tourism industry who were knowledgeable about the dynamics and trends of the international tourism industry from africa's perspective. regional market shares, and tourist arrivals from to , unwto forecasts and projections were employed. key interview informants were qualified as tourism experts on the basis of their extensive working experience directly in various sub-sectors of the tourism industry at regional and international level, that is, hotels, tour operations, conventions, nto as regional and international tourism markets, tourism attachés in charge of overseas tourism markets, tourism market development, planning and forecasting. informants' intimate knowledge on international tourism and market dynamics coupled with extensive working experience in the hospitality and tourism sector earned them the expert status. in order to participate in the study, respondents had to have over years working experience in the tourism sector at senior management level in the marketing department in charge of regional and overseas tourism markets. to widen the pool of informants, the study included responses of tourism experts including representatives from government, international organisations and other tourism industry related government departments selected through snowball technique. this was also supported by a review of recent literature and data. resultantly, a total of interviews were administered out of a total population of potential informants (krejciie and morgan ) . a pilot study was done before the actual data collection to ensure the comprehensiveness, readability and clarity. in-depth interviews were conducted with purposively sampled respondents. interview session lasted an average of min. interviews were discontinued after data saturation was reached. the study was based on predominantly a series of open-ended, semi-structured interviews conducted with ten female, and fifteen males purposively selected from tourism representative bodies. semi-structured interviews were chosen because they allowed the researcher to probe for additional information and to seek clarification. the above is in line with the assertion that semistructured interviews offer insights ''into respondents' memories and explanations of why things have come to be what they are, as well as descriptions of current problems and aspirations'' (stake and torrance , p. ) . the interviews that were conducted were restricted to people who gave their informed consent and each interview lasted on average min. items on the interview schedule were informed by literature and prior studies related to tourism growth in other touristic regions. the research participants were asked a broad range of questions in order to gain an understanding of the interplay between the global tourism industry and dynamics in the broader global operating environment in the context of africa. the line of questioning explored, key variables driving tourism at global and regional level, critical shifts in the tourism market place influencing tourism development, tourist regions' responsive strategies to market dynamics, implications of contemporary market dynamics to emerging tourist destinations among other aspects. data were recorded manually (saldana ) . the interpretation and analysis of the qualitative materials was an on-going process that proved inseparable from the field work. in the field, after each interview, the data was analysed to inform subsequent interviews and to capture preliminary emergent themes as recommended by mertens ( ) . after fieldwork, the interview material was later, thematically analysed to reveal emergent themes, following miles et al ( ) and veal's ( ) guidelines. in line with qualitative research, interviews were discontinued when theoretical saturation or data redundancy was reached (jennings ) ; in this case five out of the interviews held contained no new themes. the next section provides a detailed and concurrent presentation and discussion of the dominant themes that emerged during the interactions with the research participants. four themes were identified in the analysis of the qualitative materials that were obtained from the interviews. these were brics, senior tourism market, cites' trophy hunting debate, and the scourge of terrorism. each one of the five themes is discussed below. recurrent themes which emerged from respondents' narratives were grouped into five key themes, which were; brics, ageing tourism market, trophy hunting and terrorism. a number of respondents found that the brics economic grouping was indeed a game changer in the tourism marketplace. brics being a post phenomenon was set to establish a new economic world order, competing with the g countries which traditionally dominated the tourism sector. in particular, informants described brics as revolutionary in tilting the balance of economic prowess in favour of the developing countries. this is a critical milestone in the historical development of the tourism industry in the sense that for the first time the global south is playing a significant role in the global tourism affairs. in light of such market realities and as a way of going forward it implies africa should now improve its tourism infrastructure to match world class standards ahead of increased tourists from brics. africa's tourism product should also be now tailor made to accommodate new a new market with a new set of preferences, tastes and travel habits/behaviour different from the traditional western markets. this echoes the sentiments of unwto ( a, b) and znojek ( ) that going forward emerging economies will drive the key economic sectors at global level, including tourism. to illustrate, respondents pointed out that china, india, brazil, russia and south africa are increasingly emerging as key tourism source markets ahead of the traditional markets of western. in contemporary times, countries from the global south, buoyed by an uptick in per capita income are poised to become leading contenders for the first time in international tourism growth matrix despite being insignificant in the broader global tourism industry in the s. another insight revealed by respondents was that since wwii, the global financial sphere was been dominated by the bretton-woods institutions, however, this was changing with the rise of the asian tigers, coupled with rapid economic transformation in the emerging markets fronted by brics. tourism is driven by an economic boom, a characteristic feature punctuating the brics. brazil of south america, russia of eastern europe, india and china of asia pacific, and south africa from southern africa constitute the brics gamut. on the horizon, the five-nation state grouping is determined to set up a multilateral financial institution modelled alongside the century old international monetary fund (imf) and world bank (wb) as a way of disrupting the status quo in the global financial services market systems. the implications of the brics bank after its eventual full consummation would be the source of funding of tourism developmental projects for the emerging markets. such projects would be prioritised in terms of funding without the bureaucracy and exclusionary tendencies synonymous with the imf and wb. it also imply that nation states from the global south would easily access loans as seed capital to shore up and stimulate economic development which will later on spur economic prosperity and eventually boost tourism. the birth of brics is changing the face of the international tourism in much the same way as the boom factors of the s- s did through enhanced tourism access, free flow of international tourism traffic and capital without restrictions, enticing of fdi, and boosting of demand in favour of the emerging markets. favourable implications on africa are the characteristic features punctuating the brics which support tourism, that is, fastest growing economies, rapidly expanding middle classes and promising domestic markets, as well as the potential to overtake the g as the world's best performing economies by (pop ) . given the positive relationship between economic performance and tourism, this would mean that a huge boost for the brics nation state's respective tourism industries with a potential spill over to the rest of african region. the emerging markets of the brics countries have long been highlighted as the future power houses of the travel and tourism industry. abdou and adawy ( ) contend that brics countries are the leading economies in the world as they are expected to cause a global economic shift and have power more than europe economies and us in the near future. informants were excited by prospects of china and india morphing into citadels of commerce at global level. the brics premise is very significant to the tourism industry of emerging countries in several ways. china and india are set to mutate into hubs of manufactured goods and services globally, while brazil and russia will become leading suppliers of raw material. the brics is set to become the seat of influence on tourism affairs, from being the leading global tourism market, leading tourist destination, leading recipient of tourism related fdi unlike the period in the early s. this finding is in line with projections made by the imf and wb that in future china and india will become global centres of commerce and trade. one official had this to say: certainly, brics will upset the applecart, already there is a seismic shift in the tourism marketplace, where we see traditional tourist destinations becoming less and less popular, whilst emerging markets are shining currently, brics account for more than % of the world's population, over % of world economic growth, % of world foreign investment (zhao ; znojek ) , and has been deemed as a platform for the emerging economies to share a stronger voice on the international stage. to be specific, brazil occupies a prominent place in world affairs, and is one of the world's ten biggest economies, india is an emerging global power, south africa is equally a regional power with global aspirations and has taken a more assertive continental role. it is africa's largest economy and regarded as a doyen of democracy, whilst at the same time it is a key player in the region's stability (carothers and young ) . brics' long haul objective is to accelerate the shift towards a multi-polar international order and to gain an adequate presence for emerging economies in reformed global institutions. unlike before when the global tourism industry was dominated by the g countries, which are essentially proxies from advanced economies, the emerging markets of the brics have thus been regarded as the future powerhouses of the travel and tourism industry as evidenced by the increasing trend where upon the brics feature prominently in the world travel market industry report (world travel market ). on inbound tourism china is increasingly becoming a leading tourist destination at global level, brazil at second place challenging traditional leaders like france, spain, and the us. to its credit, brics is well endowed with natural and cultural tourism resources, massive infrastructural developments in the way of air and ground transport, protected land areas, and richest fauna in the world. this gives it comparative advantage over the traditional g countries. in essence, this is driving the global tourism trends to gravitate towards the emerging markets as opposed to the traditional western markets. africa should take a cue on how brics is also shaping a new narrative in the event tourism space. the increasing importance of mega events particularly sporting events such as the olympics and the fifa world cups provide a window of opportunity for highly significant upgrades in infrastructures, human resources, products and quality. south africa's fifa world cup was a resounding success, olympics winter games in russia federation and fifa world cup in russia, fifa world cup in in brazil and the olympics summer games of helped putting the brics on the global tourism map. there is no doubt that the growth of the global tourism industry is being driven by emerging economies, that is, brics. the present dynamics confirm that unlike in the twentieth century where economic growth was mainly driven by the developed world, in the twentyfirst century, the growth engine has relocated to the emerging and developing markets, particularly the brics. as per capita incomes increase, the services sector grows relative to the other sectors of the economy, and this dynamic is important as the brics countries are planning to go from middle to high income status. resultantly, many countries world-wide are now actively courting tourist arrivals from the brics in particular china. given its large population, and the fact that a growing percentage of people can now afford, both in terms of time and money to travel overseas has had a major impact on the global tourist market. globally, on the economic and tourism front, there is a scramble for the brics as they represent tomorrow's tourism sunrise economy. there is huge appetite world-wide to invest in the brics' tourism sector, which in itself is an endorsement in terms of the shift of balance of power in tourism demand generating markets. the brics have indeed become a force to reckon with in international tourism affairs in the period post wwii just like the g countries. china and india, for example, buoyed by the population demographic factor are set to tilt the balance of power towards the asia-pacific as both a generator and recipient of outbound and inbound international tourism traffic. as such, brics have emerged as an important player in the global economic sectors, tourism included, with its services export growing faster than the developed countries. at the same time brics are generating an increasing number of tourists as per capita income rise and a relatively big share of this increase would be spent on tourism. in this milieu, the over trodden global north tourist destinations have now matured hence the focus has turned on exotic tourist destinations which are far flung from the beaten track. the majority of the respondents suggested that the elderly population presents a market of particular relevance to a large number of industries for its high purchasing power, comparatively higher than younger groups, more so to the tourism industry. it was apparent from the response that the tourism sector was emerging as one of the biggest beneficiaries of the ageing process as a result of changes in the lifestyle of the population. this finding conforms to alen et al. ( ) and cooper et al. ( ) who similarly established that the ageing baby boom generation was slowly becoming one of the most important markets in the tourism context. indeed, the ageing of the baby boom generation marks an important milestone in the development history of the tourism sector in light of their purchasing power. schroder and widman ( ) deemed the senior tourism market demographic change as one of the biggest growth and most important markets in the tourism industry, turning it into the engine of growth for tourism. this is in consonance with the unwto ( a, b)'s prediction that by there will be more than billion international travellers aged and above compared to million in (patterson ) . such demographic shifts will affect the structure of tourism supply and demand at regional level. the implication on africa about the increasingly ageing population is that market tastes and vacation habits will change. the senior market clientele is experienced, more discerning and high spenders. this corroborates glover and prideaux ( )'s observation that population ageing affects the future choice of tourism activities and destinations, and ultimately future tourism growth projections like trends, patterns and traffic. as the global tourism market gravitates towards the senior market, so does its tastes, preferences and holiday patterns. this is in synch with weaver and oppermann ( ) and salt ( ) who support the view that demand for tourism products and experiences change with age. the senior tourism market is keen to travel to exotic tourist destinations like africa calling for an overhaul of africa's tourism product. individual factors such as family status, employment, education, health status, travel experience and generational values change with age, henceforth tourist destinations have to pay particular attention to these and adjust product offerings accordingly (glover and prideaux ) . an ageing population implies that the demand for authentic tourism products and experiences most in emerging regions like africa aimed at the senior tourism market or older population is likely to increase both in actual number and in proportion of all holidays as the number of older people grows. the senior tourism market, given its old age, takes more leisure trips more frequently courtesy of the availability of time and higher discretionary income. it is therefore instructive that if emerging tourist destinations are to remain competitive and successful they need to be aware of the differences that may be apparent in the demand profiles of specific generation gaps. from africa's perspective, the battle for the competitiveness and growth of the global tourism market share will be fought and won on the basis of them being capable to appeal to multi-generation markets. tourist destinations in the global tourism industry vigilant to tourism market shift on tourism demand based on population demographics are poised to reap the benefits. prideaux et al. ( ) posit that the inability of tourist destinations from recalibrating current range of tourism products and services to reflect the aspirations and consumption patterns of senior market may result in a slow decline in visitor numbers in the coming years. ideally, tourist destinations world-wide recognise that a change in demand is underway hence the need to start working on modifying the tourism product that resonates with an ageing population. in short, tourism demand would be a function of population demographics. an understanding of where the world and tourism market is heading is crucial for identifying opportunities that are brought about by that change. embedded in ageing are health issues such as hypertension, obesity, and heart diseases which increase in prevalence along with age. ageing population equally has a business and financial dimension, that is, the elderly are better educated and wealthier than previous generations (callister ) . the elderly tourism market is keen to give back to the community or cultures they visit, they therefore combine tourism with volunteer work, aptly labelled as voluntourism (furlong ; thornhill and martin ) . the tourism industry must ensure that appropriate facilities are available to meet the needs of these consumers. whilst developing countries are still comparatively characterised by young population, industrialised countries are confronted with an ageing population, and low birth rates (un ; goldin ) . informants were unanimous that the tourism industry experienced an unprecedented poaching and decimation of wildlife on an industrial scale in the period post wwii, which was a cause of concern as it sends shockwaves on the tourism marketplace. the situation is grim in emerging markets mostly africa. respondents were unanimous that the tide needed to be tamed as it was threatening the very foundation of tourism hence putting the future of the tourism sector at stake. the above sad state of affairs in emerging tourist regions fed into a post wwii tension increasingly mounting between the global south and global north on the emotive issue of trophy hunting, which falls under the auspices of cites. another respondent seemed to indicate that trophy hunting was more relevant to africa given that the region's tourism industry is anchored on wildlife. it was interesting to note that the draw card of emerging markets' tourism industry was now at the centre of the contemporary global stand-off pitting the global north against the global south. perspectives from africa show that the region is much concerned about the power play on over-regulation, embargoing trophy hunting, and preservation of such wildlife in light of limited budgets characterising most african countries. ironically the consumers of africa's trophy hunting products are tourists who come from the global north who are lobbying for a total ban. this creates an awkward position for africa. what this implies to africa is that the region has to adjust and endeavour to co-exist with the global tourism family in the sense that if the region pulls out of cites it risks a serious backlash from partakers of wildlife experiences. the current state of the tourism industry has been predicated on the huge wildlife resource base sprinkled across the breadth and length of tourist regions. however, post wwii upheavals in the wildlife sector characterised by increased poaching, alienation of local communities' rights to the utilisation of wildlife resources, blanket imposition of a moratorium on trophy hunting and a plethora of other issues are set to continue fuelling a bruising contestation regarding the sustainable use of wildlife in the broader context of tourism development (mkono ) . consensus on how the contentious and divisive trophy hunting issue should be handled to the full satisfaction of all cites members and secure the sustainable future development of the tourism industry is still a challenge. whilst emerging tourist regions like africa feel hard done by cites stance, with sentiments indicating that the issue seriously undermine wildlife conservation efforts, and ultimately the tourism experiences in nature parks and conservancies, it is critical to have a holistically approach on the issue. indeed, exotic tourism regions like africa are well known for their pristine wildlife sanctuaries where tourists encounter with nature. world-wide the tourism phenomenon has been driven by flora and fauna, however given the increasing rate at which poaching and depletion of wildlife resources are happening, cites justifiably came on the scene to regulate the use of wildlife within the tenets of sustainable tourism. to this effect cites outlawed trophy hunting which arguably used to generate funds for the conservation and management of wildlife resources especially in emerging markets like africa and asia-pacific. subsequently, there has been a raging debate on trophy hunting which has divided global opinion. the future of the global tourism hinges on the reform of cites's stance on trophy hunting. arguments proffered mostly by the emerging markets revolve around the urgent for a review of trophy hunting ban to avoid what they claim an impending wildlife catastrophe since the wildlife population has ballooned to unsustainable levels as a result of a moratorium imposed on trophy hunting. yet on the other side of the spectrum, the global north is advancing the argument that a ban on trophy hunting should remain in force into the foreseeable future. the stalemate would definitely impact on global tourism trends and patterns, more so on africa in a negative way. trophy hunting has thus become a delicate matter in the international tourism discourse since it can rally nation states towards the conservation of wildlife resources which are the bedrock of the tourism sector. trophy hunting is a topical issue in international tourism affairs, so much that a divided global family of nations on it foments disillusionment, smacks fragmented approaches in fighting the poaching scourge and eventually lead to the decimation or a complete loss of the wildlife resource which is a key driver of the sector. global consensus on trophy hunting and the way forward between the global south and north will define the new course of tourism growth in the foreseeable future. without wildlife resources there is no tourism sector to talk about hence this is critical at this juncture. poaching remains the greatest threat to the integrity of natural sites globally. results showed that in the contemporary globalised village, emerging tourist destinations like africa are no longer immune to the scourge of terrorism that traditionally was more pronounced in the western countries and north america. however, respondents indicated that africa is increasingly becoming a target of terrorist, citing an example of kenya in east africa; tunisia in north africa. what it therefore implies is that it can no longer be business as usual but in essence emerging markets should start investing in ports of entry screening technologies and reviewing visa regimes with a view of strengthening security protocols. safety of international tourists is of paramount importance, hence this should be guaranteed. future global tourism trends will be defined and influenced by the safety records of tourist regions, as well as their response systems to terrorist attacks. this finding corroborates paraskevasa and arendell ( ) , hoffman ( ) and chalk ( ) who established that tourists rank safety and security highly when choosing vacation holiday. given the ever increasing rate at which conflicts are erupting in emerging markets in particular and at global level in general as a result of the increasing chasm between the rich and poor, it is important that tourist regions reflect deeply on terrorism threats and the instability it poses to the development and growth of the international tourism industry. it is apparent that transnational tourism organisation like the unwto and wttc quickly issue out advisories dissuading potential tourists from visiting destinations prone to terrorist activities, as they value the safety and security of vacationers. while at face value this may sound akin to destination de-marketing, tourists' safety and security is of utmost priority. the burden lies with destinations to ensure the safety of visitors. peace and security at tourist destinations would remain the single most important factor to guide tourism development going into the future. globally, as revealed above, the security situation remains precarious, impacting negatively on tourism growth projections. with such a remarkable shift, it therefore calls for a coordinated global approach in the fight against terrorism, a serious threat to tourism, which has become a global menace embedded in a modern society characterised by extremes of rich and poor in both the developed and the underdeveloped countries. terrorism has been targeting popular tourism spaces, and given the lack lustre security systems in place in emerging markets there is need for collaborative efforts to tame the wave of terrorism in order to create a better world where tourism can thrive. africa should realise that the interconnectedness of nation states celebrated under the auspices of a global village has opened up countries to global risks and vulnerabilities like terrorism, contagious diseases, for example, covd- virus. this has huge implication on tourist regions' immigration and border control issues, visa regimes, health issues with far reaching consequences for africa's tourism sector. taken together, these issues are at the centre of curtailing the free flow of tourists. emerging tourist destinations are in a dilemma on whether they should opt for a protectionist-cautious stance in terms of the free flow of people or a more liberal approach. perspectives from africa hold that improving security is a challenge, especially creating a more seamless experience and staying ahead of evolving threats is a true test facing the sector in the period post ; balancing the traveller's safety with traveller experience will continue to define the challenge into the foreseeable future. respondents confirmed that as tourist spaces in exotic destinations become more popular with millions of tourists trouping, it becomes apparent that tourists are increasingly becoming easy targets of terrorism. the implication for emerging markets like africa is that terrorism is now ubiquitous, as illustrated by a spike in terrorist incidences. given the ever widening chasm between the political elites and the poor, fundamental different religious views and political opinions, these are fuelling terrorism irrespective of geographical location. since time immemorial, tourism has been known as a peace sector. another perspective is that whilst the end of wwii was generally interpreted as marking the dawn of political peace at global level and was hailed as a seed bed to nurture tourism development, it is increasingly being realised it was an illusion. to date global peace is becoming elusive because of indiscriminate acts of terrorism. given the global publicity and media attention attendant to terrorist attacks on tourist destinations, the scourge dents the tourism phenomenon, especially for emerging tourism destinations whose safety and security systems are regarded as weak or inadequate. indeed, the tourism phenomenon has been known to be resilient but the negative publicity associated with terrorist attacks adversely affect tourism trends and patterns. terrorism has the potential to destroy tourism overnight despite its gigantic size. the present day society is become heavily infested with terrorist groups who are increasingly targeting, attacking, kidnapping and killing international tourists (stafford et al. ) . adeloye and carr ( ) argue that terrorist attacks on tourists serve as unpleasant reminders of how fragile and vulnerable the tourism industry is to terrorism. the unwto ( a, b) advocates for tourist destinations to be proactive and institute quick response or rescue strategies in the aftermath of an attack. alongside this, tourist destinations should have in place destination recovery plans and marketing strategies to restore market confidence in the post attack period. terrorism influences tourists' perceptions of risk and their resultant travel decisions. in the twenty-first century the notorious terrorist groups threatening world peace and stability are the islamic state, hamas, hezbollah, boko haram, taliban, al-queda, and al-shabaab to mention a few. the tourism sector, economic growth and development of countries can be seriously threatened if tourist destinations increasingly become scenes of terrorist attacks. to this effect, tourist destinations need to invest in security protocols, which would put them in a stead to recover in a faster manner, provided the protocols are well created and implemented correctly (world economic forum ) . crisis protocols, recovery strategies, and strong emergency plans are indispensible for tourist destinations to recover fast and should become buzz words in future tourism development trajectories. despite the resilience of the tourism sector, recurrent incidents of violence and terrorism at global level, increased insecurity and safety of tourists, as well as ruined perceptions deter potential tourists from fully and freely partaking in tourism. the scourge of terrorism imposes restrictions to visiting tourist destinations prone to attacks, henceforth matters of tourist safety and security are very critical when it comes to the future of the tourism industry. terrorism makes the tourism sector vulnerable and fragile making its future growth prediction uncertain (abadie and gardeazabal ) . conventional literature show that terrorism disrupts the entire tourism value chain where upon key stakeholders like travel agents would not actively promote tourist destinations perceived as being unsafe. terrorist attacks have continually degraded and undermined the popularity of tourist destinations. in the aftermath of terrorist attacks, the tourism industry experiences significant down turn, the kidnapping of tourists by terrorist's network groups also frightens tourists away. from africa's viewpoint, terrorism's effects on tourism are multi-faceted: a decrease in the number of tourist arrivals, reduction in fdi, cost of reconstruction of tourist facilities, safety and security upgrades costs, and increased marketing costs to attract visitors. this is in line with what was established by barth et al. ( ) that there is a very strong connection between terrorism and tourism, tourist sites which are targeted by terrorists have their social order and economic stability greatly shaken. the tourism sector is increasingly becoming a target of terrorists; the resonance being that the tourism sector is the main source of income of many countries, so by damaging it the core function of the economic basis of the nation stops working, destroying tourism attractions is the best way for the terrorists to get their message delivered through-out media coverage, thus getting the attention they need, and the tourism sector has not focused on security matters (tarlow ) . tarlow ( ) emphasise that security plus service and value for money will become the basis for twenty-first century services. terrorism encompasses the murder of high profile journalists, and media personalities which are covered by the international media contributing to the negative image of tourist destinations. potential tourists see such cases as indicators of lack of safety; this also shows that the security system at global level is fragmented and not sufficient to ensure the security of citizens. threats on global peace will remain a major issue hampering tourism growth, and stifle tourist destinations to realise full potential for foreign visitors and under utilisation of tourist attractions. in the absence of safety and security, tourism will not flourish. the effects of terrorism have destroyed tourist destinations brands in the tourism market. in conclusion, the current study contributes to literature by investigating the global tourism industry dynamics and their implications to emerging tourist destinations. the study examined fundamental shifts characterising the global tourism landscape since the end of ww . these were identified as the formation of brics countries, ageing population, trophy hunting debate and terrorism. at the inception of tourism, boom factors influenced the growth of the industry, driven by the g member countries, however, as time went by, emerging markets increasingly became more significant, largely driven by the brics. contemporary tourism dynamics framed as the constructs of brics, trophy hunting, ageing population and terrorism have been applied simultaneously to establish the extent to which they are impacting tourism growth projections from the perspectives of emerging markets. these have impacted on the trends of international tourism in a profound way. it is apparent that emerging markets are now in the front foot dictating the pace of tourism development. in light of such fundamental shifts, it is recommended that tourist destinations recalibrate their tourism product offerings so that they reflect the contemporary market dynamics. on the investment front, the emerging markets represent the future of the tourism sector, and finally in light of the devastating effects of terrorism, emerging tourist destinations should refine their terror responsive strategies. apart from the above, another area in need of attention is policy reform, in which immigration regulations and visa regimes should be constantly revised to strike a balance between screening travellers, balancing liberalising and softening the border control formalities to allow free flow of traffic but without compromising on the security and safety matters of tourists. finally, marketing and promotion efforts need to be directed and focused on emerging markets and less on mature tourist regions since the former represent the future of the global tourism industry. this study therefore made a contribution in the specific areas of emerging markets, tourism senior market, convention on international trade in endangered species (cites), and terrorism as key aspects that can make or break the global tourism industry in the twenty-first century. this research responded to the need for continuous research on africa's tourism sector and situate it in the global tourism industry (naude and saayman ; christie and crompton ; rogerson and visser ; dieke ) . to the best of the writer's knowledge, this study presents new knowledge from an emerging tourist region context regarding the dynamics obtaining in the global tourism environment and their subsequent implications. the current study was done in the context of africa an emerging tourist region, with a less influential influence in the international tourism stage. therefore, this study provides a significant addition to literature currently dominated by insights and perspectives from advanced societies like western tourism markets. ethical approval this research was carried out on respondents after full disclosure of the purpose and objectives of the study. participants voluntarily consented to participate in the study. no minors nor vulnerable groups/individuals were involved as respondents during data collection. the study did not use unorthodox means of collecting data. there was no conflict of 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this article analyses this transformation by asking how the legal regime, designed to prepare for the pandemic, envisions the globe as an object of government. it demonstrates that the who’s international health regulations (ihr) articulate a space of global circulation that exhibits two features. first, the infrastructures of microbial traffic become the primary matters of concern. the ihr do not focus on human life so much as they aim at securing transnational mobilities. second, the ihr circumscribe a space that is fragmented by zones of intensified governmental control at transportational nodal points, such as airports and harbours. in these zones, technologies of screening and quarantine are applied to modulate the connectivity of people, organic matter and things. as a whole, the article investigates how processes of de- and re-territorialisation interact in the context of global health security. in analysing forms of legal worldmaking, it unearths a nomos of global circulation which applies its regulatory force to the post-human materialities of microbial traffic. 'world-making', david delaney ( delaney ( , has introduced the notion of the 'nomosphere ' ( - ) . the term is derived from the greek nomos that relates to acts of division, separation and demarcation. most famously, these connotations have assumed centre stage in carl schmitt's ( ) nomos of the earth. in this book, schmitt traces the geopolitical contours of the international order enshrined in the jus publicum europaeum. unlike schmitt, however, delaney does not assume a mythological foundation of law in 'concrete spatial orders'a view most palpable in schmitt's portrayal of the earth as the element that 'contains' and 'sustains' law (schmitt : ; dean ) . rather, delaney seeks to highlight how law is constitutively involved in the articulation of always contingent spatialities. accordingly, this article wants to look at how the ihr become imbricated in the production of our spatial present. undertaking such 'nomospheric investigation', however, does not imply that legal documents shape the political cartography single-handedly in a causal way. they are but one element in the material practices that configure the spatial setup of global governmental assemblages (collier and ong ; valverde ) . theoretically, the following argument engages with foucault's genealogy of liberal government (foucault ; valverde ) . foucault is important in this context since he is one of the few thinkers who have emphasised the inherent connection between political rationalities, space and infectious disease (legg ) . for him, the history of modern political power is, to a large extent, a history of how epidemics were dealt with. diseases such as leprosy, plague or smallpox gave rise to specific modes of spatial ordering that correspond with specific technologies of governing. this article adopts this perspective for understanding the making of 'nomospheres'. it looks at the legal document of the ihr as an operative device in the fabrication of governmental spaces, which are supposed to provide security against the pandemic threats to come. the analysis will show that the ihr entail a modulation of what foucault has described as the governmental rationality of planetary circulation. two particular nomospheric features encoded in the ihr stand out in this respect. the first concerns the referent object of governmental practice: the regulatory effort to secure global public health does not focus on human life so much as it does on post-human materialities of global traffic. infrastructures and objects of mobility are its main concern. the second feature pertains to the particular type of territorial control envisioned under the current conditions of intense globalisation. for governing 'viral traffic', the ihr stipulate technologies such as screening and quarantine, which supplement the liberal image of a smooth and borderless world. these technologies re-territorialise the planetary space by forming thresholds at which the movement of risky bodies is interrupted and rhythmicised. the ihr thus constitute a 'nomadic nomos' (vismann : ) that incorporates territorial strategies into the government of the networked topologies generated by global traffic. for developing this argument, the article proceeds in three steps. the first section reconstructs the relationship between epidemic crisis and the emergence of spatial orders to be found in foucault. unfolding this heuristic framework for the subsequent analysis of the ihr, it elaborates especially the role that legal concepts play in translating the idea of liberal circulation into the global sphere. against this background, the second section investigates the peculiar mode in which the ihr constitute a nomosphere of global circulation. it traces the shifting concern from the health of the individual and the population towards a continuum of organic and inorganic bodies travelling along infrastructures of transmission. the third section focuses on the role played by technologies of thermal screening and quarantine in this peculiar rationality of governing circulation. it presents them as territorial strategies designed to govern the de-subjectified flows of universal traffic. in western modernity, issues of public health have never been just about health (rosen ) . they became deeply intertwined with politics and the making of political spaces in particular. whereas the first quarantine regulations in the mediterranean city-states of the fourteenth century were famously directed at maritime trade, it was not before the seventeenth century that sanitary measures 'came to be used consciously as instruments of statecraft' (harrison : ) . on the one hand, the politics of public health influenced states' external relations deeply. to combat the epidemics of the s, england interfered with the dutch trading empire by imposing quarantines against vessels sailing from amsterdam; about a years later, austria had completed a sanitary cordon over , kilometres along the lines of a former military cordon at its eastern border (rothenberg : ) ; and in the nineteenth century, the european powers established consular commissions in alexandria or constantinople for 'defending europe from asiatic infections' (harrison : ) . on the other hand, public health had a tremendous impact on the internal politics of evolving nation states. a wide array of administrative practices, such as isolation, segregation, or urban planning, were led by the concern for health as a 'common good'an understanding that triggered regulatory reforms to set up systems of 'medical police' by the end of the eighteenth century in most european states (carroll ) . despite their extreme heterogeneity, all these instances share one common feature. in each case, the history of public health reveals itself to be tightly coupled with a history of spatio-political settings. foucault belongs among the few theorists who have explored the relation between political space and infectious diseases in a systematic manner. epidemics in particular assume a place of pride in his work. in the birth of the clinic, they are introduced as 'collective phenomena' that have 'a sort of historic individuality' (foucault : ) . epidemics appear as singular moments of crisis that provoke the development of novel spatial orders and political technologies. however, foucault is not so much interested in the historical vicissitudes as such as he uses the historical material to identify distinct rationalities. he distinguishes schematically the responses to leprosy, plague and smallpox, each of which is tied to the emergence of a peculiar cartography of power (thacker : - ) . it is worthwhile to recall shortly this reference to epidemiology in foucault's otherwise well-known genealogies of power in order to link it both to its spatial and juridical underpinnings. the government of leprosy operates through expulsion (foucault : - ) . the medieval leper is barred from the city into an outside populated by the living dead. the juridical structure of this operation is the exile that produces a life in pure abandonment. it constitutes a sovereign power based on territorial exclusion. the disciplinary response to the plague of the seventeenth century reverses this procedure. its basic formula reads: 'not rejection but inclusion.' (foucault : ) instead of drawing a single boundary delimiting an interior from an absolute exterior, discipline imposes a partitioning grid. it creates a space segmented into differentiated enclosures that seek to isolate individuals, reduce contacts and allow for panoptic surveillance. foucault describes discipline as a form of 'counter law' for it works in the interstices of liberal law, subverting freedom and equality from below through its minute normalising procedures (golder and fitzpatrick : - ) . the smallpox of the eighteenth century gave rise to yet another amalgam of political rationality and spatial order: liberal governmentality with its aim to maintain spaces of circulation (foucault : - , - ; elbe : - ; opitz ; voelkner ) . within this political rationality, epidemic disease appears as a collective affair with immanent regularities to be rendered visible by statistics. it is dealt with as a mass phenomenon through measures of public hygiene and practices of inoculation. accordingly, governmental power is not exercised over a territory but within a population. this, however, does not amount to a neglect of the individual. rather, the government of populations is linked intrinsically with the individualisation of the liberal subject (foucault : - ) . modern biopolitics addresses the health of the population through individual well-being and vice versa (foucault : - ) . governing disease within a framework of liberal governmentality has important spatial implications. the population forms a dynamic, living entity that is tied closely to the circulation of bodies, goods, and resources in space. since the circulatory flows are considered to be the well-spring of the population, liberal government aims at protecting and enhancing this metabolism in its vital force against the inherent threat of disease (swyngedouw : - ; dillon and lobo-guerrero ) . beyond this background, measures of containment and fixation through enclosures appear as inherently problematic. each parcelling of space that hinders or even immobilises those elements that are assumed to circulate is seen to constrain the life process. furthermore, since disease exists 'within a collective field' (foucault : ) it cannot be simply externalised. it is an unfortunate, but intrinsic phenomenon that cannot be made subject to a total ban. all in all, liberal government is careful not to obstruct contacts. rather, it facilitates and organises connectivities, aiming to secure them against their immanent dangers -'maximizing the good circulation by diminishing the bad' (foucault : ) . in principle, the space of circulation is therefore an open and unbounded space. liberal government operates, in foucault's own words, 'centrifugally'. 'new elements are constantly being integrated […] . security […] involves […] allowing the development of ever-wider circuits.' (foucault : ) ultimately, this centrifugal dynamic places the liberal government of circulation within a planetary horizon (mattelart : - ; lobo-guerrero ) . foucault himself devotes only a few pages to this consequence. however, this short passage that has, thus far, also received relatively little attentionis of utmost importance for the current argument, since foucault ( ) links the 'appearance of a new form of global rationality' in governmental practice with what he calls a 'juridification of the world' ( ). after gesturing towards maritime law and the problem of piracy as examples of such 'elaboration of a worldwide space' (ibid.), he turns to immanuel kant's text on 'perpetual peace' ( ). in kant, he finds the view that a global law beyond the state is to emerge from the inter-relations naturally occurring between humans all over the world. whereas political philosophers usually adopt the kantian premises for justifying the existence of cosmopolitan law, foucault turns this normative position upside down by reading kant archaeologically as a governmental script. a closer look at kant might, therefore, illuminate foucault's unusual, but innovative argument about the relation between the liberal government of global circulation and global law. kant ( : ) bases his elaborations on the 'postulate' that 'all men who can mutually affect one another must belong to some civil constitution'. in the german original, this intercourse is couched in terms of a natural 'flow' or 'in-fluence' (kant : ) that traverses the borders of state territories. it establishes a form of interrelatedness that is always already transcending the space of international law into a cosmopolitan order. kant deduces the latter from the spatial properties of the earth. because of its spherical shapeits kugelgestaltthe earth's surface forms a limited space in which human beings 'cannot disperse infinitely but must finally put up with being near one another' (kant : ) . the cosmopolitan right 'to present oneself for society' (ibid.) is thus rooted in the empirical features of global space (eberl and niesen : - ) . the earth places humans irrevocably in a proximity to one another and it generates relations of communication and exchange across the world. the means of transportsuch as ships or camels, the latter figuring in kant's ( ) view as 'ships of the desert' ( )support men in their commerce and facilitate mutual contact. they offer the technical basis for worldwide circulatory processes that follow 'naturally' from the earth's spherical shape. in this way, the cosmopolitan right is derived from those natural circulations that it has to protect. it allows individuals to get in touch with each other irrespective of their national affiliation. it stabilises the capability to connect globally, a potential that is grounded in the spatial qualities of the earth. reading kant's famous text as an instance of governmental thought fundamentally alters the role attributed to global law. from such a perspective, cosmopolitan law appears as a means to enable exchanges across the world. it secures transnational traffic and communication, thereby constituting an infrastructure for circulatory movements. in this sense, law appears as a governmental technology. again, it is worthwhile to underline the analytical twist at work here. whereas a more traditional normative reading of kant proceeds from a particular state of the world to a cosmopolitan juridical framework, the governmental reading observes how cosmopolitan law is devised as a tool to stabilise a liberal view of worldly processes. in one case, humanity's natural use of the perfectly rounded globe grounds an equally universal law. in the other case, law functions as a particular device for fostering specific modes of global movements. this difference matters strongly, since only the latter angle allows for investigating the practical work of establishing 'nomospheres'. only the second of the two viewpoints prompts empirical research to analyse how contemporary forms of global law are operative in developing governmental cartographies: how do legal textures configure movement-spaces? in which way do they specify how circulations are to be monitored, channelled and held in check in order to be maintained? how do legal regulations discriminate between what is supposed to circulate and what not? writing a full genealogy of how law becomes part and parcel of a governmental rendering of global space is beyond the scope of this article. as indicated above, the following sections concentrate on one current instance of such liberal governmentality. they excavate the spatial calculus for ensuring global health security as it is encoded in the ihr. in order to explore the intimate relationship between epidemic crisis and political space further, foucault's elaboration of governmental space serves as an analytic foil. it helps to determine the ways in which the ihr still perpetuate the rationality of liberal circulation as well as those respects in which they modify it. regulating global traffic: the post-humanism of the ihr historically, the ihr stand in continuity with the attempts at international health governance that reach back to the beginning of the nineteenth century. the system of diplomacy inaugurated at the congress of vienna ( ) constituted the framework in which the european nations began to achieve sanitary cooperation (harrison ) . the main aim was to make quarantine the object of international agreements in order to minimise impediments of commerce during a period sometimes referred to as a 'second wave of globalisation' (robertson ) . this concern led to the first international sanitary conference in . although the participants failed to agree on quarantine regulations at the first meeting in paris, ten further conferences were to follow until , most of them seeking to balance measures to prevent the spread of yellow fever and cholera against restrictions on travel, the disruption of trade and especially the costly immobilisation of ships (howard-jones : ) . in the early twentieth century, the first intergovernmental organisations grew out of the conference system: the pan-american sanitary bureau of in washington dc, the office international d'hygiène publique of in paris, and the league of nations' health organisation of in geneva. the emergence of these institutions marked the beginning of a transition from international towards global juridical structures to be continued after the second world war by the united nations and the who. according to alison bashford ( b), a particular rendering of the population question as a 'world issue' ( ) was decisive for this shift. in contrast to the national focus on matters of sexuality and reproduction, population management on a global scale was introduced primarily within an economic framework concerned with population density, spatial distribution and 'world human movement ' (ibid.: ) . 'in this way, […] 'world space' was imagined and problematized […] through 'world health', its predecessor 'international hygiene', and the problem of origin: quarantine.' (bashford b: ) against this historical background, the 'post-westphalian' contours of the ihr do not appear as an absolute novelty. according to the principles set out in article , their implementation 'shall be guided by the goal of their universal application for the protection of all people of the world from the international spread of disease'. the ihr thus follow earlier attempts at global health by situating themselves within a planetary horizon, putting forward a trans-border vision of the earth. and like earlier forms of 'germ governance' (fidler ) , which already began to exceed the demarcations of the international system about a century ago, the ihr do not simply bypass the state. they seek to realign the organisational capacities of states, integrating their institutions into a globally networked governance structure (cf. sassen ) . most importantly, the key passages of the ihr read like a clear-cut manifestation of the liberal government of circulation: 'the purpose and scope of these regulations are 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.' (ihr, article ) the mobility of disease and the mobility of goods and people are conjoined in this problem space. measures against the first should not be achieved by stifling the second. the ihr thus exhibit the liberal concern about governing too much. echoing the main gist of international trade law under the wto, they aim at circumscribing a mode of intervention that seeks to minimise potential interferences with economic circulation. if the continuity of the ihr with the basic presuppositions of liberal governmentality can be established easily, what about their specificity? what is the 'historic individuality' of the current attempt at dealing with pandemics as globally collective phenomena? to answer this question, it is necessary to understand how the ihr contain a remarkable modification of the biopolitics of liberal governmentality (lemke ) . the ihr untie the complementary relation between the individual and the population outlined in the last section. on the one hand, they almost completely remove the question of individual health care from the preoccupation with circulatory matters. this is highly significant, since during the twentieth century a right to health became implemented not only in national jurisdictions, but also in key documents of international law such as the universal declaration of human rights (article ) and the preamble to the who's constitution. yet, the ihr contain no substantial allusion to individual health, the figure of the individual person who is sick and needs care is, for the most part, absent. on the other hand, and even more curiously, the ihr also refrain from concerning themselves with the health of the population. while the figure of the population still featured prominently in the global health politics in the second half of the twentieth century, the ihr do not make a prominent reference to it. the ihr appear as an example of what niamh stephenson ( : ) or andrew lakoff ( ) have observed as a more general political trend: that the population ceases, increasingly, to be the main object of public health. although not being completely absent, it appears only marginally in the ihr. this raises the question of what has come to substitute the dual structure of the individual body and the population in public health: what is put at risk by epidemic disease? within the ihr, the concern for global circulation is expressed mostly with regard to the spatialities of global traffic. the ihr demand special attention for those 'public health risks existing in areas in which the international traffic originates, or through which it passes' (ihr, article . ). they specify 'core capacity requirements for designated airports, ports and ground crossings' (ihr, annex .b). and they include specific standard forms for controlling ship sanitation (ihr, annex ) as well as a model of a maritime declaration of health (ihr, annex ). in this way, traffic designates the particular kind of movement that is both a risk and at risk. pathogens circulate through global traffic, and the control of the spread of disease may, therefore, lead to interferences or even interruptions that are to be avoided. this problematisation resonates with accounts of emerging infectious disease (eid) that became influential at the end of the twentieth century (lakoff : - ) . most notably, the epidemiologist and virologist stephen s. morse has described topologies of contagion in terms of 'viral traffic ' ( ) and 'global microbial traffic ' ( ) . since viral trafficbroadly defined as 'movements of viruses to new species or new individuals' (morse : )is always bound up with patterns of human traffic, morse calls for 'viral traffic planning' (ibid.: ): 'basically, people are creating much […] of the traffic […] . we need to recognise this and learn how to be better "traffic engineers".' (morse (morse : especially ecological changes in land use and demographic changes in population density produce a new quality of biosocial interrelatedness: 'no one is truly isolated and therefore impervious to microbial traffic.' (ibid.: ) as to the ihr, the who seems to share this vision of global transportability: traffic appears as an almost universal frame for planetary circulation. microbial traffic is intertwined firmly with the world traffic in trade and travel, since the latter constitutes a vehicle for the former. in turn, the ihr circumscribe a liberal regime of para-medical policing. they do not concentrate on healing bodies, but rather on regulating free movement. within the spatial logic of governing global microbial traffic, processes of transmission are of key concern. this focus displaces the medical concern for individual symptoms of disease. the individual symptom becomes only relevant in so far as it may refer to potential 'routes of transmission' (ihr, annex ). whereas the symptom is a hermeneutical concept, based on the idea of interpreting signs of illness, transmission is a media concept with a postal structure that is both spatial and operative (krämer : - , - ) . in its simplest form, transmission involves a carrier that transfers a pathogen from one point to another (wald : - ) . the ihr present a broad inventory of physical bodies that may act as potential carriers, covering the whole spectrum of humans, animals and inanimate matter. disinfection, for example, is defined as the 'procedure whereby health measures are taken to control or kill infectious agents on a human or animal body surface or in or on baggage, cargo, containers, conveyances, goods and postal parcel' (article ). everything that circulates can function as a carrier of transmission: faeces, food, water are mentioned in the same manner as human remains (ihr, articles . and . ). if anything, not the human, but animals feature as crucial carriers of transmission. especially insects are seen as 'vectors' of epidemics, since they 'transport an infectious agent that constitutes a public health risk' (ihr, article ). these bodies of transmission belong to a governmental vision that pictures the world as a space of universal traffic and that focuses on routes and material means of global circulation. in order to grasp the peculiarity of this governmental view, it may be instructive to recall that issues of public health have been traditionally tied to what robert castel calls 'the social question'. according to castel ( ) , the social question highlights the way in which a society 'experiences the enigma of its own cohesion' and the 'dangers of disintegration' (xix-xx). the social question problematises the capacity 'to exist as a collectivity linked by relations of interdependency' (ibid.: xx). reading the ihr, one might say that, the social question becomes less social and more transactional. the globe is imagined as a transactional sphere in which relations of interdependency are established through modes of transportation that involve organic and inorganic matters. while the danger of disintegration remains related to the threat of an international health emergency, the referent of this threat takes on a novel form. as outlined above, the threatened object is neither the body of the individual nor the collective body of a population. it is instead the very global movement of animate and inanimate entities across boundaries, which has to be protected against immanent threats. the management of public health risks is therefore concerned primarily with what collier and lakoff ( ) have identified as 'vital systems'. it is attentive to those infrastructures, hubs and nodal points that 'operate' world traffic and realise global connectivities . within this framework, the individual tends to be seen, at least in principle, only as one risky body among others. it appears as one potential carrier, moving along routes of transmission together with other potential carriers. global health has thus turned into a thoroughly post-humanist affair. in an uncanny resonance with the vocabulary of current social theory, the ihr focus on the 'vibrant matters' (jane bennett) and 'insect media' (jussi parikka) that are vectors of transmission. what actually matters are the multiple connections established by all kinds of substances in motion, no matter if they are fluid or solid, organic or inorganic, animate or inanimate (clark ) . taking into account the 'ecologies of pathogenicity' (collier and lakoff : ) , the ihr extend the concept of global public health to all the materialities involved in the planetary movements that they seek to secure. in conjunction with a shifting problematisation of the governmental object towards the 'vital systems' of post-humanist traffic, the technologies of control become recalibrated. while the liberal maxim of 'laissez faire, laissez passer' can still be seen to capture the professed aims of the ihr, it does not tell about the territorial technologies that mark out its nomosphere. in fact, the current preoccupation with circulatory processes in the field of global health security does not amount to a 'de-territorialized smooth space' of 'uncoded flows' (deleuze and guattari : - ) . rather, letting the planetary traffic pass securely involves accompanying spatial measures that control the passage of subjects and objects within 'molecular geographies' (braun : ) . accordingly, the ihr formulate a set of 'recommendations with respect to persons, baggage, cargo, containers, goods and postal parcels' (ihr, article ). two of them in particular are designed for managing the risk of disease transmission: screening and quarantine. as will be elaborated in the following, both screening and quarantine implement spatial thresholds of 'social sorting' (bowker and star ) at which carriers of disease can be singled out. they form peculiar strategies of division and enclosure that rely on classifications of risky bodies. as such, they supplement the government of global circulation. they re-territorialise the flow of subjects and objects and, at the same time, correspond with the governmental post-humanism just elaborated. the year before the adoption of the ihr, the un high-level panel on threats, challenges and change expressed great concern about the epidemiological vulnerabilities generated by civilian air traffic: 'any one of million international airline passengers every year can be an unwitting global disease carrier' (un : ) . in order to control this potential for pathogen transport, airports in hong kong, china or singapore had already installed cameras for infrared thermal screening during the sars outbreak (ong ) . these apparatuses hold the promise of visualising threats within circulatory flux. they aim at the identification of sick bodies by scanning the temperature of travellers for fever in a supposedly non-invasive manner. actually, the attempt to use infrared thermography to govern disease involves a range of problems. leaving aside the flaws in camera instalment, the true body core temperature always differs from the cutaneous temperature, the latter depending on the body parts selected for measurement or the outdoor temperature; moreover, persons may also be infectious without developing any increase in body temperature (mercer and ring ; nishiura and kamiya ) . nonetheless, the absence of thermal screening devices at canadian airports has, apparently, been a decisive factor, when the who issued a travel advisory for toronto and other affected areas during the sars outbreak ( van wagner : . since , the ihr authorise the who to 'recommend' the application of mass screening devices in case of a 'public-health emergency of international concern' (ihr, article ). when the who declared the influenza a h n (the 'swine flu') virus a pandemic in , entry and exit thermal screening measures were adopted at airports worldwide. the spatial logic enshrined in technologies of thermal screening corresponds with the main goal laid out in the ihr: providing security against epidemic disease while reducing the interferences with traffic and trade to a minimum. as a checkpoint technology, thermal screening controls bodies in passing. it fits the liberal imaginary of flows running through space (sutherland ) . airport architectures, form choreographies of pathways and lanes that order the movement of travellers (adey ) . metaphorically speaking, they create canals and conduits for traffic flows into which checkpoints are interpolated. through thermal screening devices, the governmental function of securing global circulation gets embedded in the nodes of transportation networks. however, as a checkpoint technology, thermal screening also differs from traditional forms of border control. to begin with, thermal screening operates beyond the hermeneutics of confession (salter : - ) . it does not want to know what the traveller has just bought or how long she will stay at her destination; the apparatus for temperature detection is neither interested in intentions nor does it test the narratives for credibility. it circumvents the moment of interrogation in its desire to 'know the fleshy body' (amoore and hall : ) as it moves within world traffic. if one were to speak about confession at all, thermal screening does not elicit confessions of the flesh but 'confessions by the flesh' (adey : ) . amoore and hall ( ) have recently described the use of backscatter x-ray devices at airports in terms of 'somatic probing […] at the border' ( ), and this characterisation clearly applies to the practice of thermal screening as well. at the same time, and in contrast to passports or biometric control, thermal screening does not seek to authenticate a person. instead of verifying a social identity, it addresses the body simply as a physical object (schillmeier : ) . by focussing on the bareness of biological life, the social person reverts to an organic entity. social markers such as gender, religion or nationality do not matter for deciding if someone is eligible to move on or not. of course, those forms of border control that operate through interrogation and authentication do not disappear. rather, thermal screening works in tandem with them, enhancing the regime of 'vigilant visualities' (amoore ) at the border through its medical design. screening technologies allow for modes of classificatory sorting. as such, they generate causes for further action. they serve the strategic goal of identifying sick bodies that may be isolated subsequently. the ihr define isolation as the 'separation of ill or contaminated persons or affected baggage, containers, conveyances, goods or postal parcels' (ihr, article ). quarantine differs from isolation by its specific preventive stance: it aims at 'the separation from others of suspect persons who are not ill or of suspect baggage, containers, conveyances or goods in such a manner as to prevent the possible spread of infections or contamination.' (ihr, article , author's own emphasis) as such, quarantine uses the spatial measure of separation to insert a delay into the movements of indeterminate bodies. this practice follows, in principle, its historical predecessors (gensini et al. ). in , the rector of the seaport of ragusa issued the trentina: ships originating from areas with plague had to stay at anchor for days before disembarking. this period was soon to be extended to days, which explains the etymological roots of quarantine. even though originally quarantine had been introduced as an alternative to simply deterring ships from landing, it was soon to be regarded as deleterious to commerce and travel. as outlined above, the international sanitary conferences from the nineteenth century were motivated by the aim of regulating quarantine in europe. yet, in , when the who implemented the original version of the ihr, the term 'quarantining diseases' disappeared. at that time, public health experts began diagnosing an 'epidemiological transition' that would eliminate the need for border quarantine with infectious disease altogether (cf. king : ; hinchliffe et al. : ) . but during the sars crisis, quarantine had its great global revival before it reentered the new ihr (cetron et al. ) . in hong kong, the authorities quarantined large parts of the amoy gardens apartments; in toronto, up to , people have been subjected to temporary arrest ( van wagner : . in parallel with the implementation of the ihr, national jurisdictions amended existing quarantine laws or issued new ones. until today, most international airports have established quarantine stations, the coordination of quarantine with screening procedures being one main issue in pandemic preparedness planning (gaber et al. ). additionally, the un ( ) has attributed the responsibility for quarantine to the security council, turning quarantine into a matter of world politics: in 'the event that a state is unable to adequately quarantine large numbers of potential carriers, the security council should be prepared to support international action to assist in cordon operations. ' ( ) in the social imaginary of quarantine, the spatial aspect of enclosure prevails. quarantine is associated with the fixation of bodies in an inner outside. yet, in order to understand quarantine's role in the government of global circulation envisioned by the ihr, one has to consider how quarantine conjoins the spatial measure of containment with a temporal calculus. quarantine reckons with the temporal lag that exists between infection and the visibility of symptoms. it operates on the indeterminacy of the body during the incubation period, that is, its potential for being a vector of contagion. quarantine is, therefore, not so much about predicting what a body can become (dillon : ) , but simply about waiting for a determinable status to emerge. if biosecurity 'today names a set of political responses within globalisation that take the unpredictability of molecular life […] as their justification' (braun : ) , then quarantine constitutes a biosecurity technology that seeks to control the dynamism inherent in life bingham : ) by containing mobile bodies. it takes bodies out of circulation temporarily and puts them at a distance to other bodies in order to see if they are actually contagious entities or not. but how can one identify the risky body that shows no symptoms at all? the ihr give a hint about how to answer this question by referring to the 'tracing of contacts of suspected or affected persons' (ihr, article ). it was again within the governmental laboratory of the sars crisis that decisions over quarantine were relegated to 'contact tracing centres'. as a study of the procedure established by the singapore ministry of health in details, the 'components of contact tracing included the following: obtaining all patient movements during the symptomatic stage; identifying the persons who had contact with the patient during these movements; and instituting follow-up action on the contacts for a -day period.' (ooi et al. : ) starting from a map of movements, contact lists were to be created and a quarantine board had to decide on the basis of these lists about whom to quarantine. according to this procedure, physical contact generates 'suspicion'. it turns a person into a 'suspect person', baggage into 'suspect baggage', or containers into 'suspect containers' (ihr, article ). quarantine thus implies a thoroughly postliberal concept of suspicion based on spatial proximity. instead of referring to a voluntarily committed deed, the suspicion relates to a potential bodily state derived from physical contacts. quarantine, in response, seeks to 'reduce transmission by increasing the "social distance" ' (cetron et al. : ) . in this governmental logic, the attribute of the 'social' has become tantamount to nothing more than material connections. quarantine, is applied to potential carriers of contagious disease who have been in contact with actual carriers and whose potential for establishing connections with other bodies shall be interrupted. it provides for moments of disconnectivity by means of spatial separation until bodies can, again, be securely released into circulation. both quarantine and thermal screening are central elements that mark out the nomosphere of global health. they are technologies of governing which entail a re-territorialisation of planetary circulation (bach ; opitz and tellmann ) . according to the famous definition put forward by the human geographer robert d. sack ( : - ) , territorial practices control relationships by configuring different degrees of access to people and things. hence, territorial practices cannot be reduced to the historically specific mode of territorialisation at work in the formation of modern state territories. instead, territorial practices have to be conceived of in a broader sense: by 'carving the environment through boundary-drawing activities' (brighenti a: ) , they 'enable the production of functions, the management of distances and the setting of thresholds between events' (brighenti b: ) . this operative control of spatio-temporal relationships and accessibilities lies at the very core of both quarantine and screening. as territorial practices designed to administer circulatory movements, they do not establish habitats, but mobilitats. despite their differences, screening and quarantine share two territorial functions. first, within the contemporary context of the 'new virologies of globalisation' (galloway and thacker : ) , they introduce practices of division into circulation. both technologies implement mechanisms for identifying risky bodies, and they do so for the purpose of differentiating the safe against the potentially dangerous elements. since these modes of classificatory sorting distinguish bodies that can pass from those that cannot, one might portray them in terms of territorial exclusion. however, it is important to note that they do not seek to secure a territory against threats coming from outside. rather, according to the rationality of the ihr, they intend to moderate circulatory flows in their immanence. the notion of 'differential inclusion' (mezzadra and neilson : ) , therefore, seems preferable for characterising the role screening and quarantine play in the current regime of global health security. it avoids the idea of an outside in favour of picturing a continuum of discriminating thresholds. furthermore, both screening and quarantine configure different degrees of mobility and immobility (salter ) . borrowing from lefebvre ( ) , they can be qualified as rhythmtechnologies: by producing flexible boundaries and temporal halts within circulatory processes, they structure the velocity of movements and the intervals of connectivities. measures such as quarantine and screening thus deploy spatial means for temporal ends. they act on infection rates in order to slow down or delay the spread of disease (cf. schlaich et al. ) . such efforts at manipulating circulation take into account both social and biological rhythms. in fact, the latter distinction loses its significance in favour of those material relations that produce frequencies of connectivity. each body may be a point of contact and contagion is the prime mechanism to be reckoned with. in a thick description of the emergency government during the sars outbreak, wang min'an ( ) has noted that sociological models have failed to make sense of this situation: 'what is needed is an antisociological account, an antisignifying account […] .' ( ) min'an has observed a decreased impact of symbols and meanings as soon as the bare physicality of bodies in divided spaces takes precedence. 'in general, then, only two types of bodies exist: virus-carrying bodies and non-virus-carrying-bodies.' (ibid.) this corpo-realism that is born out of a situation of emergency seems to have captured the imaginary of global health governance. the technologies of screening and quarantine correspond with the ihr's overall concern for the materialities of human and non-human traffic. while thermal screening addresses organic life in its physical properties, quarantine seeks to control any entityanimals, humans, conveyances or even buildingsthat has been exposed to a contagious agent. as territorial strategies, they modulate the capacities of bodies to connect both by configuring their distance and their rhythm. the findings presented in this article may inform the wider theoretical debate about how to conceive of contemporary political spaces. within the last decade, spatial theorists have, to a large extent, relied on a binary matrix that opposes absolute to relational spaces, topographies to topologies, and territories to networks (amin et al. : ) . in order to evade the 'territorial trap' so famously identified by john agnew ( ) , one had to side conceptually with the relational topologies of networks, privileging the fluid over the fixed. only recently inverse warnings about a 'nonterritorial trap' (jones : ) have re-emerged together with the efforts to integrate the different registers. the analysis presented here offers a contribution to this problematic. the nomosphere of global health security delineates a 'movementspace' (thrift ) composed of mobile bodies that act as relational transmission media. potential patterns of contagion emerge from the patterns of world traffic. on the one hand, this amounts to a 'topological landscape of embeddings and disembeddings' (hinchliffe et al. : ) in which relations are conceived of in terms of intensities. topographic distances matter less than the potential of a body to affect other bodies. at the same time, however, the extensive properties of relations remain salient. the bodily potential to affect and be affected is intertwined with topographical processes of diffusion and dissemination. distances matter strongly. yet, rather than being seen as fixed, they are conceived of as highly malleable. territorial strategies seek to re-configure distances along with permeabilities, velocities and rhythms. the nomospheric investigation of global health security thus helps us understand how territorial strategies become imbricated in global topologies. instead of opposing the territorial and the topological, it prompts the sociology of political space to think of territorial practices topologically. but how does such topological territoriality challenge the national political territory as the basic unit of the modern international order? this article started with the suggestion that the diagnosis of sars being the 'first post-westphalian pathogen' belongs to a particular problematisation of governmental space. as jean-françois lyotard ( : - ) has pointed out memorably, the suffix 'post' does not claim an absolute caesura. it much more indicates a transformation that remains indebted and tied to that which it transcends. accordingly, this article has not presented a diagnosis about a neat transition from international politics to world politics (walker ) . in a way, one just has to look at the cartographic lines on world maps in order to register the persistence of the modern state form. accordingly, the ihr do not simply bypass the state. they rather mobilise intergovernmental institutional backup for realigning the organisational capacities of states, thereby assembling a globally networked governance structure designed to control circulatory processes that harbour the potential for universal viral traffic. however, the ihr do so by changing and challenging the function of territoriality. within the framework of the modern nomos of the earth, law and territory were coupled to achieve both ordnung (order) and ortung (location) for a defined political nation. this coupling seems to dissolve as soon as globalisation can be equated with 'global mobilisation' (galli : ) . the ihr as a global juridical document establish a different conjunction between law and territory: territory turns primarily into an ordering mechanism for bodies in movement. the nomos of global circulation enshrined in the ihr, therefore, resembles what legal theorist cornelia vismann ( : ) , in a different context, has termed a 'nomadic nomos'. seen from the modernist angle, a nomadic nomos can certainly only be perceived as a paradox: a nomos without the localisation of order. nonetheless, nomodicity might in fact be the political-juridical signature of the global age, in which 'global space forms itself through a universal immediacy of mediations' (galli : ) . but what happens to the political qualities formerly associated with the act of ortung? the juridical-political laboratory of epidemic communicability simultaneously contains and hides how contemporary political collectivity is 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genealogy of global health security about the author he teaches social theory with a focus on the linkages between systems theory and poststructuralist approaches. his research addresses the temporal, spatial and material aspects of security and law. he is currently working on modes of global contagion and control. recent publications include an der grenze des rechts: inklusion/ exklusion im zeichen der sicherheit (velbrück, ) and 'future emergencies: temporal politics in law and economy key: cord- -d x rekw authors: martin, allison n.; petroze, robin t. title: academic global surgery and covid- : turning impediments into opportunities date: - - journal: am j surg doi: . /j.amjsurg. . . sha: doc_id: cord_uid: d x rekw nan the covid- pandemic has revealed cracks in the united states (us) healthcare system, laying bare the vulnerabilities of our most at-risk patients. stories of overwhelmed hospitals, critical resource limitations, and disparate outcomes in african americans affirm that the us healthcare system is both fallible and frail. surgeons working in low-and middle-income countries (lmics) are no strangers to similar public health challenges. our colleagues in lmic routinely confront complex medical and surgical issuesdperforated typhoid, traumatic fractures and prolonged labor complicationsdwith fewer resources. the burden of surgical disease disproportionately falls on the poorest countries where our surgical colleagues must also navigate the milieu of everpresent endemic diseases (i.e., malaria outbreaks, locust infestation), poverty, and food insecurity. fewer resources available in the so-called "developing world", however, do not stop development. rather, it stimulates innovation. case in pointdin the midst of the covid- pandemic, senegal, a west african country with nearly million people but just resuscitation beds has developed a covid- test that costs approximately $ and has a turnaround time of minutes. this illustration suggests that it is not the resources you have but what you do with them. indeed, we likely have much to learn from a global perspective. the last ten years have seen the rise of global surgery as an academic pursuit. academic medical centers, private citizens, and foundations have started to make financial investments to establish sustainability in the mission of academic global surgery, but the true inclusion of global surgery into the academic surgical core remains in its infancy. , still, this burgeoning investment is grounded in a fundamental lesson of global surgery: surgical disease is a disease of poverty, and the most economically depressed populations have the greatest need for surgical care. understanding the specific social determinants of health that impact patients is fundamental to improving access to safe and timely surgical care around the globe. to be clear, vulnerable populations exist both globally and locally. as the covid- pandemic has shut borders and economies around the globe, many will look internally to protect our own, and the support of global surgery programs that rely on international travel exchanges may be in jeopardy. yet, a pandemic also highlights the true interdependence of health around the world, and the impediments to sustaining academic global surgery programs are perhaps also opportunities to better develop and maintain programs that incorporate the competencies of global surgery into a future of collaborative surgical education and innovation. poverty and access to surgical care are intrinsically linked to one another. the country where you were born, the financial situation you were born into, the rurality of your towndall of these factors impact ability to access healthcare and, by extension, essential surgical, obstetric, and trauma services. as the pandemic and policies of strict social distancing spread around the globe, the most susceptible populations lay prey to diseases of poverty. there will no doubt be increased morbidity and mortality from non-covid related conditions, further exacerbating strain on global healthcare systems and economic dependence of the poorest countries on the wealthiest. in rwanda, for example, necessary social distancing policies have eliminated options for public transit, such as motos, which are the primary transportation mode for individuals of all socioeconomic statuses. loss of transportation means lack of access to healthcare facilities. we are not immune in the united states as fewer elective surgeries and healthcare visits has led to impending financial devastation for many of our nations' safety-net hospitals and medicaid providers. not surprisingly, children, minorities, and other vulnerable populations are disproportionately represented in our medicaid community. academic global surgical initiatives desire to engage colleagues in exploration of meaningful solutions to issues of access and quality. resources allocated for research and development of essential services for low-income settings have always been limited. certainly, funding for global surgery was a challenge before the covid- pandemic began. in today's new economic reality, academic departments and hospitals face challenging financial decisions to sustain themselves and their missions. as travel is canceled, we fear that global surgery programs will be first on the chopping block. we submit a call to action for surgeons to build on existing relationships and resources to engage global surgery in a more proactive-and perhaps creative-way during these challenging times. we posit that in the future, these efforts will be even more important, particularly to trainees. recent research has highlighted the lack of alignment between the availability of experiences and resources in global surgery and the high level of interest amongst students and trainees imbued with a commitment to global health equity. competencies learned through global health engagement will inform how the next generation of trainees practices medicine, which will be of greater importance in the post-covid era (if such as era even exists). the current global public health crisis illustrates resource constraints, health inequities and structural disparities in healthcare systems worldwidedleaders of tomorrow need a global view, and so it is particularly important to incorporate an academic global surgery curriculum that includes principles of ethics, health economics, disparities, and varying clinical pathologies. moreover, building strong healthcare systems the american journal of surgery j o u r n a l h o m e p a g e : w w w . a m e r i c a n j o u rn a l o f s u r g e r y . c o m relies on the development of surgical services. and strong healthcare systems around the world are necessary to prevent and treat the next pandemic. additionally, what can we do moving forward to enhance access to resources for our colleagues around the globe? does our move to online teaching for students and trainees create an opportunity for a more global classroom that can include our colleagues in lmics, truly challenging academic departments to partner with an lmic training program through telehealth? innovators around the globe have worked to develop locally-sourced personal protective equipment and ventilators, for example. this highlights a renewed opportunity for global partnerships to address surgical problems through collaborative innovation. innovation to produce technology that can help fight the spread of covid- , including low cost ventilators and locally-produced particulate-filtering masks, can be shared with colleagues in any country and can be adjusted to fit available resources. similarly, curriculums and inexpensive simulation that are developed for medical students and trainees in the us can be shared and adapted for trainees globally. the looming financial impact of the covid- pandemic on academic surgical departments and hospitals is profound and has significant long-term implications for many research and programmatic endeavors. let this be a call to action for the development of robust and sustainable academic global surgery initiatives rather than sweeping these fledgling programs under the table. a foundation in global health teaches perseverance, innovative thinking, and hope, which we could all use right now. let the unprecedented changes we are seeing be an opportunity to better integrate into the global and public health dialogue as surgeons, to drive collaborative innovation and teach our medical students and residents the fundamental interconnectedness of health around the planet. none. covid- and african americans communication and prevention are the key words global surgery : evidence and solutions for achieving health, welfare, and economic development an academic career in global surgery: a position paper from the society of university surgeons committee on academic global surgery what is global surgery? identifying misconceptions among health professionals disparate outcomes of global emergency surgery -a matched comparison of patients in developed and under-developed healthcare settings poor countries need to think twice about social distancing streamlining medicaid enrollment during covid- public health emergency next generation of global surgeons: aligning interest with early access to global surgery education the authors would like to acknowledge dr. gilbert r upchurch, jr, md for his critical edits and contributions to this manuscript. key: cord- - ikq mb authors: kotabe, masaaki; murray, janet y. title: global sourcing strategy and sustainable competitive advantage date: - - journal: industrial marketing management doi: . /j.indmarman. . . sha: doc_id: cord_uid: ikq mb abstract global sourcing strategy has been one of the most hotly debated management trends in the last years. in its early years, global sourcing was examined mostly from “in-house” development and procurement perspectives; and in the last several years, research focus has shifted to “outsourcing” activities. along with this shift from internal to external focus on global sourcing, many researchers and business practitioners have applied a core competency argument to justify increased levels of outsourcing activities on a global basis. although the beneficial aspects of outsourcing are assumed in most cases, no consensus exists in reality as to the effect of outsourcing. furthermore, the increased instability of the exchange rate environment in the last several years has also led to increased difficulties in managing globally scattered operations that were once fashionable in the s- s under the rubric of global strategy. in this article, the authors explore potential limitations and negative consequences of outsourcing strategy on a global scale. global competition suggests a drastically shortened life cycle for most products and no longer permits companies a polycentric, country-by-country approach to international business. if companies that have developed a new product do follow a country-by-country approach to foreign market entry over time, a globally oriented competitor will likely overcome their initial competitive advantages by blanketing the world markets with similar products in a shorter period of time. indeed, it is imperative for companies to continuously create and acquire capabilities that would help generate a sustainable competitive advantage over their rivals. increasingly, how to source globally has become a critical strategic decision that is influenced by the capabilities needed to compete. barney ( , p. ) has stressed that a firm possesses sustained competitive advantage when it adopts a strategy that is ''not simultaneously being implemented by any current or potential competitors and when these other firms are unable to duplicate the benefits of this strategy.'' unfortunately, product innovation alone cannot guarantee that a firm would enjoy sustainable competitive advantage. instead, it is of utmost importance for a firm to complement its product innovation with strong manufacturing and marketing capabilities. this is primarily because, in today's highly competitive market, legal means of protecting proprietary technology have become ineffective as new product innovations are easily reverse engineered, improved upon, and invented around by competitors without violating patents and other proprietary protections (baumol, nelson, & wolff, ; levin, klevorick, nelson, & winter, ) . production sharing facilitates technology diffusion through official and unofficial channels among competitors. obviously, the value of owning technology has lessened drastically in recent years as the inventing company's temporary monopoly over its technology has become transitory. history has shown repeatedly that in a highly competitive environment many manufacturers begin to either produce in lower-cost locations or outsource components and finished products from lower-cost producers on a contractual original equipment manufacture (oem) basis. howev-er, companies increasingly outsource to gain access to suppliers' capabilities (barney, ) . global sourcing strategy generally refers to management of ( ) logistics identifying which production units will serve which particular markets and how components will be supplied for production and ( ) the interfaces among r&d, manufacturing, and marketing on a global basis. the ultimate objective of global sourcing strategy is for the company to exploit both its own and its suppliers' competitive advantages and the comparative locational advantages of various countries in global competition. first, we explain the nature of global sourcing strategy as practiced by multinational companies in the last years and explore its long-term strategic implications. the world economy in the last two decades of the th century was generally characterized by relatively consistent economic growth and predictable currency fluctuations. while the nature of global competition remains the same, the global market environment has drastically changed in the last several years starting with the asian financial crisis that took place in . therefore, second, we explore some sourcing strategy implications under current turbulent times. without established sourcing plans, distribution, and service networks, it is extremely difficult to exploit both emerging technology and potential markets around the world simultaneously. as a result, the increased pace of new product introduction and reduction in innovational lead time calls for more proactive management of locational and corporate resources on a global basis. we emphasize logistical management of the interfaces of r&d, manufacturing, and marketing activities on a global basis-which we call global sourcing strategy-and also the importance of retaining the company's capability and gaining access to suppliers' capabilities to design and develop major components and finished products. these capabilities allow the company to better understand the cost and quality implications of its sourcing relationship with its suppliers. global sourcing strategy requires a close coordination among r&d, manufacturing, and marketing activities across national boundaries (kotabe & helsen, , chap. ) . there always exist conflicts in the tug-of-war of differing objectives among r&d, manufacturing, and marketing. excessive product modification and proliferation for the sake of satisfying the ever-changing customer needs will forsake manufacturing efficiency and have negative cost consequences, barring a perfectly flexible computeraided design (cad) and computer-aided manufacturing (cam) facility. cad/cam technology has improved tremendously in recent years, but the full benefit of flexible manufacturing is still many years away. contrarily, excessive product standardization for the sake of lowering manufacturing costs will also be likely to result in unsatisfied or undersatisfied customers. similarly, innovative product designs and features as desired by customers may indeed be a technological feat but might not be conducive to manufacturing. therefore, topics such as product design for manufacturability and components/product standardization have become increasingly important strategic issues. it has become imperative for many companies to develop a sound sourcing strategy in order to exploit most efficiently r&d, manufacturing, and marketing on a global basis. executives should understand and appreciate the important roles that product designers, engineers, and production managers, and purchasing managers, among others, play in corporate strategy development. let us take a look at toyota's global sourcing strategy as an example. toyota is equipping its operations in the united states, europe, and southeast asia with integrated capabilities for creating and marketing automobiles. the company gives the managers at those operations ample authority to accommodate local circumstances and values without diluting the benefit of integrated global operations. thus, in the united states, calty design research, a toyota subsidiary in california, designs the bodies and interiors of new toyota models, including lexus and solara. toyota has technical centers in the united states and in brussels to adapt engine and vehicle specifications to local needs. toyota operations that make automobiles in southeast asia supply each other with key components to foster increased economies of scale and standardization in those components-gasoline engines in indonesia, steering components in malaysia, transmissions in the philippines, and diesel engines in thailand. toyota also started developing vehicles in australia and thailand in . these new bases develop passenger cars and trucks for production and sale only in the asia-pacific region. the australian base is engaged mainly in designing cars, while the thailand facility is responsible for testing them (nikkei net interactive, ) . in addition to capitalizing on the comparative advantages of different sourcing locations and its own unique capabilities by designing and manufacturing certain components in-house, toyota also reaps the advantages of outsourcing. to outsource components and parts, toyota adopts both the arm's-length and partner models in managing their external suppliers. it would purchase necessary, but nonstrategic inputs from independent suppliers on an arm's-length basis to obtain a lower cost for these inputs. examples would be belts, tires, and batteries that are not customized and do not differentiate its products from its competitors. strategic inputs that are of high value and provide differentiation (e.g., transmission, engine parts) are sourced from suppliers based on strategic partnerships to gain access to suppliers' capabilities (dyer, cho, & chu, ) . as a result, toyota is able to combine its own and its suppliers' unique capabilities to obtain a sustainable competitive advantage over its rivals. over the last years or so, gradual yet significant changes have taken place in global sourcing strategy. the cost-saving justification for international procurement in the s and s was gradually supplanted by quality and reliability concerns in the s. however, most of the changes have been in the way business executives think of the scope of global sourcing for their companies and exploit various opportunities available from it as a source of competitive advantage. peter drucker, a famed management guru and business historian, once said that sourcing and logistics would remain the darkest continent of businessthe least exploited area of business for competitive advantage. naturally, many companies, regardless of their nationality, that have a limited scope of global sourcing are at a disadvantage over those that exploit it to the fullest extent in a globally competitive marketplace. manufacturers were under pressure to compete on the basis of improved cost and quality as just-in-time (jit) production was adopted by a growing number of companies. jit production requires close working relationships with component suppliers and places an enormous amount of responsibility on purchasing managers. furthermore, sourcing directly from foreign suppliers requires greater purchasing know-how and is riskier than other alternatives that use locally based wholesalers and representatives. locally based representatives are subject to local laws and assume some of the currency risk associated with importing. however, now that purchasing managers are increasingly making long-term commitments to foreign suppliers, direct dealings with suppliers are justified. as a global company adds another international plant to its network of existing plants, it creates the need for sourcing of components and other semiprocessed goods to and from the new plant to existing plants. global manufacturing adds enormously to global sourcing activities either within the same company across national boundaries or between independent suppliers and new plants. mature companies are increasingly assigning independent design and other r&d responsibilities to satellite foreign units so as to design a regional or world product. as a result, foreign affiliates have also developed more independent r&d activities to manufacture products for the u.s. markets in addition to expanding local sales (kotabe & swan, ) . sourcing strategy includes several basic choices companies make in deciding how to serve foreign markets. one choice relates to the use of imports, assembly, or production within the country to serve a foreign market. another decision involves the use of internal or external supplies of components or finished goods. therefore, the term ''sourcing'' is used to describe management by multination-al companies of the flow of components and finished products in serving foreign and domestic markets. sourcing decision making is multifaceted and entails both contractual and locational implications. from a contractual point of view, the sourcing of major components and products by multinational companies takes place in two ways: ( ) from the parents or their foreign subsidiaries on an ''intrafirm'' basis and ( ) from independent suppliers on a ''contractual'' basis. the first type of sourcing is known as intrafirm sourcing. the second type of sourcing is commonly referred to as outsourcing. outsourcing can further be broken down into two types: on an arm's length or strategic partnership basis. similarly, from a locational point of view, multinational companies can procure components and products either ( ) domestically (i.e., domestic sourcing) or ( ) from abroad (i.e., offshore sourcing). in developing viable sourcing strategies on a global scale, companies must consider not only manufacturing costs, the costs of various resources, and exchange rate fluctuations, but also availability of infrastructure (including transportation, communications, and energy), industrial and cultural environments, the ease of working with foreign host governments, and so on. furthermore, the complex nature of sourcing strategy on a global scale spawns many barriers to its successful execution. in particular, logistics, inventory management, distance, nationalism, and lack of working knowledge about foreign business practices, among others, are major operational problems identified by multinational companies engaging in international sourcing. some studies have shown, however, that despite, or maybe, as a result of, those operational problems, where to source major components seems much less important than how to source them (kotabe & swan, ; murray, kotabe, & wildt, ) . thus, when examining the relationship between sourcing and competitiveness of multinational companies, it is crucial to distinguish between sourcing on an ''intrafirm'' basis and sourcing on a ''contractual'' basis, for these two types of sourcing will have a different impact on their long-run competitiveness. multinational companies can procure their components inhouse within their corporate system around the world. they produce major components at their respective home base and/ or at their affiliates overseas to be incorporated in their products marketed in various parts of the world. thus, trade does take place between a parent company and its subsidiaries abroad, and also between foreign subsidiaries across national boundaries. this is often referred to as intrafirm sourcing. if such in-house component procurement takes place at home, it is essentially domestic in-house sourcing. if it takes place at a company's foreign subsidiary, it is called offshore subsidiary sourcing. intrafirm sourcing makes trade statistics more complex to interpret, since part of the international flow of products and components is taking place between affiliated companies within the same multinational corporate system, which transcends national boundaries. the most recent united nations official report shows that in , about % of world trade is managed by multinational companies on an intrafirm basis (hamdani, ) . as discussed earlier, dyer et al. ( ) have observed that japanese companies make a distinction of outsourcing as to whether it is based on an arm's length or a strategic partnership basis. in the s, foreign competitors gradually caught up in a productivity race with u.s. companies. this coincided with u.s. corporate strategic emphasis shifting from manufacturing to finance and marketing. this strategic shift was based chiefly on a cost -benefit analysis that manufacturing functions could, and should, be transferred to independent operators and subcontractors, depending on the cost differential between in-house and contractedout production. a company's reliance on domestic suppliers for major components is basically a domestic purchase arrangement. furthermore, in order to lower production costs under competitive pressure, u.s. companies turned increasingly to outsourcing of components and finished products from abroad, particularly from such countries as china, singapore, south korea, taiwan, hong kong, and mexico. initially, subsidiaries were set up for production purposes (i.e., offshore subsidiary sourcing), but gradually, independent foreign suppliers took over component production for u.s. companies. this latter phenomenon is usually called offshore outsourcing (or offshore sourcing, for short). outsourcing helps reduce fixed investment in in-house manufacturing facilities and thus lower the breakeven point, which subsequently helps boost an outsourcing company's return on equity (roe). thus, if corporate executives' performance is evaluated on the basis of their contribution to the company's roe, they tend to have a strong incentive to increase outsourcing. unlike their u.s. counterparts who historically managed all suppliers in an arm's-length fashion, japanese companies managed their outsourcing activities based on the types of inputs sourced. although many studies of supplier -assembler relationships in japan implied that all suppliers are part of the keiretsu, this perception is inaccurate (dyer et al., ) . japanese companies differentiate strategic suppliers (kankei kaisha) that fall into the keiretsu category from independent suppliers (dokuritsu kaisha) that do not. in utilizing both types of outsourcing, japanese companies are able to achieve economies of scale using arm's length transactions. at the same time, they also gain access to their suppliers' capabilities for strategic inputs by using strategic partnerships. in general, ''these inputs are not subject to industry standards and may benefit from customization due to multiple interaction effects with other components in the final product'' (dyer et al., , p. ) . it is this unique combination of the firm's and its suppliers' capabilities in producing differentiated components in a product that would provide the firm with sustainable competitive advantage. as stated earlier, global sourcing strategy requires close coordination of r&d, manufacturing, and marketing activities, among others, on a global basis. while national boundaries have begun losing their significance both as a psychological and as a physical barrier to international business, the diversity of local environments still plays an important role not as a facilitator, but rather as an inhibitor, of optimal global strategy development. now the question is how successful multinational companies can circumvent the impact of local environmental diversity. these counteracting forces have since been revisited in such terms as ''standardization versus adaptation'' ( s), ''globalization versus localization'' ( s), ''global integration versus local responsiveness' ' ( s) , and, most recently, ''scale versus sensitivity'' ( s). terms have changed, but the quintessence of the strategic supply-side and demand-side dilemma that multinational companies face today has not changed and will probably remain unchanged for many years to come. one thing that has changed, however, is the ability and willingness of these companies to coordinate various activities in an attempt either to circumvent or to nullify the impact of differences in local markets to the extent possible. it may be more correct to say that these companies have been increasingly compelled to take a global view of their businesses, due primarily to increased competition, particularly among the triad regions of the world, namely, north america, western europe, and japan. this contemporary view of competitive urgency is shared by an increasing number of executives of multinational companies, irrespective of nationality. while u.s. multinational companies have subsidiaries all over the world, they have been somewhat reluctant to develop an integrated and well-coordinated global strategy that european and japanese multinational companies have managed to establish. in addition, u.s. multinational companies have historically managed their outsourcing activities on an arm's-length basis only to achieve efficiency. indeed, european and japanese multinational companies have heavily invested in, and improved upon, their strengths in manufacturing that many u.s. multinational companies have tended to ignore. furthermore, foreign multinationals, with japanese in particular, have capitalized on differentiated outsourcing to achieve both efficiency and effectiveness. in contrast, u.s. companies tend to rely more on a sequence of new product introductions as a way to maintain their competitive advantage than on well coordinated manufacturing strategy. the lack of emphasis on manufacturing activities has been traced to u.s. management's strategic emphasis having drifted away from manufacturing to marketing and to finance over the years. as a result, manufacturing management gradually lost its influence in the business organization. production managers' decision-making authority was reduced such that r&d personnel prepared specifications with which production complied and marketing imposed its own delivery, inventory, and quality conditions, but not productivity considerations. in a sense, production managers gradually took on the role of outside suppliers within their own companies. production managers' reduced influence in the organization led to a belief that manufacturing functions could be transferred easily to independent operators and subcontractors, depending on the cost differential between in-house and contracted-out production. thus, in order to lower production costs (i.e., to improve roe) under competitive pressure, u.s. multinational companies turned increasingly to outsourcing of components and finished products from such countries as china, south korea, taiwan, singapore, hong kong, and mexico, among others. akio morita, a cofounder of sony, a highly innovative japanese electronics company, once chided such u.s. multinational companies as ''hollow corporations'' that were increasingly adopting a ''designer role'' in global competition-offering innovations in product design without investing in manufacturing process technology and simply putting their brand names on foreign-made products (business week, ). however, we should not rush to a hasty conclusion that outsourcing certain components and/or finished products from foreign countries will diminish a company's competitiveness. many multinational companies with plants in various parts of the world are exploiting not only their own and their suppliers' competitive advantages (e.g., r&d, manufacturing, and marketing skills) but also the locational advantages (e.g., inexpensive labor cost, certain skills, mineral resources, government subsidy, and tax advantages) of various countries. thus, it is also plausible to argue that these multinational companies are in a more advantageous competitive position than are domestic-bound companies. then, is the ''hollowing-out'' phenomenon not indicative of a superior management of both corporate and locational resources on a global basis? what is wrong, if any, with ibm procuring most of its components for its personal computers from independent domestic and foreign suppliers? how about honeywell marketing in the united states the products manufactured in its european plants? answers to these questions hinge on a company's ability and willingness to integrate and coordinate various activities and also strategically capitalizing on outsourcing activities based on the types of advantages desired. there are two opposing views of the long-term implications of offshore sourcing especially for strategic inputs, dependent on whether the company would differentiate outsourcing activities based on an arm's-length or a strategic partnership basis. many successful companies have established strategic partnerships with their suppliers by developing a dynamic virtual organizational network through increased use of joint ventures, subcontracting, and licensing activities across international borders. however, if suppliers for strategic inputs are managed based on an arm's length basis, there could be negative long-term consequences resulting from a company's dependence on independent suppliers and subsequently the inherent difficulty for the company to keep abreast of constantly evolving design and engineering technologies without engaging in those developmental activities. in this case, companies fail to coordinate and integrate their suppliers' design and production as part of their own activities, as would be the case using strategic partnerships. these two opposing arguments will be elaborated below. a network of loosely coupled strategic alliances allows each participant to pursue its particular competence. therefore, each network participant can be seen as complementing rather than competing with the other participants for the common goals. strategic alliances may even be formed by competing companies in the same industry in pursuit of complementary abilities (new technologies or skills) from each other. the advantage of forming a virtual network is claimed to be its structural flexibility. such a network of loosely coupled partnerships can accommodate a vast amount of complexity while maximizing the specialized competence of each member, and provide much more effective use of human resources that would otherwise have to be accumulated, allocated, and maintained by a single organization. in other words, a company can concentrate on performing the task at which it is most efficient. this approach is increasingly applied on a global basis with countries participating in a dynamic network as multinational companies configure and coordinate product development, manufacturing, and sourcing activities around the world. first, due to the need for fast internationalization and related diversification, such alliances provide a relatively easy option to access the world markets, thus allowing the firms in the network to create and maintain a sustainable competitive advantage by combining capabilities and technologies in a unique way. second, reduced investment requirement for each participating company helps improve its roe. thus, for example, at&t needed olivetti's established european network to enter the european market for telephone switchboard equipment. similarly, toyota established a joint venture with general motors so that the japanese carmaker could learn to work with uaw union members while general motors could learn just-in-time inventory management from toyota. in contrast with outsourcing based on strategic partnerships, companies that rely on independent external sources of supply of major components tend to forsake part of the most important value-creating activities to, and also become dependent on, independent operators for assurance of component quality. furthermore, those multinational companies tend to promote competition among independent suppliers, ensure continuing availability of materials in the future, and exploit full benefits of changing market conditions. in addition, in an arm's length arrangement, competing firms (e.g., in the united states) tend to share a common set of suppliers (dyer et al., ) , thus diluting the degree of differentiation of these major components to the buying firms. by attempting to maintain various sources of supply and a high degree of relative bargaining power, companies (e.g., in the united states) may have also restricted the size and scale of their suppliers. furthermore, individual suppliers are forced to operate in an uncertain business environment that inherently necessitates a shorter planning horizon. the uncertainty about the potential loss of orders to competitors often forces individual suppliers to make operating decisions that will likely increase their own long-term production and materials costs. in the process, this uncertain business environment tends to adversely affect the multinational companies sourcing components and/or finished products from independent suppliers. the rapid decline of ibm offers a vivid classic example of the problems caused by its dependence on independent suppliers for crucial components in the personal computer market. those multinational companies that depend heavily on independent suppliers on an arm's-length basis (i.e., without integrating their suppliers into their activities) also tend in the long run to lose sight of emerging technologies and expertise, which could be incorporated into the development of new manufacturing processes as well as new products. thus, continual sourcing from independent suppliers, as opposed to sourcing based on strategic partnerships, is likely to forebode companies' long-term loss of the ability to manufacture at competitive cost and, as a result, loss of their global competitiveness. however, if technology and expertise developed by a multinational company are exploited within its multinational corporate system (i.e., by its foreign affiliates and by the parent company itself), the company can retain its technological base to itself without unduly disseminating them to competitors. the benefit of such internalization is likely to be great, particularly when technology is highly idiosyncratic or specific with limited alternative uses, or when it is novel in the marketplace. for such a technology, the market price mechanism is known to break down as a seller and potential buyers of the technology tend to see its value very differ-ently. potential buyers, who do not have perfect knowledge of how useful the technology will be, tend to undervalue its true market value. as a result, the seller of the technology is not likely to get a full economic benefit of the technology by selling it in the open market. in addition, by getting involved in design and production on its own or through strategic partnerships, the multinational company can keep abreast of emerging technologies and innovations originating anywhere in the world for potential use in the future. furthermore, management of the quality of major components is required to retain the goodwill and confidence of consumers in the products, which may be impossible using arm's-length outsourcing. maintaining the ability to develop major components and finished products in-house or via strategic partnerships allows the company to better understand the cost and quality implications of its sourcing relationship even with its suppliers. since the asian financial crisis took place in , the world economy has continued to stagnate with many uncertainties that have ensued. the financial crisis in asia was followed by the terrorist attack on america in , and argentina's financial crisis worsened in . these crises have finally sent the world economy into a global slowdown. furthermore, the aftermath of the u.s.-led war against iraq and the mysterious illness, known as severe acute respiratory syndrome (sars) spreading from china in continue to curb the weak world economy from recovering. as a result, asia's once booming economies are still fragile, liquidity problems are hurting regional trade, and losses from asian investments are eroding profits for many multinational companies. many u.s. companies that have large investments in asia have reported less than expected earnings. for example, the unsettling ups and downs of the dow jones industrial average reflect the precarious nature of u.s. investments in asia. these economic, political, and natural crises and their ramifications could not only have far-reaching economic consequences but also force many companies to adopt new business views and practices for competing around the world at the dawn of the new century. the global strategy models popularized by bartlett and ghoshal ( ) and porter ( ) , among others, are predicated on a complex configuration of assets and capabilities that are specialized but also dispersed. let us focus on asia as it is a major region in which many multinational companies have established procurement bases. many foreign companies operating in asian countries tend to procure certain crucial components and equipment from their parent companies or from strategic suppliers overseas. now that asian currencies depreciated precipitously during the region's financial crisis, those foreign companies are faced with those imported components and equipment whose prices have gone up enormously in local currencies. in other words, the more dispersed the company's and it's suppliers' assets and capabilities are, the more difficult it is for them to manage wild currency fluctuations. financial hedging has failed to help much. companies that have localized procurement do not have to be affected easily by fluctuating exchange rates. as a result, many companies are also scurrying to speed steps toward making their operations in asian countries more local. suffering from the recession in their domestic market as well as being most seriously affected by the asian financial crisis, japanese companies seem to stay one step ahead of u.s. and european competitors in this localization strategy. since the yen's sharp appreciation in the mid- s, japanese manufacturers have moved to build an international production system less vulnerable to currency fluctuations by investing in local procurement and more recently have begun to transfer r&d activities to local markets (nikkei weekly, , . in addition, these japanese companies have demanded that their strategic suppliers also locate their supply base in these local markets. a case in point: after honda set up its production in marysville, oh, many honda's japanese suppliers have also invested in ohio or elsewhere in the united states for producing components and parts to be close to honda's assembly plant. when financial hedging could not cope with the extensive currency fluctuations, companies are known to resort to operational hedging. operational hedging is to shift production and procurement abroad to match revenues in foreign currency. for example, by producing abroad all of the products a company sells in foreign markets, this company could create an operational hedge by shielding itself from fluctuating exchange rates (bodnar & marston, ) . this localized production and marketing strategy is fundamentally different from local responsiveness, as originally envisioned by bartlett and ghoshal ( ) . current localization movement is to address the wild, and sometimes unexpected, currency fluctuations rather than local market needs per se. on the other hand, due to constant cost pressures from many competitors, the need for global integration still remains strong for the sake of cost efficiency. however, a number of new questions have begun to emerge. in an era of technological obsolescence, no one company possesses the capabilities needed to maintain a sustainable competitive advantage for long. would outsourcing based on strategic partnerships take on a more important role than in-house sourcing? how could the benefits of global integration be achieved in a localization strategy? could the results of homegrown r&d activities be easily transferred to local subsidiaries or affiliates for local product development? how could a transnational company manage increasingly localized production and marketing without relinquishing too much autonomy to local subsidiaries and affiliates? these questions beg for answers. the scope of global sourcing has expanded over time. whether or not to procure components or products from abroad was once determined strictly on price and thus strongly influenced by the fluctuating exchange rate. thus, the appreciation of the dollar prompted companies to increase offshore sourcing, while the depreciation of the dollar encouraged domestic sourcing. today, many companies consider not simply price but also quality, reliability, and technology of components and products to be procured. these companies design their sourcing decision on the basis of the interplay between their competitive advantages and the comparative advantages of various sourcing locations for long-term gains. global sourcing strategy requires close coordination of r&d, manufacturing, and marketing activities on a global basis. managing geographically separated r&d, manufacturing, and marketing activities, those companies face difficult coordination problems of integrating their and their suppliers' operations and adapting them to different legal, political, and cultural environments in different countries. furthermore, separation of manufacturing activities involves an inherent risk that manufacturing in the value chain will gradually become neglected. such neglect can be costly as continued involvement in manufacturing tends to lead to pioneering product design and innovation over time. an effective global sourcing strategy calls for continual efforts to streamline manufacturing without sacrificing marketing flexibility. the global strategy model of the s - s drove home why it is imperative for globally operating companies to develop an organizational mechanism by which to benefit from both global integration and local responsiveness. depending on dispersed assets, specialized operations, and interdependent relationships among units of a company, bartlett and ghoshal ( ) , for example, described the plausible parent -subsidiary relationships for ''peacetime'' transnational solutions. however, they fell short of offering specific solutions as to how to cope with the world market not so peaceful, characterized by wild and unpredictable currency fluctuations as well as other unfortunate regional events. they developed a very useful conceptual framework to address the climate of the time of the s - s. the climate has changed since the asian financial crisis that wreaked havoc over what could otherwise have been a stable and growing world economy. although it is beyond the scope of this article, one broad solution may be found in modular production, or the application of modular design capabilities in product development (bettis & hitt, ; sanchez, ; schilling, ) . again, this view is consistent with global marketers' four alternative specifications on global product policy. modular production generally refers to the process of assembling final products from a number of predetermined and interchangeable modules. the fundamental difference, however, is that modular production could reduce the inherent difficulty in technology transfer, in particular, that of tacit knowledge, between units of a company, thereby making decentralized/localized production feasible without losing the benefits of global integration. another solution is attaining strategic flexibility in sourcing. companies should design their structure to include a combination of a quasihierarchical and a pure hierarchical governance structure for different activities or operations in order to ''integrate, build, and configure internal and external competences to address rapidly changing environments'' (teece, pisano, & shuen, , p. ) . a combination of a quasi-hierarchical (e.g., strategic partnerships with suppliers) and a pure hierarchical governance structure allows a firm not only to exploit its own capabilities, but also to explore new capabilities or technologies through learning from its partners, sharing risks and gaining synergy. clearly, more research is needed. one thing is clear: globally operating companies need to be in constant search of methods to ''kill two birds with one stone,'' or meeting supply-side and demand-side counteracting forces head-on for their sustainable competitive advantage. firm resources and sustained competitive advantage how a firm's capabilities affect boundary decisions managing across borders convergence of productivity: cross-national studies and historical evidence the new competitive landscape a simple model of foreign exchange exposure (working paper) special report: the hollow corporation strategic supplier segmentation: the next ''best practice'' in supply chain management the role of foreign direct investment in export strategy. (a paper presented at) executive forum on national export strategies, international trade centre, the united nations global marketing strategy offshore sourcing: reaction, maturation, and consolidation of u.s. multinationals appropriating the returns from industrial research and development strategic and financial performance implications of global sourcing strategy: a contingency analysis toyota, nissan, mitsubishi to expand overseas development bases manufacturers reshape asian strategies. and japanese r&d trickling overseas: skilled, cheap work forces in other asian nations attracting japanese firms competition in global industries modular architecture in the marketing process towards a general modular systems theory and its application to inter-firm product modularity dynamic capabilities and strategic management masaaki kotabe is the washburn chair professor of international business and marketing at the fox school of business and management at temple university murray is the associate professor of marketing and international business at john cook school of business at key: cord- - nc d v authors: aylward, r bruce; acharya, arnab; england, sarah; agocs, mary; linkins, jennifer title: global health goals: lessons from the worldwide effort to eradicate poliomyelitis date: - - journal: lancet doi: . /s - ( ) - sha: doc_id: cord_uid: nc d v the global polio eradication initiative was launched in . assessment of the politics, production, financing, and economics of this international effort has suggested six lessons that might be pertinent to the pursuit of other global health goals. first, such goals should be based on technically sound strategies with proven operational feasibility in a large geographical area. second, before launching an initiative, an informed collective decision must be negotiated and agreed in an appropriate international forum to keep to a minimum long-term risks in financing and implementation. third, if substantial community engagement is envisaged, efficient deployment of sufficient resources at that level necessitates a defined, time-limited input by the community within a properly managed partnership. fourth, although the so-called fair-share concept is arguably the best way to finance such goals, its limitations must be recognised early and alternative strategies developed for settings where it does not work. fifth, international health goals must be designed and pursued within existing health systems if they are to secure and sustain broad support. finally, countries, regions, or populations most likely to delay the achievement of a global health goal should be identified at the outset to ensure provision of sufficient resources and attention. the greatest threats to poliomyelitis eradication are a financing gap of us$ million and difficulties in strategy implementation in at most five countries. increasing travel and globalisation of commerce has farreaching implications for health. , substantial attention has been given to the threats that globalisation poses to the management of infectious diseases, but less to its opportunities. , heightened international awareness of the burden and threat of many infectious diseases has spawned partnerships and alliances to coordinate additional resources for their control. though the most cited example of international collaboration is the global fund to fight aids, tuberculosis and malaria, it is only the most recent. perhaps the best example of such collaboration was the successful international effort to eradicate smallpox in the s and s. more recently, coordinated efforts to combat global health threats have included the global partnership to stop tb, the roll back malaria initiative, and the global alliance for vaccines and immunization (gavi). innovative strategies have also been established to tackle non-communicable diseases, most notably through the framework convention on tobacco control. common to these initiatives has been the conviction that coordinated international action is in the interest of all countries. it has even been argued that these initiatives are "global public goods for health". the effort to eradicate poliomyelitis is one such initiative, since once eradication has been achieved, everyone will be protected from the virus and one person's protection will not reduce that available to others. , in this paper, we assess the politics, production, financing, and economics of poliomyelitis eradication to identify lessons that might be relevant to the pursuit of other global health goals. the decision to pursue eradication the successful conclusion of the international smallpox eradication campaign in created substantial interest in further eradication efforts. however, enthusiasm was countered by concerns that targeted objectives could compromise efforts to develop strong primary health-care systems and by doubts about the technical feasibility of eradicating any organism after smallpox. , the most important factor in overcoming scientific concerns was the interruption of poliovirus transmission in large areas of the americas by use of a four-pronged strategy. the leadership for launching a global poliomyelitis eradication initiative was secured at a meeting in march, , at which the who director-general was convinced of the merit of such an effort. , months later, the world health assembly, consisting of the ministers of health of all member states, unanimously adopted a poliomyelitis eradication resolution. the eradication goal was subsequently reviewed and endorsed by the world summit for children-the largest ever gathering of heads of state. leaders from lowincome, middle-income, and high-income countries have continued to reaffirm their commitment to poliomyelitis eradication through resolutions adopted in forums such as the organization of african unity, the south asian association for regional cooperation, and g summits. [ ] [ ] [ ] implementation of strategies by the end of , every country had introduced the who-recommended poliomyelitis eradication strategies or a variant thereof, but the effort required to do so was correlated inversely with countries' incomes. in the few high-income countries in which poliomyelitis cases were reported in (eg, france and spain) elimination of the virus was relatively straightforward because of temperate climate, higher vaccine effectiveness in such settings, high levels of sanitation, and strong health systems. by contrast, eliminating endemic poliomyelitis from low-income countries has required massive efforts sustained for - years. implementation of national immunisation days (nids) has been a huge challenge; in china and india, for example, about million and million children, respectively, were immunised in a few days-the achievement was repeated month later, and then annually global health goals: lessons from the worldwide effort to eradicate poliomyelitis the global polio eradication initiative was launched in . assessment of the politics, production, financing, and economics of this international effort has suggested six lessons that might be pertinent to the pursuit of other global health goals. first, such goals should be based on technically sound strategies with proven operational feasibility in a large geographical area. second, before launching an initiative, an informed collective decision must be negotiated and agreed in an appropriate international forum to keep to a minimum long-term risks in financing and implementation. third, if substantial community engagement is envisaged, efficient deployment of sufficient resources at that level necessitates a defined, time-limited input by the community within a properly managed partnership. fourth, although the so-called fair-share concept is arguably the best way to finance such goals, its limitations must be recognised early and alternative strategies developed for settings where it does not work. fifth, international health goals must be designed and pursued within existing health systems if they are to secure and sustain broad support. finally, countries, regions, or populations most likely to delay the achievement of a global health goal should be identified at the outset to ensure provision of sufficient resources and attention. the greatest threats to poliomyelitis eradication are a financing gap of us$ million and difficulties in strategy implementation in at most five countries. for more than years. , because of the huge numbers of people and vehicles required to implement nids, governments of many countries have drawn heavily on the private sector, as well as on ministries of information, transport, and defence, among others, to help reach all children. people crossing borders can transmit poliomyelitis during the interval between nids being held in one country and in its neighbour. recognising this factor, many countries have synchronised their nids (figure ). in operation mecacar for example, asian, european, and middle eastern countries immunised million children in april and may, , and repeated the activity each year for years. similar coordination followed in south asia, west africa, , and then central africa, where the conflict-affected countries of the democratic republic of the congo, angola, congo, and gabon synchronised three rounds of nids in july-september, , to immunise million children. , by the year , all poliomyelitis-affected countries were reporting standardised data for acutely paralysed children and surveillance performance to who either weekly or monthly. central to this surveillance capacity has been a worldwide laboratory network for enterovirus diagnosis that now comprises facilities. even in conflict-affected areas such as afghanistan, the democratic republic of the congo, and somalia, surveillance in was nearing the international standard that will be required for poliomyelitis-free certification. coordination though poliomyelitis eradication activities have been led, coordinated, and implemented by the governments of poliomyelitis-affected countries, the support of a publicprivate partnership has been essential. this partnership, spearheaded by who, rotary international, the us centers for disease control and prevention (cdc), and unicef has facilitated the inputs of donor governments and a vast array of other organisations. the most remarkable of these partners is rotary international, a private-sector service organisation, which will have contributed nearly us$ million of its own resources by the end of in addition to mobilising much of the money contributed by governments. to coordinate this partnership, mechanisms were established at global, regional, and country levels for strategic planning, policy development and priority setting, resource mobilisation, and financing. additional mechanisms were established to manage the laboratory network and govern the process for eventually certifying the world as free from poliomyelitis. direct costs a conservative estimate of the financial and in-kind expenditures in poliomyelits-endemic countries was generated on the basis of the number of hours worked per country to implement nids, the most expensive and labour-intensive eradication strategy. without wishing to diminish the broader significance of this largely volunteer effort to the success of the initiative, for the purposes of economic evaluation it has been valued by use of labour market rates from the statistical database for the year world development indicators. on the basis of these calculations, poliomyelitis-endemic countries will have contributed at least $ · billion in wages alone between and . this figure does not include substantial government and private-sector resources to pay for petrol, social mobilisation, training, and other costs. many of these people were government employees who were temporarily released from regular duties. between and , external sources will have provided at least $ billion to poliomyelitis-endemic countries. of more than external donors to date, have already contributed more than $ million and at least $ million (table ) ; some, such as rotary international, are not traditional sources of overseas development assistance. central tracking of resource requirements and funding flows, and multilateral and bilateral funding mechanisms, have enabled efficient accommodation of the needs of donors and recipient countries. the total cost of poliomyelitis eradication during - will be more than $ billion. a cost-benefit analysis of the paho regional programme noted ". . . polio eradication appeared economically justified solely in terms of reduced treatment costs, irrespective of reduced pain, suffering and incapacitation", calculating that the net present value of discounted savings during a -year period from the start of the campaign was $ · million. a similar analysis for worldwide eradication throughout - showed that even when including only the savings in direct costs for treatment and rehabilitation, " . . . the 'break-even' point at which benefits exceeded costs was the year , with a saving of us$ million by the year ". the cost-effectiveness of global poliomyelitis eradication was reassessed for - to analyse the potential effects of poliomyelitis immunisation policies that might be adopted after worldwide certification of eradication. from an economic perspective, the best-case scenario was assumed to be cessation of routine immunisation with the oral poliomyelitis vaccine as soon as possible after interruption of wild poliovirus. the worst-case scenario was assumed to be replacement of this vaccine by universal childhood immunisation with the more expensive inactivated poliovirus vaccine to reduce the risk of vaccine-associated paralytic poliomyelitis or poliomyelitis outbreaks due to a circulating vaccine-derived poliovirus. [ ] [ ] [ ] in this analysis, even in the worst-case scenario, poliomyelitis eradication would save money in all countries, apart from low-income countries where the cost per discounted disabilityadjusted life-year (daly) saved would still be low, at about $ (table ) . the world health assembly resolution that launched the global polio eradication initiative stated that eradication should be pursued in ways that strengthened the delivery of primary health-care services in general and immunisation programmes in particular. what has been the effect of poliomyelitis eradication activities on the delivery of specific health services or the development of health systems? three irrefutable benefits have included widespread vitamin a distribution, enhanced global surveillance capacity, and improved worldwide cooperation between enterovirus laboratories. , by distributing vitamin a supplements during poliomyelitis nids, an estimated childhood deaths were averted during - alone, and the value of using immunisation contacts to deliver micronutrient supplements was widely reinforced. , the surveillance capacity developed for poliomyelitis eradication has also been used to detect and respond to outbreaks of diseases such as measles, meningitis, cholera, and yellow fever. the poliomyelitis-eradication infrastructure and capacity was also used to assist in the international effort to control severe acute respiratory syndrome (sars). however, effects on routine immunisation services have been controversial. [ ] [ ] [ ] the poliomyelitis initiative has invested heavily in physical and human resources for routine immunisation. the cold chain, communications, and transport capacity have been replaced or refurbished in many low-income countries, especially in sub-saharan africa, and tens of thousands of people have been trained or retrained worldwide in giving vaccinations. questions have been asked, however, as to whether short-term disruptions by nids in the delivery of routine immunisation and other services will have long-term consequences. evaluation of the effect on health systems has been hampered by a lack of credible baseline data, the absence of control groups, and the concurrent implementation of major health-system reforms, such as decentralisation and sector-wide approaches. , most commentators agree that there are positive synergies between poliomyelitis eradication and development of health systems, but opportunities have yet to be fully exploited. , status of eradication and risks to completion when the world health assembly voted to eradicate poliomyelitis in , more than countries (defined by year geographic borders) on five continents were known or suspected to have indigenous transmission of wild poliovirus (figure ). though only cases were reported worldwide that year it is estimated that more than children were actually paralysed. , more than % of the reported cases in were in low or lower-middle income countries and half were in the asian subcontinent-mostly in india. outside the americas, few areas were free of poliomyelitis-mainly industrialised countries and small island nations. by the end of , poliomyelitis was on the brink of eradication, with only ten countries in which it was endemic and virologically confirmed cases that year. by the end of , only seven countries-the lowest number ever-were known to have endemic poliomyelitis (figure ). the total number of cases exceeded that of , however, because of marked increases in india and nigeria ( figure ). in india, the increase was due to an epidemic that originated in the northern state of uttar pradesh and spread rapidly to adjoining and distant states, many of which had been free from poliomyelitis for some years. by contrast, the increase in nigeria was largely due to improved reporting in the north of the country. complete eradication of poliovirus transmission will require overcoming challenges at national and international levels. at the national level, it will be essential to close gaps in the quality of supplementary immunisation activities in the six states or provinces of india, nigeria, and pakistan that accounted for % of poliomyelitis cases in . northern india in particular poses challenges, since the combination of a weak health infrastructure, fragile political alliances and, to a lesser degree, suspicion of government services by minority communities, has hampered efforts to mobilise all sectors of society and reach every child. in parts of afghanistan, eastern angola, and the mogadishu area of somalia, continued improvement in access to children is needed to break the few remaining chains of virus transmission in these areas. internationally, the main challenge will be closing the $ million funding gap for activities planned for - , while maintaining political visibility of, and commitment to, the eradication of a disappearing disease. increasingly, international discussion and debate has focussed on future poliomyelitis immunisation policy. from the outset of the eradication initiative, much of the attraction of this international health goal has been the argument that its achievement would reap economic as well as humanitarian benefits. these economic benefits would accrue mainly if and when poliomyelitis immunisation could stop. that these economic benefits could accumulate in perpetuity underpinned the arguments of the champions of poliomyelitis eradication, engaged political leadership, and mobilised stakeholders, in particular those from the private sector. however, several factors have complicated the development of, and consensus on, future immunisation policy. these factors range from increasing evidence that vaccine-derived polioviruses can, albeit rarely, regain the capacity to circulate and cause outbreaks, to increasing concerns about the use of biological agents. [ ] [ ] [ ] [ ] although cessation of immunisation with the oral poliovirus vaccine remains a major objective of the eradication initiative, much work is required to establish the scientific soundness, operational feasibility, and economic rationale for the strategies that have been proposed to achieve this end. in this review of the poliomyelitis eradication initiative, we have derived six lessons that could assist the planning and pursuit of worldwide health goals, whether global public goods for health or other health efforts in which international collective action might be warranted. first, and perhaps foremost, is the need for proven tools and technically sound strategies. additionally, their operational feasibility should be demonstrated conclusively on a large geographical scale, under as many conditions as possible, before attempting to launch a worldwide effort. international consensus on poliomyelitis eradication was achieved only after it had been shown in the americas during the s that strategies could be massively scaled i n d i a n i g e r i a p a k i s t a n a f g h a n i s t a n up and implemented in regions with extremely weak health systems, or that were affected by conflict, or both. such proof is essential for obtaining and sustaining the political and financial support required for the - years needed to pursue most international health goals. the second lesson is that any international health goal should be strongly endorsed at the highest possible level, arguably the world health assembly. such endorsement will be essential for dealing with the debate and concerns that will arise as the programme is scaled up and opportunity and other costs are increasingly evident and better understood. although prominent champions had a major role in promoting global eradication of poliomyelitis, the decision to launch the initiative followed debate at the world health assembly. despite consensus at that forum, an often heated debate has flared as to whether the opportunity costs of eradication outweigh benefits. of especial concern has been whether the deployment of resources has compromised the strengthening of health systems in resource-poor countries, or limited their capacity to control other diseases. it has also been noted that some delegates to the assembly in might not have made a truly informed decision on the launching of the initiative, since there had been no clear statement on resource requirements or strategies. these debates have contributed to the programme's chronic funding gap, and to the late introduction of key strategies in some countries. the cost-effectiveness analyses summarised in this paper suggest that all countries stand to benefit from this investment irrespective of income level, but this assessment is not universally accepted. a third lesson is that efficient management is needed to achieve the necessary scale of collective action. two major factors facilitated participation in the eradication initiative: a well defined, time-limited ( - days) demand on the community, and sufficient resources to enable the community to implement activities. ensuring sufficient resources required moving beyond building an international health partnership to managing one efficiently. critical to achieving efficiency was the use of common strategic plans, clear roles and responsibilities, and national and international forums to coordinate financing, human resources, and institutional arrangements. fourth, given the amount of external financing required to achieve international health goals, strategies will usually necessitate targeting political decision-makers, by means such as professional lobbying firms and international forums to establish the commitment of heads of state. because all countries will benefit economically from poliomyelitis eradication, rotary international, as part of its advocacy strategy, calculated so-called fair shares of the total budget to be financed by each major donor country, based on their contributions to who's regular budget. however, only of the who member states that traditionally give overseas development assistance had contributed to the eradication initiative by mid- . of these, seven contributed the equivalent or more than their estimated fair share and nine substantially less. the six countries that did not contribute are free riders in economic terms, since they will share in the benefits. while the fairshare concept is of great value for setting resource mobilisation targets and negotiating appropriate contributions with interested donors, it has substantial limitations. most importantly, it will not mobilise funds from donors who did not fully endorse the goal in the first place. pursuing the fair-share argument can also unveil basic, irreconcilable disagreements on their calculation. such limitations must be recognised early and alternate strategies developed for settings where this argument alone is not sufficient. fifth, worldwide health goals should be designed so that they can be pursued within existing health systems and, ideally, contribute to the strengthening of these systems. although proponents have stated that poliomyelitis eradication strengthens other health services, they and their detractors have used anecdotal information to argue their cases because of a lack of objective criteria and indicators. of note, some of the largest donors to poliomyelitis eradication are those who are institutionally committed to the strengthening of health systems, but who joined the initiative after reconciliation of concerns about the effect on the delivery of other services. however, proponents of future worldwide health goals should recognise the challenge of measuring such indirect benefits, be modest in arguing their worth, and ensure there are agreed indicators and the capacity and mechanisms for their monitoring. the final lesson is the need to identify countries, regions, or populations where strategy implementation will be particularly challenging, and to establish appropriate contingency plans. failure in just one country could be catastrophic for an eradication effort. however, other international health goals might be similarly compromised. for example, the emergence of multidrug-resistant strains of tuberculosis in one country could hamper worldwide efforts to combat that disease. similarly, uncontrolled use of antibiotics in a few countries could seriously affect international work to contain antimicrobial resistance. as the poliomyelitis eradication programme began to be implemented on a truly worldwide scale in the mid- s, substantial attention was given to the ten countries that had been identified as at particularly high risk for delaying global eradication. as a result of focusing additional human, financial, and political resources in these areas, five of those countries (bangladesh, the democratic republic of the congo, sudan, ethiopia, angola) now seem to have eradicated poliomyelitis, and only three (india, nigeria, pakistan) continue to have high-intensity transmission. although it is tempting to suggest that even greater attention earlier in the programme might have accelerated progress in these areas, the reality is that scant resources necessitated a more pragmatic approach. other international health goals will require a similar, pragmatic approach to achieve and secure gains where possible, while developing the necessary political, financial, and human resources to address the most challenging areas. contributors r b aylward wrote the introductory, status, and lessons sections, and edited the manuscript. s england developed the concept and original structure and wrote the first draft of the manuscript. m agocs did research, in particular on the background, history, and indirect benefits of poliomyelitis eradication, and wrote those sections. a acharya did the cost-effectiveness analysis. j linkins did the analysis of the direct national and international costs of poliomyelitis eradication and wrote the section in which they are detailed. none declared. macroeconomics and health: investing in health for economic development: report of the commission on macroeconomics and health. geneva: world health organization the globalization of public health, i: threats and opportunities the global fund to fight aids the intensified public health the lancet • geneva: world health organization donor responsibilities in rolling back malaria a paradigm for international cooperation: the global alliance for vaccines and immunization (gavi) and the vaccine fund who framework convention on tobacco control: a global "good" for public health health is wealth communicable disease control: a global public good perspectiveworking paper. geneva: world health organization global public goods: international cooperation in the st century global eradication of poliovirus: history and rationale report on the international conference on 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[ ] [ ] [ ] global health organisations are mostly head-quartered in hics, and run by people, primarily men, from hics. further, authorship of global health publications is dominated by people in hics, [ ] [ ] [ ] as well as editorial boards of global health journals. what about global health education? in the past two decades, global health has become very popular among students in hics. in response to higher demand and availability of increased funding, many hic universities invested heavily in global health programmes. although dozens of degree programmes in global health emerged as a consequence, it remains unclear who the target audience really is, and what it might cost to earn one of these degrees. are these degree programmes aimed at lmics, where training gaps are enormous, or are they primarily for the benefit of hic trainees and institutions? to answer this question, we identified academic programmes that offer either a master's of global health or a master's of international health degree. we used the academic global health programmes database maintained by the consortium of universities for global health (cugh), supplemented by online searches for universities not included in the cugh list (see box for details). we focused on master's of global or international health programmes (on campus or online), rather than related degrees such as master's of public health (mph) which might offer global health concentrations, options or tracks. in all, out of global or international health master's degrees identified, we were able to gather information for degree programmes, as of march . table outlines details for each degree programme considered for this analysis. as shown in figures , ( %) were located in north america, ( %) in europe, ( %) in western pacific, ( %) in asia and ( %) africa. nineteen ( %) of the degree programmes were -year programmes, and the rest could be completed over a longer period. of the degree programmes, five ( %) were entirely on-line (distance education), while the rest were on-campus. results for average tuition fees for master's degrees in global or international health are displayed in table . on average, across all degree programmes, the mean tuition fee was us$ for international students-usually defined as students who undertake studies outside their country of residence-and us$ for domestic students-usually defined as students who undertake studies in a country where they hold citizenship or other documented residency status. most programmes in our analysis ( %) were based in hics, with an average tuition of us$ . the mean tuition fee for online-option degrees (degrees which can be completed either in part or in full away from the traditional campus setting) was us$ vs us$ for on-campus programmes. on average, tuition for programmes in privately funded schools were considerably higher than for public schools, us$ and us$ , respectively. for the programmes in the usa, the average tuition fee for all students was us$ . there was little difference between domestic and international student fees (us$ for domestic vs us$ for international students). for programmes in the uk, the average tuition fee was us$ for domestic vs us$ for international students. in nordic countries (i.e., sweden and norway), the tuition was us$ for domestic students but an average of us$ for international students. interestingly, the degree programmes in asia and africa were associated with a high cost, with the master's in global health delivery in rwanda costing us$ , and degrees in asia costing, on average us$ . as previously mentioned, there is a large divide between tuition fees at public vs private institutions. this is underscored by the fact that the least expensive programme was at the university of bergen where tuition fee is us$ since, as stated on their webpage, public universities in norway do not charge students tuition fees, regardless of the student's country of origin. it is within their mandate as an institution and part of the country's general ethos to provide quality education to its students and future leaders at no cost. this philosophy is quite different from their counterparts in the usa where of the private schools are located and where the most expensive programme identified is based at duke university (us$ ). table compares the tuition fees for domestic vs international students. it shows that on average hic programmes charged higher fees for international students ( . times higher on average), while lmic countries charged the same for both international and domestic students. however, by looking at table , it can be noted that american schools generally charged the same for both categories of students. figure provides data on relative costs of living in each location as a function of the cost of attendance for international versus domestic students. using the united nations postadjustment multiplier as a proxy for cost of living, the scale of the circles is relative to the cost of living of each city; smaller circles represent locations that are less expensive to live in relative to its headquarters in new york city. while cost of living is relatively expensive for many european locations, these costs are offset by less expensive tuition fees. the same cannot be said about north american schools; many are located in cities with similarly high costs of living, yet tuition fees are much higher than for european schools. figure box lack of transparency: the approach and limitations to our analysis data were extracted by two authors (as and nav) with any discrepancies in double entry agreed on by consensus. for each degree programme we identified, we visited websites of these programmes and collected data on the tuition fees for international versus domestic applicants. we also emailed coordinators of the degree programmes to request clarifications or additional data, if needed. we focused on tuition fees for the entire degree programme rather than the annual tuition fees, since duration of degree programme varied from to years, with some degrees structured in such a way that students' graduation time was tied to their experiences and training garnered prior to programme entry. thus, it should be noted that when the final cost was calculated this was based on the typical time to graduation indicated either on the website itself or by the respective school's programme coordinator. in most european schools, fees are fixed regardless of how long a student takes to complete their degree. however, in north america time to graduation can be quite variable and students usually pay tuition for each semester or credit. this is particularly true of the us system where a degree cost can vary substantially between students. we chose to calculate total tuition based on a typical student's experience as suggested by either the school's website or the coordinator. in addition, some programmes require a project (eg, summer practicum) be conducted in elsewhere (typically, a low-income and middle-income countries (lmic)-the costs for these were not always absorbed by the tuition fees. while some students had their costs for projects abroad covered by a supervisor and others could apply for scholarships, the remainder would have to pay for the additional costs out of pocket. this information was not transparent across degree programmes. given the difficulty in collecting data on tuition itself, we did not quantify cost of living directly for each school. rather, we aimed to account for differences in living costs for any given school using an adjustment measure used by the international civil service commission (icsc), established by the united nations (un). the un postadjustment system is designed to ensure that the net remuneration pay of un staffers garners an equivalent purchasing power to that same staffer at the base of the system, new york city, regardless of their posting location. post adjustment multiplier considers differences in prices between the city in question and new york; local inflation; exchange rate of local currency relative to the usd; and average expenditure pattern of staff members currently at a given location. the multiplier is adjusted periodically to reflect changes in the cost of living in a given city. we used the multiplier from the march update. all cost information was converted into us dollars using the icsc conversion factor (march update) to make international comparisons possible. our analysis has several limitations. first, although we did an extensive search, it is possible we missed a few degree programmes. our search was limited to schools which were explicitly master's of global or international health rather than master's programmes with an option of a global health concentration. future iterations of this analysis could include other types of global health degrees (eg, master's of public health with a global health concentration). second, while efforts were made to contact each school if the tuition was not clearly listed on their webpage, it is possible that errors were made when calculating the tuition for fluctuating fees (eg, based on number of credits where the per-credit fee changes each year). for programmes which did not have a fixed total fee, it was difficult to gauge exactly how much a degree would cost in its entirety and despite seeking clarification, many schools could not give an exact number. in addition, while tuition was calculated based on the fees posted on a school's website in march , fees may have changed for the fall cohort. there was a lack of transparency both on the websites themselves and after contacting the universities. in addition, many programmes were reluctant to disclose the exact duration of a degree, since the duration depended largely on the profile of the incoming trainee and how quickly they could meet programme requirements. third, we used a simplistic marker for cost for living established by the un. while it would have been ideal to have gathered information of the average cost of living for a typical student in any given year, this information was not usually available for most schools, with some exceptions. fourth, we could not get data on diversity of the students who are in these global health degree programmes. thus, we do not know what proportion of the student body is made up of high-income country versus lmic trainees. lastly, we also do not have data on how many lmic trainees receive tuitionfee waivers or scholarships to complete global health degrees. also shows that many schools charge the same amount to domestic and international students (with the exception of western pacific and nordic schools), and that there is a wide dispersion in costs of tuition by region. despite limitations (see box ), we can make some key inferences from this analysis. the data presented suggest that there may be a disconnect between where global health training is needed most versus where the degree programmes are currently offered. it would thus be useful to apply the health labour market framework to better understand this discrepancy between demand and supply and the mechanisms behind this apparent divide. one potential explanation for this disconnect is that the idea of 'global health training' is itself an hic phenomenon; much of what is taught in such programmes in hics are likely typically covered in mph and related programmes (eg, community health) in lmics. another explanation, which we discuss later, is that global health degrees are a revenue-generating activity for the universities, which seek to take advantage of growing student interest in global health. tuition fees are high for most programmes. these costs will be even higher if we added costs beyond tuition (eg, travel, living expenses, accommodation, health insurance and summer practicum). without substantial external support, these degrees, we believe, would be unaffordable to trainees in lmics. additional research is needed to calculate fully loaded costs for global health degrees. this would vary a lot, depending on the country and cost of living and what financial aid or fellowships to this extent, we hope global health degree programmes will be transparent about diversity in their student body and provide information on what proportion of their lmic students receive tuition waivers or fellowships. we need data on diversity among global health students. we also need data on what proportion of the lmic students in these degrees get full tuition fee waivers. we know almost all schools offer such fee waivers, but cannot provide data on how many. this could be a topic of future research. tracking and improving this could help enhance reciprocity in global health. if students are paying high fees to get global health degrees, it is unclear what their job prospects are after completing such degrees. to recover the costs, they would need to find high-paying jobs (which might not be in the field of global health) and/or work in hics. we need to further study whether and to what extent global health degrees actually help build global health capacity and address the massive healthcare workforce shortage in lmics. in making the decision on fee waiver, another consideration should be the provenance of global health knowledge. the cost of global health training programmes for lmic students should reflect the fact that lmics are the origin of much of the knowledge that gets shared (or should ideally be shared) in hic global health training programmes. this is one of many reasons why lmic candidates should, as a matter of fairness, receive fee waivers. fee waivers may also represent a form of reparation, given the colonial and extractive origins of many hic universities and global/ public health schools. based on where global health degrees are offered and the high fees charged, we infer that most degrees might be catering to hic students and students from elite and privileged backgrounds in lmics, thus privileging a student group that is already privileged. the current leaders of global health organisations are drawn from this same limited pool. the pattern of global health training serves to perpetuate lack of diversity, a huge problem in global health that risks perpetuating colonial approaches and structures. if global health schools in hics truly care about making global health training accessible to lmics and believe in equity and reciprocity, then we should expect to see tiered tuition fee structures. we found that most schools, especially those in the usa, charge the same for domestic and international students, suggesting a lack of lower and affordable pricing for lmic trainees. this may be because the degree programmes are meant to generate revenues and be 'self-supporting' or 'self-financing.' but this explanation also suggests that, contrary to using global health degrees to enhance equity and reciprocity, many hic universities, especially medical schools, (including private universities with billions in endowments) apparently see global health training as a mechanism to generate revenue. to democratise global health education and improve equity, fairness and reciprocity, hic universities can and must allocate a certain proportion of their slots for lmic students, offer full funding support (including accommodation), and support with travel and visas. the fogarty international center training programmes by the us national institutes of health (nih) is a good model for all hics to replicate, as it has helped train over scientists worldwide, spending a small fraction of the overall nih budget. we are not surprised that there are few degree programmes in global health in lmics, since nationals of lmics do not see their day-to-day public health or clinical work as 'global health.' but we are puzzled as to why the few degree programmes based in asia and africa are priced so high. so, even within lmics, these degree programmes may be serving the privileged and elite. while these schools have indicated that they offer scholarships to candidates from lmics it is unclear how much funding is given to each student and how many students are granted these awards. this transparency would be useful. because of the covid- pandemic, more global health degrees might move to remote or distance education. it is disappointing that distance education global health degrees still cost about us$ for international students. if tuition fees were more affordable for lmic trainees, then thousands of students can be trained. but beyond affordability, there are other major barriers for lmic trainees, including the struggle to get visas to enter countries such as the usa and uk, especially with brexit and us visa bans. by working with lmic experts to create affordable, quality, online training programmes for lmic students, hic universities can demonstrate that they can deliver on reciprocity and equity. in conclusion, even if hic universities made their degrees more accessible, we should still ask why an african trainee must go to london or boston to learn about control of sleeping sickness or malaria (and pay top dollars for such training)? the traditional mindset in global health that expertise flows from north to south, is reflected in research, training, consultancy and technical assistance. this colonial model is ripe for disruption. building top-notch institutions in lmics is critical, to reduce dependence on hics, and to improve the overall quality, depth and relevance of global health training and research. someday, we hope hic trainees will earn global health degrees from such lmic universities, and learn directly from experts who are closest to the problems and closest to the solution. twitter seye abimbola @seyeabimbola and madhukar pai @paimadhu acknowledgements we are grateful to all the universities that responded to our request for information about their degree programmes in global health. errors, if any, are our own. contributors mp and sa conceived the study. as and nav collected and verified the data. as and mp wrote the initial draft. all authors revised and approved the final version. funding the authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. disclaimer the depiction of boundaries on this map does not imply the expression of any opinion whatsoever on the part of bmj (or any member of its group) concerning the legal status of any country, territory, jurisdiction or area or of its authorities. this map is provided without any warranty of any kind, either express or implied. competing interests mp is on the editorial board of bmj global health. sa is editor-in-chief of bmj global health. they are from india and nigeria, respectively, but had the privilege of training in hic universities. they are currently based in hic universities, and are aware of their obligation to address the inequities discussed in this paper. patient consent for publication not required. provenance and peer review not commissioned; internally peer reviewed. towards a common definition of global health global health research needs more than a makeover on the meaning of global health and the role of global health journals global health needs to be global & diverse. usa: forbes global health / . the global health / report : power, privilege and priorities the foreign gaze: authorship in academic global health stuck in the middle: a systematic review of authorship in collaborative health research in africa who is telling the story? a systematic review of authorship for infectious disease research conducted in africa diversity in the editorial boards of global health journals global health journals need to address equity, diversity and inclusion consortium of universities for global health world health organization. the labour market for human resources for health in low-and middle-income countries a comprehensive health labour market framework for universal health coverage offline: the case against global health teaching global health from the south: challenges and proposals reciprocity in global health: here is how we can do better. forbes. usa: forbes on the coloniality of global public heath ebola and the narrative of mistrust global health still mimics colonial ways: here's how to break the pattern our role in global health. bethesda: national institutes of health the lancet global h. passports and privilege: access denied international civil service commission. the post adjustment index key: cord- -yl j x p authors: gupta, mrinal; abdelmaksoud, ayman; jafferany, mohammad; lotti, torello; sadoughifar, roxanna; goldust, mohamad title: covid‐ and economy date: - - journal: dermatol ther doi: . /dth. sha: doc_id: cord_uid: yl j x p nan concern, covid- is having major consequences on the world economy, and experts have predicted that covid- will lower global gross domestic product growth by one-half a percentage point for (from . % to . %). the whole world is now a single global community, where any major happening in one part is bound to have repercussions in rest of the world. chinese government, in order to control the spread of the disease, had to close the major production centers and as china being a manufacturing hub, led to disruption in the global supply chain which affected almost all sectors ranging from pharmaceuticals to automobile. world health organization declares global emergency: a review of the novel coronavirus (covid- ) going viral-covid- impact assessment: a perspective beyond clinical practice how is the world responding to the coronavirus disease compared with the west african ebola epidemic? the importance of china as a player in the global economy the global macroeconomic impacts of covid- : seven scenarios the australian national university key: cord- - oc lisi authors: abbott, patricia a.; coenen, amy title: globalization and advances in information and communication technologies: the impact on nursing and health date: - - journal: nursing outlook doi: . /j.outlook. . . sha: doc_id: cord_uid: oc lisi globalization and information and communication technology (ict) continue to change us and the world we live in. nursing stands at an opportunity intersection where challenging global health issues, an international workforce shortage, and massive growth of ict combine to create a very unique space for nursing leadership and nursing intervention. learning from prior successes in the field can assist nurse leaders in planning and advancing strategies for global health using ict. attention to lessons learned will assist in combating the technological apartheid that is already present in many areas of the globe and will highlight opportunities for innovative applications in health. ict has opened new channels of communication, creating the beginnings of a global information society that will facilitate access to isolated areas where health needs are extreme and where nursing can contribute significantly to the achievement of “health for all.” the purpose of this article is to discuss the relationships between globalization, health, and ict, and to illuminate opportunities for nursing in this flattening and increasingly interconnected world. lenges, human rights, and consideration of local and cultural context. nursing leadership, creativity, advocacy, and experience are needed to provide stewardship for health ict growth and application in the face of a complex, interconnected, and increasingly globalized world. the term globalization describes the increased mobility of goods, services, labor, technology and capital throughout the world. most would agree that globalization has a much broader impact than just an economic impact; its impact is also political, technological, and cultural-strongly influenced by information and communication technology. globalization, whether we recognize it or not, touches all parts of our lives-both personal and professional; it changes the way our nations and communities work. globalization and health have been discussed by many experts who have noted influences on wellness that are both promising and potentially devastating. [ ] [ ] [ ] [ ] globalization in a positive sense has resulted in trade expansion, with an increase in living standards and improved social and economic status, particularly for women. sachs, a global economist known for his work in developing nations, repeatedly makes the important point that the health of a nation is directly tied to the wealth of a nation. wealth is enhanced by heightened competition, comparative advantage, economies of scale, and access to a greater range of products and services in globalized markets, all enabled by access to knowledge. asymmetries of information have been reduced in an era of globalized knowledge exchange, contributing to a reduction of isolation, an increase in life spans, and improved health. conversely, advances in globalization are blamed for some health problems, including an increased adoption of unhealthy western habits and lifestyle, resulting in increases in obesity and the increased prevalence of chronic disease. open borders and open access, hallmarks of globalization, have also resulted in faster transmission of infectious agents, the so-called "microbial hitchhikers." many societies find globalization and open information exchange threatening to current ideologies and social structure. others view the concept of globalization, particularly via ict, as a new age form of electronic colonialism, where existent cultures are bulldozed and assimilated. how does ict fit in this discussion of health and globalization? the world health organization (who) believes that ict holds great promise for improving health and health care around the world and is critical to achievement of the millennium development goals. the core beliefs that ict will contribute significantly to the reduction of poverty, improve the delivery of education and health care, and make government services more accessible are prominent in the world health report. the report, towards a safer future, continues to emphasize the importance of ict in relation to health: "today, the public health security of all countries depends on the capacity of each to act effectively and contribute to the security of all. the world is rapidly changing and nothing today moves faster than information. this makes the sharing of essential health information one of the most feasible routes to global public health security." a widely held view, both within the who and elsewhere, is that ict in health enables rapid and global access to new therapies, techniques, and knowledge resources, with the potential to forever change the health of nations. the role of ict in the severe acute respiratory syndrome (sars) crisis of is a prime example. during the first cases of sars in china in , the who initiated a digital virtual environment consisting of laboratories in countries connected via ict. using e-mail and a secure website, these collaborators shared outcomes, post-mortem tissue analysis, electron-microscope pictures of viruses, genetic sequences and other related materials in real-time to collaboratively identify and intervene in a markedly dangerous public health risk. other examples exist that point to the impact that ict has had on global health efforts, such as the academic model for the prevention and treatment of hiv/aids medical record system for africa (ampath-mrs), the partners in health electronic medical record in peru, the hiv electronic medical record system in haiti. efforts such as those mentioned above and scores of others, too extensive to enumerate, have made significant impacts in the health of large regions of the globe. however, it is important to realize that ict can never be viewed as a panacea or singular solution to the very multifaceted problem of worldwide health. the contributors to global health are very complex, rooted in societal structures, political agendas, and the presence of marked global poverty. solving one issue without addressing the others will result in the same outcome experienced by sisyphus; the summit is reached, only to have the boulder roll back down to the base. in particular, efforts to improve health without addressing the pressing problem of poverty will be unsustainable. poverty reduction as a precursor to improvements in health is reflected in the world health report: "hungry children easily acquire diseases, and easily die from the diseases they do acquire. dwellings without sanitation provide fertile environments for transmission of intestinal infections. hopeless life circumstances thrust young girls into prostitution with its attendant risks of violence and sexually transmitted diseases." productivity drops when the human capacity that fuels economic growth declines due to morbidity and mortality, and the high financial burden of disease in developing nations precludes economic advancement and health improvement efforts. the paradox is, of course, that declining health impedes the climb out of poverty while poverty contributes to declining health. could further enhancement of global ict for health care be a potential strategy for escaping this paradox? what are the realities and reasoned approaches for application of ict to impact the health of nations? what roles and opportunities for nursing leadership exist in regards to ict regardless of geographic location? in many instances, the idealism of ict potential and the reality of ict application are discordant. therefore, while there is acknowledged need for ict in the coordination and monitoring of treatment, surveillance, response, education, and communication in health care, in reality there are significant barriers in the application of ict that slow progress. these barriers are in no way restricted to the developing world. the united states and other more technologically advanced nations have their own sets of challenges. cost, misalignment of incentives, resistance, an unskilled workforce, concerns about impact on productivity, lack of standards and interoperability, and other issues contribute to a poor level of healthcare ict adoption in the industrialized world. the digital divide has resulted in large segments of low income and/or other underserved groups being excluded from online health resources. economic hardships and difficult tradeoff decisions in the us healthcare industry have further inhibited healthcare information technology growth. in developing nations, the problem of ict uptake is even further compounded. a lack of local expertise and decades of well-meaning but non-sustainable ict projects in the developing world have left a legacy of skepticism in their wake. systems built for westernized health care delivery often do not match the local context, resulting in a misalignment between need and technology. poverty and illiteracy in developing nations stand as major barriers to the adoption and sustainability of information technologies, and many believe it is difficult to make the case for ict when basic needs for survival are barely being met. the "e-health paradox," a term coined by liaw and humphries, refers to this seeming conundrum; populations that may have the most to gain from ict in health are those who are thwarted in their use due to barriers of untrained personnel, poor infrastructure, and lack of resources. issues such as these have fueled technological apartheid and continue to subvert the delivery of knowledge to areas of the globe that most desperately need it. are the current realities in global health ict all bad? actually, they are not. from adversity often come new ideas. new opportunities and avenues for access and innovation in the use of ict are emerging to improve health and facilitate the delivery of health care. the use of ict in health care in more industrialized nations such as the united states, the united kingdom, and australia continues to grow, albeit at modest rates, reaching a tipping point. as discussed earlier, there are many successful implementations of ict-enabled health communications and electronic health record systems in developing nations such as kenya, malawi, peru, rwanda, haiti, tanzania, and others as part of efforts like the open medical record system (open mrs). creative thinkers are already capitalizing upon widely available forms of ict (such as cellular telephony) to affect health. muhammad yunus, whose work in microloans in bangladesh was honored in with a nobel prize, is an excellent example of how the creative introduction of ict via simple cellular telephony into a low resource area could institute profound change. dr. yunus and the telecom company he founded were convinced that economic and social development should begin at the grassroots level. yunus believed that attacking poverty is essential to peace, that private enterprise is essential to reversing poverty, and that peace and poverty reduction are essential to health. yunus' microloans enabled destitute village women in bangladesh to purchase cell phones and become village phone operators (vpos). the women then sold telecommunication services on a per-call basis to neighbors. this has resulted in considerable wealth generation not only for the vpos, but for the farmers and village dwellers who are using this technology to access the outside world and improve their businesses. the vpos provide affordable rates to their neighbors, preventing residents from making (historically, in many locales) a -hour roundtrip to reach a telephone, which consequently impacted community productivity and increased community wealth. the vpos earned enough to invest in their children's health, nutrition, and education, and fund other business growth. the improvement in community wealth translated into improved community health, as funds became available for the drilling of wells for clean water and preventive health services. the vpo model has been rolled out through much of africa and is viewed by governments and development agencies such as the united nations, usaid (united states agency for international development), and the world bank as a sustainable development tool. wealth has impacted health, which is a welcomed consequence. the swell of cellular telephony has also expanded directly into the realm of health and health care in other ways, particularly as the use of short messaging service (sms)-otherwise known as text messaging-has grown in popularity as a form of communication. for example, "sexinfo," a sms-based health information service offered by the san francisco department of public health, is being used to educate and assist teens who have questions about sexual health. the centers for disease control and stanford university teamed up recently to hold a conference called "texting for health" where public health initiatives using sms were presented. south africa is using sms features in cellular telephony to issue reminders to patients and caregivers in hopes of increasing adherence with antiretroviral therapies. phones for health, a presidents emergency fund for aids relief (pepfar)-funded project, is also using mobile telephony to combat hiv/aids in sub-saharan africa. this project allows nurses and other health workers in the field to use a standard mobile phone handset to enter health data. the system uses cellular methods to relay the data to a central database, where it is immediately available to health authorities via the internet. the system also supports the delivery of health alerts and reminder messages to caregivers. each of these examples illustrates a movement using ict to enhance information distribution that empowers financial growth, health, and social betterment, in both developed and developing nations. the success of such initiatives opens the door to innovative global ict methods for enhancing education, public health monitoring and surveillance, and delivery and management of health. it also speaks to opportunities for those who stand at the frontline of global health efforts to consider new ways to reach and teach. where is the opportunity for nurses to make a difference in regards to health care in a digital world? when one considers that - % of all health care provided "in country" is delivered by non-physician providers and the accessibility of ict is accelerating, the opportunities for nurses and midwives are vast. as those who most often stand at the interface of the patient and the healthcare system, there is a growing awareness of the need for nursing leadership, nursing innovation, and the nursing voice in global health ict. a number of areas of development demonstrate how nursing has already embraced ict to harness its global potential and should illustrate potential areas for growth and further investigation. examples of success stories from a global perspective include: ( ) advances in education and collaborative learning, ( ) telenursing/ telehealth, ( ) movement toward electronic health records (ehrs), ( ) nursing knowledge management and knowledge generation. in consideration of the challenges and opportunities cited earlier, these examples may stimulate critical and creative thinking about how these established examples and methods may be extended and applied by the nursing community to address the e-health paradox. information and communication technology has influenced both traditional and non-traditional approaches to education and the development of the next generation of nursing leaders. distance education programs in nursing are exploding across the globe and are enabling outreach to geographically distributed individuals. the use of ict to elevate the educational level of nurses worldwide is a crucial area for expansion, investigation, and application, particularly as the nursing workforce crisis grows, global health declines, and medically underserved areas increase. considering the issues of nurse migration and nursing brain drain, ict may be an effective strategy to reduce some of the contributors to out-migration, such as isolation and lack of educational opportunity. methods such as ict for education to train rural providers in place can prove to be more cost effective and less disruptive to families, communities, and nations than out-migration to more developed countries. moreover, collaborative learning opportunities are enabled via ict, where geography becomes irrelevant. the opportunity for students and faculty to interact, share knowledge, discuss global health issues, and share cultural perspectives across nations affords students and faculty exposure to the world beyond them. such experiences can increase cultural competency, raising awareness of and appreciation for global health issues. although the promise in using ict to reach and teach is great, there is also a need for caution and careful consideration. as discussed earlier, the notion of western solutions as being universally appropriate is erroneous. understanding how information and knowledge is relevant to context and culture is essential, so as not to impose approaches or solutions that do not fit the learners' reality. approaches that seem appropriate for delivery in one environment may be offensive or totally unrealistic and unvalued in another, highlighting the need for local involvement, flexibility, and creativity. this is particularly apropos when considering the vast differences between industrialized and non-industrialized nations or in nations that are in conflict. nursing has taken the lead in several successful international collaborations involving education and collaborative learning. two examples of the use of distributed e-learning in industrialized and non-industrialized nations are provided as a stimulus for further study and application: international virtual nursing school (ivinurs) a central activity of ivinurs is the building of its digital repository and the development of associated e-learning support products, with the aim of providing quality, learning resources that can be shared on a global level by its partners, and used to enhance both e-learning and traditional instruction in their respective settings. this not-for-profit entity, registered in the united kingdom as a limited company with charitable status, is still in formative stages, and expects to make available studies of its impact in the near future. uganda is an example of using ict in the developing world for nursing education and scale-up. this public-private partnership plans to increase the basic education level of kenyan nurses up to the level of "registered" (diploma) from the current level of "enrolled" (certificate) within years. at present, % of the nursing workforce in kenya is comprised of "enrolled" nurses, whose level of education leaves them ill-prepared to handle the complex health needs of the kenyan population. the amref's "virtual nursing college" currently has nurses enrolled at computer-equipped training centers in provinces, including several refugee camps. the curriculum is delivered via ict and, in october of , the first class of icttrained kenyan nurses completed the program. while too early to discuss program outcomes, the fact that % of all nurses enrolled in this program are from rural areas speaks to a great potential for communities outside of urban centers. this model is planned to be extended to other african nations who are experiencing similar nursing crises. the amref program is also important because of an important but less publicized goal-that all nurses will be computer literate. this very unique and vital component leaves kenya ready to lead in the movement towards e-health in the developing world. this could accelerate the achievement of the who resolution wha . , an e-health strategy adopted by the fifty-eighth world health assembly in may that articulates the preparation of an ict-competent global health workforce. these brief examples, while using different methods and addressing different audiences of nurses, demonstrate the potential of ict within the nursing education realm. it also demonstrates the reach of it-enabled methods in rapidly digitizing developing nations-further illustrating an area of opportunity for expansion. considering the global workforce crises in nursing, these models are worth further consideration. telenursing is the use of technology to deliver nursing care and conduct nursing practice. telenursing is often used interchangeably with the term telemedicine or telehealth with the distinction implied that a nurse provides telenursing and a physician provides telemedicine. the use of the term telehealth may be more appropriate, as the success of this modality requires multiple partners, including the professionals delivering services, technical support personnel, and the client or patients themselves whose participation is essential to successful outcomes. telehealth, in all of its definitions and permutations, has made large strides in expanding healthcare services to underserved areas around the globe. in a recent study, nurses representing countries responded to a survey querying their telenursing competencies and skills. patients with chronic illnesses were those most often cared for using telenursing services. although most telenurses worked in hospitals, the settings varied widely, including traditional work places such as clinics to community-based settings such as schools and prisons. several countries have well-developed telenurse programs, including canada and new zealand. the trend towards expansion of this nursing specialty is expected to continue, particularly as ict continues to reach all areas of the globe and as the medically underserved areas of the world are illuminated. telehealth/telenursing in the traditional sense may conjure up visions of expensive computer workstations, call-centers, or a nurse in a chat room. while these visions are perfectly realistic in the developed world, they are quite unrealistic in many parts of the globe. however, with the growth of cellular telephony, particularly in africa, tremendous opportunities exist for nurses to creatively apply telehealth modalities to long-standing patient care issues. for example, elder and clarke cite the following examples for the potential use of cellular telephones and personal digital assistants (pdas) for telehealth in africa and asia: • automation of demographic surveillance activities such as those at the core of pioneering health care initiatives (e.g., the tanzanian essential health interventions project) • testing of the use of sms (short message service) reminders in the treatment of tuberculosis in cape town, south africa • delivery of continuing medical education and professional development via pda • delivery of time-sensitive alerts to patients and health care workers • maintenance of patient records for hiv-positive patients' lifelong drug treatments • management of specific health care initiatives such as the roll-out of antiretroviral therapy and tuberculosis treatment initiatives again, realizing the numbers of nurses who are in the frontline of primary care around the globe and in light of the massive growth of ict for health, tremendous opportunity awaits those who are primed to capitalize upon these factors. making the application of telehealth/telenursing successful in developing countries will require strong nursing partnerships and leadership, however. nurses are in a position to drive the development of science in this area, since many aspects of nursing care are naturally amenable to virtual delivery, especially in areas of assessment, patient teaching, decision support, and early identification of problems. globalization is driving the need to communicate and share healthcare data and information across national borders. many countries are focusing on interoperable electronic health record systems (ehrs) as a solution for sharing data and information among various sources (e.g., clinical information systems, personal health records, public health surveillance systems, and knowledge repositories). for ehrs to reach full potential, however, interoperability and connectivity to distributed data repositories is fundamental, particularly in light of distributed healthcare services, geographical challenges, and migrating populations. in a global sense however, there are vastly different levels of ehrs readiness and capacity for ehrs interoperability. in many places, ehrs are unknown yet the need for health data (in any fashion) is great. even the most remote of locales often have reporting requirements, either from ministries of health or donor agencies. accountability for receipt and utilization of goods and services, demonstration of outcome achievement, and measurement of milestones are resulting in increasing pressures on nurses, other providers, and administrators for improved information management and tracking. quick fixes or one-off solutions, characteristic of many health data tracking efforts, often result in unusable, non-interoperable, and unsustainable systems that are soon abandoned, threatening clinic viability and leaving service providers frustrated. efforts such as open mrs are gaining in popularity, due to its open source (free) and interoperable nature, and its well-established success in many clinical settings across the global south. open mrs is an example of an ehrs system, built to agreed-upon standards that enable interoperability, data exchange, and the ability to use it in many different settings in many different locales. while this is an open source and freely available system, there are no documented examples of nursing use-which is puzzling when one considers the number of nurses who are responsible for clinic operations around the globe. it is important to note that, even in developed nations, nursing involvement in ehrs specification and development is disappointingly low. such lack of ehrs involvement by nursing in both developed and developing nations makes it that much easier for nursing data to remain invisible and inconsequential to determination of health outcomes. healthcare, both nationally and internationally, is a product of teams (including the patients), and such teams are reliant upon the sharing of information and knowledge. standards facilitate sharing of data, information and knowledge and are a foundational underpinning for system interoperability. those who do not participate in standards development, implementation, and use face the prospect of exclusion in ehrs. as is, the contributions that nurses make to patient outcomes and the achievement of larger health care goals are frequently invisible in ehrs because the standards that exist to represent nursing practice in automated systems are either underused or excluded. nurse-sensitive measures are frequently omitted from ehrs for a multitude of reasons, and they will continue to be, unless the case is made for inclusion. as nurses accelerate their utilization of and leadership in ict-based efforts such as the ehrs, the chance to share perspectives, experiences, and best practices via standardized and exchangeable data must not be missed. nursing experience, leadership, and the nursing voice are needed. interoperability from a global perspective requires international standards in many dimensions such as messaging, security, language, ethical information use, ict management, and other areas-all of which impact nursing and ehrs. again, nursing involvement is critical. one challenge is that there are multiple standardssetting agencies and, most likely, always will be due to the complexity of stakeholders, which increases the difficulty of nursing participation, particularly in consideration of the dearth of qualified standards-literate nurses. while there are many standards organizations around the globe, the international standards organization (iso) and health level (hl ) are of the major standards-setting organizations where nursing is represented (albeit in small numbers), and it must continue to be so. an example of successful nursing involvement and leadership in global standards work is the icnp®. initiated in by the international council of nurses (icn), icnp® is defined as a unified nursing language system to represent nursing diagnoses, interventions, and outcomes. the vision of icnp® is to be an integral part of the global information infrastructure informing health care practice and policy to improve patient care worldwide. through standardizing the clinical terminology nurses use to describe their practice, icnp® can improve nursing practice and contribute to the advancement of nursing science. the icn also recently partnered with the international medical informatics association-nursing informatics and the international nursing informatics community to establish an international standard through iso. this standard, integration of a reference terminology model for nursing, provides a framework which can be used to map concepts across different terminologies, thereby increasing communication and comparability of data across languages and countries. this iso standard is currently under routine review and is expected to contribute to ongoing harmonization across multiple international standards, giving structure to nursing data in global ehrs efforts. this work is critical to understanding the full processes of and contributors to health care. analysis of data that does not include nursesensitive measures, nursing interventions, and nursing contributions to outcomes is deficient, incomplete, and prone to spuriousness. the international telecommunication union (itu) is another organization involved in standards development that has direct bearing on nursing practice, particularly as related to communications protocols used in disaster relief and community-based services in the aftermath. as the leading united nations agency for information and communication technologies, itu plays a prominent role in the development and deployment of global ict standards. for example, in the aftermath of the indian ocean tsunami in , itu played a major role in pushing for standards for public warnings (called cap or common alerting protocol), disaster management, prevention, and relief. there is a great need for the nursing perspective in these concerns, particularly since a great deal of the care in disaster relief efforts is provided by teams heavily infused with nursing personnel. nurses, as first responders and those often managing the ongoing health needs of a community after disaster teams have left, have a vested interest in ict that supports information and workflow needs. unfortunately, nursing is often absent from the development and deployment of such standards and are frequently left to deal with suboptimal systems. nursing leadership is critical to break the chicken and the egg cycle that comes from unstructured, nonstandardized, and invisible nursing data in the rapidly digitizing world. without comprehensive, rigorous and accessible digital nursing data from large healthcare datasets, nursing practice remains largely invisible, and invisible nursing contributions lead to false assumptions of low nursing contribution to health and health outcomes. in reality, much has not changed since florence nightingale wrote in her book notes on a hospital, "in attempting to arrive at the truth, i have applied everywhere for information, but in scarcely an instance have i been able to obtain hospital records fit for any purposes of comparison. if they could be obtained . . . they would show subscribers how their money was being spent, what amount of good was really being done with it, or whether the money was not doing mischief rather than good . . ." in , years later, we are still struggling to determine the amount of good that is being provided, largely because the nursing data that is foundational to a full understanding of nursing contributions to outcomes, both good and bad, is still unfit and unavailable for comparison. the opportunities and critical need for nursing leadership are growing exponentially. information itself is becoming a major commodity in health; there are multiple stakeholders interested in access to and sharing of data and information. access to reservoirs of experiential knowledge and collections of explicit information allows for the development of new knowledge based on identified needs, to refine knowledge that already exists, to avoid duplication of effort, to increase alignment with local circumstances, and enhance the creation of actionable knowledge. the value to nursing of such collections of knowledge and experience becomes quite obvious, particularly when considered in the global context and in the face of asymmetries of information. effken and abbott have identified ict solutions for knowledge management in nursing, including the creation and participation in communities of practice (cops). cops trace their roots back to constructivism where the control of learning shifts from the instructor to the learner. wenger discusses ict supported cops specifically, stating "every group that shares interest on a website is called a community today, but communities of practice are a specific kind of community. they are focused on a domain of knowledge and over time accumulate expertise in this domain. they develop their shared practice by interacting around problems, solutions, and insights, and building a common store of knowledge." from a global nursing perspective, especially in light of the scarcity of nursing resources, reusable and accessible nursing knowledge empowered by ict is a powerful tool for the profession. one such ict-supported cop is the global alliance for nursing & midwifery, different countries. the alliance has served as a learning platform, a library, and a knowledge exchange forum for global nurses to exchange best practices, participate in open continuing education, and manage knowledge. the global alliance is unique in that it runs over very low-bandwidth, standard telephone service to allow participation by those in areas without full internet connectivity. participation from low-resource areas is surprisingly robust. other cops exist for nursing, and growth in this area is expected. for example, hara and hew in studying an online cop for critical care nurses in the pacific rim found that an e-cop helped not only to reinforce the identity of the practice of critical care nursing among participants, but that it also served as an important avenue for information and knowledge exchange within the context of everyday work. these authors believe that: "communities of practice can be described as groups of people who are informally bound together by shared expertise and a passion for joint enterprise. they can be viewed as informal networks that support professional practitioners to develop a shared meaning and engage in knowledge building among members. the theoretical construct of communities of practice is grounded in an anthropological perspective that studies how adults learn through everyday social practices rather than focusing on environments that are intentionally designed to support learning." information and communication technology has also stimulated the growth of other approaches to knowledge generation and nursing research. for example, icn recently initiated an electronic international nursing partnership database project. the goal of this project is to document and share ongoing and new international partnerships, as a tool to encourage similar initiatives and aid in planning new ventures. rather than relying on the traditional literature sources for networking and proposal development, this database can provide researchers and others with pre-publication information about existing projects in process. similar to the cop concept, the icn shared database allows the sharing of partnership experiences and results to maximize efficiency and effectiveness. the icn has also developed a portal called the international nursing network to facilitate the exchange of ideas, experience, and expertise for the nursing profession crossing a variety of areas from advanced practice nursing to disaster preparedness. this open access portal serves as a mechanism to encourage global nursing interaction. the management and generation of new nursing and healthcare knowledge is deepened and advanced as new evidence, new perspectives, and new discoveries are shared among global nurses and midwives. information and communication technology provides an opportunity to facilitate participation and to establish partnerships using technology that connects those otherwise not connected. enabling these connections will promote approaches not yet realized to managing, sharing, and generating nursing knowledge. the ultimate benefactors include not only the patients and communities that we serve, but the profession of nursing itself. some scholars suggest that there is a leadership void in nursing, particularly in the global south, where the needs are the greatest. leadership for strategic use of ict and informatics in nursing, and strategic partnerships to support mutual enhancement of ict is an important strategy for the promotion of global health. entrepreneurial opportunities exist for those proactive and creative thinkers who stand ready to capitalize upon them. nurses cannot wait for ict to bring answers to the problems faced in today's world; rather, they need to be engaged in problem-solving activities, testing and evaluating solutions to global health issues using ict. the pace at which ict seeps into health care is only expected to increase, and reasoned action by the nursing community is imperative. the nursing informatics arena has provided avenues for nurses to serve as leaders, including multiple roles in nursing and through participation in professional organizations. however, nursing informatics, like nursing in general, stands at the edge of a workforce crisis that threatens nursing participation in the rapidly progressing world of ict. nursing as a profession cannot leave the progress needed in the face of accelerated global ict solely in the hands of nurse informaticians. informatics practice is quickly becoming part of the expected competency of every nurse and, therefore, is becoming not only a responsibility of every nurse, but as an opportunity for every nurse. the absence of the nursing voice and nursing leadership as global e-health explodes is foreboding. in addition to leadership, strong partnerships are essential to advancing health globally. these partnerships should not only include corporate and philanthropic organizations, but partnerships within the healthcare team as well. interdisciplinary work is critically important and the major contributions that nurses make to global health must be acknowledged and supported at levels much higher than they currently are. similar to the efforts undertaken by the robert wood johnson foundation's commitment to nursing, it would seem appropriate that major foundations and funding agencies would support the investigation and growth of ict as a strategy to support frontline nursing care, since nurses are such a vital source for the delivery of health services worldwide. it is also important to emphasize that the agenda for using ict to advance global health is in no way limited to experts in informatics. nursing expertise in practice, education, administration, research, and policy are all required to advance this agenda. the nursing profession, as partners in improving global health care, has much to contribute, particularly in this new interconnected and flattened world. entrepreneurial opportunities for nurses who are interested in global health and who understand and are intrigued by digital innovation abound. the authors have highlighted examples of first steps that the nursing community has already taken in applying ict to health and healthcare. following the example of amref in uganda and the online training of nursescould this model not be built upon and expanded to the global nursing workforce? could nurses, long known for their crucial role in patient education, develop ict-supported solutions to reach patients, their families and caregivers-regardless of geographic location? can we use ict to provide lifelines to isolated nurses, midwives and others who are serving their communities? can we deploy simple ict solutions to combat the problems of collecting critical individual and population health data in remote locations? considering that there are more mobile telephones in use in china today than there are people in the united states, what innovative mobile methods could be developed to deliver health messages, answer questions, or collect data? what role might social networking (e.g., wikis, blogs, virtual communities) play in nursing of the future? what shall be the legacy of the current generation of nursing leaders in this rapidly digitizing world? to answer these questions, we need nurses who have what henry ford classified as those with an "infinite capacity to not know what can't be done." nursing has a long-standing history of advocacy, innovation, and education. the growth of ict in the health and healthcare sector should be looked at as an opportunity for nursing to use a new medium to meet the mission of our profession, not as something to be approached with trepidation and fear. as globalization expands, nursing has the opportunity to step forward and harness the power of ict to serve the greater good. while it is often difficult to make the case for ict in areas where running water and electricity are considered a luxury, access to information must be viewed as a basic tenet of a developing nation, with efforts to increase ict and decrease poverty as complementary, not competitive activities. as nurses, we have the opportunity to renovate and innovate, as we shepherd developments in a way that promotes health for all. at the nursing outlook website: www.nursingoutlook.org. references . friedman t. the world is flat: a brief history of the twenty-first century health in an age of globalization globalization definition nursing leadership: international council of nursing globalisation and public health is globalization dangerous to our health? globalization and health: targets met, new needs the globalization of public health. i. threats and opportunities the end of poverty: economic possibilities for our time globalization and its discontents globalization, information and communication technologies, and the prospect of a 'global village': promises of inclusion or electronic colonization? working together for health. world health organization towards a safer future. world health organization implementing electronic medical record systems in developing countries health, wealth, and the chinese oedipus free internet access, the digital divide, and health information slowing the growth of u.s. health care expenditures: what are the options? the commonwealth fund report rural ehealth paradox: it's not just geography! grameen foundation microloan pioneer and his bank win nobel peace prize texting for health distance education: the solution for nursing and midwifery in africa? geneva: international council of nurses pageidϭ & searchstrϭe% dlearning. accessed on kenya graduates first nurse definitions of telenursing, telepresence report of the - international telenursing survey national initiative for telehealth framework of guidelines. nifte website, national initiative for telehealth professional standards for telenursing practice past, present and future: experiences and lessons from telehealth projects international competencies for telenursing. published by: international council of nurses international classification of nursing practice version . , geneva: published by: international council of nurses iso: integration of a reference terminology model for nursing nursing language-terminology models for nurses available at: http://my.ibpinitiative. org/displayknowledge.aspx?cϭ c - b - e- e- a &fϭf f - c- d - adc-ac d b f& iϭ b e a-c - f-a -ccf cf acc the nursing role in health it-enabled care management in rural, frontier, and other underserved populations agency for health care quality and research a study of technologies for communities of practice available at: my.ibpinitiative.org/public/ganm/. accessed on a case study of a longstanding online community of practice involving critical care and advanced practice nurses available at poverty and development: pulling forces and the challenges for nursing in africa the robert wood johnson foundation anthology: to improve health and health care volume viii key: cord- - bxx db authors: salmerón-manzano, esther; manzano-agugliaro, francisco title: bibliometric studies and worldwide research trends on global health date: - - journal: int j environ res public health doi: . /ijerph sha: doc_id: cord_uid: bxx db global health, conceived as a discipline, aims to train, research and respond to problems of a transboundary nature in order to improve health and health equity at the global level. the current worldwide situation is ruled by globalization, and therefore the concept of global health involves not only health-related issues but also those related to the environment and climate change. therefore, in this special issue, the problems related to global health have been addressed from a bibliometric approach in four main areas: environmental issues, diseases, health, education and society. science aims to answer questions, and from a pragmatic approach, science can be understood as a resolution of problems in our society. science cannot be considered an independent activity, and therefore, it must be remembered that prior studies have been carried out in any given scientific field. combining scientific aspects with documental aspects gives rise to a certain type of scientific work: scientometric, bibliometric, and informetric studies. these take different titles according to the final approach of the work, such as the following: examining the scholarly literature, evolution, and new trends; worldwide research trends; mapping of the knowledge base; visualizing the knowledge structure; analysis of global research; publication trends; knowledge domain visualization. scientific literature is losing its relevance more and more quickly, but the aging of literature is not uniform for all scientific subjects. this means that being up to date in a scientific field requires bibliometric studies through which new trends are revealed when undertaking scientific studies of interest to the community. two topics of special interest to society today are environmental research and public health, and within these larger topics are sub-topics related to global health. global health, in a broad context, refers to improving health worldwide, reducing disparities, and protecting against global threats that do not consider national borders. this special issue aims to provide a global view of all of these global health issues, and through bibliometric studies, we believe that this objective can be achieved. therefore, articles reviewing the state of the art in any of these fields, bibliometric or scientometric studies, and research articles dealing with a global perspective are welcome. the summary of the call for papers for this special issue on the manuscripts submitted: rejected ( ; %) and published ( ; %). the submitted manuscripts come from many countries and are summarized in table . for this statistic only the first affiliation of the authors has been considered, in which it gives the opportunity to observe authors from nine countries. note that it is common for a manuscript to be signed by more than one author and for authors to belong to different affiliations. the average number of authors per published manuscript in this special issue was seven authors. there are different affiliations of the authors. note that only the first affiliation per author has been considered. table summarizes the authors and their first affiliations. table summarizes the research conducted by the authors in this special issue, by identifying the areas to which they report. it was noted that they have been grouped into four main lines of research: environmental issues, diseases, health and society. they have mainly explored the issue of disease research, these have been: covid- , asthma, pulmonary disease, hiv/aids, and diabetes. related to health, they were: medicinal plants, musculoskeletal risks, and obesity. the environmental issues were related to: microplastics, climate change, and wastewater treatment. finally, research related to education and society: academic performance, patents, bibliometric analysis, and social networks and young people. table . topics for worldwide research trends on global health. current state and future trends: a citation network analysis of the academic performance field global research output and theme trends on climate change and infectious diseases: a restrospective bibliometric and co-word biclustering investigation of papers indexed in pubmed ( - ) studies of novel coronavirus disease (covid- ) pandemic: a global analysis of literature the contribution of spanish science to patents: medicine as case of study global mapping of research trends on interventions to improve health-related quality of life in asthma patients interventions to improve the quality of life of patients with chronic obstructive pulmonary disease: a global mapping during a scientometric analysis of global health research global research on quality of life of patients with hiv/aids: is it socio-culturally addressed modeling the research landscapes of artificial intelligence applications in diabetes (gapresearch) global mapping of interventions to improve quality of life of people with diabetes in - wastewater treatment by advanced oxidation process and their worldwide research trends characterizing obesity interventions and treatment for children and youths during - a bibliometric analysis of the health field regarding social networks and young people musculoskeletal risks: rula bibliometric review bibliometric profile of global microplastics research from to author contributions: the authors all made equal contributions to this article. all authors have read and agreed to the published version of the manuscript.funding: this research received no external funding. the authors state that there are no conflict of interest. key: cord- -ozm f dy authors: naqvi, zainab batul; russell, yvette title: a wench’s guide to surviving a ‘global’ pandemic crisis: feminist publishing in a time of covid- date: - - journal: fem leg stud doi: . /s - - - sha: doc_id: cord_uid: ozm f dy it has been quite a year so far(!) and as the wenches we are, we have been taking our time to collect our thoughts and reflections before sharing them at the start of this issue of the journal. in this editorial we think through the covid- pandemic and its devastating effects on the world, on our lives and on our editorial processes. we renew our commitment to improving our operations as a journal and its health along with our own as we deploy wench tactics to restore, sustain and slow down to negotiate this new reality, this new world. we conclude with an introduction to the fascinating contents of this issue along with a collaborative statement of values on open access as part of a collective of intersectional feminist and social justice editors. through all of the pain and suffering we focus our gaze on hope: hope that we can come through this global crisis together engaging in critical conversations about how we can be better and do better as editors, academics and individuals for ourselves, our colleagues and our journal. in these strange times…in these uncertain times…in these unprecedented times. how quickly our conversations and communications have become prefixed with a constant reminder of our current situation. our concern, our sympathies and our connectedness have all increased for one another as we 'check in' with those we interact with regularly, and crucially, those we don't. as pandemic-related lockdowns in the uk and many parts of the world continue, causing many to experience restrictions in their movement and routines that they have never encountered before along with the enforced closure of businesses and places of work, we have been reflecting on the spaces and positions we inhabit as feminist individuals, academics and editors. in this editorial we think through some of the consequences of the covid- pandemic and state responses to the spread of the virus in the context of our ongoing efforts to employ decolonising techniques and deploy wench tactics (fletcher et al. ; naqvi et al. ) . in doing so, we seek to make sense of our new lived realities, although in many ways, just this attempt to make sense of the effects on our existence is both bewildering and revealing. one way this lack of sense is most starkly manifest is in the way it plays with and disrupts time. we experience time as both exponentially sped up and painfully slowed down. over the three months during which we have tried to draft this editorial there have been political, social and economic changes and events too numerous to detail; literally thousands of people have died. but somehow this flux is accompanied by a nagging sense of stasis; we're mulling the same issues, many of us are 'stuck' in our homes with or away from family, and we are still beholden to the virus. this discombobulating confrontation with the contingency of linear time leads us here to feminist work that contemplates time and timeliness and to a necessary reflection on the nature of scholarly work and publishing and the temporal imperatives driving them. in mulling our work and the time in and according to which it occurs, we are also led inevitably to a rumination on health: what is 'health', and who possesses it? the oversimplified answer is that human health refers to our state of physical, mental and emotional wellbeing; and that surely everyone has health which makes it a global concern. unfortunately, we have seen that it really isn't that simple or tidy. fassin ( ) warns us that concern for global health is not something we can take for granted. both 'global' and 'health' are contested concepts (bonhomme ) . global health is neither universal nor worldwide; it is not free from the politics of life and the value-giving processes that lead to lives being weighed against each other. the term 'global' is not only a geographical signifier but a "political work in progress that calls on us to remain ever mindful of the imperial durabilities of our time" (biehl , referring to stoler . in what follows we reflect further on the lessons of the pandemic and how we view health: as a global public good that we should all be working together to improve and maintain for everyone? or as a privilege that in this patriarchal capitalist society is only available to those who can afford it? we return to the question of time and the timely and try to think collectively with our feminist colleagues about publishing, 'slow scholarship' and wench tactics. we consider what feminist leadership looks like in a time of covid- and renew our calls for a firm commitment to decolonising academic publishing and the university. for us, this has recently manifested in a collective statement on publishing and open access, which we have jointly produced and signed with several other intersectional feminist and social justice journal editorial boards. the editorial concludes with an acknowledgement of recently retired editorial board members and an introduction to the copy included in this issue of fls. they are dirty, they are unsuited for life, they are unable, they are incapable, they are disposable, they are non-believers, they are unworthy, they are made to benefit us, they hate our freedom, they are undocumented, they are queer, they are black, they are indigenous, they are less than, they are against us, until finally, they are no more. (indigenous action ) a pandemic is the worldwide spread of a new disease (who ) in her discussion of affliction, disease and poverty, das ( ) discusses the way in which definitions of global health centre on the control of communicable diseases. controlling the spread of infectious disease between us then, is how we measure the success of global health. along the same vein, the world health organization (who) has defined a pandemic as "the worldwide spread of a disease" ( ). these two statements may seem innocuous but contain layers of historical and contemporary oppressions trapped within their layers of meaning. it would be naive to claim that the covid- crisis is the first phenomenon to lay bare the structural injustices and inequalities which already plague us. and that is the key takeaway for us: we are already plagued and have always been plagued with communicable diseases including war, poverty, racism, colonialism, sexism (bonhomme ; siyada ) . all around the world, lives are lost unnecessarily because of these diseases and now the privileged among us are personally at risk we urgently realise that the status quo is a problem-that we are all fragile (msimang ) . these existing diseases have spread worldwide and mutate into new forms all the time: we have been living through multiple, simultaneous pandemics our entire lives and for many of us, this is only now being thrown into stark relief. if we broaden this out further, the editors in us start to inquire into health as a broader concept. health is not only relevant to the human condition but can be applied to systems, processes and institutions such as the academy and the academic publishing industry. the crisis has highlighted the urgent need for us to reflect on the health of our academic lives and spaces along with the ways in which social plagues have infected our ways of writing, editing, working and being. in doing so, we plan and strategise the best ways to be 'wenches in the works' (franklin ) taking advantage of this period to deploy wench tactics and rest, restore and sustain. we aim then, to take an all-encompassing approach to health to interrogate the sicknesses and weaknesses that afflict our spaces and worlds and then try to act for change. whilst the who states that a pandemic involves a new disease spreading throughout the world, the current situation shows us that it is not just the spread of this viral pathogen that is causing the pandemic. it is the combination of intersecting oppressions with the spread of the covid- viral molecules that make up the pandemic. we always benefit from employing decolonising techniques, by looking back to the past to better understand the present. the history of global health is a neo-colonial project (biehl ; magenya ) mired in imperialist and eurocentric attitudes towards disease control. disease control has been repeatedly used "to bolster the moral case for colonialism" (flint and hewitt , ) with colonialist administrators considering their ability to control the spread of infectious diseases in the colonies as an important skill. this speaks to their civilising missionary attitude that in purportedly tackling the spread of infectious disease, they were benefitting the natives and their presence was therefore positive (flint and hewitt , ) . this is further reflected in the international regulations for containing infectious disease spread, which have historically emphasised controls to protect european and north american interests. the us' endorsement of the who prior to its inception in was predicated on concerns for trading relationships, which were central to us economic growth (white ) . the us was only dedicated to "wiping out disease everywhere" when there was a risk disease would enter its borders and affect its economy (white (white , . these imperialist attitudes around prioritising the health and economies of majority white countries in europe, north america and australia display the lack of regard for the deaths of those outside of these territories. the spread of cholera in haiti in , the ebola outbreaks (one of which is still ongoing in drc), avian flu, swine flu, and bse have all been deemed epidemics which are not seen as serious or widespread enough to count as pandemics despite the alarming number of sufferers and fatalities. these disease outbreaks all have one thing in common: they affected racialised people in "exotic, far-away and (made-to-be) poor lands" . these are lands that have deficient healthcare systems and resources because of imperial exploitation. this perception of communicable disease outbreaks as afflicting unhealthy and dirty others in far-away places underpins global health approaches and policy along with responses to the outbreaks in the west. even the labelling of the covid- crisis as a 'global pandemic' is loaded with meaning: it represents that the disease has spread to and is also killing white people in the west on a mass scale. if it were not affecting this subset of the population in a meaningful way, it would 'just' be an epidemic. this is clearly demonstrated by the uk government's woeful response to the disease and the increasing mortality rate we are experiencing. aaltola states that "diseases exist, flourish and die wider than physical environments where they adapt to local memories, practices and cultures" ( , ). by thinking that the uk is invincible because of imperial arrogance, the government has wilfully ignored the memories, practices and cultures of other countries with experience of managing such crises. instead of rushing to save lives, there was a rush to save the economy telling us that there has been no progress in mindset since the s. who suffers the most as a result of this? the marginalised, the poor and the underpaid key workers who are disproportionately not white because diseases are "embedded in and violently react with the fabric of political power" making them "signifiers of the underlying patterns of power" (aaltola , ; asia pacific forum on women, law and development ). the virus may not discriminate but systems and structures by which the imperial state dictates who lives and survives do (anumo ; rutazibwa ) . this discrimination has spilled onto our streets and into our living rooms with the racist and xenophobic discourses that have led to the unjust treatment of vulnerable minorities in society. from the us president deliberately calling covid- the 'chinese virus' to the abuse shouted at east asian people on the streets, reactions to the virus have been rooted in intolerance and ignorance. these unsurprising (and imperialist) responses are further manifested in policy responses which disadvantage the most vulnerable of us including minorities with greater representation in lower socioeconomic groups; victims of abuse who are now told to stay locked up in the house with their abuser; elderly people in care homes or congregate living arrangements; those with 'pre-existing' conditions or disabilities and; immigrants who are being subjected to yet more nationalist rhetoric around border control and surveillance (see also step up migrant women uk amidst these waves of pain and suffering we reel as we witness the continual devaluing of life with the deaths of breonna taylor on march; belly mujinga on april; george floyd on may; bibaa henry and nicole smallman on june; dominique rem'mie fells on june and riah milton on june. these are just a few of the black women and men whose lives have been cruelly and callously taken this year. the list is endless: bleeding and weeping like an open wound. the black lives matter movement was given the attention it deserves by the national and international media as people took to the streets in solidarity, but the wheels of justice move slowly, grinding regularly to a halt leaving us feeling helpless and hopeless at times. we wanted to express our support and decided to share links to free downloads of our articles on a twitter thread written by black authors and papers that adopt critical race approaches. we have now provided a period of openaccess to some key contributions made by black scholars and activists to fls over the last years. what might have always been an inadequate response/intervention quickly revealed some undeniable shortcomings in the journal, its processes and the academic publishing context we negotiate every day. the lack of contributions published in the journal by black scholars is undeniable and something we intend to reflect further on as a board. we know that this needs to be better and we need to have more critical conversations around realising this. we are not looking for an immediate fix or cure. much like the coronavirus, there is none forthcoming yet. but health for humans and for journals is in a state of constant flux, it is an ongoing journey and we can only keep trying to take steps in the right direction to be the best we can: to affirm the value of black scholarship and black lives and counter the appalling racism of the institutions and operations that has heightened in visibility throughout this pandemic. so, yes, we are afflicted and have been since before this pandemic spread, but amongst the fear and the trauma, this situation has revealed hope in humanity and offered an opportunity to step back and re-evaluate. if what they say is true, things will never be the same again and that's exactly what we need: for things to change for the better; to remind us that our health is our wealth and that we need a (genuinely) global effort towards achieving this and not just for certain parts of the world. as feminist academics, writers, dreamers and above all wenches, we have been thinking about how to best deploy our tactics, our resources and our energies to change the 'global' health of academic publishing for the better. an approach to health which is not geared towards saving the economy of the industry first, but the people, their ideas and creativity, their knowledges from all over this suffering world. this leads to us to try and make sense of the gendered and racialised impacts of the virus and this 'new reality' on the workforce and our work as part of an industry: the academic industry. as is to be expected, the recent crisis has laid bare and exacerbated existing socioeconomic inequalities. in the united kingdom, for example, british black africans and british pakistanis are over two and a half times more likely to die in hospital of covid- than the white population (platt and warwick ) . researchers speculate that among the reasons for the higher death rates among black, asian and minority ethnic (bame) populations in the uk include the fact that that a third of all working-age black africans are employed in key worker roles, % more than the share of the white british population. pakistani, indian and black african men are respectively %, % and % more likely to work in healthcare, where they are particularly at risk, than white british men (siddique ) . underlying health conditions which render people more vulnerable to risk from infection are also overrepresented in older british bangladeshi men and in older people of a pakistani or black caribbean background. over % of those national health service workers who have died due to covid- thus far were from bame ethnic backgrounds (cook et al. ) . in addition to these stark ethnic and racial mortality disparities, research continues to emerge attesting to the disproportionate health, social protection and security, care, and economic burdens shouldered by women as the pandemic progresses (united nations ). while men appear to carry a higher risk of mortality from the virus, the differential impacts on men and women of covid- remain largely ignored by governments and global health institutions, perpetuating gender and health inequities (wenham et al. ) . in terms of labour politics, a noticeable shift in working patterns during the pandemic has, perhaps unsurprisingly, disproportionately impacted women. as joanne conaghan observes, the effects of the pandemic are compounded for women due variously to "…their weak labour market position in low paid, highly precarious, and socially unprotected sectors of employment, their greater propensity to be living in poverty, along with the practical constraints which a significant increase in unpaid care work is likely to place on women's ability to pursue paid work" ( ). conaghan points out that the gender division of labour manifests itself in different ways throughout history, affecting the social and economic status of women. but what the covid- crisis reveals in this historical time period is the extent to which labouring practices for many have been 'feminised', "not just in the sense that the proportion of women participating in paid work has exponentially increased but also because the working conditions traditionally associated with women's work-lowpaid, precarious, and service-based rather than manufacturing-have become the norm" (conaghan ). thus women workers, but also vulnerable young people, migrants, and low-paid precarious workers are further exposed by the "perfect storm of poverty, destitution, sickness and death" generated by covid- (conaghan ) . how then are these labour realities relevant to us in the academic publishing sector? some editors are reporting a noticeable downturn in submissions by women authors and, in some cases, an upturn in submissions by men (fazackerley ) , which would be consistent with conaghan's thesis. the current paradigm, however, provides us with another opportunity to look at the mode of production operating in journal publishing, one that we at fls are implicated in and have long been critical of (fletcher et al. (fletcher et al. , . our insistence that academic publishing, and feminist publishing in particular, be seen as a political endeavour drives a lot of our editorial policies including an emphasis on the importance of global south scholarship, employing decolonising techniques in our editorial practice, our involvement in the recent global south writing workshops (naqvi et al. ) and our continuing support for early career researchers (ecrs), particularly those from marginalised or minoritised communities. we remain troubled, however, by the insidious ambivalence of the neoliberal university as it lumbers on, undeterred and uninterested in the new lives we are all trying to adjust to. it was of serious concern to us, for example, that the ref publication deadline remained unaltered well into the onset of the pandemic with associated impacts on journal editors and boards, reviewers and authors. in another appalling example of how structural disadvantages for black researchers are embedded in the zainab naqvi and kay lalor have recently secured a grant from feminist review trust to run a workshop for 'global south' feminist ecrs based in the uk who work in the social sciences and humanities. see https ://www.femin ist-revie w-trust .com/award s/. we joined with many colleagues in signing this open letter to demand an immediate cancelation of the publication deadline: https ://femre v.wordp ress.com/ / / /call-for-the-immed iate-cance llati on-ofthe-ref- -publi catio n-perio d/. may . academy, we are currently watching the unfolding saga of none of the £ . million worth of funding allocated by ukri and nihr to investigate the disproportionate impacts of covid- on 'bame' communities being awarded to black academics. this is compounded by the revelation that of the grants awarded, had a member of the awards assessment panel as a named co-investigator. many of those in our feminist community have come together over the last four months in various fora to share ideas and to support one another as we both adjust to this new paradigm, and resist the continued imposition of the old one (see, for example, graham et al. ) . we took part in collective discussion in july with colleagues on the editorial boards of feminist theory, feminist review, european journal of cultural studies, european journal of women's studies and sociological review about the academic publishing in the context of covid- . that discussion enabled us to share resources and build morale with a view to envisioning a future for feminist and critical academic publishing. a future in which we challenge existing models of open access in publishing as a starting point. the issues with open access are manifold and we have reflected on these previously (fletcher et al. ) . we aim to build and strengthen the links between the board and our fellow social justice and feminist journals to address this along with the other problems that we have identified, experienced and maybe even fed into as editors. as a first step, we have written a collaborative statement on our joint reflections concerning open access which sets out a non-exhaustive list of some of the values we wish to embody as journals and imbue our editorial work and processes with going forward. you can read the collective statement below at the end of this editorial, and we encourage other journals to join and sign the statement. reflecting on what has changed in this time of covid- and what has stayed the same has led us back in many ways to where we started with wench tactics (fletcher et al. ) . how do we engender our own time and space when what little time and space there is isn't really for us? returning to a conscious consideration of timeliness and to the promise of the decolonial public university might be a way to carve out time and space anew or to resist the pull back to 'normality'. one way of undoing time in the institutional contexts in which we find ourselves is through attempting to articulate and practice an ethics of slowness. mountz and colleagues deploy a feminist ethics of care in trying to reimagine working conditions that challenge the imperatives of the neoliberal university ( ). the authors emphasise the need to prioritise "slow-moving conversation[s] on ways to slow we support this open letter that has been produced by ten black women colleagues to call on ukri for transparency and accountability regarding this: https ://knowl edgei spowe r.live/about /. august . the letter points out that according to hesa data, only . % of full-time research positions in the uk are awarded to black and mixed heritage women exposing the seriousness of this marginalisation where black researchers cannot even get grants to do research with their own communities. down and claim time for slow scholarship and collective action informed by feminist politics" (mountz et al. (mountz et al. , . this understanding of slow scholarship is predicated, of course, on a thoroughgoing critique of neoliberal governance and its drivers, which have fundamentally transformed the university in the uk (and elsewhere) over the last years. karin van marle points out how neoliberal epistemologies crowd out other ways of knowing and being such that they become common sense. this has a chilling effect on the university, which "instead of being a space where multiple views and knowledges are celebrated… becomes a very specific place of exclusion and limitation" ( ). van marle insists that we try and think of the university by reference to a different set of aesthetics: "at least it should be one that acknowledges bodily-presence, sensory experiences, complexity and the need to slow down, to step aside from counting, competitiveness and suffocation" ( ). amid covid- we are on the precipice of an economic catastrophe for higher education in which many of our colleagues will lose their jobs and the futures of early career researchers and those without permanent jobs is looking more precarious than ever. we are also concerned about those vulnerable and disabled colleagues, pregnant people and others who can't acclimatise to the changes that are going to be demanded of us. we need to combine our ethos of slow scholarship with sustainable collective labour politics that prioritises the most vulnerable among us, and one that is particularly attentive to the disadvantages that devolve in line with the socio-economic/class, race and gender disparities discussed above. that the sector has long been poised on a knife-edge is something that many of our colleagues and unions have been warning about, and in the uk this has become more and more acute as austerity politics ravage the state sector, of which the university used to be a part. the notion of the public university feels often like a concept that is fast fading in our collective consciousness, but publishing, teaching and living in a time of covid- makes it prescient once again. as corey robin puts it: "public spending, for public universities, is a bequest of permanence from one generation to the next. it is a promise to the future that it will enjoy the learning of the present and the literature of the past. it is what we need, more than ever, today" ( ). that imagining how we want our world(s) and universities to be is also a profoundly decolonial imperative is something that we must reckon with and take responsibility for (see also, otto and grear ). as many institutions of higher learning in the global north have been forced to confront their complicity in the global slave trade and in other forms of imperialism in the wake of #blacklivesmatter, we have to insist on meaningful accountability and not, as foluke adebisi warns, pr stunts or marketing sops to 'diversity' politics ( ). adebisi makes clear the importance of locating ourselves as researchers and teachers as a continuing part of the university's legacy, and the need to acknowledge racism and colonialism as ongoing processes: "my constant fear is that in the process of universities 'coming to terms', our proposals can turn out to be non-contextualised recommendations that do not take into account the embedded and extended nature of slavery and the slave trade" ( ). what if we showed to our students, asks adebisi, "in very concrete terms, exactly how the past bleeds into the present, how we walk side by side with histories ghosts, how we breathe coloniality every day, how our collective history is literally present in every single thing we do?" ( ). in other words, how can we effectively distinguish, asks olivia rutazibwa, between teaching and learning that foregrounds the will to power versus the will to live? by this she means that in our attempts at decolonising we "go beyond the merely representational" by engaging with and understanding the very materiality of being and the systems that determine and produce our lives (and deaths) (rutazibwa , ) . that such pedagogical and activist praxis necessarily requires time, space and slow conversations is immediately clear. trying to think through slowness in the context of feminist decolonial editorial praxis is also a key aspect of wench tactics (fletcher et al. ; fletcher ) . being a wench in the works entails us deploying tactics to influence how our journal is used, accessed and circulated. we add to this by now utilising wench tactics to influence how our journal is produced. intrinsic in this is the timeline around production, use, access and circulation. as we work from home, experiencing lockdowns and shielding and distancing, time simultaneously runs away from us and stretches out before us. to ground ourselves then, we take a step back: we step out of the rat race that life has become and prioritise health; for ourselves, for others and for the journal. we first set out to rest and restore. we break out of the increasingly frantic rhythms and deadlines that are being fired at us by our institutions and do something else-we aim to remind ourselves of who we are and what we do. in practical terms, this has reminded us that the production and success of our journal are not dependent on us alone but on others including our amazing authors, reviewers, copyediting team and of course our readers. in recognition of the hard work, commitment and engagement of all these people, we have given extended periods for the different steps in the issue production process from reviews to revisions and even writing this editorial. as we do this, we remain defiant and difficult in the face of the publishing industry's environment which requires constant, enthusiastic engagement. this is mirrored in higher education more broadly as we are inundated with email after email about all the changes we must effect to our teaching, research and general working practices in the upcoming year. we need to rest and take restoration measures; we need time and resources to return to ourselves and using wench tactics is an important way to achieve this. to support our rest and restoration, we have also been guided by slow scholarship principles which sideline the measures of productivity, competition and finances underpinning the current institutional and structural approaches to this crisis. instead we emphasise slower conversations and work to sustain ourselves, our health and the journal. we withdraw from institutional priorities which value automation-levels of speed so that we can sustain critical engagement with ourselves, our editorial practices and one another. we place worth and value then on ways of being and working which sustain us, nourish us and keep us grounded, reminding ourselves and one another that it is completely understandable things will take time, need more time, deserve more time than the industry wants us to believe. again, this requires us to be difficult and defiant; a decolonial feminist technique which reconfigures what is seen as valuable and worthy. here, we critically question what is currently being positioned as valuable and worthy in industrial terms and then re-order the list to move our rest, restoration and sustenance to the top. getting things done is valuable and worthy but ensuring that we are rested and restored so that we can sustain ourselves, our engagement with the work we do, and our health are more so. fls is a community and we have been taking time in our meetings to make the space to check in with one another, hear how each member is doing and to practise building care and solidarity with and for one another. this is not limited to our meetings but even the spaces and platforms outside of our 'formal', scheduled interactions. we aim to be there for each other on social media and in collective and individual ways. in doing so, we seek to model best practices of feminist leadership. inspired by leila billing's writings ( ), we first make the invisible, visible and cultivate cultures of mutual care. we make ourselves visible to one another, and to others-we want to be accessible to all of you and remind our colleagues and readers that like you, we are human beings struggling with our lives, health and commitments during this crisis. we are there for each other in an ongoing state of mutual care. in response to the terrible impacts this crisis and the already toxic aspects of the academy are having on minoritised ecrs and to make us more visible and model these mutual care principles, zainab and kay have secured funding to run a writing and mentoring workshop for 'global south' feminist ecrs in the social sciences and humanities based in the uk. more information will be released on our social media channels, so please look out for it and apply if you are eligible and interested. finally, we want to model feminist leadership by imagining and celebrating alternatives. this is exhibited in our recent work to imagine what a life after existing models of open access could and should look like with our colleagues from other feminist and social justice journals (see below). the dreamers inside us envisage alternative ways to share our research and celebrate forms and productions of knowledges that are not given enough attention by us or the academy. in her work around complaint sara ahmed advances the formation of the 'complaint collective' ( ). when we complain, we object to something that should not be happening, but also because we are hopeful about how things could be different (ahmed ) . as we speak out against existing publishing models, we are optimistic about how things can change and become connected with others who have the same complaints and same hope. this leads us to form a complaint collective with our fellow editors and those who are also concerned about the status quo giving us the necessary space, time and opportunity to collaboratively imagine, celebrate and speak out in hope for an alternative model of publishing that is healthier, more equitable and representative. change and movement are inevitable and as we face the challenges of the present and dream about how we can make things better for the future, we now celebrate several of our cherished colleagues who are moving on to new and exciting things. before we introduce the papers that make up this issue of the journal, we want to acknowledge the work of our colleagues who have recently retired from their roles on the editorial board of fls. julie mccandless, nicola barker and diamond ashiagbor are irreplaceable members of our collective and we already miss their sage wisdom, warmth and dedication to fls. all three joined the fls editorial board in , when the journal became independent of the university of kent and were instrumental in guiding the journal as it has grown over the last six years. julie mccandless is a powerhouse whose commitment to and influence on fls cannot be overstated. she was a co-ordinating editor for the journal for most of her tenure and authors will remember her thoroughness, care and generosity as an editor. nicola barker was a book reviews editor during her time on the board and her invaluable contributions to our lively discussions and decision-making processes filled our time together with warmth and laughter. finally, diamond ashiagbor, as well as serving as a book review editor for a significant period of her tenure, brought such vast experience and rigour to her role on the editorial board we will dearly miss her wise counsel. we send our love and solidarity with these wonderful colleagues (and fellow wenches) and wish them well as they continue to blaze a feminist trail for us. and so, we are on the lookout for some more wonderful colleagues to join our editorial board. we have released a call for members aiming to recruit colleagues from the uk and ireland through an application process. if you are interested in joining the board, please do apply. we want the board to be as representative as possible and especially encourage colleagues with a feminist background at any career stage from minoritised groups to apply. if you have any questions about applying, please do get in touch with us, we would be delighted to tell you just how much fun it is to be a wench in the works. this issue of the journal includes some remarkable feminist legal scholarship, notable for its breadth, both scholarly and geographically. caroline dick's article entitled 'sex, sexism, and judicial misconduct: how the canadian judicial council perpetuates sexism in the legal realm' is a fascinating and sobering look bias in decisions of the canadian judicial council. dick considers two separate judicial misconduct complaints adjudicated by the council, one in which a male judge exhibited bias against women while adjudicating a sexual assault trial and a second in which graphic, sexual pictures of a female judge were posted on the internet without her knowledge or consent. dick concludes that the decisions of the council indicate that it is itself perpetuating gendered stereotypes informed by the notional ideal victim, further perpetuating sexism both in canadian courtrooms and among the judiciary. in our second article of this issue, maame efua addadzi-koom carefully examines the history and effectiveness of the maputo protocol, a uniquely african instrument on women's rights that was established with the promise of addressing the regional peculiarities of african women. analysing what little case law there is invoking the protocol and concerning gender-based violence against women, addadzi-koom takes stock of the potential of the protocol and the burgeoning due diligence principle on the women's rights jurisprudence of the ecowas community court of justice (eccj). addadzi-koom concludes her discussion with some recommendations arguing that the protocol and the due diligence principle should be more widely applied by the eccj to centre women's rights in the sub-region and beyond. in '"is this a time of beautiful chaos?": reflecting on international feminist legal methods' faye bird delves deep into feminist jurisprudence with an intriguing interrogation of margaret radin's work, and in particular, her distinction between 'ideal' and 'non-ideal' to evaluate different methodologies for critiquing international law and institutions. bird asserts that (re)viewing radin's framework in this context presages a new and more fruitful feminist pluralism through which we might better navigate institutional strategising. having featured heavily in faye bird's foregoing article, in our next paper dianne otto reflects artfully on the latest iteration of the feminist judgments project in her review essay: "feminist judging in action: reflecting on the feminist judgments in international law project". otto observes aspects of the feminist judgments that were transformative, before turning to the contributors' 'reflections', which highlight some of the obstructions encountered and compromises made in the processes of judging. otto concludes that the new collection makes a useful and compelling contribution to concretising feminist methods and highlighting the role of international jurisprudence as a feminist endeavour, while contributing to the insight of the feminist judgments project more broadly by exposing the scope and limits of justice delivered by the legal form of judging. the issue is completed by book reviews of three exciting new titles, all of which speak to issues of immediate concern to feminist legal scholars: eva nanopoulos reviews honor brabazon's wonderful edited collection neoliberal legality: understanding the role of law in the neoliberal project; lynsey mitchell considers the research handbook on feminist engagement with international law, edited by susan harris rimmer and kate ogg and; felicity adams reviews emma k russell on queer histories and the politics of policing. we are, as always, eternally grateful for the generosity and collegiality of our reviewers, without whom the journal could not function. we conclude this editorial with the recently written feminist and social justice editors' collaborative statement of intent on the values and principles we wish to adopt and embody in our work and efforts to survive, thrive and maybe even dismantle parts of the academic publishing machine. our journey and vital conversations around and towards health continue as we try to become better editors, academics and women: taking the time and resources, to be our best (and healthiest) wench selves. we are a collective of intersectional feminist and social justice journal editors. we reject the narrow values of efficiency, transparency and compliance that inform current developments and policies in open access and platform publishing. together, we seek further collaboration in the development of alternative publishing processes, practices and infrastructures imbued with the values of social and environmental justice. the dominant model of open access is dominated by commercial values. commercial licenses, such as cc-by are mandated or preferred by governments, funders and policy makers who are effectively seeking more public subsidy for the private sector's use of university research, with no reciprocal financial arrangement (berry ) . open access platforms such as academia.edu are extractive and exploitative. they defer the costs of publishing to publishers, universities and independent scholars, while selling the data derived from the uses of publicly funded research. as such they represent the next stage in the capitalisation of knowledge. commercial platforms are emphatically not open source and tend towards monopoly ownership. presenting themselves as mere intermediaries between users, they obtain privileged access to surveil and record user activity and benefit from network effects. a major irony of open access policy is that it aims to break up the giants of commercial journal publishing but facilitates existing or emerging platform monopolies. the tech industry-now dominating publishing, and seeking to dominate the academy through publishing-having offered open access as a solution to the ills of scholarly publishing is currently offering solutions to the problems caused by open access including discoverability, distribution, digital preservation and the development and networking of institutional repositories that stand little to no chance of competing with academia.edu. platforms are not only extractive but have material effects on research, helping to effect a movement upstream in the research cycle whereby knowledge is redesigned, automatically pre-fitted for an economy based on efficiency, competition, performance, engagement or impact. alongside the transformative agreements currently being made between commercial journal publishers (mainly) and consortia led by powerful universities, publishers such as elsevier are gaining greater access to the research cycle and to the data currently owned by universities. open access benefits commercial interests. the current model also serves to sideline research and scholarship produced outside of universities altogether, creating financial barriers to publishing for scholars outside of the global north/west and for independent scholars, as well as for early career researchers and others whose institutional affiliation is, like their employment status, highly precarious and contingent, and for authors who do not have the support of well-funded institutions and/or whose research is not funded by research councils. moreover, stem fields and preprint platforms are determining the development of open access publishing cultures. these are forms of content management that offer cost reduction and other efficiencies by erasing the publisher and minimising editorial function. they raise questions of quality assurance and further the technologisation, standardisation and systematisation of scholarly research such as the automation of peer review, and the disaggregation of journals and books into article or article-based units that can be easily monitored and tracked. therefore, the underlying values of widening participation, public knowledge and the fair sharing of resources need to be reclaimed. platforms should be refitted for ahss scholarship (where speed, for example, is not an indicator of the importance of research) and integrated with more conventional modes of dissemination and distribution more suited to the field and its preference for print monographs. platform development should be distributed and institutionally owned and instead of replacing the publisher-as-problem, it should recognise and represent a more diverse set of publishing interests, stemming from scholar-led and university press publishers that are mission-driven and not-for-profit. it should enable and sustain the innovation generated through intellectual kinship across diaspora spaces. open access reaches into, and disrupts the academy through policy mandates that are, at present, unfunded or underfunded and that defer more of the costs of publishing onto a sector that could not support them even before the covid- pandemic and its catastrophic effect on institutional finances as well as individual lives and wellbeing. as a collective of feminist and social justice journal editors we believe that journal publishing during and after the pandemic should seek to end the exploitation of scholarly labour and foreground a new ecological economics of scholarly publishing based on cooperation and collaboration instead of competition; responsible householding, or careful management of the environment rather than the extraction; and the fair-sharing of finite resources (such as time and materials). rather than extracting more resource (including free labour) from an already depleted and uneven sector, thereby further entrenching inequalities within and between universities globally, and sidelining scholarship produced outside of universities altogether, journal publishing after open access should be responsive and responsible toward the wellbeing, values and ambitions of diverse scholars and institutions across ahss and stem in the global south and the global north. we will learn from, and engage with other collaborative ventures such as amel-ica in latin america, coko in the us and copim in the uk. building on these initiatives, which are primarily concerned with implementing open science or open humanities agendas, we are inaugurating a more radical project of reevaluating and reorganising journal publishing: • replacing the values of efficiency, transparency and compliance with those of equality, diversity, solidarity, care and inclusion • providing a more sustainable and equitable ecological economics of scholarly publishing in tune with social and environmental justice • working collectively and collaboratively rather than competitively • thinking and acting internationally, rather than through parochial national or regional policies • working across publishing and the academy with a view to responsible householding and accountability in both sectors • seeking to work across funding and institutional barriers, including between stem and ahss scholars • seeking further collaborations and partnerships in order to build new structures (disciplines, ethics, processes and practices of scholarship including peer review, citation, impact, engagement and metrics) and infrastructures to support a more healthy and diverse publishing ecology • challenging the technologisation and systematisation of research by working to increase our visibility as editors and academics making us and our publications more accessible and approachable for those who are minoritised in academic publishing publishing after open access does not have a resolution (let alone a technological solution) or endpoint, but rather is a continual process of discussion, controversymaking and opening up to possibilities. we do not know what journal publishing after open access is, but we do know that we must work together in order to create a just alternative to the existing extractive and predatory model, an alternative that operates according to a different set of values and priorities than those that dominate scholarly publishing at the moment. these values and priorities need to inform or constitute new publishing systems committed to the public ownership rather than the continued privatisation of knowledge. we recognise that the choice we face is not between open and closed access, since these are coterminous, but between publishing practices that either threaten or promote justice. we fully recognise the scale of the challenge in promoting justice against the global trend of entrenched populism, nationalism and neoliberalism. collective action and intervention is a start point, and we take inspiration from the recent statement issued by the black writers' guild. our open exploration of the future of journal publishing will be informed by the history of radical and social justice publishing and by intersectional feminist knowledge and communication practices that are non-binary, non-hierarchical, situated, embodied and affective. against the instrumentalisation and operationalisation of knowledge, we will foreground both validation and experimentation, authority and ethics. we will ask, against a narrow implementation of impact and metrics, what really counts as scholarship, who gets to decide, who gets counted within its remit, and what it can still do in the world. we believe that knowledge operates in, rather than on the world, co-constituting it, rather than serving as a form of mastery and control. the re-evaluation of knowledge and its dissemination is, therefore, we believe, a necessary and urgent form of re-worlding. we are open to other journals joining this collective. if you are interested please get in touch with any of the signatories below: european journal of cultural studies european journal of women's studies feminist legal studies feminist theory the sociological review understanding the politics of pandemic scares: an introduction to global politosomatics complaint as diversity work why complain? feministkilljoys unchecked corporate power paved the way for covid- and globally, women are at the frontlines. cambridge core covid- highlights the failure of neoliberal capitalism: we need feminist global solidarity the uses of open access. stunlaw, philosophy and critique for a digital age theorizing global health what does feminist leadership look like in a pandemic? medium epidemics and global history: the power of medicine in the middle east coronavirus, colonization, and capitalism. common dreams exclusive: deaths of nhs staff from covid- analysed covid- and inequalities at work: a gender lens. futures of work affliction: disease health and poverty (forms of living) that obscure object of global health women's research plummets during lockdown -but articles from men increase. the guardian on being uncomfortable wench tactics? openings in conditions of closure playing with the slow university? thinking about rhythm, routine and rest in decelerating life. presentation at qmul sexism as a means of reproduction: some reflections on the politics of academic practice colonial tropes and hiv/aids in africa: sex, disease and race dialogue on the impact of coronavirus on research and publishing indigenous action. . rethinking the apocalypse: an indigenous anti-futurist manifesto making a feminist internet in africa: why the internet needs african feminists and feminisms for slow scholarship: a feminist politics of resistance through collective action in the neoliberal university homesick: notes on a lockdown back at the kitchen table: reflections on decolonising and internationalising with the global south sociolegal writing workshops international law, social change and resistance: a conversation between professor anna grear (cardiff) and professorial fellow dianne otto (melbourne) are some ethnic groups more vulnerable to covid- than others? the institute for fiscal studies the pandemic is the time to resurrect the public university. the new yorker on babies and bathwater: decolonizing international development studies the corona pandemic blows the lid off the idea western superiority https ://olivi aruta zibwa .wordp ress.com/ / / /the-coron a-pande mic-blows -the-lid-off-the-idea-ofweste rn-super iorit what they did yesterday afternoon british bame covid- death rate 'more than twice that of whites'. the guardian coronavirus pandemic in the shadow of capitalist exploitation and imperialist domination of people and nature-statement by the regional secretariat for the north african network for food sovereignty. committee for the abolition of illegitimate debt migrant women: failed by the state, locked in abuse duress: imperial durabilities in our times. durham: duke up. united nations. . policy brief: the impact of covid- on women. april life is not simply fact" -aesthetics, atmosphere & the neoliberal university covid- : the gendered impacts of the outbreak the art of medicine -historical linkages: epidemic threat, economic risk, and xenophobia key: cord- -jwjr po authors: mantel, carsten; cherian, thomas title: new immunization strategies: adapting to global challenges date: - - journal: bundesgesundheitsblatt gesundheitsforschung gesundheitsschutz doi: . /s - - -x sha: doc_id: cord_uid: jwjr po immunization has made an enormous contribution to global health. global vaccination coverage has dramatically improved and mortality rates among children due to vaccine-preventable diseases have been significantly reduced since the creation of the expanded programme of immunization in , the formation of gavi, the vaccine alliance, in , and the development of the global vaccine action plan in . however, challenges remain and persisting inequities in vaccine uptake contribute to the continued occurrence and outbreaks of vaccine-preventable diseases. inequalities in immunization coverage by geography, urban-rural, and socio-economic status jeopardize the achievement of global immunization goals and call for renewed immunization strategies. these should take into account emerging opportunities for building better immunization systems and services, as well as the development of new vaccine products and delivery technologies. such strategies need to achieve equity in vaccination coverage across and within countries. this will require the participation of communities, a better understanding of vaccine acceptance and hesitancy, the expansion of vaccination across the life course, approaches to improve immunization in middle-income countries, enhanced use of data and possible financial and non-financial incentives. vaccines also have an important role to play in comprehensive disease control, including the fight against antimicrobial resistance. lessons learned from disease eradication and elimination efforts of polio, measles and maternal and neonatal tetanus are instrumental in further enhancing global immunization strategies in line with the revised goals and targets of the new immunization agenda , which is currently being developed. immunization is one of public health's most successful and cost-effective interventions, saving up to three million lives every year, according to un figures [ ] . the expanded program on immunization (epi) was initiated in with the goal of providing universal immunization with essential vaccines. among the initially targeted six vaccine-preventable diseases (vpds), diphtheria, pertussis, tetanus, measles, poliomyelitis, tuberculosis, a substantial reduction in the burden of preventable childhood illnesses and deaths was achieved in its initial years [ , ] . over the past decades, national immunization programmes (nips) have become substantially more complex, with vaccines now available to protect against more than infectious diseases, while health, societal, and political changes created additional volatility and ambiguity in often more uncertain environments (e.g., with the occurrence of conflicts, epidemics, or increasing vaccine hesitancy). gavi, the vaccine alliance, was established in primarilytoallownew vaccines to reach children in the poorest countries [ ] . stagnating global immunization coverage rates in many countries led global partners of the decade of vaccines collaboration to initiate the global vaccine action plan (gvap) in [ ] . this plan states in its mission "to extend, by and beyond, the full benefits of immunization to all people, regardless of where they are born, who they are, or where they live". the im- who, unicef, gavi, bmgf, niaid. portant focus on equitable immunization uptake and coverage is also reflected in the present gavi strategy - , and will likely be sustained in a subsequent gavi strategy leading up to [ ] and in the new immunization agenda (ia ) [ ] . major successes were accomplished during the decade. the mortality rate among children under years of age has been driven down from / to / children in only years between and [ ] . more children than ever ( . million) are receiving three doses of dtp before their first birthday, . million more than in . by , countries had reached at least % coverage of the third dose of dtp vaccine [ ] . country decision-making capabilities were strengthened, and many lifesaving vaccines were introduced primarily in the poorest countries [ ] . regional vaccine action plans were designed, a global immunization monitoring and evaluation framework was established, and efforts were made to shape vaccine markets and to improve vaccine price transparency. overall, the gvap helped to build political will and kept immunization visible on the global agenda [ ] . but challenges remain, and nips across the world need to adapt to these by continuously revising and updating their immunization policies and strategies. elimination and eradication goals for polio, measles, rubella, and neonatal tetanus have not been met everywhere and vaccine-derived polio virus and measles outbreaks are still circulating. importantly, not every child or eligible person is being reached everywhere [ , ] . inequities in vaccine uptake and disease persist across countries, and inequalities in routine immunization coverage can contribute to the continued occurrence and outbreaks of vpds. the global coverage of the third dose of diphtheria-pertussis-tetanus-pertussis (dpt) vaccine is stagnating at % with little change since . in some countries, progress has even gone into reverse. one in infants worldwide has still not received any vaccine as reflected in first dose dpt coverage and an estimated . million infants were not reached with routine immunization services such as three primary doses of dpt vaccine [ , ] . coverage with the full complement of doses, including booster doses, is far lower and immunization in the second year of life and beyond still broadly inadequate. an additional . million deaths could be avoided if global immunization coverage improves [ ] . within countries, geographical inequalities are apparent with district-level coverage varying substantially between easily accessible and more remote areas [ ] . social determinants of health, such as individual and household income and education, impact immunization uptake [ ] and areas of low coverage often overlap with those that are home to ethnic minorities, as well as marginalized or nomadic and migrant populations [ ] [ ] [ ] . in many situations, governments face challenges in reaching such underserved populations or lack the political will to do so. increasingly, there are also substantial inequities in vaccine use between urban and rural populations [ ] , with coverage in urban slum populations often as low as in remote rural communities. a preliminary sce-nario based on projected proportions of unimmunized children in rural and urban areas shows that almost half ( %) of the unimmunized and under-immunized children in the top countries that were home to more than half of the unimmunized and under-immunized children in lived in urban areas, and almost every fifth unimmunized child ( %) lived in a slum [ , ] . inequalities in the vaccine coverage by wealth quintiles can also reach enormous dimensions. a child from a rich family can be up to times more likely to be vaccinated for dtp than a child from a poor family in certain countries [ ] . these challenges call fora renewed and sustained global immunization strategy, taking into account emerging opportunities for building better immunization systems and services, but also for the development of new products and technologies. such a global strategy is presently being drafted as part of the ia [ ] . the following four immunization approaches and strategies important to achieving both the existing gvap and future ia goals are discussed: ( ) achieving equity in vaccination coverage; ( ) expanding vaccination across the life course; ( ) promoting integration of immunization in the health sector; and ( ) learning lessons from disease eradication and elimination efforts. expanding access and ensuring equality in uptake of vaccines requires strong immunization systems. in this context, the ongoing emphasis on new vaccine introduction, while exposing the fragility of these systems specifically in low-income countries, also created opportunities in several ways: it generated additional advocacy and visibility for immunization and provided opportunities for training and change in immunization practices. vaccine management and service implementation was improved in many countries, including planning, demand forecasting, vaccine supply, cold chain and logistics, and improved data quality through better recording, report-ing, and use of immunization data for programme monitoring [ , ] . however, strong service delivery systems alone are not enough to achieve optimal impact and need to be accompanied by appropriate policies and strategies that promote the equitable delivery of vaccination. the who global routine immunization strategies and practices (grisp) lays these out in a comprehensive manner [ ] . in this framework, delivery of immunization services through fixed health facilities and mobile outreach services is considered the most basic means for reaching all populations. this includes strategies for detecting and reaching marginalized and partially served populations, adjusting service availability and convenience, creating synergies with accelerated disease control activities, and creating demand for vaccination. these routine services may be supplemented by a strategy termed the periodic intensification of routine immunization (piri) as a mechanism to catch up individuals who may have missed their routine doses. another strategy to rapidly increase population immunity is to deliver additional doses of vaccines through supplementary immunization activities (sias) or vaccination campaigns. inclusion of communities and civil society is crucial to make sure the vaccines and their delivery are acceptable, appropriate, and sustainable. community-based organizations have stepped up their involvement in immunization and developed locally adapted solutions to removing social and cultural barriers, to re-create trust in immunization services, where it had waned, and to increase the locally adapted use of vaccines. in this context, important advances were also made in better understanding vaccine acceptance and hesitancy, which led to stagnant or declining vaccination coverage and resulted in outbreaks of vpds in some places. the who guide to tailoring immunization programmes (tip) helps to identify and prioritize vaccine hesitant populations and subgroups, diagnose the demand and supply-side barriers to vaccination in these populations, and design responses to vaccine hesitancy appropriate to the setting, context, and population [ ] . at the same time, efforts are being made to measure and publish data on inequalities in immunization coverage [ ] . the world health organization (who) and united nations children's fund (unicef) are encouraging all countries to conduct respective analysis to inform programme planning. a new who technical guide outlines in further detail how to progress from measurement of inequities to developing and implementing operational plans to achieve their reduction [ ] . there is also a growing interest in the use of incentives to attain higher immunization coverage and improved health outcomes. result-based financing (rbf) is a broad term that includes a variety of incentive schemes to provide resources to individuals, households, health workers, and district or local governments, whereby payment is conditional on the achievement of agreed-on and measurable outcomes. although there is potential to improve coverage with such programmes, the overall quality of evidence is still relatively low. countries with weaker management and monitoring and evaluation systems in place can face challenges in implementing rbf mechanisms, and the impact of rbf in countries with weak health systems is unclear [ ] . other approaches to improving immunization coverage include national vaccine legislation that mandates immunization and often includes the provision of a budget line for vaccine procurement [ ] . examples of successfully adapted national vaccination strategies are seen in india, where strong political will coupled with innovative and flexible immunization approaches and an appropriate monitoring framework (e.g., with geospatial mapping) led to a substantial increase in equitable coverage across the country [ , ] . in spite of their relatively higher gross national income (gni)/capita, middleincome countries (mics) that have been excluded from gavi support or are about to lose this support, increasingly recognize inequities in vaccine coverage as a se- bundesgesundheitsbl · : - https://doi.org/ . /s - - -x © springer-verlag gmbh deutschland, ein teil von springer nature immunization has made an enormous contribution to global health. global vaccination coverage has dramatically improved and mortality rates among children due to vaccine-preventable diseases have been significantly reduced since the creation of the expanded programme of immunization in , the formation of gavi, the vaccine alliance, in , and the development of the global vaccine action plan in . however, challenges remain and persisting inequities in vaccine uptake contribute to the continued occurrence and outbreaks of vaccine-preventable diseases. inequalities in immunization coverage by geography, urbanrural, and socio-economic status jeopardize the achievement of global immunization goals and call for renewed immunization strategies. these should take into account emerging opportunities for building better immunization systems and services, as well as the development of new vaccine products and delivery technologies. such strategies need to achieve equity in vaccination coverage across and within countries. this will require the participation of communities, a better understanding of vaccine acceptance and hesitancy, the expansion of vaccination across the life course, approaches to improve immunization in middle-income countries, enhanced use of data and possible financial and non-financial incentives. vaccines also have an important role to play in comprehensive disease control, including the fight against antimicrobial resistance. lessons learned from disease eradication and elimination efforts of polio, measles and maternal and neonatal tetanus are instrumental in further enhancing global immunization strategies in line with the revised goals and targets of the new immunization agenda , which is currently being developed. vaccines · global strategies · expanded programme on immunization · health systems · integration neue impfstrategien -anpassung an globale herausforderungen zusammenfassung impfungen haben in den letzten jahrzehnten deutlich zur verbesserung der globalen gesundheit beigetragen. im globalen durchschnitt haben sich die impfquoten signifikant verbessert, und die kindersterblichkeit aufgrund impfpräventabler erkrankungen ging seit beginn des "erweiterten impfprogramms" (expanded programme on immunization [ impfstoffe · globale strategien · erweitertes impfprogramm · gesundheitssysteme · integration rious problem in achieving their health goals [ ] . currently, more than two thirds of the world's poor live in mics and the largest fraction of children without access to vaccines is born in these countries [ ] . delays in vaccine procurement resulting in interruption in services, together with increasingly reported vaccine hesitancy, contribute to declining or stagnant coverage in some of these countries [ ] . in addition, there is persistent inequality in coverage in some socially disadvantaged populations and among the increasing number of migrants. in response to these equity challenges, mics with support from major immunization partners have developed strategies addressing a number of specific issues important to sustainably reach the underserved populations [ ] . these include support for decision-making and political commitment, financial sustainability, enhanced demand and eq- who, unicef, gavi, bmgf and others. uitable delivery, as well as affordable and timely supply [ ] . the new gavi strategy . also includes an additional provision for addressing immunization challenges in mics, specifically with regard to vaccine price, quality, and supply [ , ] . finally, further developments in vaccine delivery technologies could help in improving equitable vaccine coverage. a -year old technology for the administration of vaccines based on needle and syringe is still in use today. this technology is relatively complex to use, requires substantial training, is prone to programmatic errors, results in sharps waste, and may be a factor in the decreasing acceptability of vaccination [ ] . new technologies, e.g., microarray vaccine skin patches could allow less well-trained health workers to administer parenteral vaccines, reduce fear and hesitancy, simplify vaccine storage and transport, and improve vaccination coverage and reach [ ] . another important approach to reducing inequities in immunization is the extension of immunization beyond infant vaccination [ ] . with many more vaccines in the schedule and the need for administering booster doses, epi services need to increasingly achieve adequate coverage in all target populations across the life course. additional vaccines for all age groups are available or will likely become available in the near future targeting infants and young children (e.g., vaccines against measles [ nd dose], mumps, rubella, japanese encephalitis, group a and w meningococcus, varicella, hepatitis a, typhoid fever, malaria, dengue, enterotoxigenic e. coli, shigella, and group a streptococcus), older children and adolescents (tetanus adolescent dose, human papilloma virus [hpv] vaccine), pregnant women (influenza, pertussis, group b streptococcus, respiratory syncytial virus vaccines), and older adults (varicella-zoster vaccine). these new contacts with the health systems will also offer opportunities to provide missed vaccine doses that should have been administered earlier. new platforms for vaccine delivery are further explored, such as antenatal maternal services, pre-school and school-based delivery, adolescent health programs, as well as risk-based, targeted services for health workers and for specific patient groups in need of certain vaccines (e.g., diabetics). among all preventive healthprogrammes and initiatives, the epi traditionally has the greatest ability to reach infants, children, and pregnant women. with the ambitious goals set by the sustainable development goals (sdgs) and the who's th general programme of work, including a renewed emphasis on primary health care and universal health coverage, further synergies among different health programmes are being promoted [ ] . given the broader spectrum of diseases against which vaccines are or will soon be available, nips will need to work in a more cohesive way using integrated delivery platforms and broader collaboration in planning processes to achieve sustained equity and efficiencies. vaccines have an important place in comprehensive approaches to disease control. the use of vaccines against hepatitis b, pneumococcal, rotavirus, and hpv infection are vital interventions in the broader disease control efforts against chronic liver disease, acute respiratory infections, meningitis, severe diarrhoea, and cervical cancer [ ] . elimination of maternal and neonatal tetanus as a public health problem should be achievable in the near future in the remaining countries (as of july ) by applying integrated strategies and activities including the immunization of children, mothers, and women of reproductive age together with the promotion of clean deliveries and cord care practices. in this broader context, tetanus toxoid will successively be replaced with tetanus-diphtheria vaccines to ensure sustained protection against both diseases [ ] . the new who strategy to achieve the elimination of cervical cancer as a public health concern focuses on increasing the coverage of vaccination against hpv as one of three key targets besides screening and hpv testing [ ] . nips can also help to further increase equitable coverage of other health interventions, such as vitamin a supplementation, anti-helminthic treatment, nutrition interventions, insecticide-impregnated bed-nets, and intermittent preventive treatment against malaria. other important preventive interventions are being added, e.g., for adolescents [ ] . improving coordination and collaboration between immunization and other preventive and curative services can result in efficiency gains, save resources by offering one-stop services at the point of delivery, and increase the use of social mobilization to increase demand [ ] . in addition, non-governmental and private vaccinators can enhance the ability of programmes to deliver recommended vaccine doses, especially to clients who prefer them over public services. an added operational approach to increasing equitable immunization coverage is the reduction of missed opportunities for vaccination. unvaccinated and under-vaccinated children and pregnant women may access health services to seek care, and such a visit becomes a missed opportunity if immunization is not addressed. this could quite easily be rectifiedbyhealthfacilitystaffinbothnon-immunization and immunization services reviewing the vaccination status of all clients presenting or accompanying others and providing any missed doses [ , ] . recent work has shown that immunization coverage increases of %, and more can be achieved with relatively simple measures. chad, with % of eligible children leaving health facilities unvaccinated, made a quick evaluation and initiated a missed-opportunities-forvaccination strategy using cross-referral, which led to a sizable increase in the number of vaccinated children [ ] . a further example of using vaccines in an integrated approach to curb global health threats is the fight against antimicrobial resistance (amr), currently one of the most alarming issues for human health. drug resistant infections may already cause , deaths per year and it is estimated that million deaths due to amr may occur every year after [ ] . vaccines can impact antibiotic-resistant infections through a direct reduction in the resistant organisms and strains that are specifically targeted by the vaccine, as well as through a reduction in common illnesses that often lead to the use of antibiotics and therefore selection pressure on pathogens [ ] . the widespread use of haemophilus influenzae type b (hib) and pneumococcal vaccines have resulted in a dramatic reduction in disease burden and have been associated with decreased incidence of resistant strains. universal coverage with pneumococcal vaccination could potentially avoid more than million days of antibiotic use per year in children under [ , ] . a newer typhoid conjugate vaccine has a potential for high impact on prevention and control of antimicrobial resistant typhoid fever and was recently strategically used to control an extensively drug resistant typhoid outbreak in pakistan [ ] . but vaccines against viruses, e.g., influenza, can also exert a major impact here, due to the inappropriate prescription of antibiotics. vaccines offer a more sustainable approach to infection prevention, since pathogen resistance to vaccines is uncommon [ ] . the equitable use of vaccines is expected to avert substantial parts of the amrrelated fraction of disease, reduce antibiotic use, and-together with other interventions across human and animal health-add to the reduction in the economic and societal burden of amr [ ] . while the aspirational gvap goals to eradicate polio and eliminate measles and rubella will not be met by , substantial progress has been achieved in these areas. wild poliovirus (wpv) type was certified as eradicated in and wpv type has not been detected since . wp type is circulating in a mere two countries. at the same time, measles cases have been reduced through vaccination by % since , preventing . million deaths [ ] . important lessons informing enhanced immunization strategies can be learned from these efforts. the new polio endgame strategy for the years - uses intensified immunization approaches in afghanistan and pakistan, e.g., so-called hit-and-run vaccine delivery in conflict-affected and insecure areas [ ] . at the same time, strides are being made to integrate the delivery of polio vaccination and ded-icated surveillance networks fully into nips [ ] . measles, due to its high contagiousness, is often viewed as the "canary in the coal mine, " exposing even small areas of inequities that are not visible when just looking at inequalities in coverage. again, strategies to accelerate progress towards measles elimination comprise the enhanced use of surveillance platforms, which have been established in many countries to detect and respond to communicable diseases. in addition to conducting surveillance, the collection of detailed subnational coverage data and outbreak investigations are used to distinctly map areas and age groups with immunity gaps. specific approaches can then be used to fill these gaps in line with the measles and rubella strategic plan, e.g., through targeted sias [ ] . other epidemic-prone diseases periodically threaten the health and livelihoods of people [ , ] . outbreak risks are magnified by rapid population growth in areas with weak health systems, urbanization, human mobility, conflict, and the changing nature of pathogen transmission between human and animal populations [ ] . these drivers of disease emergence are likely to continue and intensify, while ecological changes, including climate change, can further amplify disease emergence risk [ ] . reducing the risk of epidemic-prone vpds involves several strategies: anticipating and preventing outbreaks using preventive vaccination campaigns (e.g., when immunity gaps accumulate or when natural disasters or other humanitarian emergencies increase risk); timely outbreak response to limit spread; postoutbreak initiatives to rebuild resilient health systems or address shortfalls that led to the outbreak. where possible, such initiatives should be combined with other vaccines or interventions, as appropriate, to maximize impact and achieve efficiency gains [ ] . capacities for the rapid deployment of vaccines and other interventions have been strengthened as a legacy of polio eradication and measles elimination efforts. major efforts for rebuilding systems with enhanced preparedness and response capacities were seen with the recent ebola outbreaks in west and central africa; this strategy was also pursued in the cholera outbreaks in conflict zones of syria and yemen or the diphtheria outbreaks among the rohingya refugees in bangladesh. outbreaks sometimes necessitate the use of new pre-licensure vaccines, as successfully implemented during the ebola outbreaks. a new entity, the coalition for epidemic preparedness innovations (cepi) was set up with the mission of stimulating and accelerating the development of vaccines against emerging infectious disease and enabling access to these vaccines for people during outbreaks [ ] . cepi is presently working on the preparedness and response against five priority pathogens: chikungunya, lassa virus, marburg virus, mers coronavirus, and nipah virus, thereby covering some of the who research and development 'blueprint' priority diseases [ ] . cepi's work includes manufacturing across the supply chain, stockpile establishment, and research to accelerate vaccine development with the aim to stop epidemics before they turn into large-scale health emergencies. firming up synergies between accelerated disease control efforts and routine immunization can contribute to achieving immunization goals. using the added attention on outbreaks, vaccination campaigns can also be used to actively look for and refer inadequately immunized persons to regular vaccination sessions, thus reinforcing overall immunization systems [ ] . extensive global progress has been made using immunization strategies specifically adapted to low-and lower middleincome countries and significant reductions in vpd and mortality were achieved. the many factors affecting vaccine implementation, ranging from weak health systems to humanitarian crises, outbreaks, hesitancy, and flagging demand for vaccination show the clear need for continued support of implementation of these strategies to sustain overall health gains and reach globally agreed immunization targets. equitable access to vaccines across and within countries is key to success. robust delivery mechanisms are needed if vaccines are to reach their full potential. to be effectively implemented, vaccines should be integrated into primary health care, so that vaccine schedules can be optimized for all age groups (e.g., by using school, adolescent, and other agespecific health services) and opportunities to vaccinate are not missed. immunization should be delivered in peoplecentered ways as part of primary health care in order to reach universal health coverage. in addition, vaccines are well placed for preparing for and responding to epidemics and may exert a major positive effect on amr. the next decade will see new and improved vaccines, opportunities, and technologies to build better immunization services. global immunization partners are presently developing the ia , which aims to exploit these opportunities by positioning immunization as a human right and as an investment to make the world healthier, safer, and more prosperous. it will include strategic priorities and worldwide goals for the new decade and will be accompanied by diseasespecific strategies, regional and country plans, immunization partner strategies, and an overall monitoring and evaluation framework. the strategy will be endorsed by the world health assembly (wha) in may and is designed to further evolve according to changing needs [ ] . meeting the challenges of immunization in the near future will require commitment and contributions from many stakeholders, including national governments, global agencies, development partners, regional bodies, and civil society, and such commitment is one of the crucial links for sustainability, delivering more vaccines to more along the full life course. united nations children's fund ( ) #vac-cineswork: vaccines are safe and save lives. un news global perspective expanded programme on immunization and primary health care protecting the world's children: the story of who's immunization programme national immunization programmes global vaccine action plan gavi the vaccine alliance ( ) gavi's strategy phase iv ( - ) and v immunization agenda . a global strategy to leave no one behind status of new vaccine introduction-worldwide immunization today and in the next decade-assessment report of the global vaccine action global vaccine action plan: report by the director-general. st world health assembly. who, geneva . world health organization ( ) who vaccine-preventable disease monitoring system. global summary children: reducing mortality fact sheets subnational immunization coverage data towards equity in immunisation jabs and jags: a qualitative exploration of barriers and facilitators to child and adult immunisation uptake among gypsies, travellers and roma immunization divide: who do get vaccinated in bangladesh? ethnicity and delay in measles vaccination in a nairobi slum inequalities in full immunization coverage: trends in low-and middle-income countries unimmunized children: urbanrural differences in top countries with un-and under-immunized children country urbanization profiles: a review of national health or immunization policies and immunization strategies global vaccine action plan: progress report the impact of new vaccine introductiononimmunizationandhealthsystems: a review of the published literature world health organization ( ) principles and considerations for adding a vaccine to a national immunization programme. from decision to implementation and monitoring global routine immunization strategies and practices (grisp): a companion document to the global vaccine action plan (gvap) commentaryto: guideto tailoring immunization programmes in the who european region world health organization ( ) global health observatory data. health equity monitor world health organization regional office for europe ( ) equity in immunization. a technical guide for addressing inequities in immunization in: an overview of research on the effects of results-based financing. knowledge centre for the health services at the norwegian institute of public health (niph) national legislation and spending on vaccines in latin america and the caribbean mission indradhanush makes vaccination progress in india national immunization programme-mission indradhanush programme: newer approaches and interventions the world bank in middle income countries middle income country task force ( ) the middle income country strategy-enhancing sustainable access to vaccines for populations in middle-income countriesi the assessment report of the global vaccine action plan challenges to sustainable immunization systems in gavi transitioning countries gavi's role in market shaping and procurement: progress, challenegs, and recommendations for an evolving approach challenges of vaccine presentation and delivery: how can we design vaccines to have optimal programmatic impact? vaccine exploring new packaging and delivery options for the immunization supply chain life-course immunization as a gateway to health promote health, keep the world safe, serve the vulnerable ending preventable child deaths from pneumonia and diarrhoea by . development of the integrated global action plan for the prevention and control of pneumonia and diarrhoea protecting all against tetanus: guid to sustaining maternal and neonatal tetanus elimination and broadening tetanus protection for all populations who leads the way towards the elimination of cervical cancer as a public health concern building on the success of the expanded programme on immunization: enhancing the focus on disease preventionandcontrol can vaccination coverage be improved by reducing missed opportunities for vaccination? findings from assessments in chad and malawi using the new who methodology enhancing immunization during second year of life by reducing missed opportunities for vaccinations in countries changing priorities in vaccinology: antibiotic resistance moving to the top impact of existing vaccines in reducing antibiotic resistance: primary and secondary effects vaccines to tackle drug resistant infections. an evaluation of r&d opportunities impactofpneumococcalconjugate vaccineoninfectionscausedbyantibiotic-resistant streptococcus pneumoniae extensively drug-resistant typhoid fever in pakistan call to action on antimirobial resistance r.t.g. ghana government, uk government approaches to vaccination among populations in areas of conflict global polio eradication initiative ( ) polio endgame strategy - : eradication, integration, certification and containment world health organization ( ) global measles and rubella strategic plan prediction and prevention of the next pandemic zoonosis global trends in emerging infectious diseases infectious disease threats in the twenty-first century: strengthening the global response assessing global preparednessforthenextpandemic: development and application of an epidemic preparedness index world health organization ( ) vaccination in acute humanitarian emergencies: a framework for decisionmaking coalition for epidemic preparedness innovations annual review of diseases prioritized under the research and development blueprint for this article no studies with human participants or animals were performed by any of the authors. all studies performed were in accordance with the ethical standards indicated in each case. key: cord- -zemaygnt authors: johnson, stephanie b. title: advancing global health equity in the covid- response: beyond solidarity date: - - journal: j bioeth inq doi: . /s - - - sha: doc_id: cord_uid: zemaygnt in the coming weeks and months sars-cov- may ravage countries with weak health systems and populations disproportionately affected by hiv, tuberculosis (tb), and other infectious diseases. without safeguards and proper attention to global health equity and justice, the effects of this pandemic are likely to exacerbate existing health and socio-economic inequalities. this paper argues that achieving global health equity in the context of covid- will require that notions of reciprocity and relational equity are introduced to the response. while much of the world's attention is currently focused on europe and the united states, experts worry that in the coming weeks and months sars-cov- may ravage countries with weak health systems and populations disproportionately affected by hiv, tuberculosis (tb), and other infectious diseases (nordling ) . at the same time, the trump administration has been accused of offering a german medical company "large sums of money" for exclusive access to a coronavirus disease vaccine (oltermann ) . according to an anonymous source, trump was aiming to secure a vaccine against the coronavirus for the united states, "but for the us only." it was also reported that the german government was offering its own financial incentives for the vaccine to stay in the country. this stark example reveals the unfairness and inequities of the global political and health systems. unfortunately, inequitable distribution of vaccines is not the only way in which global inequities can be reproduced. without safeguards and proper attention to global health equity and justice, the effects of this pandemic are likely to exacerbate existing health and socio-economic inequalities. global coordinated efforts in response to covid- led by international organizations such as unicef and the world health organization (who) have attempted to integrate notions of global "solidarity" into practice and policy. in this paper we explore how solidarity is used in this context and how it can be manifest. we argue that achieving global health equity in the context of covid- will also require that other equityorientated perspectives, namely reciprocity and relational equity, must be introduced to the response. in april , the un general assembly unanimously adopted a resolution calling for increased global solidarity and international cooperation against the novel coronavirus outbreak. similarly, in april the who and unicef initiated the covid- solidarity response fund. unicef ( ) reports that "money collected through the fund will be used, among others, to train and equip communities and health-care workers to prevent, detect and treat covid- . it will help countries expand their health-care capacity and mitigate its social impact." similarly, the who publication addressing human rights as key to the covid- response sets out that [u] nder international human rights law, the obligations undertaken by state parties beyond their borders, i.e. to international assistance and cooperation are akin to their domestic obligations, not subsidiary or secondary in any way. covid- is a reminder, not only of the global connectedness of the pandemic, but also of its solutions. providing lmics with international assistance and cooperation, both fiscal and technical, is crucial not only to individual nations' efforts to address this pandemic but also to global efforts. (world health organization , ) while "solidarity" is presented as the conceptual umbrella under which these moral and practical commitments fall, several reasons are offered for the importance of global solidarity: ) it is legally required, ) it will help lmics address the outbreak in their own countries, and ) global cooperation will also be instrumental in avoiding a second wave of infection in high-income countries. in this regard, solidarity is used instrumentally to avert crisis in highincome countries and also as a moral basis for a commitment to countries elsewhere. the bioethical literature offers differing views on conceptual understanding of solidarity and the practical work that "global solidarity" might be able to do. in the context of global health, solidarity is often invoked normatively in connection with providing assistance to poor countries (prainsack and buyx ) . some, however, including gostin et al. ( ) , reject the notion of solidarity as "aid" and endorse an understanding of mutual assistance between countries motivated by a sense of shared duty, as distinct from charity (prainsack and buyx ) : framing global health funding as "aid" is fundamentally flawed because it presupposes an inherently unequal benefactor-dependent relationship. rather, global collaboration requires a collective response to shared risks and fundamental rights, where all states have mutual responsibilities. charitable giving usually means that the donor decides how much to give, for what and to whom. consequently, aid is not predictable, scalable or sustainable. it undermines the host country's ownership of-and responsibility for-health programmes. (gostin et al. , ¶ ) prainsack and buyx offer that of authors writing about solidarity and global health, most agree that solidarity should help to materialize a better distribution of resources and more equal access to healthcare across the globe. they also argue that "in its most bare-bones form, solidarity signifies shared practices reflecting a collective commitment to carry 'costs' (financial, social, emotional, or otherwise) to assist others" (prainsack and buyx , ) . solidarity is understood as a practice and not as an inner sentiment or an abstract value, one that can be reflected across three tiers: the individual, the institutional, and the legal and contractual (prainsack and buyx ) . dawson and jennings deny that "costs" are a necessary requirement for solidarity. they "hold solidarity to be a deep and enmeshed concept, a value that supports and structures the way we in fact do and ought to see other kinds of moral considerations" (dawson and jennings , ) and suggest that "the foundational aspect of solidarity can be captured by the fundamental idea of 'standing up beside'" ( ). this is taken to have several key elements: solidarity requires a public action; the purpose of the action is orientated towards improving or correcting past or present disadvantage or injustice; and what is important is that action does not derive out of expectation of benefit from the other but out of moral concern for that other (dawson and jennings ) . what all this demonstrates is that it is "impossible to give an uncontroversial definition of solidarity" (dawson and jennings , ) . solidarity is conceptually contested; the concept often poorly defined in practice and by most accounts does not imply direct obligations. solidarity can therefore fail to manifest in a meaningful way when aiming to advance global health equity. further, solidarity does not incorporate important ethical and moral dimensions of global equity. that is to say "solidarity," by most accounts, fails to account for the contributions that lmics make to global health security and what they may be owed in return. theories of justice from political philosophy most often establish obligations for parties from highincome countries owed to parties from low-and middle-income countries (pratt and loff ). yet, in recent decades, global collaborative efforts have formed a key part of addressing emerging infectious disease threats. the global health security agenda (ghsa), for example, is a group of countries, international organizations, ngos, and private sector companies that have come together to advance a world safe and secure from infectious disease threats (ghsa ). thirty-one countries around the world are partnering to reach the goals of the ghsa, under which nations make new, concrete commitments to elevate global health security as a national leaders-level priority (ghsa ). in the research domain, important work to develop globally compatible surveillance systems has been ongoing (gardy and loman ) . indeed, ongoing surveillance is a core part of covid- global strategy. recognition of the required collaborative nature of disease detection means research practices have evolved within the scientific community, emphasizing openness, transparency, networks, and free exchange (laird et al. ). the covid- pandemic has seen unprecedented levels of collaboration and openness. nextstrain, for example, is an open repository that pulls in data from labs around the world that are sequencing sars-cov- 's genome and centralizes it in a phylogenetic tree (berditchevskaia and peach ) . researchers have also been sharing new findings about the virus's genomic profile through open source publications and preprint sites such as biorxiv and chinaxiv (berditchevskaia and peach ) . what all this demonstrates is that lmics are not merely the recipients of knowledge and resources. as others have noted "northern researchers are not selfsufficient benefactors providing capacity-building and strengthening resources. they need the data, samples, skills, experience and expertise contributed by their southern partners" (parker and kingori ) . "reciprocity is generally understood to be based on the notion of mutual regard and fair play. reciprocity demands an appropriate balancing of the benefits and burdens of the social cooperation necessary to obtain the good of public health" (viens et al., , ) . global pathogen threat detection systems create both burdens and benefits. benefits may include creation of technologies and vaccines and increased healthcare and surveillance capacity in lmics. similarly, burdens may include use of resources, risks to privacy (through data-donation), and undesirable political or trade consequences. countries that have participated in global surveillance and have borne the costs and burdens are owed something in return. this is true whether the downstream benefits of that participation have yet been realized or can be measured. so far, we have taken a distributive view of justice. relational egalitarians have proposed a different way of conceptualizing equity which focuses not on distributions as inherently important but instead on the quality of social relations among citizens and/or the ways in which social institutions "treat" citizens (voigt and wester ) . in this context, other ways in which equity might be reflected in current and future pandemic responses is in the processes through which policies are designed and decided upon. participation in decisions about public health policy in particular should increase the involvement of marginalized groups as "agents" of policy rather than merely recipients (weinstock ) . this could play out on many levels; here we focus on geopolitical issues and international science. progress is required in this regard so that existing and historical injustices are not perpetuated or exacerbated. recent polling of the international advisory board of the lancet global health on questions of authorship and recognition illustrate some of the challenges that continue to arise in ensuring fair involvement and recognition of researchers in lmics. the greatest challenge being the greater power and resources of their partners and a lack of consensus on what is "fair" (the lancet global health ). in january , the nuffield council of bioethics report research in global health emergencies: ethical issues (nuffield council of bioethics ) highlighted the research fairness initiative guide to high-quality reporting on measures and conditions that promote fair research partnerships (research fairness initiative ). recommendations include, amongst others, early engagement of all partners; data ownership, storage, access, and use during and after research for lmic partners; and specific measures to share intellectual property rights in collaborative research (research fairness initiative ). of the more than three hundred clinical trials that have been launched to find a treatment for covid- , most are in china and south korea, with more developing in the united states and europe (roussi and maxmen ) . very few are taking place in africa, latin america, and south and southeast asia (roussi and maxmen ) . early trial entrants for the who's solidarity clinical trial, which seeks to compare the effectiveness of four drugs and drug combinations in treating covid- , are from europe, where countries have some of the highest covid- cases. but so far the only country in africa to have formally joined the trial is south africa (roussi and maxmen ) . this has significant implications for the applicability of trial results to different populations. if the benefits of research are to be achieved and a just global response to covid- realized, this will be dependent upon both distributive and relational concerns. a successful global research effort will require attention to the ways in which all partners are treated and the ways in which priorities, interventions, and policies are decided upon. in their qualitative study examining the ethics of global research collaborations, parker and kingori ( ) found that addressing ethical concerns in global research collaborations is not only morally desirable, but is required for collaborative global health research to be both successful and sustainable. the successful functioning of global health research networks and hence the successful production of scientific knowledge was seen by scientists in the global south to include an interweaving of scientific, practical, and moral practices. these include the building and maintaining of trust, paying careful attention to fairness in the recognition of efforts, ensuring that scientists in low-income settings are able to meet their obligations to local communities, and the promotion of mutual respect (parker and kingori ) . addressing the covid- pandemic will require global efforts in surveillance and public health, bringing together scientists, practitioners, policymakers, governments, and many other global health actors. a substantial bioethics literature exists around global health equity and in particular on the ethical distribution of vaccines and the conceptualization and requirements of global solidarity. in this paper we have argued that global health equity in the context of the covid- response can be further advanced by acknowledging the role that lmics play in global science, as well as through attention to the ethical aspects of collaborative working and the processes by which scientific knowledge is produced and policies decided (parker and kingori ) . funding information the author is supported by a wellcome centre grant ( /z/ /z) and a wellcome strategic award ( ). open access this article is licensed under a creative commons attribution . international license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons licence, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons licence, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. to view a copy of this licence, visit http://creativecommons.org/licenses/by/ . /. coronavirus: seven ways collective intelligence is tackling the pandemic. the conversation the place of solidarity in public health ethics towards a genomics-informed, real-time, global pathogen surveillance system ghsa (global health security agenda). . global health security agenda national and global responsibilities for health rethink the expansion of access and benefit sharing closing the door on parachutes and parasites a ticking time bomb": scientists worry about coronavirus spread in africa research in global health emergencies: ethical issues trump "offers large sums" for exclusive access to coronavirus vaccine. the guardian good and bad research collaborations: researchers' views on science and ethics in global health research solidarity in contemporary bioethics-towards a new approach a framework to link international clinical research to the promotion of justice in global health research fairness initiative african nations missing from coronavirus trials unicef. . who and unicef to partner on pandemic response through covid- solidarity response fund, p r e s s r e l e a s e your liberty or your life: reciprocity in the use of restrictive measures in contexts of contagion relational equality and health world health organization. . addressing human rights as key to the covid- response publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord- - nkrh authors: bernards, nick; campbell‐verduyn, malcolm; rodima‐taylor, daivi; duberry, jerome; dupont, quinn; dimmelmeier, andreas; huetten, moritz; mahrenbach, laura c.; porter, tony; reinsberg, bernhard title: interrogating technology‐led experiments in sustainability governance date: - - journal: glob policy doi: . / - . sha: doc_id: cord_uid: nkrh solutions to global sustainability challenges are increasingly technology‐intensive. yet, technologies are neither developed nor applied to governance problems in a socio‐political vacuum. despite aspirations to provide novel solutions to current sustainability governance challenges, many technology‐centred projects, pilots and plans remain implicated in longer‐standing global governance trends shaping the possibilities for success in often under‐recognized ways. this article identifies three overlapping contexts within which technology‐led efforts to address sustainability challenges are evolving, highlighting the growing roles of: ( ) private actors; ( ) experimentalism; and ( ) informality. the confluence of these interconnected trends illuminates an important yet often under‐recognized paradox: that the use of technology in multi‐stakeholder initiatives tends to reduce rather than expand the set of actors, enhancing instead of reducing challenges to participation and transparency, and reinforcing rather than transforming existing forms of power relations. without recognizing and attempting to address these limits, technology‐led multi‐stakeholder initiatives will remain less effective in addressing the complexity and uncertainty surrounding global sustainability governance. we provide pathways for interrogating the ways that novel technologies are being harnessed to address long‐standing global sustainability issues in manners that foreground key ethical, social and political considerations and the contexts in which they are evolving. digital technologies in sustainability governance: possibilities, politics, power efforts to harness emerging technologies to address a host of new and longer-standing sustainability challenges have recently proliferated. artificial intelligence (ai), blockchain, big data and other new technologies are central to a growing number of on-going experiments, ranging from the tracking of greenhouse emissions to monitoring wildlife poaching and global supply chains, to transnational efforts to combat human trafficking, and manage the covid- pandemic. these unfolding experiments seek to mobilize digital technologies to meet a growing range of governance challenges that are typically grouped together under the banner of sustainability and sustainable development. these developments have not, however, been much interrogated in international relations and global governance scholarship (though see boersma and nolan, ; duberry, ; gale, ascui, and lovell, ) . existing policy and practitioner debates, meanwhile, tend to emphasize the affordances and pathologies of specific digital technologies (beaumier et al., ) . a number of important questions have thus remained unaddressed: how do unfolding initiatives centred on ai, blockchains, big data and other emerging technologies seek to overcome, or extend and reinforce, the limits of existing global governance? what debates and conflicts of interest are elided by appeals to technological applications as solutions to governance challenges? how does the development and deployment of new technologies intersect with existing disparities of power, resources, and access? this article begins to address these questions, synthesizing discussions an interdisciplinary workshop on these themes held at the university of warwick in december . we situate on-going technology-led experiments in sustainability governance within three longer-standing global trends: ( ) a growing reliance on private, voluntary codes of conduct, standards, and third-party auditing; ( ) global experimentalist governance; and ( ) efforts to adapt governance mechanisms to deal with the growing prevalence of informal and illicit economies. in light of this, we argue that uses of technology in multi-stakeholder initiatives have tended to reduce rather the scope for participation in sustainability governance, deepen challenges to participation and transparency, and reinforce rather than transform existing power relations. in what follows, we outline the above three global governance trends in turn, tracing their intersections with emerging technology-centred initiatives in global sustainability governance. we then conclude by outlining a number of questions for scholars, practitioners and policy makers to consider in interrogating the uses of technology in sustainability governance. technology-centred initiatives to improve global sustainability governance are in many ways extensions of the patchwork of private codes of conducts and corporate social responsibility (csr) policies developed in recent decades. the inability of these corporate-led modes of 'responsible governance' to yield significant improvements for workers and the planet is well-documented (fransen and burgoon, ; koenig-archibugi, ; lebaron, lister and dauvergne, ) . such initiatives have frequently resulted in mere 'corporate philanthropy' that favours powerful stakeholders over grassroots communities (orock, ) . these modes of governance have often reinforced existing inequalities. for example, corporate codes of conduct for worker safety in garment supply chains have been found to pass costs of compliance on to supplier factories. yet, they do little to alleviate the time and cost pressures placed on suppliers by major branded buyers, who often drive unsafe working conditions in the first place (scheper, ; taylor, ) . recent responses to these failures increasingly rely new technologies. big data and blockchain technologies, for example, are increasingly instrumental to a growing range of 'multi-stakeholder' arrangements between private forprofit firms and public bodies seeking, for instance, to protect working conditions or to trace and disclose greenhouse gas emissions and 'conflict minerals' across global supply chains. these experiments are being developed and applied in ways that reinforce existing patterns of governance and relations of power. novel technologies are being integrated into the longstanding practices of private professional service firms in monitoring sustainability across global supply chains. previous research shows how the 'big four' professional services firms (kpmg, pwc, deloitte, and ey) firms play a significant and growing role in shaping private supply chain governance (fransen and lebaron, ) . the big four, along with smaller audit firms and consultancies (e.g. rcs global) increasingly promote blockchains as means of improving the effectiveness of supply chain governance. blockchain delivers a record of the origin and journey of the raw materials, which is accessible to all relevant parties yet not manipulable by any single 'node' in the shared digital network. in so doing, blockchains can establish a community of participants and an authoritative record of provenance, and by moving confidential data freely between trading partners, could enhance transparency and accountability. yet, these developments leave supply chain governance dominated by lead firms, often working with the 'big four' and more specialized supply chain management consultants. the entities developing and supporting such technology-led projects are frequently the same ones involved in existing global supply chain governance. the prominent roles of audit firms and private sector consultants in developing technological solutions to global sustainability governance challenges raise important issues. the profit models of such firms rest primarily on service fees. there is a danger that private actors' profit incentives could further fragment standards and enforcement across the proliferating range of 'sustainability services'. competition for clients threatens to produce a 'race to the bottom' of the kind seen among credit ratings agencies in the build-up to the global financial crisis (kruck, ) . equally, such initiatives provide no new standards or enforcement mechanisms and remain reliant on existing forms of factory-, farm-, or mine-level monitoring. in the words of a manager at one blockchain-based audit start-up: a blockchain will record an immutable record of custody of a material, the locations it's traveled through, its composition over time, and all that . . . but if you're trying to make sure the wrong material never enters the system in the first place, you need processes to make this work. (hyperledger n.d., p. ) . in brief, blockchain applications for supply chain governance leave market-based forms of governance rooted in 'disclosure' and soft standards largely intact, both in terms of the actors involved and the standards being enforced. we can see similar issues at stake if we move from supply chain governance to new methods of 'greening' financial markets, another key area where experiments with new technologies are underway. environmental, social and governance (esg) investment and esg ratings have grown rapidly as big data and other technologies have enabled investors to quantify hard-to-measure socio-political variables. yet, standards for what counts as 'sustainable' still vary. earlier accounting frameworks related to csrincluding the global reporting initiative and the carbon disclosure projecthave been accused of providing an 'alphabet soup' of poorly-correlated indicators (imf, ). more recent industry-led efforts like the taskforce for climate-related financial disclosures (tcfd) are somewhat better. the tcfd has departed from earlier csr definitions of sustainability by only including 'financial material' esg issues. led by bank of america chief executive and working closely with the big four accounting firms, the world economic forum (wef) has initiated a framework to standardize esg metrics and link them to the un's sdgs (naumann and temple west, ) . debates over applications of new technologies in sustainability governance need to be situated within these exercises in classification and standardization regarding what qualifies as 'sustainable'. the eu taxonomy, for instance, has been linked to a green-supporting or brown-penalizing factor for capital requirements (fleming and brunsden, ) . more encompassing policies like 'green quantitative easing' suggested by central banks can only become feasible once consensual definitions of green or brown investing are established. put differently, to realize the potential of technologies, we must first bring the context of private governance to the forefront of discussions about which technologies can and should be used, as well as for which purposes. the manners in which technology-led experiments in global sustainability governance foreground private over public was also illustrated in many of the immediate responses to the covid- pandemic. the world health organization, for instance, began coordinating a blockchain-based data storage and communication platform to address the surge in cyber attacks and mis-information during what it described as the related 'infodemic'. the platform, mipasa, is built on hyperledger fabric a permissioned (e.g. private) blockchain originally built by ibm and whose governing board consists of representatives of large technology (e.g. hitachi, intel, oracle, microsoft), finance (american express, bbva, jp morgan chase), professional services firms (accenture) and other mncs (daimler). beyond blockchain projects, the wider trend towards reliance on private, individual deployment novel technologies in global sustainability governance was prominently encapsulated in the strategic partnership framework agreement signed between the un and wef in for 'accelerating the implementation of the sustainable development goals' (wef, ). the first key focus area of this public-private partnership is harnessing the 'potential of financial innovation, new technologies and digitalisation to increase financing for the sdgs' (wef, ). in sum, technology-centred arrangements may tend to perpetuate and even expand the roles of private actors in sustainability governance, while potentially deepening the pathologies of existing forms of private governance. as we argue further in the next section, these tendencies are reinforced by a parallel trend of experimentalism in global governance. despite the considerable hype surrounding them, applications of emerging technologies in sustainability governance remain very much provisional and experimental. it is thus useful to consider such initiatives in relation to on-going trends towards experimentalist forms of global governance. experimentalist governance involves the setting of goals, trialling of multiple policy measures, continuous monitoring of progress through quantitative indicators, and revision based on rigorous peer review (sabel and zeitlin, ) . unlike centrally defined and potentially more static forms of management, such looser and 'provisional' governance forms can promote the flexible arrangements necessary to respond to sustainability challenges in environments of uncertainty (best, ) . while academic literature on experimentalist governance originated in the study of devolved responses for addressing common concerns in the european union (sabel and zeitlin, ) , wider forms of 'global experimentalism' have recently been outlined (de b urca et al., ; nance and cottrell, ) . to date, these studies have provided little consideration of the role of technologies in private-led patterns of global governance (armeni, ; campbell-verduyn and porter, ) . this can overlap with the forms of private governance discussed aboveprivate authorities can rely on experimentalist modes of governance (see brassett et al., ) . the distinction is essentially that, in referring to 'private' governance, the concern is with who is doing the governing, while references to 'experimentalist' modes of governance are more about how governance is done. critically, engagements both by public and private actors with blockchain, ai, and other emerging technologies are notably experimentalist in character. one example here is in the area of development aid. there are theoretical elaborations on potential applications of blockchain to development aid effectiveness, highlighting the potential of transparent and immutable ledgers to enhance the credibility of policy commitments or address verification problems (e.g. reinsberg, ) . actual policy interventions using these technologies, though, have generally taken precisely the form of trialling multiple measures, measuring outcomes, and constant revision. one notable example here is the german gesellschaft f€ ur internationale zusammenarbeit's (giz) 'blockchain lab', which sponsors and organizes pilot projects by public and private actors using blockchain to address challenges directly relating to the sdgs. bottom-up, less hierarchical forms of experimentalist governance enabled by new technologies, could in theory enrich sustainability governance by inviting participation from local actors. linders ( , p. ) , for instance, writes about potential open data platforms for developing countries to generate a 'sort of tripadvisor or yelp for aid' that can encourage local accountability of technology-enhanced programs. in practice, experimentalism's tendency to also offer highly technical solutions may deepen barriers to participation. experimentalist decision-making often draws heavily on calculative rationalities derived from financial accounting in order to accurately compare the results of the diverse approaches employed to achieve common goals. in their focus on measuring and auditing performance, these rationalities often recast governance as merely a technical and administrative matter. this diminishes the role and input of local knowledge (shore and wright, ; strathern, ) . likewise, the growing technology-intensiveness of experimentalist governance narrows the range of non-state actors able to participate in public-private partnerships. it is primarily private companies and the largest ingos that have the resources to create and manipulate the technologies at the heart of novel solutions to global sustainability challenges (duberry, ) . consequently, smaller and more local actors, in particular from the global south, may be left out, entrenching existing disparities in access and participation. moreover, these disparities may well be amplified as large technology firms seek to maximize both data collection and possession. private companies' access to a growing amount and diversity of data can thus shape agendas in ways that favour particularistic over collective concerns (arora, ) . for example, governments face domestic political pressures and economic challenges that open up space for internationally-coordinated, experimentalist governance of the digital economy. the un's global pulse programme connects academics, private and government actors and un personnel to generate 'actionable' insights about how big data can facilitate sustainable development. but global pulse projects in practice are dominated by private businesses and governments, with relatively limited possibilities for the involvement of csos. likewise, geopolitical competition among data powers, such as china, the us and the eu, can encourage domestic experimentalist governance innovations, as these states seek to enhance and secure their own digital capabilities (mahrenbach and mayer, ) . one prominent example is china's great firewall, which simultaneously cleared the path for ground-breaking research and industrial development of ai and made it more difficult for non-chinese businesses to operate in china (aaronson and leblond, ) . diverse government incentives thus encourage experimentalist governance in the digital economy as a means of achieving preferred outcomes, while reinforcing patterns of political power and participation that may tend towards particularistic rather than collective gains. the crucial roles of large technology firms in sustainability experiments could enable them to define the agendas and goals pursued. the competing pressures faced by governments seeking to both expand their own gains from the digital economy and to use modern technologies further complicate the benefits of experimentalism. finally, efforts to apply new technologies to sustainability challenges have very frequently been driven by efforts to grapple with the growing prevalence of informal economies. here, our concern is with who and what are being governed. economic informality in this sense has been an important, cross-cutting concern in sustainable development policy in recent decades (see bernards, ; phillips, ; rodima-taylor, ; taylor, ) . informality refers to the activities and actors that operate outside the regulations and laws of the modern economy (loayza, ). informal actors who usually represent marginal populations and groups are not able to fully benefit from public services or formal sector protection and risk mitigation, while also not able to contribute to the creation of public goods through taxation and other mechanisms. at the same time, informal sector enterprises may benefit from greater flexibility and dynamism of their activities as well as serve as a source of employment for marginal populations during economic down-turns (loayza, ). the dynamics of local informality are intricate, yet better attempts need to be made to understand the contexts in which many technology-led sustainability governance initiatives are ultimately grounded. localized informal practices are wrapped up in global value chains, for instance, through casualized labour in agriculture or outsourcing in clothing production. these present particular governance challenges around labour rights and environmental standards (meagher, ) . technological applications in sustainability governance are often aimed at making informal or illicit economies 'legible' both to regulators and to global capital. muirhead and porter ( ) argue that the 'traceability systems' enabled by new digital technologies for tracking the cross-border travel of an increasingly diverse range of objectsincluding conflict minerals, pharmaceuticals, carbon emissions, and money launderingform complex, heterogenous constellations between the physical properties of the objects being traced and the networks and infrastructures used for their management. by enabling clearer visibility and authentication of objectsincluding intangible onestraceability systems can, in some instances, help reduce areas of informal or illicit activity. new technologies may render human trafficking more visible and governable (e.g. by tracking illegal financial transactions), broaden awareness of victims' plight and facilitate networking between law enforcement and non-state organizations combatting human trafficking. an example here is the global emancipation network which brings together technology partners such as microsoft, splunk, deep vision ai and others with law enforcement, anti-trafficking non-profits, and businesses in hospitality, finance and transportation to deploy advanced data analytics to make human trafficking more visible as a means of helping to stop it. once again, there are important tradeoffs. rendering local actors 'legible' through technological means in the context of global supply chains dominated by distant lead firms or development projects by metropolitan donors can result in the imposition of external, pre-determined criteria on local spaces and practices. this interplay of informal activities with efforts to promote sustainability through formalization, transparency, and traceability, in turn, has significant, if ambiguous, implications for livelihoods. efforts to govern artisanal mining are a notable example (vogel et al., ) , as are conservation measures (witter and satterfield, ) , both of which are prone to excluding local populations. technological applications can exacerbate these dynamics, particularly where they double down on the weaknesses of market-led forms of supply chain governance discussed above. for example, there has been a recent flurry of blockchain applications for preventing child labour in cobalt mining in the democratic republic of the congo, as demand for cobalt (a key component of batteries for electric cars and portable electronics) has surged in recent years (e.g. lewis, ) . most of these programmes aim to prevent child labour by reliably certifying that cobalt has been mined from specific industrial installations rather than from artisanal mines, where most child labour takes place. even if it were to eliminate child labour from global supply chains, displacing artisanal mining with industrial mining would likely have ambiguous livelihood consequences for mining communities at best. recent research has highlighted, for instance, growing evidence of labour market segmentation, including a preference for expat workers in industrial mining, as well as limited wage gains for workers moving from artisanal to industrial mining in the copperbelt, driving a rise in inequality in the region (radley, ; rubbers, ) . there are serious questions here that need to be raised about the kinds of risks, and for whom, new technologies might be used to mitigate. in sum, technological solutions to sustainability issues often boil down to attempts to render complex and geographically dispersed informal spheres of activity 'legible' and traceable. such transparency efforts have important, yet often underexplored, implications. on the input-side, early processes of technological development and application can be hampered by significant disparities in access to material resources and representation that underpin digital and socio-economic divides. on the output side, transparency provided in evolving technological experiments is geared to the investment decision matrices of financiers, to the regulatory compliance mandates of governments, and to end consumers. policy making and broader public discussion over the integration of emerging technologies such as artificial intelligence, big data, and blockchain into global sustainability governance need to be far more socially and politically sensitive than is currently the case. recognizing and overcoming these issues is particularly important now as these and other technologies are also being foregrounded in transnational efforts to secure global supply chains and other responses to the covid- pandemic. digital technologies being applied in complex and evolving environments both shape and are shaped by diverse human, material, and normative elements (bernards and campbell-verduyn, ) . heterogenous assemblages combine local inventive practices and cultural repertoires related to new technology solutions with old and new infrastructural pipelines and institutional actors (rodima- taylor and grimes, ) . the integration of new technologies into multi-stakeholder efforts to address sustainability challenges must be understood within the longer-standing patterns of private authority, experimentalism, and struggles to cope with informal economies in global governance. by way of conclusion, we highlight a number of areas of concern that must become central to discussion, analysis and implementation of technology-led initiatives in global sustainability governance. these questions are crucial if we are to avoid extending well-known problems in attempting to address global sustainability governance challenges. unfolding technological experiments do, of course, hold some promise, and constitute quite a wide terrain. they thus need to be assessed on a case-by-case basis. yet, such assessments can collectively consider important but often backgrounded social, political, and economic relations through which new technologies are being developed and into which they are deployed: first and foremost, attention must be given to what new technologies cannot do. technologies cannot solve problems that are social and political at the roota point underlined in our discussion above. many sustainability governance problems concern politics and power. three guiding questions can encourage a systematic approach to overcome contextual hindrances in employing technology to actualize sustainability goals: whose problems are new for instance, probabilistic means of detecting likely human trafficking victims through ai applications might be helpful in separating out forced and exploitative forms of mobility from benign ones. however, identifying victims alone is not enough to resolve the knot of issues shaping and driving human trafficking. ais cannot say what should happen after victims of trafficking are located, or resolve the underlying conditions which facilitate trafficking in the first place. without substantive attention to victims' rights and the overall institutional environment of reinforcing these rights, detection of trafficked people might even render victims susceptible in new ways (e.g. to securitized and criminalized systems of border enforcement). we have argued that experimentalist modes of technologydriven sustainability governance can facilitate the introduction of novel intermediaries and brokers, while also entrenching the roles of existing actors. many of the latter actors are private parties, such as audit and consulting companies; many of the former are new tech firms. moreover, fluid areas of activity enabled via new connective technologies bring together a variety of formal and informal actors. as we have noted in the discussions of informality and experimentalism above, these developments are creating new political spaces, which can deepen old forms of exclusion and uneven access to participation. for example, the private firms involved in esg have a potential to promote industry-driven visions of future research and development in environmental governance. these activities can also create new global publics through awareness-raising and lobbying, and define what 'count' as global sustainable practices. there is a need to recognize the costs of accessing these new quasi-public spaces, which can threaten to reinforce existing inequalities and divides. the resources and roles of large, well-funded international non-state organizations in developing ai applications in environmental conservation, and the comparatively limited scope for participation by affected communities, are notable examples here. the new technologies increasingly used in sustainability governance are accompanied by security implications, particularly regarding privacy, which are often not been adequately addressed in extant debates. security technologies are fundamentally 'sites of experimentation', enmeshed in both ethical and practical dilemmas (bosma, , p. ) . the inner workings of technologies have remained opaque 'black boxes' to many, if not most, stakeholders on grounds of security or economic competitiveness. to ensure then that local voicesparticularly those of affected communitiesremain at the forefront of technology-enhanced sustainability governance activities, we suggest the following guiding questions. first, what kinds of actors are new technologies actually (dis)empowering? second, what kinds of exclusions or inequalities might be reinforced and/or created through technology-centred governance processes? we have situated technology-led sustainability governance initiatives in the concomitant rise of private, voluntary codes and standards. we equally illustrated how experimentalist modes of decision-making that may extend standardized accounting practices and calculative rationales across diverse forms of sustainability governance might do so at the cost of local spaces and practices. the result of merging these 'human accounting' protocols and techniques of financial accounting with those of socio-economic management can be a prioritization of short-term profit maximization and financial markets' agendas over longer-term sustainability needs. in recasting governance as a technical and administrative affair, sustainability accounting can minimize opportunities for and contributions from local actors and knowledge, respectively. soft-law governance approachesfrom emerging esg standards to labour codesexacerbate these issues, being both difficult to challenge in case of disputes and posing barriers to binding public regulation or independent civil society monitoring. these insights should focus attention on the need to interrogate the kinds of transparency and accountability sought in advancing common templates across diverse and informal communities. in seeking to render 'legible' activities in grassroots communities, private-driven sustainable governance initiatives may paradoxically by-pass the roles and needs of key local mediators. bottom-up forms of 'everyday experimentation' and 'frugal innovation' at the grassroots level can be crucial to addressing sustainability issues, yet are often overlooked or marginalized in many current applications (altamirano and van beers, ; leliveld and knorringa, ) . ethical technology standards and frameworks must be developed in collaboration with local communities and stakeholders and by considering local norms and morals. several guiding questions can help systematize this process of interrogation. first, what kinds of transparency and accountability are promoted by applications of new technologies? and, second, who benefits from the forms of accountability that are pursued in specific sustainability governance efforts? asking 'big' questions on the need for participatory and accountable frameworks we have argued that private-led environmental and sustainability initiatives have a potential to reinforce power imbalances and exclusion when interacting with communities and institutional actors in the global south. this is because the use and development of new technological solutions interacts with formal and informal, local and geopolitical agendas and interests. the incomplete nature of frameworks and standards governing new digital technologies can do little to ameliorate these issues. here again, we need local-specific, participatory development of accountability standards and frameworks in sustainability governance, in particular standards that embody local norms and morals. from this perspective, stressing the novelty of technological solutions for complex and evolving sustainability challenges can distract from the larger structural issues in which such governance is embedded. helpful guiding questions here include: what kinds of end-goals should sustainability governance initiatives consider, and for whom? what kinds of sustainability are emphasized in discoursesclimate risk, environmental risks, human/labour rights, or others? what political and moral assumptions are bundled into technological applications and their use? who has access to 'sustech' applications and the capacity to use them? and are such solutions creating new digital divides? in the current environments of high complexity and uncertainty surrounding sustainable governance initiatives, we argue that ethical, social and political considerations should be given foremost priority. this article has situated the novelty of new technologies in three wider trends to provide pathways for directing attention beyond mere technical considerations. there is undoubtedly room for these and other technological initiatives to be grounded in further trends. we expect that doing so will raise a host of other questions pertaining to the evolving roles of technologies in sustainability governance. we look forward to engaging with themand encourage public and private actors central to sustainability governance to do the same. may ]. . we are focused primarily in this section on efforts to govern informal economies, rather than informality in governance itself, though the latter is undoubtedly important in governing a number of policy areas relevant to sustainability and technology (morin et al. ). . https://www.globalemancipation.ngo/global-emancipation-networkmission-offerings/ [accessed may ]. . by the 'usual suspects' noted above such as the big four professional services firms (deloitte ), the wef (liao ), but also scholars (mashamba-thompson and crayton ) who "recommend a low cost blockchain and artificial intelligence-coupled self-testing and tracking systems for covid- and other emerging infectious diseases" in sub-saharan africa. international organization at the university of groningen. his research combines a general focus on ideas and materiality with a specific interest in the roles of non-state actors, technologies and technical artefacts in contemporary global governance. daivi rodima-taylor is a social anthropologist and researcher at the african studies center of boston university, and visiting researcher at the university of california, irvine. she has taught anthropology and international relations and engaged in longitudinal ethnographic fieldwork in african communities. her current research focuses on the intersection of grassroots economies and information technology. jerome duberry is a research associate at the albert hirschman center on democracy, graduate institute geneva. his research activities focus on the use of emerging technologies to support nature conservation and foster political participation. jerome examines how civil society organizations can benefit from the latest technological advances in artificial intelligence and blockchain to participate in collective decisionmaking and environmental governance. technology and sustainability another digital divide: the rise of data realms and its implications for the wto' frugal innovations in technological and institutional infrastructure: impact of mobile phone technology on productivity, public service provision, and inclusiveness global experimentalist governance, international law and climate change technologies the bottom of the data pyramid: big data and the global south global regulations for a digital economy: between new and old challenges the global governance of precarity: primitive accumulation and the politics of irregular work understanding technological change in global finance through infrastructures governing failure: provisional expertise and the transformation of global development finance 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briefs digital polarity theory: how to explain the great internet splintering blockchain and artificial intelligence technology for novel coronavirus disease- self-testing', diagnostics the scramble for africa: demography, globalisation and africa's labour markets how informality can address emerging issues: making the most of the g traceability in global governance a turn towards experimentalism? rethinking security and governance in the twenty-first century bofa chief leads new effort to tame unruly esg metrics less-told stories about corporate globalization: transnational corporations and csr as the politics of (ir) responsibility in africa informality, global production networks and the dynamics of 'adverse incorporation'', global networks a distributional analysis of artisanal and industrial wage levels and expenditure in the congolese mining sector sdg : decent work and economic growth: a gendered analysis blockchain technology and the governance of foreign aid passageways of 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mozambique's limpopo national park nick bernards is assistant professor of global sustainable development at the university of warwick. his research focuses on the political economy of irregular work, technology, and poverty finance.malcolm campbell-verduyn is assistant professor of international political economy in the department of international relations and key: cord- -qckn lvx authors: cáceres, sigfrido burgos title: global health security in an era of global health threats date: - - journal: emerg infect dis doi: . /eid . sha: doc_id: cord_uid: qckn lvx nan to the editor: global health security is the protection of the health of persons and societies worldwide. it includes access to medicines, vaccines, and health care, as well as reductions in collective vulnerabilities to global public health events that have the potential to spread across borders. for example, transboundary zoonotic diseases such as avian infl uenza (h n ) infections affect animals and humans, thereby threatening health security worldwide because of their high death rates (≈ % in humans) ( ) . during the past years, fairly standardized responses to threats have been implemented around the globe. some of these responses have been against severe acute respiratory syndrome and avian infl uenza (h n ), which have been overseen by a well-resourced international health system ( ) . these global health threats have raised the highest levels of political and social concern. this concern has provoked governments and international agencies to address health threats through a security rationale, which emphasizes the themes of national security, biosecurity, and human security. this amalgamation of health issues and security concerns has produced a notion of health security, which is dominated by technical medical approaches and pharmaceutical interventions. these approaches and interventions have already begun to shape the way international health policy is formulated ( ) . a global vision of health security is very much part of contemporary rhetoric. however, this vision lacks the drive and speed needed to make proposals materialize and operationalize ideas in the geographic areas where they are most desperately needed. small benefi ts accrue to members of vulnerable populations who, in fact, are those most likely to be affected by epidemic diseases. a public health security design that impinges on a global approach runs the risk of neglecting cultural, economic, ecologic, and social conditions on the ground. regional approaches that address hazards and threats may be more inclusive of context-specifi c conditions ( ) . global public health threats related to infectious pathogens of animal origin are expected to rise. to address these threats, several experts and strategists suggest the initiation of a worldwide early-alerting and -reporting mechanism. aggregation of disease threats through an eventfocused web-based platform could enable this mechanism. this timely gathering of disease intelligence can inform policymakers about the nature of risks. disease maps can display details needed to design tailored policies and control measures to tackle diseases according to their specifi cs ( ) . leading scientists and researchers continue to try to understand the global temporal and spatial patterns of animal diseases. this understanding is gained through an array of instruments, ranging from the use of satellite images to cutting-edge molecular technologies. the momentum so far has created an open forum for decisionmakers to collaborate with the leading international agencies to advocate for surveillance, identifi cation, and control of zoonotic diseases to uphold global public health security ( ). however, global initiatives suffer from the free-rider problem and from moral hazards. some low-income countries with weak governance have alerted the international community about their fragile health care systems to capture a nontrivial portion of funds that seldom reach their intended destinations. these resource allocations to developing countries foster aid dependence ( ). the international technical agencies tasked with upholding animal and human health should remain at the forefront of identifying and addressing evolving threats. this process will demand continuous fl exibility, agility, and a coordinated international effort. attaining goals of mitigating threats and reducing risks posed by the emergence of zoonoses requires close collaborations with national health authorities and local governments. the large investments planned to improve foresight and prevention might or might not work. if they do not work, apportioning blame to countries or regions for disease fl are-ups can result in social, political, cultural, and economic consequences that in the past have turned out to be unjustifi ed, unfair, and ultimately detrimental ( ). clearly, global health threats can be reduced only by the concerted actions of national and international actors. in the years ahead, the international community will almost certainly be expected to bring its formidable technical knowledge, skills, and analytic capabilities to confront this expanded global health threat environment ( ). it would be wrong, however, to forget the many insights that current advances in epidemiology and surveillance have delivered. in fact, should the impetus to fi nance a global health agenda encounter opposition or obstacles, it would seem easier and logical to strengthen already functional activities. lastly, the realities and the prevalent policymaking environment have created a trap between a desire to prioritize global health by portraying aspects of it as an existential security issue and the fact that security ultimately might not be the most useful language for describing and institutionalizing the health threats and hazards confronted by societies around the world ( ). regardless of whether a trap has been created, action is urgently needed. to the editor: we applaud mann et al. on their use of a school-based absenteeism surveillance system to compare daily all-causes absenteeism data against a historic baseline to detect outbreaks of infl uenza-like illness (ili) as an adjunct to traditional disease reporting ( ) . the growing availability of electronic human resources systems has increased the potential to harness near realtime workplace absenteeism data to complement school absenteeism surveillance and other sources of traditional outbreak surveillance. in london, united kingdom, during the fi rst wave of pandemic infl uenza a (h n ) , workplace absenteeism data from the transport for london attendance/absence reporting system were compared with the historical baseline -year mean for comparative weeks of the year. the proportion of transport for london employees absent because of selfreported or medically certifi ed ili, during june -october , , generated surveillance alerts when compared with historical baseline data above the th and th percentile thresholds (sds . and . ). for the same period, cause-specifi c workplace infl uenza absenteeism data were highly correlated with routinely published ili surveillance, including the national pandemic flu surveillance and sentinel general practitioner systems (figure) ( ). in australia, workplace all-causes absenteeism for a major australiawide employer has been included as a nonspecifi c indicator of infl uenza surveillance by the australian government for > years. a recent study during a severe infl uenza season in australia confi rmed that employee avian infl uenza: fact sheet avian infl uenza: science, policy and politics. london: earthscan security and global health. cambridge: polity epidemics: science, governance and social justice emerging zoonotic diseases in a changed world: strategic vision or fi re-fi ghting? key: cord- -hnakpl a authors: ruckert, arne; fafard, patrick; hindmarch, suzanne; morris, andrew; packer, corinne; patrick, david; weese, scott; wilson, kumanan; wong, alex; labonté, ronald title: governing antimicrobial resistance: a narrative review of global governance mechanisms date: - - journal: j public health policy doi: . /s - - - sha: doc_id: cord_uid: hnakpl a antimicrobial resistance (amr), a central health challenge of the twenty first century, poses substantial population health risks, with deaths currently estimated to be around , per year globally. the international community has signaled its commitment to exploring and implementing effective policy responses to amr, with a global action plan on amr approved by the world health assembly in . major governance challenges could thwart collective efforts to address amr, along with limited knowledge about how to design effective global governance mechanisms. to identify common ground for more coordinated global actions we conducted a narrative review to map dominant ideas and academic debates about amr governance. we found two categories of global governance mechanisms: binding and non-binding and discuss advantages and drawbacks of each. we suggest that a combination of non-binding and binding governance mechanisms supported by leading antimicrobial use countries and important amr stakeholders, and informed by one health principles, may be best suited to tackle amr. electronic supplementary material: the online version of this article ( . /s - - - ) contains supplementary material, which is available to authorized users. antimicrobial resistance (amr) has been widely recognized as one of the central health challenges of the twenty first century [ ] [ ] [ ] . since discovery of antibiotics, they have been a cornerstone of modern medicine [ , ] . amr predates human use of antibiotics and is naturally occurring as the outcome of the evolutionary adaptation process of microbes. but it has become increasingly clear that use of antibiotics, both in human and veterinarian practice and agriculture and animal husbandry, contributes to antimicrobial resistance [ ] . amr poses significant population health risks, with annual deaths estimated to be around , globally [ ] . the international community recently identified it as a major threat to achievement of the sustainable development goals, sdgs [ ] . amr has potential to disrupt the global economy as severely as the global financial crisis of / , with an eventual cost in the trillions of dollars if unaddressed [ ] . the recent covid- outbreak and widespread use of antibiotics with it have raised concerns about the potential of the global pandemic to speed up antimicrobial resistance [ ] . the international community signaled its commitment to exploring effective policy responses, with a global action plan on amr approved by the world health assembly in [ ] . major governance challenges could thwart collective efforts to address amr. we reflect through a narrative review of binding and non-binding governance mechanisms discussed in the academic literature on amr. by mapping these debates, we aim to inform decision-making about the global governance of amr-particularly by identifying potential points of agreement as starting points for strengthening a global amr response. in a growing body of literature about amr governance, many authors begin from a normative preference for a specific governance mechanism, then build a case for that preferred mechanism [ ] . we take a 'step back' to map the preferences and debates, then seek the global governance options that appear most feasible. identifying options for improved global governance of amr is vitally important; despite declaring firm commitment, many countries have not implemented national action plans or taken even sporadic actions to better align the domestic policies with global recommendations [ ] . various sectors involved in amr governance have conflicting interests (such as human and animal health, agriculture, the pharmaceutical industry, and the environment) which could impede collaboration and challenge implementation of solutions-such as enhanced amr surveillance across sectors or addressing excessive use of antimicrobials in agriculture and horticulture [ ] . addressing amr will require global collaboration because no single country can prevent or mitigate amr through its own actions [ ] . as a global common good, safeguarding antimicrobial effectiveness and mitigating the threat of amr in a collaborative fashion are necessarily a responsibility of all countries and multilateral organizations. the global action plan produced by the world health organization, who [ ] , and similar action plans by the food and agricultural organization, fao [ ] and the world organization for animal health, oie [ ] , identify five areas of essential global collective action to address amr: • effective antimicrobial surveillance; • better infection prevention and control (ipc) measures; • global awareness campaigns; • promoting responsible use through stewardship; • innovation for successful containment of amr emergence and spread, including through development of novel antimicrobial drugs. thus, we address the question: which global governance modalities and mechanisms are most likely to produce an effective amr response? we conducted a narrative review to identify global governance mechanisms to address amr currently explored in the academic literature [ ] . because the global amr response is at a relatively early stage and lacks consensus about how best to proceed, this approach allowed us to map out the dominant topics and debates as a first step toward identifying common ground for a basis of more coordinated global action. we used two electronic databases (scopus and pubmed) to identify relevant articles (n = ) and a boolean search strategy (see supplementary materials file). by screening abstracts we identified relevant articles and added more recommended by reviewers during the revision process (for a total of n = ). after removing duplicates, we retained articles using the following inclusion criteria: ( ) identifies governance mechanisms to address amr; ( ) discusses policy framings of amr; ( ) provides policy solutions to effective amr governance; ( ) identifies barriers to, or facilitators of, effective amr governance; and ( ) has been published since . we imported articles into nvivo and conducted a constant comparative analysis based on a deductively developed coding structure, enriched inductively as new ideas and concepts emerged (see supplemental materials file). a limitation is that we included only english language articles. amr governance mechanisms fit in two categories: binding or non-binding. global governance attempts to achieve a purposeful order from institutions, processes, norms, formal agreements, and informal mechanisms that regulate action for a common good, with the question of enforcement of global rules are central to most academic discussions of global governance [ ] . binding governance mechanisms include treaties, covenants, protocols, and accords-the 'gold standard' in global health governance [ ] -because they hold signatories legally responsible and accountable. no such agreement on amr presently exists. the literature considers two approaches-treaties and regulations, each with advantages and disadvantages. some global governance scholars propose developing an international treaty to rectify the current fragmented approach and lack of leadership [ ] [ ] [ ] [ ] [ ] . one notes: "a treaty on managing antimicrobials and containing amr emergence and spread could help coordinate efforts in this area, especially when combined with strong implementation mechanisms and regulatory functions" [ ] . a treaty to promote international compliance would also help to minimize market and competitive disadvantages in particular industries. without such a treaty, a nation's livestock producers who refrained from using antimicrobial growth promoters could be disadvantaged by producers in other countries who did not [ ] . a treaty could promote a global system to facilitate coordination and the legalization of gathering and sharing of surveillance data, and improve transparency and accountability [ ] . a global treaty, if established per article of the who constitution, could also promote wide-scale reductions of infection rates by improving implementation of infection prevention and control (ipc) through development and enforcement of guidelines on sanitation, mapping of microbial spread patterns, and setting standards for infection prevention and control practices [ ] . it could promote stewardship programs, product labelling requirements, better medical waste management policies, and improved sanitation measures by states, for example, by setting desirable benchmarks for antimicrobial use [ ] . a treaty could also impose a global marketing ban on antimicrobials as one element of a larger antimicrobial conservation strategy [ ] . the review revealed considerable challenges and several arguments against pursuing it. reconciling diverse stakeholder interests is one hurdle. states are unlikely to support an international agreement unless it would benefit domestic stakeholders, especially if the corporate sector lobbies against new regulations; all actors must find that benefits outweigh costs and potential harm [ ] . a treaty would likely include an obligation to report regularly on compliance, and few countries have infrastructure or reporting mechanisms for meaningful reporting (observed in partial reporting under the global antimicrobial resistance surveillance system [ ] ). in addition to treaties, regulations can also be legally binding under international law. regulations on antimicrobial use could have binding targets for agricultural use of antibiotics [ , ] . thakur and panda [ ] recommend banning use of all medically important antibiotics in food for animals through global harmonization. the goal is to preserve their effectiveness for necessary medical use. this approach might require global harmonization of categorization and terminology, because what constitutes 'medically important', 'highly important', 'critically important', or 'highest priority critically important antimicrobials' varies across countries. the variations may create confusion-a barrier to effective regulation. regulations could also ban over-the-counter sale of antibiotics and online sale of antimicrobials without prescription globally [ ] . regulation can also encompass quality standards. bloom et al. argue that governments should coordinate their actions globally, set quality standards for drugs and treatment guidelines, and negotiate the contents of advertising material to limit counterfeit and substandard drugs and influence the packaging and marketing of pharmaceutical drugs [ ] . they recommend that this process involve the pharmaceutical sector and leaders of the medical profession to encourage adherence to regulations and quality standards. wernli et al. suggest that emergence and spread of antimicrobial-resistant bacteria, especially those involving new pan-resistant strains for which there are no suitable treatments, may constitute a public health emergency of international concern (pheic). under these circumstances, countries should be required to notify the world health organization under the international health regulations, ihrs [ ] . the ihrs provide a legal framework for international efforts to contain spread of acute health risks, including a surveillance and a global alert system, definitions of core public health capacities for surveillance and response in all countries, and who guidance through standing recommendations. applying the ihrs to amr could "serve as a 'wake-up call' and strengthen global amr surveillance and response, which could in turn contribute to containing the spread of amr" [ ] . another article highlights that, given the prevalence of drug resistant bacteria in traded food commodities, trade agreements should increasingly consider amr, especially in discussions and adjudication of disputes over intellectual property protection [ ] . here the codex alimentarius commission and the world organization for animal health (oie) play important roles because world trade organization members and countries party to other bilateral or regional trade agreements must base regulations on international standards. by establishing stronger regulations these bodies could help tackle amr and contribute to achieving the sustainable development goals [ ] . some raise concerns that existing trade agreements might hamper antimicrobial stewardship initiatives, for example by limiting policy space to restrict food imports from countries that overuse antibiotics [ ] . the european commission raised this issue recently in connection with its ban on antimicrobials to boost growth and yield. some scholars ask whether this new european union (eu) legislation could be challenged at the wto by a country importing food into the eu. the literature discusses non-binding governance mechanisms including political declarations, resolutions, and operational guidelines; public-private partnerships (ppp) based governance mechanisms; and voluntary (consumer and industry driven) governance initiatives. political declarations (resolutions or operational guidelines) cannot compel action, but can foster consensus and cooperation through gradual diffusion of norms [ ] . one article notes: "political declarations offer a nimbler, more adaptive option to the rigidity of legally binding global governance mechanisms such as treaties, and […] allow for more dynamic discourse and better responsiveness to changing global priorities" for amr [ ] . another highlights that non-binding and participatory governance mechanisms could incorporate incentives to private industry to participate in antimicrobial stewardship and surveillance initiatives [ ] . another approach involves a voluntary global antimicrobial conservation fund to provide a transnational resource transfer to boost capacities and program development in the lowest income countries: such a fund would not diminish the responsibility of national governments in the development of their national amr plans nor for delivering meaningful outputs. rather, it would confer support for accelerated action to conserve a rapidly dwindling resource and could be linked to a formal resource conservation agreement [ ] . a pooled fund with contributions tied to gross national income could ensure that assistance supports implementation of the amr global action plan [ ] . not all commentators agree; some warn that normatively based international agreements on amr would lack effective mechanisms for transparency, oversight, and complaint, providing little international pressure or incentives for countries to comply with the unenforceable terms [ ] . the literature also offers financial models to spur the development of new antibiotics, particularly discovery of new drug classes. the use of ppps has a long history in drug innovation, for example with neglected tropical diseases [ ] . given a recent slow-down in commercial development of antimicrobial drugs, analysts have identified ppps as a potential solution to some challenges of developing new antimicrobials. these include high initial development costs; the low price point of most antimicrobials; and the need to limit the use of new drugs once they become available to ensure efficacy over time. one article highlights that, given the economics of the development of new antibiotics, profits from 'drugs of last resort' might not justify investment in this area by private pharmaceutical companies alone. solutions therefore need to include government action in industrialized countries to overcome this 'market failure' by both reducing regulatory barriers to entry and improving the economic incentives for re-engagement by private enterprises [ ] . global governance mechanisms to foster drug innovation should explore and encourage ppps, particularly for treatment of infections in economically disadvantaged parts of the world [ ] . following this logic, government, non-governmental and intergovernmental agencies have called for the development of ppps and innovative funding mechanisms for amr. in its global action plan, the who calls for new partnership models "for providing incentives for innovation and promoting cooperation among policy-makers, academia and the pharmaceutical industry to ensure that new technologies are available globally to prevent, diagnose and treat resistant infections" [ ] . the innovative medicines initiative joint undertaking programme in europe is a prominent example for drug innovation that has invested more than € million. it seeks matching contributions from the european commission and the european federation of pharmaceutical industries and associations. through the new drugs for bad bugs programme, this initiative invests in promising research to fight against amr "at every level from basic science and drug discovery, through clinical development to new business models and responsible use of antibiotics" [ ] . another global partnership, carb-x, accelerates antibacterial research to tackle the global rising threat of drug-resistant bacteria. it boasts the world's largest early development pipeline of new antibiotics, vaccines, rapid diagnostics, and other products to prevent and treat life-threatening bacterial infections. some articles focus on the potential roles for non-state actors, voluntary industry initiatives, and other forms of self-regulation in amr governance [ ] . canada established a deadline of for voluntary phasing out of category i antibiotics, those most important to human health, for the chicken industry. in may , the chicken farmers of canada announced a plan to eliminate preventative use of category ii antibiotics by the end of and a goal to eliminate preventive use of category iii antibiotics by the end of [ ] . growing popular awareness of the risks of the presence of antimicrobials in the food chain and related changes in consumer choices drive these initiatives. the range of binding and non-binding mechanisms proposed indicates a lack of consensus about how best to proceed. it also affirms the complexity of amr as a policy problem. what are the strengths and weaknesses of each approach? and, what are shared principles to undergird an effective governance regime to address amr? currently amr global governance relies entirely on non-binding governance mechanisms. the world health assembly resolution / , the associated global action plan on amr [ ] , and the un general assembly's political declaration on amr (resolution / ) [ ] are the strongest of nonbinding global governance mechanisms implemented. their champions hope these will encourage decisive and lasting global action to curb amr. in theory, such mechanisms could facilitate country driven actions and policy ownership-and increase likelihood that countries implement national-level actions. although voluntary in nature, nonbinding mechanisms may use stronger implementation language than legally binding treaties, and integrate civil society organizations and non-state actors into implementation. this provides political and legal support without the legal consequences of binding governance mechanisms if states fail to meet their commitments [ ] . voluntary contributions and a bottom-up approach to amr would allow low-and middle-income countries to balance safeguarding of antimicrobials with other priorities, such as economic development and food security-and could increase political support among these states. despite the benefits that hierarchical governance might offer through an enforceable treaty, a non-binding network approach could increase shared responsibility to reach goals and more sustainable governance of amr [ ] . failure by many countries to voluntarily adhere to the commitments inscribed in the global action plan, however, is a major concern. the / who report on amr implementation shows that countries developed, or implement national amr action plans reflecting objectives of the global action plan; only countries have directly allocated funding to implement action plans, engaged relevant sectors, and designed a monitoring and evaluation process (as recommended by who) [ ] . aguirre finds that despite needed concerted global effort, only % of countries have implemented a national policy to address antibiotic resistance [ ] . it is not surprising that low-income countries might find it difficult to identify resources to develop and implement an intersectoral amr action plan. but middle-and high-income countries are falling behind as well: only european countries had approved an adequate action plan by [ ] . voluntary governance mechanisms related to climate change and the sustainable development goals (sdgs) have also shown limited impact on state behavior; countries are already falling behind with their voluntary 'nationally determined contributions' (ndcs) to mitigate climate change (agreed upon at the cop paris climate summit) [ ] . concerns that voluntary reporting mechanisms might lack transparency and consistency arise; thus assessing progress might prove difficult. previous experiences of reliance on voluntary governance mechanisms without enforcement instruments indicate limits of norm change as a means to catalyze effective and efficient state action. binding governance mechanisms may be needed. the ad hoc inter-agency coordination group (iacg) for the governance of antimicrobial resistance (made up of who, fao, oie, and various individual experts), acknowledged this recently in laying out a vision for achieving a global treaty within years, either an intergovernmental treaty or a multi-stakeholder amr protocol [ ] . the limits of non-binding governance mechanisms may lend support to the literature advocating a legally binding amr treaty to ensure national compliance with governance principles established at the global level. one recent precedent, the framework convention on tobacco control (fctc), may offer lessons about the impact of international treaties on health governance. a recent review argues: the influence of the who fctc in global governance can be at least partially attributed to its status as an international legal obligation. while tobacco control would have likely been a priority in international public health even in the absence of the who fctc, the importance of tobacco control has been relatively greater as a result of the treaty [ ] . amr, however, poses a very different set of public health problems from tobacco control: it is transboundary, multisectoral, and constantly evolving in a way that tobacco control is not. given these differences, to what extent can lessons from the fctc can be applied to amr governance? also, binding agreements face their own challenges. for example, only industrialized countries committed to legally binding reductions in emissions in the kyoto protocol, one of the most prominent binding global governance efforts. even the committed countries have mixed compliance results [ ] . a binding global agreement is no guarantee of effective domestic actions, especially without political mobilization [ ] . yet, even when expected benefits from binding legal agreements are marginal, such agreements may be useful in supporting implementation of domestic amr policies-albeit incrementally and indirectly: • they might contribute to norm change, and therefore incentivize governments to participate in amr-related activities [ ] . • they could assist domestic non-governmental amr actors in advocating for policy change. lack of consensus, scholarly or political, about how best to structure amr governance indicates major barriers to achieving a binding agreement soon: • to be politically feasible, states and stakeholders must perceive the benefits of any amr treaty or agreement to outweigh current and projected costs and potential health and economic harms [ ] . at a minimum, this would require concerted education campaigns amongst stakeholders, and incentive schemes for industry to partake in stewardship. even then, a widespread perception that a treaty is unlikely if not supported by the most powerful economic countries, especially the united states, china, and japan, could hinder progress. creation of a 'coalition of the willing' might mitigate resistance and entice others to join global amr efforts [ ] . ideally a coalition would include 'initiator countries' (those leading reduction of antibiotic use) and 'pivotal countries', (those with strong influence due to economic and political power). • particularly low-income countries may perceive treaties that impose domestic obligations as coercive and paternalistic; standard setting in international treaties are largely dictated by high-income countries on the basis of policy guidelines/ actions that these countries already meet. ensuring development of governance rules in international fora or by international organizations in which countries have equal standing (the who versus world bank), and ensuring any international treaty includes binding agreements for resource transfer from north-south (hic-lic) might mitigate this barrier. our review did find virtually unanimous agreement on a key principle to undergird effective global governance: all efforts, legally binding or nonbinding, should approach amr through a one health lens to address human, animal, and environmental health and their complex interactions [ ] . one health entails balancing of competing interests across sectors, while privileging human over animal health: "typically, human health interests should predominate, but animal health and welfare are also important considerations,… economic interests are subordinate to health considerations" and "antimicrobial stewardship programs should seek to ensure that antimicrobials are reserved for the treatment of clinical infections in humans" [ ] . apparent consensus about one health may indicate the emergence of a new norm as a promising foundation for coordination. over time, it could generate the shared political will required to support development of more robust binding mechanisms. our review indicates strong interest in and a good rationale for top-down global governance mechanisms to address amr. a lack of consensus persists, however, about which specific mechanisms are most desirable, politically feasible, and likely to be effective. deep and divergent perspectives remain (often implicit rather than explicitly stated) about the causal relation between legal and normative change: • is norm change a necessary antecedent to generating the political will required to produce legal change in the form of a binding agreement? • or does legal change, by compelling changes in actors' behavior and policies, represent the catalyst for a subsequent change in reinforcing norms? clearly, securing an international treaty and enforceable market regulations might not be sufficient to address amr, especially if the biggest user countries of antimicrobials, and the agricultural industries in them, remain opposed to strong amr regulations. currently, this seems to be the case. a reduction of amr consumption might therefore best be achieved by combining a governance system with an enforceable treaty (initially with those countries willing to volunteer), with the development of various non-binding governance and stewardship initiatives with engagement of important stakeholders to raise awareness and shift deeply entrenched human and animal health practices. thus, we advocate combining pressure from below (by civil society and progressive actors promoting grass-roots solutions to amr) with pressure from above (through international legal obligations) that could generate momentum towards implementation of effective policy solutions to this important global health issue. author contributions all authors contributed to the study design. data collection and coding of data was led by ar and rl. all authors equally contributed to drafting the manuscript and approved the final version of the article. the study received funding from the canadian institute of health research through operating grant no. . the study received logistical support from the one health network on the global governance of infectious disease and antimicrobial resistance (global hn). antimicrobial resistance in g countries and beyond: policy brief. organization for economic development and cooperation drug-resistant infections; a threat to our economic future tackling antimicrobial resistance: ensuring-sustainable r&d. world health organization global governance mechanisms to address antimicrobial resistance antimicrobial resistance: action to combat the rising microbial challenges antibiotics overuse in animal agriculture: a call to action for health care providers tackling drug-resistant infections globally: final report and recommendations. london: united kingdom review on antimicrobial resistance antimicrobial resistance-a threat to the world's sustainable development antimicrobial resistance in the age of covid- monitoring global progress on addressing antimicrobial resistance. geneva: who combating antimicrobial resistance demands nation-wide action and global governance global governance of antimicrobial resistance the fao action plan on antimicrobial resistance world organisation for animal health scoping studies: towards a methodological framework oxford: pergamon towards an international treaty on antimicrobial resistance addressing antibiotic resistance requires robust international accountability mechanisms an international legal framework to address antimicrobial resistance assessing proposals for new global health treaties: an analytic framework effective global action on antibiotic resistance requires careful consideration of convening forums global health law clinic: using international instruments to address antimicrobial resistance. global health law clinic publication series developing an approach to assessing the political feasibility of global collective action and an international agreement on antimicrobial resistance a call for action: the application of the international health regulations to the global threat of antimicrobial resistance rational use of antimicrobials in animal production: a prerequisite to stem the tide of antimicrobial resistance antimicrobial resistance and universal health coverage trade is central to achieving the sustainable development goals: a case study of antimicrobial resistance antimicrobial resistance, trade, food safety and security comparison of governance approaches for the control of antimicrobial resistance: analysis of three european countries a global antimicrobial conservation fund for low-and middle-income countries much can be learned about addressing antibiotic resistance from multilateral environmental agreements virtual drug discovery and development for neglected diseases through public-private partnerships tackling antibiotic resistance reflections on the future of pharmaceutical public-private partnerships: from input to impact the innovative medicines initiative's new drugs for bad bugs programme: european public-private partnerships for the development of new strategies to tackle antibiotic resistance what matters to us: antibiotics. chicken farmers of canada an international model for antibiotics regulation beyond headline mitigation numbers: we need more transparent and comparable ndcs to achieve the paris agreement on climate change future global governance for antimicrobial resistance who fctc and global governance: effects and implications for future global public health instruments the glocalization of antimicrobial stewardship. glob health exploring models for an international legal agreement on the global antimicrobial commons: lessons from climate agreements. health care anal antimicrobial resistance: a one health perspective governing antimicrobial resistance: a narrative review of… pdf?expir es= &id=id&accna me=esid &check sum= c b e a bd b c e f e conflict of interest the authors have no competing interests to declare. the study received ethics approval from the university of ottawa ethics review board.governing antimicrobial resistance: a narrative review of… key: cord- -cvvyf cb authors: kelley, patrick w. title: global health: governance and policy development date: - - journal: infectious disease clinics of north america doi: . /j.idc. . . sha: doc_id: cord_uid: cvvyf cb global health policy is now being influenced by an ever-increasing number of nonstate and non-intergovernmental actors to include influential foundations, multinational corporations, multi-sectoral partnerships, and civil society organizations. this article reviews how globalization is a key driver for the ongoing evolution of global health governance. it describes the massive increases in bilateral and multilateral investments in global health and it highlights the current global and us architecture for performing global health programs. the article closes describing some of the challenges and prospects that characterize global health governance today. recent inspection rates it would cost the fda $ . billion and take more than years to inspect the , foreign facilities involved with registered food production for export to the united states. governance structures for building consensus and for collectively managing public health actions are necessary because the world's inhabitants cannot create societies and economies that are largely self-contained and insulated from outside threats. the world's inhabitants increasingly share the same air, water, exposure to infectious diseases, foods, pharmaceuticals, and health workforce. through climate change, the impact of human activities in a few countries can affect harvests, the epidemiology of infectious diseases, and the potential for global natural disasters. even among countries with strong public health programs, harmonization of standards and processes is important for effective and efficient collective action. today's global health governance structures include a complex web of un agencies, public/private partnerships, donor and recipient governments, foundations, corporations, and civil society organizations. a recent report from the kaiser family foundation identified multilateral international health treaties, commitments, partnerships, and other agreements, of which are legally binding under international law. the united states is a party to of these of agreements, of which are legally binding. these agreements cover many topical areas, including specific diseases, environmental issues, trade and intellectual property, specific populations (eg, refugees or children), health security/preparedness, water, and food/nutrition. in the aftermath of the nineteenth-century international sanitary conferences that focused on threats to ports and trade, the early twentieth century saw international $ , global health governance reflected in new institutions, such as the international sanitary bureau (isb) based in washington, dc, and the office internationale d'hygié ne publique in paris. the isb subsequently became the pan american health organization, which since has been one of regional offices of the who. when the un system was conceived in , brazil and china proposed the who. the who constitution contains several key principles, including: health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition. the health of all peoples is fundamental to the attainment of peace and security and is dependent upon the fullest co-operation of individuals and states. the broad mandate of the who has core functions: the provision of collective health leadership, the shaping of research as well as the generation and dissemination of knowledge, the setting of norms and standards and the promotion and monitoring of their implementation, the production of ethical and evidence-based policy options, the provision of technical support and capacity-building, and the monitoring of health situations and trends. the organization has a -point agenda: promote development; foster health security; strengthen health systems; harness research, information, and evidence; enhance partnerships; and improve performance. this agenda is shaped at annual meetings in geneva by the member countries that compose the world health assembly. an -person secretariat based in geneva and at the regional and country offices performs who programs. the breadth of the programs undertaken is vast, although not always deep. some of the topics addressed include hiv/aids; malaria; tuberculosis; chronic noncommunicable diseases; mental disorders; violence; traffic safety; visual impairment; maternal and child health; aging; disasters; health equity; environmental health; nutrition and food safety; drug access; research; health systems strengthening; and tobacco, alcohol, and drug abuse, and other unsafe behaviors. when the who was envisioned, the concept of its operations was quite vertical and focused primarily on relationships with member states. few other actors were engaged in global health. since its founding, the who has celebrated major accomplishments but has also suffered from an erosion of its influence. beyond the eradication of smallpox (an event that has likely saved more than million lives since ), who technical leadership has also played a role in the near eradication of polio; the containment of the deadly sars epidemic; the landmark who framework convention on tobacco control (the first treaty negotiated under the auspices of who); and the revision of the international health regulations (ihr). compared with the previous ihr that was focused on classical diseases of international importance, plague, yellow fever, and cholera, the revision is more powerful and practical in that it encompasses all acute public health risks of transnational significance. the new ihr defines broad reporting requirements and establishes the authority of the who to initiate disease-control actions, if necessary, through use of information sources other than country governments. the new ihr also requires countries to strengthen their existing surveillance capacities. many have hoped that the who would take a stronger role in the setting and enforcement of norms, given its extraordinary constitutional authorities and its quasi-legislative power to adopt binding regulations. the who has, however, leaned more toward providing technical advice than toward exerting bold, proactive leadership through binding norms and regulations. kelley given its mandate, the who is handicapped by a modest budget and by its dependent fiscal relationships. the proposed budget for to was $ . billion before currency adjustments. because only about . % of the who budget comes from the dues assessments of member countries, its flexibility in focusing its program based on the scientific priorities it determines is constrained. wealthier countries pay larger assessments and thus have more influence over the direction of who programming than poorer countries, which have the greater need for help. moreover, the remaining . % of the budget is projected as "voluntary contributions," which are largely earmarked by donors for specific purposes. this arrangement contributes to fragmented programming and perhaps to certain donor-influenced compromises. in this century, the who also faces growing challenges. although its members are sovereign governments, many other powerful actors (including nongovernmental entities, such as other un agencies, foundations, corporations, and civil society organizations) have entered the global-health arena. placating these competing interests is not a recipe for bold action. the who is the lead un agency for health. owing to the increasing recognition that health is fundamental to the broader un goals of fostering the international rule of law, global security, economic development, social progress, human rights, and world peace, health issues have now taken a more prominent place than they had in the united nation's first years. in , world leaders came together at the un headquarters to adopt the millennium development goals (mdgs), of which are focused on health. the leaders of un member states agreed to partner to achieve these goals by . the health-related goals have directly provided high-level, consensus global health policy direction (box ). another goal is related to hunger reduction. regrettably, the mdgs lack a target for chronic diseases, such as cardiovascular diseases and cancers, which now account for more than % of the global burden of disease. since , progress toward the mdg targets has been mixed. for example, between and , the number of individuals infected with hiv placed on antiretroviral drugs rose from , to million (ie, % of the . million people in target c: have halted and begun to reverse the incidence of malaria and other major diseases by need). in developing countries, % of births in still took place without a trained birth attendant present, and maternal mortality remains shockingly high. as a result of the hiv/aids pandemic and its immense scale and impact on human life, dignity, rights, social cohesion, and economic development, a un general assembly special session issued a formal declaration of commitment on hiv/aids in june . that declaration endorsed the establishment of the "global aids and health fund," which would pool contributions from countries and from the private sector to fund hiv prevention and treatment efforts. it also set out a policy approach to providing leadership; improving prevention, care, and treatment; preserving human rights; reducing the vulnerability of women and children at risk for or affected by hiv/aids; and mobilizing financial resources. a un special session on noncommunicable diseases and their prevention will convene in september . as illustrated in box , the un has spawned a wide array of specialized agencies and other entities with direct or indirect interests in health. to some degree, these compete with the who for legitimacy and resources, and some have a significant role in global health governance. in world trade organization treatment, especially among migrants, women and girls, peacekeepers, travelers, and orphans; it unites the relevant un agencies, civil society organizations, governments, and the private sector; it advocates for rights, resources, and accountability; it empowers actors with strategic information; and it supports country leadership. created by the general assembly in for post-war relief, unicef is now focused on providing on-the-ground, long-term humanitarian and developmental assistance to children and mothers in developing countries. funded by governments and the private sector, the unicef expenditures totaled $ . billion. based in rome, the food and agriculture organization of the united nations (fao) operates through regional offices and through more than country offices around the world. with a biennial budget in to of $ . million, the fao leads un efforts to enhance food security and to eliminate hunger, the number-one mdg. the fao provides a neutral forum in which all countries can negotiate agreements and debate policy. its experts disseminate technical information and assist countries with disease outbreaks and in developing sound agriculture policies. where issues of human health and animal health intersect (eg, avian influenza or food safety emergencies), the fao plays a role. although not actually a un agency, the world organization for animal health (previously known as the office international des epizooties and still known as the oie) is also an intergovernmental organization; it seeks to perform global disease control for the animal population. based in paris and having regional and subregional offices worldwide, the oie is an important partner of the who, the fao, and the world trade organization (wto). like the who, it operates under the collective control and authority of an assembly of member countries. oie relevance to global health governance stems from the often-underappreciated connection between human health and animal health. this connection, embodied in the one-health concept, is most evident in the context of emerging zoonotic diseases and food safety. in , an institute of medicine (iom) committee concluded that the oie rules lacked critical provisions found in the who ihr, provisions that would be valuable for an organization involved in protecting animals capable of transmitting infections to humans. the committee recommended that the oie create legally binding obligations for members to develop and maintain core surveillance-and-response capabilities, that the oie be authorized to publically disseminate the animal-disease information received from nongovernmental sources when the member state does not do so in a timely and accurate way, and that the oie director general be empowered to declare animalhealth emergencies and related recommendations as appropriate. the wto, a member of the un family since , is primarily concerned with the rules of trade between nations. with globalization, however, trade and health are increasingly connected. the wto has several agreements related to health and health policies, including the agreements on technical barriers to trade; the sanitary and phytosanitary measures; the trade-related intellectual property rights (trips); and the trade in services. although trade can be restrained for scientifically valid reasons related to health, relevant interpretations can be controversial. some health issues relevant to wto agreements include food safety and protection from zoonotic diseases; trips patent protection for pharmaceuticals (to balance incentives for drug development vs ensuring affordable access to drugs); tobacco control; biotechnology; and the transnational migrations of health workers, patients, and investment in health services. the world bank group, founded in , is a critical source of financial and technical help for developing countries. headquartered in washington, dc, it employs more than , people worldwide. the bank provides low-interest loans, interest-free credits, and grants to developing countries for health and other purposes. the world bank consists primarily of unique development institutions owned by member countries: the international bank for reconstruction and development (ibrd) and the international development association (ida). the ibrd serves middle-income and creditworthy poorer countries; whereas, the ida mission is to serve the world's poorest countries. ibrd lending is primarily financed through aaa-rated bonds sold on the world's financial markets; the ida funds come from donor countries and are replenished periodically. additional funds come from repayments of loan principal on longterm, no-interest loans. the ida accounts for more than % of world bank lending, and its loans are largely supervised and evaluated by the world bank country offices. ida loans have been used to improve sanitation and water supplies, support immunization programs, and combat the hiv/aids pandemic. in fiscal , the world bank health, nutrition, and population program lent $ . billion, a -fold increase from . since , the bank group provided $ billion in country-level project financing and $ million in private health and pharmaceutical investments. in fiscal , the bank disbursed $ million for existing hiv projects and committed nearly $ million to new hiv/aids efforts. it also committed funds in fiscal for pandemic preparedness. achieving the mdgs will require an estimated $ billion to $ billion annually. higher-income countries have made substantial policy commitments to support the lower-income countries that have insufficient resources to provide a basic package of essential health benefits (estimated at $ per capita per year). funding for action by wealthier countries has often been coordinated through governance mechanisms, including the annual group of eight (g ) summits. g progress toward these commitments is summarized in table . in , the un millennium project estimated that to meet the mdgs, the total overseas development assistance (oda) from high-income countries would need to rise to . % of gross national income (gni). in absolute terms, the us government has contributed great amounts to oda; however, as depicted in fig. , the relative amount contributed in was only . % of us gni, a figure less generous than the percentage contributed by most european countries, australia, and canada. the us government's global health program, compared with that of many other donor governments, cuts across many departments. it draws upon both the foreign-assistance structure but also the government's extensive public health capabilities. in addition to well-known actors, such as the us agency for international development and the us centers for disease control and prevention, executive branch agencies with a significant involvement in global health include the departments of state, defense, agriculture, homeland security, labor, and commerce, as well as the national institutes of health, the food and drug administration, the environmental protection agency, the peace corps, and the health resources and services administration. these agencies carry out programs in more than countries and are overseen by more than congressional committees. the us financial commitment to global health has dramatically increased over the last decade, especially with the implementation of the president's emergency plan for aids relief (pepfar) and the president's malaria initiative (fig. ) . originally authorized in at about $ billion, pepfar focused on countries, mostly in africa. over its first years, pepfar sought to support antiretroviral treatment for million people infected with hiv; prevent million hiv infections; and provide care, including care for orphans and vulnerable children, for million individuals. the program has been viewed as a major success for us global health policy. with wide bipartisan support, pepfar was reauthorized in for another years at $ billion, with substantial increases in the prevention, treatment, and care targets. the legislation also authorized $ billion for tuberculosis programming and $ billion for malaria efforts. although pepfar represents a landmark us achievement in global health, it also illustrates how policy can be skewed by nonscientific factors. fig. shows that among i r e l a n d f i n l a n d u n i t e d k i n g d o m s w i t z e r l a n d s p a i n f r a n c e g e r m a n y a u s t r i a c a n a d a a u s t r a l i a n e w z e a l a n d p o r t u g a l u n i t e d s t a t e s g r e e c e j a p a n i t a l y health called for a rebalancing of this portfolio to better support initiatives against noncommunicable diseases, malnutrition, and injuries. the signature global health program of the obama administration, the global health initiative (ghi), aims to provide $ billion in health assistance between and . although hiv/aids still dominates the ghi, increased investments are being made for neglected tropical diseases, malaria, maternal and child health, and family planning (box ). the aims of the ghi are to implement a woman-centered and girlcentered approach; increase impact and efficiency through strategic coordination and integration; strengthen and leverage key partnerships, multilateral organizations, and private contributions; encourage country ownership and investing in country-led plans; improve metrics, monitoring, and evaluation; and promote research and innovation. the us government's policy commitment to global health has been greatly lauded as a reflection of our vital health and economic self-interests, our humanitarian values, and "smart power." [ ] [ ] [ ] in many ways, it is an important form of diplomacy; however, some aspects of it may also hinder diplomatic prerogatives. some forms of oda can be used as leverage in diplomatic negotiations, but once a patient infected with hiv is taken into a pepfar-funded treatment program, it would be unethical for the us government to threaten the loss of those lifesaving drugs for diplomatic advantage. beyond un agencies and national governments, the global health enterprise is now a much more horizontal and networked endeavor than it was even years ago. although this makes it harder for the who to lead, it also brings a wider array of talent and resources to bear on problems. fig. illustrates an example of the partnership paradigm of global health governance today: the roll back malaria (rbm) partnership, a -member collaboration. even though the who was one of the founders of rbm and hosts the secretariat, it is not positioned as the dominant core of the effort. the rbm partnership not only works to facilitate policy coordination at the global level but also executes an operating framework with performance targets reflective of the mdg malaria goal; it articulates technical strategies and provides multidirectional accountability through its partners forum. a decision-making partnership board with members ( ex-officio) represents the broad rbm constituencies and meets periodically. there are voting members of the board representing foundations ( seat), malaria-endemic countries ( seats), multilateral institutions ( seats), ngos ( seats), organization for economic cooperation and development (oecd) donor countries ( seats), private sector ( seats), and research and academia ( seat). the stop tb partnership (http://www.stoptb.org/) also has many similarities to rbm. founded in , the global alliance for vaccines and immunizations (gavi) is another innovative partnership that links developing-world governments and donor governments; philanthropic foundations; the financial community; vaccine manufacturers from developed and developing countries; research and technical institutes; civil society organizations; and intergovernmental entities, such as who, unicef, and the world bank. immunizations funded by gavi have prevented an estimated . million deaths in developing countries. gavi also supports innovative financing box the goals and targets of the us government global health initiative hiv/aids: the us president's emergency plan for aids relief will: ( ) support the prevention of more than million new hiv infections; ( ) provide direct support for more than million people on treatment; and ( ) support care for more than million people, including million orphans and vulnerable children. malaria: the president's malaria initiative will reduce the burden of malaria by % for million people, representing % of the at-risk population in africa, and expand malaria efforts into nigeria and the democratic republic of the congo. tuberculosis (tb): save approximately . million lives by reducing tb prevalence by %, which will involve treating . million new tb cases and , multidrug-resistant cases of tb. maternal health: save approximately , women's lives by reducing maternal mortality by % across assisted countries. child health: save approximately million children's lives, including . million newborns, by reducing under- mortality rates by % across assisted countries. nutrition: reduce child undernutrition by % across assisted food-insecure countries, in conjunction with the president's feed the future initiative. family planning and reproductive health: prevent million unintended pregnancies by meeting unmet need for modern contraception. contraceptive prevalence is expected to rise to % across assisted countries, reflecting an average annual increase of percentage points. first births by women younger than years should decline to %. neglected tropical diseases: reduce the prevalence of neglected tropical diseases by % among % of the affected population, and eliminate onchocerciasis in latin america by , lymphatic filariasis globally by , and leprosy. data from available at: http://www.usaid.gov/ghi/factsheet.html. mechanisms, such as advanced market commitments to reduce the costs of immunizations needed by developing countries. the un declaration of commitment on hiv/aids called for the establishment of a global fund of pooled contributions to support hiv/aids needs. this global fund to fight aids, tuberculosis, and malaria (gfatm), unlike the previously mentioned partnerships, has as its sole focus mobilizing and distributing financial resources in a manner driven by technically sound national plans and priorities and principles of transparency and accountability. the gfatm is a partnership between governments, civil society, the private sector, and affected communities. more than countries have pledged funds to the gfatm; other major donors include the bill and melinda gates foundation, unitaid, and chevron. about $ billion has been pledged, of which more than $ billion has already been paid. with funding approved for more than programs in nearly countries, the gfatm is the source of onequarter of all international financing for aids globally as well as for two-thirds of that for tuberculosis and three-quarters of that for malaria. an innovative fiscal contribution to solving the crisis of antimalarial drug resistance and the dwindling number of effective drugs has been the creation of the affordable medicines facility for malaria (amfm). conceived by the iom committee on the economics of antimalarial drugs, the amfm was designed to re-engineer market forces to favor the effective treatment of resistant malaria through the appropriate use of artemisinin-containing combination antimalarial drugs (acts). in the committee recommended the commitment of $ to $ million per year to subsidize the entire global act market to create a steady supply of affordable and desirably priced acts in all malarious areas. several donors accepted this recommendation. the amfm was established by the gfatm and initially capitalized with more than $ million. although the greatest sources of funding, technical support, and leadership will continue to come from donor governments, recipient governments, and un agencies, contributions from the world of philanthropy have never been more significant. early in the twentieth century, rockefeller philanthropy supported efforts to eliminate hookworm, first domestically and then internationally. it has since taken on many other disease-control efforts directed toward conditions, including malaria, schistosomiasis, yellow fever, and vaccine-preventable childhood infections. in , it created the china medical board to develop modern medicine in that country but arguably its most significant contributions to advancing global health governance were investments to establish the johns hopkins school of hygiene and public health as well as schools of public health at harvard and the university of michigan. reflecting the emergence of the new era in global health governance, in the rockefeller foundation established an initiative to create innovative new public-private partnerships, including the medicines for malaria venture, the global alliance for tb drug development, and the international partnership on microbicides. over the years, many other foundations have made important contributions to facilitating global health action, including the ford foundation, atlantic philanthropies, the carnegie corporation, the bloomberg family foundation, the burroughs wellcome trust, the burroughs wellcome foundation, and the doris duke charitable foundation. the most noteworthy newcomer is the bill and melinda gates foundation. with assets of approximately $ billion, the gates foundation is the largest private philanthropy in the world. its current annual disbursements are approximately $ billion, much of which goes to global health. among foundations, its major commitments to gavi (at least $ . billion), the rotary international polio-eradication effort ($ million), and the gfatm ($ million) give it a uniquely powerful and sometimes controversial voice in global health governance. its investments in research, implementation, and advocacy encompass enteric and diarrheal diseases; hiv/aids; malaria, pneumonia, tuberculosis, and neglected and other infectious diseases; family planning; nutrition; maternal, neonatal and child health; tobacco control; and vaccine-preventable diseases. private funding now accounts for almost one-quarter of global health aid. unlike the foundations previously mentioned, the william j. clinton foundation is not a grant-making organization. for nearly a decade, however, it has been a unique contributor to advancing global health. by capitalizing on the influence of former president bill clinton, this foundation has catalyzed many initiatives. among these initiatives have been tremendous gains in access to hiv/aids treatment through negotiations with suppliers of drugs and diagnostic tests. through successive agreements, suppliers to low-income countries have reduced the prices of first-line treatments by %, pediatric medicines by %, and second-line hiv/aids medicines by a cumulative reduction of %. over the last decade, the corporate sector has also been making an increasing mark on global health. although corporate initiatives are too numerous to catalog in detail, their donations of drugs are especially noteworthy. since , for example, merck has donated ivermectin for the control of onchocerciasis (river blindness) worldwide. in , in partnership with glaxosmithkline, this commitment was expanded to include the elimination of lymphatic filariasis; ivermectin and glaxosmithkline's albendazole were coadministered in african countries and in yemen (countries where lymphatic filariasis and onchocerciasis are coendemic). over years, more than billion treatments for these infections have been provided though a large partnership. johnson and johnson donates enough mebendazole each year to treat million children for intestinal helminthes; boehringer ingelheim donates nevirapine to prevent mother-to-child transmission of hiv. pfizer has proved to be a valuable and innovative partner with its support for capacity-building activities, such as the pfizer global health fellows program. each year, this program deploys up to talented employees to work on high-impact, capacity-building projects in developing countries. similarly, bd strengthens capacity through a partnership with pepfar to improve laboratory systems in countries highly affected by hiv/aids and tb. the emerging corporate role in global health is not limited to companies focused on the business of health. companies as diverse as exxonmobil, warner brothers, and nike have engaged in important partnerships focused on controlling malaria, hiv/ aids, and violence against girls. american cyanamid has donated millions of dollars of the larvicide temephos to support guinea worm eradication efforts. formal business coalitions have developed to take on issues of malaria, tuberculosis, and hiv/aids. the role of civil society organizations in global health predates all of those entities previously named. the who lists ngos with which it has an official relationship. as the who notes: no longer the domain of medical specialists, health work now involves politicians, economists, lawyers, communicators, social scientists and ordinary people everywhere. the involvement of civil society has profoundly affected not only the concepts underpinning public health but the formulation and implementation of public health programs and policies as well. global health: governance and policy development civil society organizations span a wide array of secular and faith-based entities. they include groups with a disease-specific orientation; groups with a professionalspecialty focus; charities that work on the ground; and global professional service organizations, such as rotary international. (rotary international is a key global partner in the who campaign for polio eradication. ) perhaps the most exciting recent development in the united states has been the explosion in interest in global health education at universities. suffice it to say that if governance is the constellation of mechanisms a society uses to effect collective action toward common goals, then the catalyst of the many new us multidisciplinary university programs in global health education will initiate and energize an unprecedented level of collective action. despite the vast inflow of resources for global health, the remaining policy challenges are significant. perhaps today's most acute global health challenge is achieving the health-related mdgs. current trends indicate that none of these basic targets will be near achievement by . overall access to care is still lacking or suboptimal for billions of people. access to clean water and essential medicines is uneven. modern pharmaceuticals are often unaffordable or unavailable. globalization has brought some health benefits to the world's poorest, but it has also fostered the transnational spread of infectious diseases, the brain drain of skilled health care workers from developing countries, and the trade in poor-quality food and pharmaceuticals. surveillance for human and animal diseases is of variable quality and the enforcement of the relevant regulatory regimes needs improvement. despite the challenges that remain in coordinating the many diverse players now engaged in global health, the vast increase in the commitment of both private and public wealth over the last decade is to be celebrated. commitments have gone far beyond money and have brought forth legions of individuals who choose to commit themselves in the global context to the universal value of health. research is steadily discovering and developing new technological interventions. new mechanisms of cooperation have been developed, and there is a growing interest in implementation science and in program evaluation to increase accountability and effectiveness. improved global health governance to better catalyze and coordinate collective action remains an essential underpinning to meeting the diverse challenges to saving lives in all parts of the globe. global governance in health -do historical experiences of industrialized countries teach any lessons? the emergence of new virus diseases: an overview learning from sars: preparing for the next disease outbreak (workshop summary) the domestic and international impacts of the -h n influenza a pandemic: global challenges, global solutions (workshop summary) infectious disease movement in a borderless world (workshop summary) convention on the prohibition of the development, production and stockpiling of bacteriological (biological) and toxin weapons and on their destruction top u.s. agricultural import sources drug safety: preliminary findings suggest recent fda initiatives have potential, but do not fully address weaknesses in its foreign drug inspection program (testimony before the subcommittee on oversight and investigations, committee on energy and commerce, us house of representatives). washington, dc. the united states government accountability office global climate change and extreme weather events: understanding the contributions to infectious disease emergence (workshop summary) global health policy: u.s. participation in international health treaties, commitments, partnerships, and other agreements constitution of the world health organization the role of the who in public health global health governance report (commissioned paper). the u.s. commitment to global health: recommendations for the public and private sectors draft proposed programme budget united nations united nations general assembly special session on hiv the convention on the rights of the child. new york: unicef one health initiative task force: final report. one health -a new professional imperative sustaining global surveillance and response to emerging zoonotic diseases world trade organization/world health organization the world bank annual report -year in review. the international bank for reconstruction and development/the world bank millennium development goals for health: what will it take to accelerate progress? global health policy: the u.s. government's global health policy architecture: structure, programs, and funding committee for the evaluation of the president's emergency plan for aids relief (pepfar) implementation. pepfar implementation: progress and promise. institute of medicine public law - . united states global leadership against hiv/aids, tuberculosis, and malaria reauthorization act of the institute of medicine committee on the us commitment to global health. the u.s. commitment to global health: recommendations for the public and private sectors report of the csis commission on smart global health policy: a healthier, safer, and more prosperous world america's vital interest in global health: protecting our people, enhancing our economy, and advancing our international interests the institute of medicine committee on the u.s. commitment to global health. the u.s. commitment to global health: recommendations for the public and private sectors no good deed goes unpunished: the unintended consequences of washington's hiv/aids programs the global fund to fight aids, tuberculosis, and malaria -pledges about the global fund saving lives: buying time: economics of malaria drugs in an age of resistance rockefeller foundation-our history governing global health global health fellows: pfizer investments in health. available at: https:// globalhealthfellows.pfizer.com/login.asp?returnurl home.asp. accessed september bd's global health initiative global business coalition on hiv/aids, tuberculosis and malaria world health organization. list of ngos in official relations with who world health organization. civil society initiative (csi) rotary international/the rotary foundation the dramatic expansion of university engagement in global health: implications for us policy: a report of the csis global health policy center key: cord- - t ru z authors: kohler, jillian clare; bowra, andrea title: exploring anti-corruption, transparency, and accountability in the world health organization, the united nations development programme, the world bank group, and the global fund to fight aids, tuberculosis and malaria date: - - journal: global health doi: . /s - - - sha: doc_id: cord_uid: t ru z corruption is recognized by the global community as a threat to development generally and to achieving health goals, such as the united nations sustainable development goal # : ensuring healthy lives and promoting well-being for all. as such, international organizations such as the world health organizations and the united nations development program are creating an evidence base on how best to address corruption in health systems. at present, the risk of corruption is even more apparent, given the need for quick and nimble responses to the covid- pandemic, which may include a relaxation of standards and the rapid mobilization of large funds. as international organizations and governments attempt to respond to the ever-changing demands of this pandemic, there is a need to acknowledge and address the increased opportunity for corruption. in order to explore how such risks of corruption are addressed in international organizations, this paper focuses on the question: how are international organizations implementing measures to promote accountability and transparency, and anti-corruption, in their own operations? the following international organizations were selected as the focus of this paper given their current involvement in anti-corruption, transparency, and accountability in the health sector: the world health organization, the united nations development program, the world bank group, and the global fund to fight aids, tuberculosis and malaria. our findings demonstrate that there has been a clear increase in the volume and scope of anti-corruption, accountability, and transparency measures implemented by these international organizations in recent years. however, the efficacy of these measures remains unclear. further research is needed to determine how these measures are achieving their transparency, accountability, and anti-corruption goals. the united nations office of the high commissioner on human rights has underscored that corruption is an "enormous obstacle to the realization of all human rights," and has stated that transparency, accountability, non-discrimination and meaningful participation are effective means to fight corruption [ ] . corruption, defined by transparency international is, "the misuse of entrusted power for private gain" [ ] , fuels inequity as it skews how resources are allocated and distributed. its cost is massive: every year, us$ . trillion are stolenmore than % of the global gross domestic product (gdp), with an additional us$ trillion paid in bribes [ ] . a report by the international monetary fund (imf) further found that if all countries were to reduce levels of corruption, $ trillion in lost tax revenues could be gained constituting . % of the global gdp [ ] . corruption can be understood as a global wicked problem, which is characteristically described as being challenging and "influenced by a constellation of complex social and political factors" [ ] . corruption manifests in many forms; it may, for instance, be petty or grand, and it transcends all jurisdictional borders. although there is seldom a single identifiable cause of corruption, certain factors may contribute to its manifestation including poverty, low social and economic status of public officials, and insufficient or an absence of institutional transparency and accountability mechanisms. corruption has, in light of this, been gaining traction as a policy issue for many international organizations. during the past two decades, there has been a veritable shift in the number of international organizations (ios) addressing corruption. this shift can be attributed to a number of factors including the rising monetary costs of corruption as mentioned above, increased media attention on corruption, and an increase in public perceptions of corruption as 'detrimental' to society [ , ] . the topic of corruption and its impact on development goals is no longer relegated to quiet conversations amongst policy makers and government officials. it is not being pushed out of public discourse with the view that it is simply, "too complex" or "too political." instead, ios have developed anti-corruption policies and practices as well as corresponding institutions to oversee compliance with anti-corruption efforts. can best reduce corruption in the health system. in doing so, they are aiming to contribute to programing that is in line with the global sustainable development goals (sdgs), such as sdg# "good health and well-being" and sdg # "peace, justice and strong institutions," which includes the sub-target . "(to) substantially reduce corruption and bribery in all their forms. in , these ios initiated a global effort with broad stakeholder representation to construct a proposed acta alliance for health that seeks, amongst other objectives, to build up human capacity in anti-corruption and health and to monitor and evaluate acta measures in health [ , ] . the justification for this focus on corruption in health is compelling, as there is ample evidence about how the health sector provides an optimal breeding ground for corruption to thrive [ , ] . the embezzlement of public health budgets and kickbacks in the pharmaceutical procurement process, as but two examples, can result in wastage that limits access of a population to essential health services and medicines [ , [ ] [ ] [ ] . the current covid- pandemic has amplified the risks that corruption poses to the health sector. health systems around the world are facing unprecedented and unpredictable demands on potentially already fragile systems [ ] . the rapid responses from ios and governments as they attempt to reduce the spread of the disease and attend to those who are already suffering, though necessary, are creating conditions that may be highly conducive to corruption [ ] . such conditions include flexibility in responses, the simplification of procurement controls, the rapid flow of large funds, and the need for urgent responses [ ] [ ] [ ] . as a result, corruption and fraud are already revealing themselves in the forms of price gouging and flawed and falsified goods [ , [ ] [ ] [ ] . this threatens to undermine the sustainability of health systems and have negative impacts that could persist long after the outbreak itself is controlled [ ] . but while a focus on acta in health warrants examination, specifically during a global pandemic, before advancing this agenda there is value in stepping back to understand first what institutions and mechanisms ios have in place to advance acta in their operations more generally. what makes this messy at times is that anticorruption efforts have often been taken up by the global community within the framework of good governance. given this, a closer examination of what good governance means conceptually and how it is institutionally implemented is of value for more informed policy generation in acta generally and in relation to the health sector, in particular. accordingly, this paper focuses on the question: how are ios implementing measures to promote accountability and transparency, as well as anti-corruption, in their own operations? this paper is organized in the following way: first, the topic is introduced broadly, and a brief discussion about how corruption can impact health goals follows, as above. next, the methods are described. then the importance of good governance as a mechanism to reduce corruption is discussed. next, a description of examples of acta mechanisms within the who, undp and the global fund, and the world bank are described. lastly, findings and conclusions are provided. this research consisted of a targeted website review as well as an academic literature review in order to explore and synthesize the acta measures and processes employed by the following four ios: the global fund, the who, the undp, and the world bank. first, we conducted a targeted website review of the global fund, who, undp, and world bank websites. this review was conducted between september -october , and again in june . materials extracted included organizational reports, policies, internal and external audits, as well as other relevant documents. the website review was then supplemented by a rapid literature review searching the following databases: scopus, medline, google, and google scholar. search strategies were utilized with a combination of the following keywords: ("undp" or "who" or "world bank" or "global fund") and ("corruption" or "anti-corruption" or "transparency" or "accountability" or "good governance"). no restrictions were applied based on geographical location, but searches were limited to articles published between and to ensure the most relevant and current material was captured. titles and abstracts were then examined to ensure the following criteria were met: ) the article addressed one of the four specified institutions; ) the article addressed the measures implemented by the organization; and ) the article was written or translated into english. all documents were then analyzed, and the acta measures employed by the ios were extracted and summarized to be presented as below. the importance of good governance as a mechanism to reduce corruption prior to examining the acta measures implemented by ios, we first discuss the conceptual framework of good governance, particularly, accountability and transparency. these concepts have been applied programmatically in countries by the who, particularly in terms of its good governance for medicines initiative, the democratic governance program of the undp and others, since they are often more palatable than anti-corruption to government officials, as public policy areas of focus [ ] . indeed, governing institutions are better able to respond to community needs and demands when their processes are inclusive, transparent, accountable to all stakeholders, and responsive to the demands of the governed [ ] . the thinking here is that accountability and transparency can more likely illuminate areas where corruption may be present, there may be corruption risks, and/or inefficiencies [ ] . in an evidence review of causes of corruption, the organization for economic co-operation and development (oecd) found that weak governance is "… one of the fundamental leading causes of corruption" [ ] . good governance is accordingly viewed as a credible conceptual framework to operationalize anti-corruption efforts and can contribute to achieving more sustainable social and economic development [ ] . handl underscores that "sustainable development is achievable only in a social setting that allows for public access to information … and governmental accountability [ ] ." what is more, lacking good governance in international organizations has been linked, rightly or wrongly, to corruption and the inefficiency of international financial institutions [ , ] . as thomas describes, "the ifis [international financial institutions] have defined good governance as the elimination of corruption through the establishment of the rule of law and the efficiency and accountability of the public sector" [ ] . the focus on good governance is therefore of value if we consider it as a sine qua non for advancing efficient and effective healthcare systems and for mitigating mismanagement [ ] . it is also regarded as one of the key building blocks of the health system, helping to ensure that adequate policies, effective oversight, and strong accountability mechanisms are in place for its proper design and management. the complexities of the health system thus require tailored governance approaches to identify vulnerabilities to corruption, waste, mismanagement, and fraud. anticorruption efforts that translate good governance principles have been considered as a "gold standard" for tackling sector vulnerabilities. savedoff and hussmann have found that, "corruption in healthcare is less likely in societies where there is broad adherence to the rule of law, transparency and trust, and where the public sector is ruled by effective civil service codes and strong accountability mechanisms" [ ] . good governance, such as accountability and transparency, allows citizens to hold authorities accountable for better development results, since it encourages civic engagement in the policy-making process and increases transparency [ ] . it guides the creation and implementation of anticorruption strategies and tactics. yet as vian and kohler emphasize, how stakeholders define and implement transparency and accountability efforts can be vastly different across countries and institutional contexts in the health sector [ ] . even so, they propose definitions from existing literature. they explain that accountability can be understood as those mechanisms that make institutions responsive to their particular publics. it requires institutions or organizations to be accountable to those who will be impacted by their decisions [ ] . accountability can reduce corruption and other abuses, assure compliance with standards and procedures, and improve performance and organizational learning [ ] . in addition, accountability requires institutions to justify their results to internal and external monitors and stakeholders and impose sanctions for nonperformance or corrupt behavior. vian and kohler also illuminate that accountability and transparency are essentially coupled. accountability requires transparency and vice versa. here, transparency is understood as when citizens are informed about how and why public policy decisions are taken. to understand how public decisions are made requires information about the procedures followed and the criteria used by policymakers to reach decisions. understanding why decisions are made requires disclosure of the information drawn on by policy makers and revelation of the arguments adduced in favour and against particular decisions [ ] . government transparency can further be understood as the level of access to government information which is made available to the population. still, the use of good governance as an entry point to address corruption is not a straight-forward enterprise. as noted earlier, anti-corruption efforts and good governance often become entangled together. furthermore, the concept of good governance holds many meanings. often these meanings are based on the mechanisms through which it can be achieved, such as participatory democracy, transparency, accountable, efficient public services, and the presence and enforcement of civil rights [ ] . other definitions are based more on specific outcomes, such as assuring that the most marginalized groups in society have a voice and receive fair, equitable treatment. in order to understand how corruption is being addressed by ios, we set forth to find examples of how the who, the undp, the global fund, and the world bank operationalize good governance and acta concepts within their own operations. the below describes the relevant institutions/mechanisms that these four ios have in place. the who is overseen by the office of internal audit and oversight (iao) who inspects, monitors and evaluates the who's internal control, financial management, and is also responsible for addressing any alleged breaches. it is composed of three divisions: ( ) internal audit; ( ) inspection and evaluation; ( ) investigation [ ] . the iao produces an annual report that is submitted to the world health assembly (wha). the report includes summaries of investigations into allegations of misconduct at the who. in addition, the panel of external auditor also monitors the who's operations in terms of its financial risk management and the efficacy of the organization's internal control system. its stated main objective is to "further the coordination of the audits for which its members are responsible, and to exchange information on the audit methods and findings" [ ] . in the most recent report of the internal auditor to the wha ( ), the overall ratings on operating effectiveness of internal controls from audits were reported as the same as : a total of % of overall conclusions assessed as either "satisfactory" or "partially satisfactory with some improvement required" [ ] . this overall rating is broken down further to reveal a significant increase of % in to % in in effectiveness of internal controls at regional offices, headquarters, and global cross-cutting areas [ ] . however, the operating effectiveness of controls in country offices declined as equally significantly from % in to % in [ ] . given these findings, the iao identified five priority areas: (i) improving assurance actions over direct financial cooperation; (ii) strengthening direct implementation assurance activities, (iii) more robust vendor management and procurement documentation for goods and services; (iv) development of action plans to address human resource needs; and (v) improving resource mobilization for key underfunded programs [ ] . who is also subject to an independent expert oversight advisory committee that is organized through its executive board. the purpose of the committee is to advise the program, budget and administration committee and through it the executive board, in fulfilling their oversight advisory responsibility; on request, it also advises the director-general on issues within its mandate. last, a relatively recent addition (established in january ) to monitoring accountability within the who is the office of compliance, risk management and ethics (cre). cre's cited aims are to promote transparency and accountability through improving compliance, managing a risk framework, and promoting ethical values [ ] . the office of audit and investigations (oai) is responsible for investigating alleged breaches [ ] , commensurate with the undp legal framework for addressing non-compliance with un standards of conduct and with the oai investigations guidelines [ , ] . the oai also has an investigator hotline, which is "managed by an independent service provider on behalf of undp" and includes a confidential phone number and mailing address [ ] . any alleged staff misconduct within the undp is reported in the "annual reports of the administrator on disciplinary measures and other actions taken in response to fraud, corruption and other wrongdoing" and are publicly available from [ ] [ ] [ ] . still, the reports are slim in terms of their details. this may be a result of oai's investigative guidelines, which states that investigations are strictly confidential [ ] . information regarding investigations are provided only to those with a "legitimate need to know," such as affected staff members [ ] . the oai conducts regular internal audits of undp activity, which are publicly available on the undp website. internal audits are undertaken by the oai annually, reported to the administrator and submitted to the audit and evaluation advisory committee for review [ ] . additionally, the oai submits an annual report which highlights important observations from audits and investigations throughout the year which is presented to the undp executive board at an annual session in june [ ] . in an effort to promote transparency, audit reports of member state offices and eligible donors since december have been publicly disclosed [ ] . prior to this, audits may be requested but must be kept confidential [ ] . the undp also is overseen by an ethics office that is active in an investigation process conducted by oai when staff members report that retaliatory actions have been taken against them for reporting a breach or providing information for an audit or investigation [ , ] . the ethics office is an independent institution that reports directly to the administrator of the undp [ ] . the audit and evaluation advisory committee (aeac) is tasked with working with the administrator on oversight, financial management, reporting accountability, evaluation and internal and external audits [ ] . the aeac is an independent body and is composed of members, external to the undp. the mandate of this committee is highly ambitious: to promote proper governance, high ethical standards, and the adoption of best practices. the committee reviews annual reports and financial statements and provides recommendations to senior undp management [ ] . the un board of auditors prepares an audit report. every year, it presents its report of the financial statements of the undp at the general assembly through the administrative and budgetary committee and to the undp executive board [ ] . the undp has a transparency portal (open.undp.org) in place, allowing public access to over , undp projects. the transparency portal publishes project data from . in october , the portal had data about undp projects in countries. each project profile consists of information regarding its funding donor, outputs and, relevant documents (such as quarterly reports and project management documents) and purchase orders [ , ] . the undp also publishes an annual report of the administrator on disciplinary measures and other actions taken in response to fraud, corruption and other wrongdoings. these reports are accessible from and summarize cases of misconduct and other violations of standards of conduct by undp staff, other personnel such as un volunteers and contractors such as services contractors, and vendors [ ] . corruption cases are reported in the undp financial report and audited financial statements, which are annual reports produced by the un board of auditors (boa). these reports contain cases of fraud and presumptive fraud disclosed by management and contains slightly more detailed descriptions of investigations of undp activities [ ] . the cases outlined in the boa report contains information of the region of the incident, time it was reported, a description of the incident, any remedial action against the persons involved, loss to the undp, and management action to deter recurrence of the incident. reports are published on the un board of auditor's website dating back to , however cases of fraud were only included in the report from onwards [ , ] . interestingly, the report diverts from previous structures of reporting, as it does not contain specific information on cases of fraud and corruption [ ] . in , a total of cases concerning fraud, corruption and misconducted were reported, with of these cases being carried over from . this represents a slight increase in caseload, as identified . in , % of these cases concerned financial irregularities, such as procurement fraud, theft and embezzlement. this number has remained relatively consistent throughout the past years, with the exception of which saw an increase in financially related fraud. in , cases primarily involved staff ( substantiated cases) followed by vendors ( substantiated cases) and service contractors ( substantiated cases) [ ] . the global fund, like the undp, promotes the aspirational policy of zero tolerance for corruption and fraud. what is noteworthy is how many institutional checks the global fund has in place to reduce corruption risks and advance accountability and transparency. this makes sense given the intense scrutiny the global fund has come under given public exposure of corruption scandals in its operations. the office of the inspector general (oig) is responsible for conducting investigations and audits of global fund supported programs; all oig reports are publicly accessible online, and the oig even helps to disseminate information creating tweets about audits and investigations. additionally, the oig leads the i speak out now! campaign, designed to encourage staff and grant implementers to report any suspected fraud and corruption incidents. the board of the global fund includes an "audit and finance committee" and the "ethics and governance committee" [ ] . the audit and finance committee oversee the global fund's financial resources and audit and investigation reports that it receives from the office of the inspector general (oig) while the ethics and governance committee are responsible for "ethics-related matters" [ ] . the oig is responsible for overseeing global fund's activities and investigations of alleged "prohibited practices [ ] ." the global fund defines its list of "prohibited practices" in its "policy to combat fraud and corruption [ ] ." pursuant to the global fund's whistleblowing policy, (updated in ), the oig is also responsible for ensuring that there are adequate mechanisms for whistle-blowers to use [ ] . the oig is independent from the secretariat and reports directly to the board [ ] . importantly, the oig also performs annual self-assessments and has external assessments every years [ ] . in , the oig planned and completed audits, and screened allegations, of which allegations required more detailed assessment or investigation, resulting in the oig opening new investigations [ ] . the majority of allegations came from whistle-blowers ( allegations), followed by the secretariat ( allegations) and fund recipients ( allegations) [ ] . notably, the oig also performs proactive investigations that are "intelligence-led and does not rely on allegations from third parties or whistle-blowers" to detect wrongdoing before they escalate [ ] . for example, in its most recently published proactive investigation, the oig discovered non-compliance in the procurement of hiv rapid diagnostic test kits [ ] . the oig publishes detailed audits and investigations, which are available on the oig's website [ ] . in , the global fund also developed its "ethics and integrity framework" and in may , it established an ethics office and recruited an ethics officer [ ] . the ethics officer reports to the executive director and the board's "ethics and governance committee [ ] ." in , the ethics office processed cases, of which cases were related to conflicts of interest [ ] . of the conflict of interest cases, were cleared, had "mitigating measures" put in place, and were not cleared [ ] . individuals or institutions who were not cleared either couldn't take the position/assignment or had to step down [ ] . within the global fund, there has been significant improvement in reporting conflicts of interest. for example, % of board members completed "declarations of interest" in compared to % completion in [ ] . the fund also implements agreed management actions (amas) which are "an agreed course of action, decided jointly between the secretariat and the office of the inspector general, to remedy an identified root cause, targeting specific portfolios where progress is needed [ ] ." the amas are published in audit and investigation reports completed by the oig. the global fund tracks the progress it makes towards completing the amas in its "joint amas progress reports" [ ] . in its publication of november - , , the global fund reported that it had open amas and overdue amas, which represented an all-time low, demonstrating "significant progress" [ ] . in audits and investigations where funds have been lost or were non-compliant with the grant agreement, an ama is often to recover lost funds. each year, the global fund secretariat prepares a "recoveries report" for the board that lists amounts owed and amounts recovered [ ] . in november , the global fund's board approved a measure of last resort called the " -for- allocation reduction" to recover lost funds from countries that are "unwilling to budge" [ ] . this measure allowed the global fund to withhold grants amounting to double the amount owed by the country [ ] . for example, in the case of bangladesh, the global fund spent . years negotiating with the government to recover us$ . million in lost funds, but there were no results [ ] . mark dybul, (the former executive director of the global fund) in the end approved a us$ . million reduction in bangladesh's allocation [ ] . as of june , the " for- allocation reduction" penalty has been used seven times to recover us$ . million [ ] . the oig publishes audits and investigations on its website dating back to september [ ] . there are internal and country audit reports and investigational reports [ ] . what is noticeable is that the global fund has seen a change in trends of fraud and corruption from largely procurement fraud in - to a diverse range of fraud and corruption [ ] . the oig's annual board report shows that % of investigations related to procurement fraud between and , compared to only % of investigations in [ ] . of the ten published investigations, two related to procurement fraud, two to embezzlement, two to "training/travel fraud," two to drug theft, one to "salary kickbacks," and one to "data fraud" [ ] . the world bank, like the undp and the global fund, has an aspirational zero-tolerance policy towards corruption in its financed projects [ ] . the integrity vice presidency (int) leads efforts to address corruption. it is an independent unit reporting directly to the president of the world bank group and overseen by the audit committee of the executive board [ ] . int mitigates risks of fraud and corruption through its investigations, sanctions and compliance, and prevention [ ] . int investigates both internal and external cases related to the world bank's sanctionable practices [ ] . the investigation results produced are submitted to the world bank group president, as well as sent in referral reports to relevant national authorities [ ] . this information is also provided in redacted reports to the board of executive directors and posted on int's website [ ] . investigated cases found to have engaged in fraudulent, corrupt, collusive, coercive, or obstructive practices are sanctioned through a two-tiered system that includes the office of suspension and debarment and the world bank group sanction board [ , ] . in one recent example of this process, a sanction was imposed on the government of bangladesh as a result of the finding that there were collusive practices during the procurement of radiotherapy equipment for their health sector development program [ ] . this sanction involved a posted letter of reprimand on the world bank's website for a sixmonth period starting on the date of the decision [ ] . the world bank states that sanctions like these are able to, "… hold wrongdoers accountable for their misconduct and help deter others from engaging in similar behaviour" [ ] . information about the sanction system are detailed further in annual reports published on the world bank's website dating back to [ ] . their most recent report ( ), reports a total of cases opened in , compared to a total of cases opened in , and cases opened in [ ] . of the total cases opened in , % were related to fraud, % to corruption, % to collusion, % to coercion, and % to obstruction [ ] . int further mitigates risks of fraud and corruption through their preventive services unit (psu). the psu was instituted in in response to requests from operational staff and a recommendation from the independent panel review of int [ ] . the psu prevents risks of fraud and corruption through applying the knowledge gained from investigative activities to the development and implementation of advice and training on the prevention of corruption in world bank-financed projects [ ] . the world bank also supports its member countries in its efforts to "build capable, efficient, open, inclusive, and accountable institutions" through its global governance practices (ggp) [ ] . the ggp recognizes the heightened pressures that the current covid- pandemic is putting on governments as they attempt to respond to rapidly changing service delivery needs [ ] . in order to build strong institutions, the ggp states broadly that it is working with its partners to aid them in addressing complex governance challenges, and working internationally to create global standards [ ] . at present, the ggp reports briefly on the success of six such capacity building programs on its website [ ] . for example, the world bank supported columbia in its reforms of its judicial branch. this included developing digital services, such as a digital transformation plan and a data governance strategy [ ] . another example is india's madhya pradesh citizens' access to responsive project which intends to increase public service access for women and other under-represented communities [ ] . this involved the expansion of a number of "citizen service kiosks" in remote areas in order to improve coverage and provision of public services [ ] . the number and scope of acta efforts by ios has had a marked increase over the last two decades [ ] . while this paper provides an initial overview of such efforts employed by the undp, the global fund, the who, and the world bank, it is by no means exhaustive. the searches conducted both within the academic literature and of the organizational websites were limited to material that was reported in or translated into english. furthermore, this review did not examine all audit material provided by the ios. rather, it explored recent reports and extracted relevant and illustrative examples of the vast efforts ios have made in recent years to demonstrate their accountability and transparency. our findings demonstrate that this is being done primarily through the adoption of accountability policies, frameworks, and public postings of their financial information and other relevant information on their websites, along with oversight of their operations by independent bodies. the above examples of the acta institutions/ mechanisms the who, the global fund, the undp, and the world bank have in place tend to be predominately audits and information sharing. some mechanisms are clearly anti-corruption specific, while others provide broader mechanisms of accountability and transparency. this at the surface seems positive. less apparent, however, is how effective these various mechanisms are towards achieving institutional goals of accountability and transparency and anti-corruption, specifically in times of crisis such as the current covid- pandemic. we need to know more about what mechanisms, whether they be preventative or retroactive, are being implemented when the usual acta procedures and protocols are bypassed to allow for more timely responses. will the number of cases of corruption addressed by ios increase over the course of the covid- pandemic? if not, is this an indication that the retroactive acta mechanisms are ineffective? this is a difficult question to answer as there is a general absence of material demonstrating the efficacy of acta mechanisms. for example, if there are less reports of breaches and/or corruption, does this imply that the institutions/mechanisms are working satisfactorily? or, is it the opposite case that these mechanisms are failing to catch them? furthermore, if the institutions/mechanisms do catch them, do they have sufficient power and resources to effectively address the issue? the precise impacts of acta measures are challenging to discern and an important area for future research [ ] . first, as noted earlier, there are no common definitions applied by ios for accountability and transparency. accordingly, it is challenging at best to make cross-comparisons amongst ios. and, therein lies the thorny question: how do we measure their outcomes? what has complicated this enterprise further is as rose-ackerman underscores, good governance has become intertwined with the anticorruption agenda and may in fact simply be "a convenient euphemism for corruption" [ ] . this mixing of good governance with acta obfuscates the intent of these initiatives. are they seeking to promote accountability and transparency or are they aiming to reduce the risk of corruption? rose-ackerman & palifka importantly also ask the question "who is guarding the guard dogs?" [ ] . lastly, we are faced with challenges in terms of providing cross-institutional comparisons in this area as there is no common standard of transparency or accountability against which ios can be evaluated [ ] . evaluations in ios are missing techniques and methodologies and are "fragmented, non-comprehensive and nonintegrated" [ , ] . of equal importance, international evaluations offices are often internal and missing critical independent reviews [ ] [ ] [ ] [ ] . in short, there has clearly been a growth of efforts by ios to demonstrate that they are accountable, transparent and taking steps to address corruption. all the same, it is timely and possibly urgent for ios to step back and examine how they define concepts, such as good governance and acta, determine what they are doing in terms of advancing goals related to these areas, and most importantly, evaluate if their institutional "watch dogs" are achieving their intended purposes [ ] . united nations human rights office of 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emergence of international accountability standards corruption and government: causes, consequences, and reform horizonal review between international organizations: why, how, and who cares about corporate regulatory capture how do international organizations promote quality of government? contestation, integration, and the limits of io power evaluation, international organizations, and global policy: an introduction the fight against corruption: international organizations at a cross-roads international organizations and government transparency: linking the international and domestic realms expounding the place of legal doctrinal methods in legalinterdisciplinary research publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations the authors thank sandani hapuhennedige and emma charlotte bernsen, who co-authored with jillian clare kohler, "exploring accountability and transparency within international organizations: what do we know and what do we need to know" in k. cahyurt's integrity, transparency and corruption in healthcare & research on health, volume i , ., which helped inform this paper. the authors also thank anna wong, marvin chang,tara faghani hamadini and matineh rasteger panah for their much appreciated research contributions.authors' contributions jc conceived the study design, extracted data, and drafted the paper. ab conducted data extraction and contributed to paper drafts. both authors read and approved the final paper. key: cord- - tqi n authors: hunter, anita; wilson, lynda; stanhope, marcia; hatcher, barbara; hattar, marianne; hilfinger messias, deanne k.; powell, dorothy title: global health diplomacy: an integrative review of the literature and implications for nursing date: - - journal: nurs outlook doi: . /j.outlook. . . sha: doc_id: cord_uid: tqi n the increasing interconnectedness of the world and the factors that affect health lay the foundation for the evolving practice of global health diplomacy. there has been limited discussion in the nursing literature about the concept of global health diplomacy or the role of nurses in such initiatives. a discussion of this concept is presented here by the members of a task force on global health diplomacy of the american academy of nursing expert panel on global nursing and health (aan epgnh). the purpose of this article is to present an integrative review of literature on the concept of global health diplomacy and to identify implications of this emerging field for nursing education, practice, and research. the steps proposed by whittemore and knafl ( ) were adapted and applied to the integrative review of theoretical and descriptive articles about the concept of global health diplomacy. this review included an analysis of the historical background, definition, and challenges of global health diplomacy and suggestions about the preparation of global health diplomats. the article concludes with a discussion of implications for nursing practice, education, and research. the task force endorses the definition of global health diplomacy proposed by adams, novotny, and leslie ( ) but recommends that further dialogue and research is necessary to identify opportunities and educational requirements for nurses to contribute to the emerging field of global health diplomacy. the increasing interconnectedness in the world that has resulted from globalization has significant implications for nursing and healthcare. the american academy of nursing expert panel on global nursing and health (aan epgnh), whose members are active participants in the global arena, recognize that health problems transcend national borders and that all nurses must be prepared to address global health challenges. since , global health has become the top foreign policy issue of our times (labonté & gagnon, ) , encouraging the interaction of state and nonstate participants to position health issues more prominently in foreign policy decision-making. this process and the engagement of all key stakeholders are parts of a new approach to global health called "global health diplomacy" (labonté & gagnon, ) . nurses who work in the global health arena need to be aware of this new emphasis and identify their responsibilities as global health diplomats. novotny and adams (novotny & adams, ) defined global health diplomacy as "a political change activity that meets the dual goals of improving global health while maintaining and strengthening international relations abroad, particularly in conflict areas and resource-poor environments [and that] health diplomacy is not only the job of diplomats or health leaders in government structures, it is a professional practice that should inform any group or individual with responsibility to conduct research, service, programs, or direct international health assistance between donor and recipient institutions" (p. - ). to better inform nurses about the concept of global health diplomacy, this paper presents an integrative review of literature on the concept of global health diplomacy and identifies implications of this emerging field for nursing education, practice, and research. whittemore and knafl ( ) described an integrative review of the literature as the broadest type of research review, combining data from both empirical and theoretical literature to define concepts, review evidence, review theories, and analyze methodological issues. those authors modified the original framework for literature reviews proposed by cooper ( ) and suggested that an integrative review should include: (a) a clear statement identifying the problem or purpose of the review; (b) identification of the strategies used to search and identify relevant literature; (c) evaluation of the quality of the data; (d) analysis of the data; and (e) final synthesis and presentation of the data. whittemore and knafl ( ) acknowledged that many strategies can be used for each of these stages. the purpose of this review was to analyze the concept of global health diplomacy and identify implications of global health diplomacy for nursing practice, education, and research. the framework proposed by whittemore and knafl ( ) was used to organize the review. we did not find reports of empirical research other than descriptions of existing health-diplomacy programs, so our review focused on theoretical articles and empirical descriptions of global health initiatives. the articles included in this review were identified by searching the cumulative index to nursing and allied health literature (cinahl) and pubmed databases using the search term "global health diplomacy," without specifying any date restrictions. additional articles were identified by reviewing reference lists of the original papers, and by searching google scholar using the keywords "global health diplomacy." empirical or theoretical articles were included in the review if they addressed the historical development of global health diplomacy, defined the components and challenges of health diplomacy, proposed future development of global health diplomacy, and/or discussed strategies for preparing global health diplomats. to evaluate the quality of the articles that were included in the review, the authors adopted one of the strategies proposed by whittemore and knafl ( ) , which was to consider authenticity, informational value, representativeness of sources, and methodological quality of each document that was included in the review. to analyze and synthesize the data from these diverse sources, the authors reviewed all papers, wrote annotated summaries of each paper, and then developed a system for classifying the articles, displaying the data, comparing the themes that emerged from each paper, and drawing inferences and conclusions, using the methods proposed by whittemore and knafl ( ) . the review is organized according to the main themes that emerged from analysis of the papers: historical development of global health diplomacy, definition and components of global health diplomacy, challenges in global health diplomacy, and preparation of global health diplomats. the review concludes with the authors' recommendations and implications for nursing practice, education, and research. the term global health refers to "an area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide. global health emphasizes transnational health issues, determinants, and solutions; involves many disciplines within and beyond the health sciences and promotes interdisciplinary collaboration; and [it] is a synthesis of population based prevention with individual-level clinical care" (koplan et al., (koplan et al., , p. . adams, novotny, and leslie ( ) defined global health diplomacy as "an emerging field that addresses the dual goals of improving global health and bettering international n u r s o u t l o o k ( ) e relations, particularly in conflict areas and in resourcepoor environments" (p. ). katz et al. ( ) proposed that the varying definitions of global health diplomacy fall into three different categories ( ) core diplomacy or formal negotiations between and among nations; ( ) multi-stakeholder diplomacy or negotiations that are not necessarily intended to lead to binding agreements; and ( ) informal diplomacy or interactions between international public health actors and their counterparts in the field, including host country officials, nongovernmental organizations (ngos), private-sector companies, and the public. identifying these different categories of global health diplomacy may be important to clarify services/resources that may be offered, especially when governments argue for incorporating health issues into their foreign-policy debates (kaufmann & feldbaum, ) . global health diplomacy combines the art of diplomacy with the science of public health; it balances concrete national interest with the abstract collective concern of the larger international community's health; it reduces health inequities; it secures human rights; and it recognizes that effective international health interventions are ethical and sensitive to historical, political, social, economic, and cultural differences (schrecker, labonté , & de vogli, ; world health organization, ) . the plethora of definitions supports the basic premise that global health diplomacy encompasses a political change activity and requires both the art of diplomacy and the science of public health to promote formal negotiations between and among nations and international public health actors and their counterparts in the field to address security, development, global public goods, trade, human rights and ethical/ moral reasoning. there is growing recognition of the importance of promoting global health. the united states (u.s.) institute of medicine (iom) ( a, b) published two reports outlining recommendations to enhance the u.s. commitment to global health. a consortium of universities for global health (cugh) was developed in with a mission to define the field of global health, standardize curricula, expand research, and coordinate projects in low-resource countries (consortium of universisties for global health, ). the center for strategic and international studies (csis) ( ) was also commissioned to identify recommendations for smart global health policy in the united states, and for the first time, the u.s. national institutes of health ( ) made global health one of its top five priorities. the u.s. government document healthy people (united states department of health and human services, ) included a new global health goal for the first time in the history of the healthy people series: to improve public health and strengthen u.s. national security through global disease detection, response, prevention, and control strategies. the healthy people document outlines the u.s. objectives for meeting this new global health goal to address continuing emerging disease threats: promote health abroad, prevent the international spread of disease, and protect the health of the u.s. population. badeau ( ) described the historical evolution of the concept of "medical diplomacy," noting that centuries ago physician-priests sometimes accompanied egyptian missions to neighboring countries and acted as ambassadors. he also noted that the nature of diplomacy changed following world war i and that diplomacy is no longer the purview of only a small elite corps of professional diplomats. factors such as improved communication, educational levels, an end to colonial rule in many parts of the world, and increased public demand for civic participation has resulted in changes in the face of diplomacy. fidler ( ) suggested that health diplomacy emerged because of global threats to public health in the th century. the marshall plan, the end of the cold war era, and the medical assistance provided by the u.s. military in europe and japan following world war ii signaled increased emphasis on the importance of foreign aid and "persuasion" as a key component of foreign diplomatic initiatives in both the u.s. and in other countries (adams, et al., ; badeau, ) . feldbaum, lee, and michaud ( ) noted that global health has historically been of importance in foreign policy as evidenced by the international sanitary conventions that began in . these international sanitary conventions subsequently evolved into the international health regulations (ihr), focused on enforcing disease control with minimum interference with international trade (world health organization, ) . feldbaum et al. ( ) suggested that although the world health organization (who) has had problems enforcing ihrs in the past, the e outbreak of the severe acute respiratory syndrome (sars) resulted in revision of ihrs and granted the who authority to supersede interests of member states using surveillance data for purposes of infectious disease control. those authors further described the historical link between international aid and foreign policy interests, which was a key factor in the establishment of the u.s. agency for international development (usaid). addressing health without addressing the causative factors for illnesses has contributed to the failure of many well-intentioned global health programs. cahill ( ) called for "the diplomatic potential of medicine as a vehicle for international goodwill" (p. ). subsequently, cahill ( ) introduced the term "preventive diplomacy," noting that diplomats and politicians frequently lack an understanding of the health and humanitarian issues that they address and challenged health professionals to become active in addressing global health and human rights issues to offer innovative approaches to health and human rights issues that may be more effective than the methods used in the past. katz, kornblet, arnold, lief, and fischer ( ) noted that the concept of medical diplomacy was first introduced in the carter administration in , as a "vehicle by which channels of communication can be established between nations when international relations are strained or severed" (p. ). feldbaum et al. ( ) noted three recent trends in international aid to address health issues: (a) dramatic increase in funding for health; (b) increased number of organizations involved; and (c) a tendency to focus on hiv/aids as a single health problem. others have also noted the increase in health-related aid and the increased international focus on hiv/aids (ravishankar et al., ; shiffman, berlan, & hafner, ) . other factors that have contributed to the growing interest in global health diplomacy include the growth of ngos participating in international health programs, the increasing globalization of science and of pharmaceutical research, and growing concerns about biosecurity (adams, et al., , p. ) . a major impetus to the development of global health diplomacy is the concern about threats to global health security. the who annual report focused on threats to global public health security, such as epidemic diseases, food-borne diseases, accidental or deliberate outbreaks (e.g., nuclear accidents, toxic spills), environmental disasters, and the identification of strategies to minimize and address those threats (world health organization, a). chan, director general of the who, argued for "..inputs from policy analysis and research; . [and] improved training opportunities for both diplomats and public health specialists in the interface between health and foreign policy" (chan, store, & kouchner, , p. ). kickbusch and buss ( ) described the use of health diplomacy to promote peace and to encourage the evolving global partnerships of countries across hemispheres to address global health issues. the authors cited several examples of global health leadership roles and emphasized the importance of the who in providing global coordination for the multiple initiatives in the often-overcrowded global health landscape. for example, in brazil hosted the "global conference on social determinants of health," and in may , the world health assembly formally accepted the "health as a bridge for peace" initiative as a feature of the "health for all in the st century" strategy (world health organization). who launched the "health as a bridge for peace initiative," promoting cease-fires during times of conflict to permit health projects, such as vaccination campaigns, and promoting collaboration in training initiatives among countries that were previous enemies (rodriguez-garcia, schlesser, & bernstein, ). further, the foreign ministers of brazil, france, indonesia, norway, senegal, south africa, and thailand issued the oslo declaration and agenda for action to increase the priority of global health issues in foreign policy (amorim et al., ) . barber, cohen, and rockswold ( ) noted that in the united states, the field of global health diplomacy has been bolstered by the $ billion u.s. global health initiative that was launched in to address hiv/aids, growing challenges posed by chronic diseases, and to strengthen health systems. labonte and gagnon ( ) reviewed the literature published from to to identify arguments that governments have used to incorporate health issues into their foreign policy deliberations. the literature revealed six policy frames: security, development, global public goods, trade, human rights and ethical/ moral reasoning, noting that arguments within the different frames are sometimes contradictory. the most frequently mentioned argument was concern for national and economic security, followed by the use of health to stimulate development and promotion of the public good (by preventing pandemics, addressing problems related to climate change, or regulating health-damaging products such as tobacco). in summary, the notion of incorporating medical or health care in foreign policy or international aid programs is not new; however, there has been limited discussion about this concept in the nursing literature. badeau ( ) described a key challenge related to health diplomacy initiatives, noting that "the use of aid for political ends is always resented by those who receive it, but it is particularly resented when that aid deals with basic human needs such as food or health" (pp. - ). other authors have also identified this challenge, particularly when aid that is tied to political ends addresses basic human needs such as food or health. in addition, focusing on health as a political instrument often limits the ability of global health initiatives to address priority health problems in a sustainable way (feldbaum, et al., ; institute of medicine, a; kickbusch & buss, ; kickbusch, silberschmidt, & buss, ) . ingram ( ) identified three potential problems with the use of health as a foreign policy tool: (a) decreasing the credibility of health workers who have previously been viewed as neutral and not involved with state politics; (b) giving priority to narrow state interests over the interests of alliances needed to address global health issues; and (c) focusing on health as a political instrument rather than a human rights issue. to address the potential challenges associated with linking healthcare assistance to foreign policy goals, badeau ( ) advocated separating u.s. foreign aid that addresses basic human needs for food, health, and education from other technical assistance programs and placing the responsibility for such programs with a private organization that receives u.s. governmental funding (similar to the model of the british council in the united kingdom). labonté and gagnon ( ) noted that some have recommended explicit ethical principles to guide policy decisions to prevent the "high politics" of foreign policy from consistently overriding the "low politics" of global health (p. ). lemery ( ) suggested that the u.s. state department engage physicians in "white coat diplomacy" to address humanitarian needs and foster "good will," but noted the concern of academic skeptics who fear that linking healthcare services to diplomatic goals might invite "manipulation." novotny ( ) noted the instances of interference by federal agencies into the scientific independence of global health programs, such as restrictions on travel, scientific input, and collaboration. other challenges for global health diplomacy relate to confusion and failure to develop a common definition of the concept of global health security, the conflict between the rights of individual nations versus the need for international health regulations (aldis, ) , and the increasing number of stakeholders interested in global health issues and the potential problems resulting from failure to coordinate global health initiatives (katz, et al., ) . an example of this conflict was indonesia's refusal in to share influenza virus samples with the who collaborating centers on influenza that traditionally receive samples from around the world for analyses to be used in development of new vaccines. indonesia's refusal was based on the perception that the vaccines would be used to benefit only wealthier nations and would not benefit indonesia (katz, et al., ) . many writers have emphasized the importance of coordination of global health initiatives by groups such as the world health assembly (chan, et al., ; kickbusch & buss, ; novotny, ) . it is important for nurses to be aware of the potential ethical issues that arise when healthcare that is provided as a foreign-policy tool decreases the credibility of health workers who have previously been viewed as neutral and have not been involved with state politics; when it gives priority to narrow state interests over the interests of alliances needed to address global health issues; and when it focuses on health as a political instrument rather than a human rights issue. there is growing recognition of the need to develop educational programs to prepare global health diplomats. u.s. secretary of state hillary rodham clinton called for the creation of a corps of civilian health diplomats who could contribute to the joint goals of diplomacy and international development by addressing problems related to health, food insecurity, environmental challenges, and challenges related to global warming (clinton, ) . hotez ( ) suggested that the core of health diplomats proposed by secretary clinton could make significant contributions to addressing the global health challenges posed by neglected tropical diseases that affect nearly all of the world's "bottom billion" citizens who live on less than $ per day. kerry, auld, and farmer ( ) described a specific proposal for an international health service corps (ihsc) to enhance local health capacity, similar to the health outreach programs that have been provided by cuba. interdisciplinary programs to prepare future global health diplomats should involve experts in fields such as foreign policy, academia, global health, epidemiology, health policy, economics, law, environmental science, and bioethics (kickbush, novotny, drager, silberschmidt, & alcazar, ; lemery, ; novotny, ) . barber, cohen, and rockswold ( ) also recommended training u.s. military personnel in strategies for collaboration with humanitarian organizations and local governments, strategies to promote sustainability, cross-cultural and historical sensitivity, and disaster response. adams, et al. ( ) summarized the goals of health diplomacy training programs, noting that "successful health development efforts have depended on functional and respectful relations among all the stakeholders, including donor and recipient governments, health care providers, local political leaders, and field-based ngos. a capable health diplomat must have a sophisticated understanding of the structures, programs, approaches, and pitfalls surrounding these relationships to achieve success, whether working in the clinical setting or at the policymaking table" (p. ). although no articles were identified specifically discussing global diplomacy content in nursing curricula, there are references related to addressing the general topic of global health in nursing curricula. bradbury-jones ( ) suggested that nurses have a global responsibility to address non-communicable diseases, as the leading cause of death worldwide, through work in health policy, research, education, and individual practice. archambault ( ) recommended that undergraduate nursing programs address the key global health concepts of global citizenship, social justice, health equity, and the determinants of health, and suggested that content should include: introduction to global health, global health goals, determinants of health, healthcare systems policy and politics, primary health care, global nursing issues, culture and, healthcare, epidemics, communicable and non-communicable diseases, epidemiology and health outcomes, and humanitarian emergencies. the association of faculties of medicine of canada (afmc) resource group on global health and the global health education consortium (ghec) proposed a set of global health competencies for medical students (association of faculties of medicine of canada reference group on global health and global health education consortium, ). wilson et al. ( wilson et al. ( , adapted these competencies for nurses, and surveyed nursing faculty in the u.s., canada, and latin america to identify their perceptions about whether the adapted competencies were appropriate for nurses. the competencies are divided into six broad categories: (a) global burden of disease; (b) health implications of travel, migration, and displacement; (c) social and environmental determinants of health; (d) globalization of health and healthcare; (e) healthcare in low resource settings; and (f) health as a human right and development resource. survey responses were received from nursing faculty members in the u.s. and canada and from nursing faculty in latin america, indicating general agreement that the competencies identified in these categories were important and appropriate for inclusion in nursing curricula. although there is a need for further research to refine and validate these competencies, the survey results can be used to guide development of curricula to prepare nurses to contribute to addressing global health problems. finally, the association for prevention teaching and research convened a healthy people curriculum task force consisting of representatives from eight health professional educational associations in order to promote achievement of healthy people objectives by integrating more content related to health promotion and disease prevention in curricula of the various health professions. the task force identified specific content related to global health that should be integrated into the curriculum (association for prevention teaching and research healthy people curriculum task force, ). the literature reviewed provides important guidance that can be used to develop interdisciplinary curricula to prepare nurses and other healthcare providers to develop competencies in global health and global health diplomacy. the estimated million nurses and midwives in the world make up the greatest proportion of the global health workforce (world health organization, a , b , and thus nurses could play a critical role in global health diplomacy initiatives if they were properly educated and prepared to be global healthcare providers and diplomats. since the time of florence nightingale, nurses have provided culturally appropriate healthcare in diverse global settings. they have been key participants in addressing global natural disasters such as the tsunami in thailand or the earthquake in haiti. global health diplomacy is an interdisciplinary academic field. global health diplomacy is guided by wisdom gained through experience and the ability to find mutually acceptable solutions to global health challenges. preparing nurses to contribute to global health diplomacy initiatives begins with the preparation of nurses as global citizens who are morally and ethically bound to understand and help individuals and groups at local, national, and global levels. in addition to building on initial efforts to identify global health competencies for nurses, research is needed to identify additional competencies necessary to prepare nurses as global health diplomats. there is a need for dialogue and discussion among leaders in diverse disciplines such as nursing, medicine, political sciences, social sciences, law, business, and economics to further define these competencies and develop curricula that will prepare future leaders both in global health and in global health diplomacy (lemery, ) . before nursing can support the concept of global health diplomacy as a dimension of this profession's global work, it is important to have a critical dialogue about the ethical and moral conflicts inherent in this concept e providing healthcare as a humanitarian responsibility versus using healthcare as an instrument of political activity. to begin such dialogue and promote further research to evaluate and refine the concept of global health diplomacy as a nursing phenomenon, the members of the aan epgnh task force on global health diplomacy in nursing endorse the definition of global health diplomacy proposed by adams, novotny, and leslie ( ) as "an emerging field that addresses the dual goals of improving global health and bettering international relations, particularly in conflict areas and in resource-poor environments" (p. ). further, the task force members believe that health diplomacy "is not only the job of diplomats or health leaders in government structures, it is a professional practice that should inform any group or individual with responsibility to conduct research, service, programs, or direct international health assistance between donor and recipient institutions" (novotny & adams, , p. ) . if healthcare and healthcare providers truly wish to make a difference in the health of the people of the world, then identifying the causes of health problems, finding solutions, and implementing interventions are required steps. global health diplomats must be prepared academically and experientially with astute negotiation skills; with collaboration skills to work with nations to protect health interests; with economic development acumen; epidemiological and research skills; and with diplomatic, economic, political, legal, medical, cultural, and conflict-resolution skills. there is need for further dialogue in the professional nursing community to identify nursing's role in global health diplomacy and identify competencies that should be global health diplomacy health security as a public health concept: a critical analysis oslo ministerial declarationdglobal health: a pressing foreign policy issue of our time incorporating global health into undergraduate nursing education. vancouver, british columbia: msn, university of british columbia. association for prevention teaching and research healthy people curriculum task force association of faculties of medicine of canada reference group on global health and global health education consortium diplomacy and medicine global health diplomacy: a call to action globalisation and its implications for health care and nursing practice editorial: medicine and diplomacy a healthier, safer, and more prosperous world: report of the csis commission on smart global health policy foreign policy and global public health: working together towards common goals leading through civilian power saving lives: universities transforming global health synthesizing research: a guide for literature reviews global health and foreign policy the globalization of public health: the first years of international health diplomacy unleashing ''civilian power'': a new american diplomacy through neglected tropical disease control, elimination, research, and development the u.s. commitment to global health: recommendations for the new administration u.s. commitment to global health: recommendations for the public and private sectors i defining health diplomacy: changing demands in the era of globalization diplomacy and the polio immunization boycott in northern nigeria an international service corps for healthean unconventional prescription for diplomacy global health diplomacy: the need for new perspectives, strategic approaches and skills in global health global health diplomacy: training across disciplines towards a common definition of global health framing health and foreign policy: lessons for global health diplomacy a case for white coat diplomacy us department of health and human services: a need for global health leadership in preparedness and health diplomacy global health diplomacy: a global health sciences working paper. university of california san francisco global health sciences financing of global health: tracking development assistance for health from certi: crisis and transition toolkit: how can health serve as a bridge to peace globalisation and health: the need for a global vision has aid for aids raised all health funding boats? united states department of health and human services the integrative review: updated methodology global health competencies for nurses in the americas. paper presented at the global health education consortium, cuerna vaca ), e . world health organization. what is health as a bridge for peace? the world health report : a safer future: global public health security in the st century in world health statistics key: cord- - of ertf authors: lo, catherine yuk-ping title: securitizing hiv/aids: a game changer in state-societal relations in china? date: - - journal: global health doi: . /s - - - sha: doc_id: cord_uid: of ertf background: china has experienced unprecedented economic growth since the s. despite this impressive economic development, this growth exists side by side with the human immunodeficiency virus/acquired immune deficiency syndrome (hiv/aids) and severe acute respiratory syndrome (sars) crises and the persisting deficiencies in public health provision in china. acknowledging the prevailing health problems, the chinese government has encouraged the development of health non-governmental organizations (ngos) to respond to the health challenges and address the gaps in public health provision of the government. hiv/aids-focused ngos have been perceived as the most outstanding civil society group developed in china. considering the low priority of health policies since the economic reform, the limitation of the “third sector” activity permitted in authoritarian china, together with the political sensitivity of the hiv/aids problem in the country, this article aims to explain the proliferation of hiv/aids-focused ngos in china with the usage of the securitization framework in the field of international relations (ir). methods: the research that underpins this article is based on a desk-based literature review as well as in-depth field interviews with individuals working in hiv/aids-focused ngos in china. face-to-face interviews for this research were conducted between january and may in , and between december and january , in china. discourse analysis was in particular employed in the study of the security-threat framing process (securitization) of hiv/aids in china. results: this article argues that the proliferation of hiv/aids-related ngos in china is largely attributed to the normative and technical effects of hiv/aids securitization ushered in by the united nations security council (unsc) and supported by the global fund to fight aids, tuberculosis, and malaria (hereinafter global fund) observed in china. despite depicting a positive scenario, the development of hiv/aids-focused ngos in china generated by the international securitization efforts is largely limited. an internal and external factor was identified to verify the argument, namely ( ) the reduction of international financial commitments, as well as ( ) the fragmentation of hiv/aids-focused ngo community in china. conclusions: this article shows that international securitization weakened with the rise of chinese commitment on hiv/aids interventions. in other words, hiv/aids-related responses delivered by the national government are no longer checked by the global mechanism of hiv/aids; thus it is unclear whether these ngos would remain of interest as partners for the government. the fragmentation of the hiv/aids community would further hinder the development, preventing from ngos with the same interest forming alliances to call for changes in current political environment. such restriction on the concerted efforts of hiv/aids-related ngos in china would make achievement of the sustainable development goals (sdgs) to foster stronger partnerships between the government and civil society difficult, which in turn hindering the realization of ending hiv/aids in the world by . china has experienced remarkable economic growth since the initiation of the economic reform in the s. the average gdp growth in china was . % annually during the first two decades of the economic reform [ ] . the rising nation became the world's leading manufacturing power in , and it surpassed the united states as the world's largest trading country [ ] . jakovljievic further predicted that the economic growth in china would continue at least up to the middle of the st century [ ] . despite such impressive economic performance, the provision of public health and the control of infectious diseases have been marginalized. between the late s and , the chinese national government public health spending as a proportion of total health spending plunged from % to just over % [ ] , despite the fact that china has outperformed other developing countries, such as other brics members, regarding the public health spending in nominal terms [ ] . as argued by yip and mahal, chinese political leaders in the abovementioned period of time simply perceived health as "a consumption activity rather than a productive good and therefore was given lower priority in government funding" [ ] . in this regard, the chinese authorities deliberately curtailed the level of public health expenditures so that economic development could be pursued and the legitimacy of the one-party authoritarian regime bolstered. acknowledging the economic success in the past decades, hiv/aids nevertheless emerged as one of the "negative externalities" of public health threats brought about by the s economic reform. hiv/aids was first discovered in china during the mid- s, the same period when the economic reform was just beginning. the epidemic was exacerbated in china in the s mainly because of government-supported blood plasma selling, which did not follow adequate sterilization procedures. this lack of regulation resulted in the emergence of so-called aids villages (aizibing cun) in henan and its outlying provinces, where a large percentage of rural residents were infected with hiv/aids [ ] . having little benefit from the economic reform in ways that coastal provinces did during the s, many residents in the central plains had little choice but to engage in the blood-plasma industry to improve their standard of living. since , hiv/aids has become a politically sensitive issue in china because of the international condemnation of the henan blood scandal. according to the latest figures released by the joint united nations program on hiv/aids (unaids), , people were estimated to have hiv/aids in china in [ ] . the country has the second largest hiv/aids population in asia after india. the chinese government started addressing the hiv/ aids problem after years of denial and underestimation of the hiv/aids prevalence in the country, especially among the most-at-risk populations (marps) including injecting drug users (idus), female sex workers (fsw), and men who have sex with men (msm) [ ] . however, national hiv/aids policies in the early years were very much driven in a top-down manner with government institutions (i.e. mainly the chinese centers for disease control and prevention [china cdc hereinafter] ) playing a leading role and with limited engagement of the "third sector" [ , ] . given the association of the disease with behaviors that are legally or socially unacceptable in the country (i.e., commercial sex work, injecting drug use, and men having sex with men), hiv/aids high-risk individuals refrain from using the related services provided by the government agencies because they wish to avoid being seized or humiliated by public security officials or by thugs hired by local officials [ ] . in this regard, gåsemyr claimed that the emergence of hiv/aids-focused non-governmental organizations (ngos) in china during the early s could fill the capacity gap of the government by implementing national hiv/aids policies and providing the related services for those marps that are hard to reach by the authorities [ ] . considering the low priority of health policies since the economic reform, the limitation of the "third sector" activity permitted in authoritarian china, together with the political sensitivity of the hiv/aids problem in the country, it is believed that the involvement of hiv/aids-related ngos in china would be largely limited. this is however not the case. over the last years there has been a dramatic increase in the number of hiv/aids-focused ngos operating in china. while gåsemyr argued that the growth of hiv/ aids-related ngos is mainly attributed to the devastating health crisis of sars in china and the new chinese leadership in [ ] , the previous work cannot explain why a high degree of political recognition was observed in solely hiv/aids ngos, instead of other health ngos, such as tb or cancer ngos in china. this article aims to fill this research gap with regard to the proliferation of hiv/aids-focused ngos in china with the use of the securitization framework in the field of ir. the research that underpins this article is based on desk-based literature review as well as in-depth field interviews with individuals working in hiv/aids-focused ngos in china. discourse analysis was in particular employed to study the securitization of hiv/aids in china. potter argued that "discourse analysis has an analytic commitment to studying discourses as texts and talks in social practice…the focus is…on language as… the medium for interaction…one theme that is particularly emphasized here is the rhetorical or augmentative organization of talk and texts" [ ] . silverman pointed out that the intellectual ancestor of discourse analysis is john langshaw austin, the original inventor of the idea of speech acts that later became the core element in securitization theory [ ] . concerning discourse analysis and speech acts share the austinian concern with the rhetorical structure of talk and texts, the founding scholars of securitization theory, buzan, waever and wilde explicitly stated, "the obvious method [to study securitization] is discourse analysis, since we are interested in when and how something is established by whom as a security threat" [ ] . the authors also noted that the technique of employing discourse analysis to securitization studies is to "read[ing], looking for arguments that take the rhetorical and logical form defined here as security" [ ] . the meaning of security is constructed when the political leaders (securitizing actors) frames an issue as an existential threat to the referent objects, claiming the issue as having an absolute priority on the government agenda, thereby invoking a right to handle such an issue with extraordinary/emergency measures to ensure the survival of the referent objects [ ] . in this research, public speeches (in written form) related to hiv/aids problems, which were delivered by the top-level political leaders, were examined. a specific rhetorical structure had to be located in their discourses, consisting of either one or all of the following elements: ( ) the existence of an existential threat; and/or ( ) the perceived threat is challenging the survival of the states or people in the states (referent objects), and/or which it requires to ( ) be urgently dealt with by new political measures of the respective country. an array of documents ranging from official documents, reports, newspaper articles was initially identified via the search engines of google scholar and proquest with the keywords of "hiv/aids", "security threat", and "china". nine key articles were consequently singled out to identify the textual discourses related to hiv/aids threat/ security nexus in china, published or released between and (table ) . a total of semi-structured interviews were conducted along with the discourse analysis. apart from the background information of the respective ngos, the interview questions used in this study are categorized into three main dimensions: ( ) the priority of hiv/aids on the government agenda; ( ) the perceptions on the changing international and national financial commitment on hiv/aids interventions; and ( ) civil society involvement and coordination in national hiv/aids policies. the first dimension aimed to ensure that the ngos respondents were knowledgeable about the changing national government perceptions and policy priority towards hiv/aids in china, therefore, the researcher could rule out those comments given by unknowledgeable respondents so as to enhance the internal validity of the data collected. the second dimension was included to study their perceptions on the level of hiv/aids funding and effect (if any) on the service provision. the third dimension aimed to discover the actual level of involvement of ngos in national hiv/aids interventions as well as the level of coordination and cooperation between different ngos working on hiv/aids. two types of non-probability sampling-purposive sampling, including "theoretical sampling" and snowball sampling-were employed in the selection process of key informants. for purposive sampling method, samples were selected based on the "logic" or "commonsense" of the researcher in terms of the target population, its elements, and the purpose of the study. in this study, the target population consisted of the individuals working in hiv/aids-related ngos at global, national, and grassroots levels. in the course of the data collection, "theoretical sampling" was also applied to understand the subjects from a theoretical perspective. hence, academic scholars who have conducted research on hiv/aids policies in china were also included in the interviewee list. interviewees were also recruited via snowball sampling. the researcher collected data on the few members, and each respondent was asked to suggest people whom the respondent believed to be the most influential for interviewing. interviews for this research were undertaken between january and may in , and between december and january with leaders or senior officers working on hiv/aids in china, including international ngos, nine self-help groups, four gongos, five advocacy groups, two national ngo, one independent consultant, two academia, and two networks (see table ). twenty-six respondents were pinpointed based on the civil society (minjian shehui) was not considered as part of the political system in the pre-modern era; the emergence of a relatively independent civil society is a product of modern china. the changing socio-economic relations brought about by "open door policy" resulted in the recognition and growth of civil society for the first time in the chinese history [ ] . despite the early emergence of civil society, the falung gong incident showcased the destructive power of civil society in the eyes of the chinese government, worrying a robust, well-organized, and out-of-control civil society could overthrow and replace the ccp ruling position. meanwhile, the authorities realized the supplementary role ngos could perform in policy implementation. the chinese government has thus resolved such dilemma by adopting a "state-led" approach to manage civil society in china. based on frolic's concept of "state-led civil society", civil society is created by and belong to the state, thus the independence and autonomy of civil society are at all time bounded by the state [ ] . the state has the role of legitimating social organizations, demanding a disciplined partnership. accordingly, antagonism inherited in the western concept of civil society is not allowed to exist in the state-society relations in chinese authoritarian regime; any alternative force to the state is considered as an attempt to curtail or overturn its political legitimacy and power. accordingly, the state apparatus has managed the numbers and restricted the growth of both international and grassroots ngos via various legislative means, thereby allowing ngos to operate openly but at the same time keep the organization growth in check [ , ] despite these regulations, the chinese authorities had relatively given more autonomy to ingos than grassroots ngos operating in its territory, since the government could access international expertise and tap foreign money to tackle with the emerging social problems in china [ ] . such degree of autonomy is nevertheless problematic after the promulgation of foreign ngos management law (jingwai fei zhengfu zuzhi guanli fa) in april . the law stipulates that ingos operating in china must register with public security officials, and must not engage in political or religious activities that damage "china's national interests" or "ethnic unity". international community and western governments perceived the new law as a reinforcement of restriction of the numbers and scopes of foreign entities operating in the authoritarian regime. grassroots ngos are regulated by the regulation on registration and administration of social organizations (shehui tuanti dengji guanli tiaoli). according to the regulation (amended in february ), a ngo must possess a minimum asset of , yuan and have a "professional management unit" (zhuguan danwei) that acts as a supervisory body to the organization in order to register under the ministry of civic affairs (moca). fulfilling these two requirements is very formidable for grassroots ngos. the financial situation is problematic in many grassroots ngos because of the limited source of funding. on the one hand, most grassroots ngos receive limited financial support from the government, as they usually do not have political ties with the government. grassroots ngos also seldom receive donations from local communities because ( ) newly developed ngos do not have good track records that enable them to win the trust of the locals, and ( ) donors cannot receive tax breaks for their donation to unregistered ngos [ , ] . in addition, most government departments simply reject their applications due to fear of consequences of taking responsibilities for grassroots ngos. many grassroots ngos are hence often unregistered or registered as business entities with the ministry of industry and commerce (moic) [ ] . in addition to the abovementioned restrictions, the regulation also bans "similar organizations" coexisting at the various administrative levels [ ] , facilitating the management and even control the legal status of grassroots ngos in china. having official registration, to certain extent, is sine qua non to the survival of organizations as the legal status entitles ngos as official recognized entities to receive legal and financial supports from the government; unregistered ngos are officially perceived as illegal that would be subjected to prosecution and coercion by the state apparatus. considering a restrictive engagement of grassroots ngos in china, instead of grassroots ngos, early hiv/ aids-related responses at societal level were largely conducted by gongos [ ] , [ ] . considering the low priority of health policies since the economic reform, the limitation of the "third sector" activity permitted in authoritarian china, together with the political sensitivity of the hiv/aids problem in the country, it is intriguing to uncover the reasons for the growth of hiv/aids-focused ngos in china since . gåsemyr argued that the growth of hiv/aids-related ngos is mainly attributed to the devastating health crisis of sars in china and the new chinese leadership in [ ] . having said that the chinese government realized the impacts health problems or infectious diseases could have on its economic and social development, the previous work cannot explain why a high degree of political recognition was observed solely in hiv/ aids ngos, instead of other health ngos, such as tb or cancer ngos in china. considering the regime type of the government, allowing the growth of local ngos would in turn potentially attenuate the supremacy of the chinese communist party (ccp) in ruling the country or erode the autonomy of the state, why the chinese government tolerated, allowed, or even encouraged the growth of ngos in fixing hiv/aids problems, especially the epidemic has been viewed as a politically sensitive issue in china? how can one account for and understand the phenomenon? answering the key question with an ir perspective, this article argues that the rapid development of hiv/ aids-related ngos in china is attributed to the effects of hiv/aids securitization at the international level since . considering one of the most influential theories developed in the field of ir, securitization describes the process of defining an issue as a security threat (speech acts) and the corresponding political responses to block the adverse development of the perceived threat (emergency measures). this article particularly pinpoints the unsc and the global fund, which provide normative and technical supports, to study this endeavor. normative influences in this article refer to the effects of security-threat discourses, primarily resolution of the unsc, on the national government's perception on hiv/aids problems, whereas technical influences refer to the effects of global emergency measures, in particular the global fund, on the funding and management of hiv/aids-related policies at the state level [ ] . this article aims to demonstrate the ways in which international hiv/aids securitization has served as a game changer in altering state-society relations in china. drawing on literature reviews and fieldwork materials, this article further argues that the proliferation of hiv/aids-focused ngos in china generated by the international securitization efforts is nevertheless largely limited owing to the reduction of international financial commitments. the fragmentation of hiv/aids-focused ngo community is another factor hindering the development of a full-fledged third sector in the country. securitization in the ir discipline is a model outlining the process of framing an issue as a security threat and the corresponding political reactions to block the adverse development of the perceived threat. employing the theory, one is required to look for three criteria to determine whether an issue is a threat to the country and its people, including ) discourses uttered by toplevel political leader (securitizing actor) declaring a particular referent objects as an existential threat to security; ) acceptance by the targeted audience convinced of its potential to be an existential threat (audience acceptance); and also ) redirections of existing financial resources, new policies, or practices (emergency measures) are implemented to address the issue following the security-threat claim [ ] . in other words, the resolution of the "existential threat" posed by "x" takes precedence over other problems [ ] . numbers of security studies scholars believed that hiv/aids is the first infectious disease being securitized by the international institutions and national governments as the abovementioned criteria were all fulfilled in the case of hiv/aids [ , [ ] [ ] [ ] . speech acts concerning hiv/aids as a security threat were first identified in a unsc meeting in january . in july of the same year, the unsc passed resolution , acknowledging the urgent need to address hiv/aids, which threatens the stability and security if left unchecked [ ] . it is perceived that the particular security framing of hiv/aids gained acceptance by the national governments (audience of the hiv/aids security-threat claim) since countries unanimously adopted and signed the declaration of commitment on hiv/aids in . the urgency of addressing hiv/aids problems was reinforced in the special united nations general assembly special session (ungass) devoted to hiv/aids that has taken place every years since [ ] [ ] [ ] [ ] . the abovementioned events are significant because they represented the first time that the unsc general assembly devoted an entire session to a single disease, and the first time that the international political authorities framed hiv/ aids as a global health threat to national and international security instead of solely as a developmental or public health problem [ ] . the rhetorical act was backed by operational emergency responses in terms of the augmentation of the global hiv/aids spending since . the amount was exponentially surged from about us$ million in to us$ billion by ; and to an estimated us$ billion in [ ] . several hiv/aids-related funding agencies and health programs formulated after , also referred to global health initiatives (ghis), brought in additional monetary resources for hiv/aids [ ] . perceiving as the most prominent ghis, the global fund pledges to accelerate the end of the three epidemics, [hiv/]aids, tuberculosis, and malaria by providing financial support (us$ billion annually) for low-income countries to respond to the three diseases [ ] . undoubtedly, the introduction of the abovementioned ghis has brought about unprecedented levels of funding for diseases, in particular hiv/aids, in countries that have insufficient resources, whether because of poor socio-economic development or lack of political will, to orchestrate appropriate responses to the intractable disease. acknowledging international securitizing efforts on hiv/aids, this article illustrates the normative effects of resolution of the unsc and the technical influences of the global fund on national-level hiv/aids responses. china is selected as a case study to investigate this endeavor. china's response to the hiv/aids problem changed from an ignorance of "global evidencebased policy recommendations and international advice" into "one of our success stories [in global hiv/aids fight] during this past years," as claimed by michel sidibe, executive director of the unaids [ , ] . the subsequent sections demonstrate the ways in which the securitization effort in the international level acted as a game changer for hiv/aids-focused ngos in participating in national hiv/aids undertakings in china. chinese case study discourse analysis: normative influences and the role of the unsc in china, many of the first cases of hiv/aids since occurred among foreigners and homosexuals. therefore, the official discourses at that time promoted the idea that hiv/aids only affected non-local chinese people and foreigners, asserting "drug taking, alcoholism, robbery, homicide, suicide, divorce, prostitution, homosexuality, syphilis, aids…these kinds of western social ills come from their ideology", and also claiming "china had no sources of hiv/aids" [ , ] . the rhetorical acknowledgement of hiv/aids as a health security threat to the chinese population was largely absent during the early period of time. ramiah also pinpointed that the chinese leadership was extremely reluctant to acknowledge hiv/aids as a problem and securitize hiv/aids in china prior to the s [ ]. one probable reason for the resistance to hiv/aids securitization is economic: the period of early hiv/aids outbreak coincided with the initial years of open door policy and economic reform (gaige kaifang) of china to the outside world. the thirst for economic growth and performance preceded the urgency of disease management: local authorities feared their respected jurisdictions would lose external or foreign investment if the full extent of the problem were known, or that they would be punished by superiors for failing to prevent the hiv/aids spread. the "cover-up" practice also oc- in response to the designated targets, the securitythreat framing of hiv/aids has been fully adopted in the official discourses of chinese leaders and in official documents since . previously viewing hiv/aids as a "western disease" or "non-chinese disease", executive vice minister of health gao qiang stated in the hiv/ aids high-level meeting of the un general assembly that "hiv/aids is a common enemy of the whole mankind as it seriously threatens public health and safety. the chinese government has attached great importance to hiv/aids prevention and treatment and has treated it as a strategic issue for social stability, economic development, national prosperity and security, making it a first priority of the government work" [emphasis added] [ ] . the chinese president hu jintao once claimed in a public speech that "hiv/aids prevention, care and treatment is a major issue pertinent to the quality and prosperity of the chinese nation"; whereas premier wen likewise asserted that "dealing with hiv/aids as an urgent and major issue is related to the fundamental interests of the whole chinese nation" [emphasis added] [ ] . the ideas in the speeches were restated in the official document entitled state council notice on strengthening hiv/aids prevention and control (guowuyuan guanyu qieshi jiangqiang aizibing fangzhi gongzuo de tongzi). this document explicitly demonstrated the determination of the chinese authorities in grappling with the disease and stated that "hiv/aids prevention and control is linked to economic development, social stability, and national security and prosperity. long-term commitment to respond to hiv/aids is hence necessary" [emphasis added] [ ] . china's hiv/ aids prevention and control policies were further strengthened in the state council notice on further strengthening hiv/aids prevention and control (guowuyuan guanyu jinyibu jiangqiang aizibing fangzhi gongzuo de tongzi) in late , claiming that "the prevention and control of hiv/aids is related to the people's physical health and social and economic development, as well as to national security and the rise and fall of the nation. the party central committee and the state council have always attached great importance to the prevention and treatment of hiv/aids" [emphasis added] [ ] . based on the discourse analysis of the official documents and newspaper articles, it is argued that chinese national leaders followed suit the international move (i.e. unsc resolution ) to securitize hiv/aids in the country, framing hiv/ aids as a threat with social, political, economic, and security implications. such an alteration in perception toward the epidemic brought about the political recognition of the hiv/ aids-focused ngos, which has also been highlighted by multiple statements delivered by various top-level government officials since . in , vice premier wu yi stated, "we should mobilize all the partners in society to participate in the fight against hiv/aids. we need to improve our policies and strategies to build a better environment for the society to participate in the response, and try our best to facilitate the involvement of all sectors" [ ] . in , vice minister of health yin li publicly proclaimed "civil societies play an indispensable role in effective hiv/aids interventions led by the government" [ ] . premier li keqiang even promoted tax break for ngos specializing in hiv/aids prevention, claiming the role of ngos in hiv/aids prevention "is an irreplaceable and unique force" [ ] . to a certain extent, these aforementioned statements demonstrate the state's recognition of ngos' works and its willingness to engage with ngos in national hiv/aids interventions, although the political space of involvement is by and large bounded by the state [ ] . the previous section illustrates the change in the perception of the chinese government toward the hiv/ aids problems: from denial to the acceptance of the threats that could be posed by the disease on the country and its people. such threat recognition also brought about the acknowledgement that the government alone could not resolve the hiv/aids problems because of the complicated nature of the epidemic; the involvement of civil society groups was a globally recognized recommendation leading to the successful containment of the epidemic. nevertheless, verbal recognition is not sufficient to enhance the engagement and development of hiv/aids-focused ngos, especially in the preexisting authoritarian government structure; the governance and funding mechanism for hiv/aids responses requires alternation in china. as illustrated in the following section, this was the mechanism of the global fund that enhanced the funding for hiv/aids-focused ngos, facilitating the involvement of civil society groups in translating the rhetorical acts into emergency responses of hiv/aids in china. among the international funding agencies emerging after the hiv/aids securitization launched by the unsc, the global fund was the most renowned major contributor to the hiv/aids interventions in china. the global fund finally accepted the first proposal submitted by the chinese government on hiv/aids interventions in late , after the previous proposals being turned down twice in [ ] . between and , the chinese government has received over us$ billion in grants from the global fund; approximately us$ million were disbursed to hiv/aids intervention programs [ ] . further information regarding the global fund on hiv/aids in china is illustrated in table . intervention of the global fund's funding mechanism was deemed to transform the primary hiv/aids governance in china [ ] . the global fund required the governments to set up a country-level country coordination mechanism (ccm) to construct the grant proposals in line with the national hiv/aids-related strategies, manage the use and distribution of grants, and also oversee the implementation of successful applications. as per the requirement of the global fund, ccm should consist of a broad representation from the government, ngos, multilateral and bilateral agencies, and private sector [ ] . in the existing government structure in china, grassroots ngos have limited channels to participate in policymaking and implementation processes. thus, the multi-sectoral structure of ccm contributed to enhancing the government's commitment to involve ngos in national hiv/aids prevention and control measures [ ] . two among the seats in chinese ccm were reserved for the representatives of hiv/ aids-related grassroots ngos and people living with hiv/aids are a case in point [ ] . considering the existing government structure does not allow the full involvement of ngos in china, the ccm provided valuable opportunities for civil society groups to engage in hiv/aids-related policymaking. the involvement of ngos in national hiv/aids programs was notably highlighted in round of the global fund in china, since the theme of the grant proposal submitted by the ccm was directly linked to the development of civil society groups (refer to table ). in the course of the interview, a director of a hong kongbased ngo commented on the profound influence of the round on the ngo development: "round of the global fund acts as a pushing force for the government to involve more grassroots ngos in hiv/aids interventions" (national ngo- ). in line with the respondent's opinion, kaufman argued the round in particular "was seen by many as a further mechanism to institutionalize hiv/[aids] ngos roles in china's [hiv]/aids response [ ] ." in addition to the increase in participation, financial support for ngos working on hiv/aids-related programs surged through the global fund. as the principal recipient (pr) of the country, the chinese government (i.e., china cdc or the nhfpc) was required to disburse a designated portion of the grants to hiv/aids-related ngos (in the form of sub-recipients) operating in the country [ ] . following the instruction, % of the total grant was allocated to support ngos in round and , whereas % of its grant was distributed to ngos in round of the global fund [ ] . in line with the theme of round entitled "mobilizing civil society to scale up hiv/aids control efforts in china" proposed by the chinese ccm, the proportion granted to hv/aids-related ngos reached % [ ] . owing to the constructive political atmosphere and promising financial resources in the country, a burgeoning number of individual-organized hiv/aids-focused ngos was established in china; over % of the number of grassroots ngos increased in china between and [ ] . the suspension of the global fund in demonstrated that the funding mechanism to some extent held the chinese government accountable for the financial supports of hiv/aids-focused ngos. the global fund once suspended its funding to chinese hiv/aids programs in early because the chinese ccm failed to allocate % of the us$ million hiv/aids grant to grassroots ngos as pledged; less than % was distributed to hiv/aids-focused ngos [ ] . a program officer of a ngo mentioned the failure of ccm to allocate the right portion of the global fund grant to grassroots ngos: "government officials and representatives from gongos dominate the ccm. only a few representatives are from grassroots ngos and civil society" (advocacy group- ). the improper management and use of the global fund was even admitted by a senior government official in the shanghai cdc in times of the interview: first, the global fund required at least percent to percent of the grant should be given to grassroots ngos. however, the government failed to achieve this requirement. second, the management fee in some provinces was too high. third, one of the elements in the rcc program was related to budget aggregation (i.e., monetary contribution by both the national government and the global fund). however, the chinese government did not allocate enough money for the aggregated budget (ccdc/nhfpc- ). the determination of the chinese government to resolve the suspension of the global fund was observed in the course of fieldwork research. during a face-to-face interview inside the office building of the ministry of health (renamed national health and family planning commission in ) in may , the respondent told the investigator "the representatives of the chinese government and the global fund representatives are meeting upstairs to negotiate for the resumption of the grants" (ccdc/nhfpc- ). the dispute was eventually resolved; the chinese government promised to allocate at least % of the global fund grant to ngo work [ ] . in this regard, the global fund mechanism contributed to the political and financial supports of ngos, thereby resulting in the proliferation of hiv/aids-specific grassroots ngos in china, and also the proactive involvement of ngos in national hiv/aids undertakings. in other words, international securitization altered the hiv/aids policy in china, allowing numerous grassroots-level ngos working on hiv/aids to grow in a prevailing political system with "bounded autonomy". an injecting drug use self-help group leader believed the upsurge in the involvement of civil society also resulted in the improvement of state-societal relations, stating, "in the past, the relationship with the government was not good, but it becomes much better now. the government sent officials to visit our center to learn the management strategy of our organization" (self-help group- ). another ngo interviewee in beijing also claimed that "an increase in the acceptance of the government, especially the ministry of health, on grassroots ngos, [is observed in china] . the ministry of health does open the opportunity for ngos to cooperate with the government" (advocacy group- ). having said that the improvement of state-societal relations, it is noted that the chinese state is not a monolithic actor, but a conglomeration of departments and officials with competing and sometimes conflicting agendas in the national and sub-national levels [ ] . a beijing ngo leader pinpointed this phenomenon, stating, "the ministry of health is fine to cooperate with those ngos that can help, regardless of whom. however, state security bureau usually holds a relatively hostile view on the existence of grassroots ngos since the bureau is concerned about social stability" (advocacy group- ). considering hiv/aids as a health threat to the country and its people, the recognition and involvement by the central government and the nhfpc and other related government agencies is of particular vital to the proliferation of hiv/aids-focused ngos in a statedominated society in the current political regime. despite depicting a positive scenario, this article further illustrates that the development of hiv/aids-focused ngos in china generated by the international securitization efforts is largely limited. in other words, the growth of the number of ngos working on hiv/ aids in china would be ceased or even decreased in long term, and also the political space for grassroots to involve in hiv/aids policy making and implementation would be further restricted. an internal and external factor was identified to verify the argument, namely ( ) the reduction of international financial commitment, as well as ( ) the fragmentation of hiv/aids-focused ngo community in china. external factor: the reduction of international financial commitment china resembles some developing countries in that it has faced the problem of decreasing international hiv/ aids financial commitments in supporting its national hiv/aids responses [ ] . given the global financial crisis and the continuous economic boom in china, international and bilateral funding agencies argue that china should be the donor instead of the recipient of international hiv/aids-specific grants and loans [ ] . owing to a lack of international and national hiv/ aids funding, the number of ngos working on hiv/ aids was drastically reduced; many ngos and cbos were simply closed down, only a few of them could barely survive with the support by other funding sources (national ngo- ). the retreat of the global fund has subsequently created a policy vacuum for the chinese government in taking the lead in managing the development of hiv/ aids-related ngos in china. mimicking the funding mechanism of the global fund, the state council launched the china aids fund for non-governmental organizations (cafngo) (shehui zuzhi canyu aizibing fangzhi jijin), providing financial resources for hiv/ aids-related ngos via the submission of grant proposal starting from [ ] . the reduction of the chinese government's reliance on the global fund implies that the hiv/aids-related responses delivered by the national government are no longer checked by the external mechanism. the authoritarian regime is probably the only agency defining/restricting the political space that ngos could work in. explaining the interaction between the chinese authorities and ngos, a university professor in beijing suggested: "in normal circumstances, local cdc staff hand over treatment delivery work to grassroots ngos. nonetheless, cdc officials intend to keep these ngos small, giving them just enough money to run the programs, so that they will not grow too strong to pose potential threats to the government" (academic- ). along with the weakening of international securitization efforts and the rise of chinese government's involvement in managing ngos in the post-global fund era, the continuous proliferation of ngos is further complicated by the fragmented nature of hiv/aids-focused civil society groups in china. it is argued that the existing ngo registration system, as previously mentioned, has brought about a fragmented ngo community in china. apparently, governmentorganized non-government organization (gongo) and registered ngos working on hiv/aids are included in hiv/aids national policy implementation processes, whereas excluding unregistered grassroots ngos that are perceived as illegal or "anti-government" organizations. based on the nature of services that individual hiv/ aids-focused ngos provided, service providers are preferred by the state, whereas ngos serving as advocates of human rights and agencies providing legal services for hiv/aids-infected people would be subjected to prosecution and coercion. a hiv/aids specialist working in an international ngo in beijing stated, "during a hiv/aids ngo meeting, the chinese government clearly claimed that the authorities would like to work with ngos/cbos conducting service delivery, but not with those working on hiv/aids-related human rights or gender issues" (ingo- ). to further illustrate this point, the chinese political leaders publicly praised a guangxi-based ngo named aids care china, recognizing the work the organization had been done in hiv/aids prevention, meanwhile stifling numbers of hiv/aids activists through imprisonment, house arrest, or assault. dr. wang yanhai and dr. gao yaojie were two of the prominent chinese hiv/aids activists that fled to the united states in and , respectively, due to the recurrent pressure and disturbance exerted by chinese authorities owing to their advocacy work. in june , a hiv/aids-related legal aid ngo, beijing yirenping, was raided, and two of its activists were detained. in this regard, the continuous inclusion/exclusion selection process would weaken unregistered or advocacy groups that conceived as threats to the legitimacy of the authoritarian regime [ ] , while preserving ngos that are willing to under control by the state apparatus and prepared to accept the regime's policy measures. for the sake of reaching a modus vivendi, these ngos usually display self-limiting behaviors, avoiding actions that would be interpreted as threats to the regime [ ] , such as having close relationship or cooperation with ngos being "excluded" by the state apparatus. while a formal local network for hiv/aids-related ngos or civil society groups has been established in many countries in asia, such coordination mechanism between non-state actors is largely absent in china. the fragmentation of hiv/aids ngo community is likewise observed in the course of interview sessions. amongst the interviewees, the majority of the ngo respondents believed that cooperation dramatically increased between the government and ngos working on hiv/aids, especially in the areas of treatment, care, and prevention. only a few of them nevertheless stated that communication and coordination occurred amongst ngos in policy implementation. a national-wide ngo respondent claimed that "we seldom cooperate with other ngos or ingos; we have our own teams to do the work" (national ngo- ). some grassroots ngo respondents in shanghai and kunming expressed their unwillingness to cooperate with so-called "unauthentic" ngos or ngos having so-called "government background": few ngos have cooperative relationship. there are lots of "fake" ngos in china. the cdc found some patients to set up grassroots ngos and then through the name of such ngo to apply for the global fund. after they received the money, cdc would become the one who controlled the funding (self-help group- ). eighty-five percent of the hiv/aids-focused ngos in yunnan have government background…for those ngos that are funded by the global fund or china-bill gates projects, these are organizations with the government background…or if you read their introduction saying "with the help and support of government", you will know these are ngos with the government background (self-help group- ). a "we-they" distinction has apparently prevailed amongst the hiv/aids ngos community in china, reinforcing the atomization of hiv/aids-focused ngos, discouraging the proliferation of civil society in china. horizontal relationship amongst ngos working on hiv/aids is relatively weak and ill-organized, thereby avoiding these organizations joining hand to call for favorable political environment or monetary supports to continue their operation in china. owing to the reduction of international financial commitments, as well as the fragmentation of hiv/aids-focused ngo community in china, the proliferation of hiv/aids-focused ngos in china generated by the international securitization efforts is nevertheless largely limited in long run. such restriction on the concerted efforts of hiv/aids-related ngos will inevitably pose challenges to china to fulfill the pledge of the agenda to end hiv/aids as one of the targets of the sustainable development goals (sdgs) [ ] . hiv/aids was officially announced as a security issue in by the unsc resolution , which claimed that the pandemic could pose security threats if left unchecked. the rhetorical security-threat claim resulted in the burgeoning number of ghis organized by the international and bilateral organizations operating at the state level. this article illustrates the ways in which the unsc resolution and the global fund influencing the hiv/aids governance in china. rhetorically acknowledged the hiv/aids problems and the irreplaceable role of hiv/aids-focused ngos in combating the disease by the chinese government, the monetary and technical supports by the global fund enabled hiv/aids-focused ngos to participate in the national policymaking process, facilitating the proliferation and development of civil society in china. this success nevertheless does come with concerns regarding sustainability. this article shows that international securitization weakened with the rise of chinese commitment on hiv/aids interventions. in other words, hiv/aids-related responses delivered by the national government are no longer checked by the global mechanism of hiv/aids; thus it is unclear whether these ngos would remain of interest as partners for the government [ ] . the fragmentation of the hiv/aids community would further hinder the development, preventing from ngos with the same interest forming alliances to call for changes in current political environment. such restriction on the concerted efforts of hiv/ aids-related ngos in china would make achievement of the sdgs to foster stronger partnerships between the government and civil society (goal ) difficult, which in turn hindering the realization of ending hiv/aids in the world by (goal ). this research has several limitations. firstly, there is a lack of available information regarding the operation of local or grassroots hiv/aids-specific ngos that are in particular helping marps in china, owing to the political sensitivity of hiv/aids, the unregistered status of ngos working on hiv/aids, the increasing restrictive environment for ngos operating in china especially under the xi administration, together with the social stigma attached to their service objects as well as the ngos themselves as the service providers. secondly, it is difficult to conduct longitudinal study on the development of hiv/aids-specific ngos in china. the researcher realized that many of the ngos that had been interviewed in were no longer under operation in the follow-up fieldwork in , either because these ngos could not secure sustainable funding, or they were cracked down by local authorities for advocating hiv/aids-related human rights or gender equality, or having very close links to foreign (western) organizations. further research therefore needs to be conducted to remedy these technical weaknesses. it is suggested that comparative research could be conducted on the effects (if any) of the regime types, such as china and thailand, and the level of socio-economic development of the country, such as china and singapore, on the effects of international hiv/aids securitization in the national levels. endnotes here ngos does not include government-organized non-governmental organizations (gongos). referent objects refer to "things that are seen to be existentially threatened and that have a legitimate claim to survival." see buzan b et al., security: a new framework for analysis, p. . "civil society" is often translated as "minjian shehui", "shiming shehui" and "gongming shehui" in chinese. in fact, the three different chinese terms do not have the same meaning. many scholars actually use these different chinese terms of civil society simultaneously. "minjian shehui" is used in this article because the term is widely used in the academic research in china's modern civil organizations. "civil society" in this article refers to a sphere that is conceptually separable from the state and government. at the same time the state council abolished the jijin guanli banfa stipulated in . the chinese and english versions of the revised regulation ( ) can be found in chinalawinfo. "regulation on registration and administration of social organizations ( ) (shehui tuanti dengji guanli tiaoli). nevertheless, grassroots ngos registered under the moic also encounter problems with regard to the amount and source of funding. as registered commercial entities, grassroots ngos are required to pay a % tax on any revenue, even for funding received for non-profit purposes. in recent years, the abovementioned legislative hurdle in ngo registration has been relaxed in some parts of china, first in shenzhen and then in beijing. the local government in these two cities relaxed its ngo registration rule, and allowed ngos in the fields of business, charity, welfare, and social services to register directly with the moca. such a move can also be observed at the national level. in early , the national government started planning to revise the regulations on ngo registration and management. if the revised version is passed by the state council, the individual-organized or grassroots ngos can directly register with the moca without seeking a supervisory body prior to the registration. it is noted that the author is fully aware of the arguments put forward by timothy hildebrandt, stating chinese ngos could be favored or cracked down by the state apparatus irrespective of registration status. the author is argued that unregistered ngos are comparatively easier to be targeted and cracked down by the government officials in the name of "unlawful organizations". for hildebrandt's argument, see hildebrandt, t. the political economy of social organization registration in china. the china quarterly. ; : - . gongos are composed of three types of organizations existed in the s and s: ( ) private organizations from the "old china"; ( ) friendship associations for the promotion of trade, and cultural exchange agencies; and ( ) people's organizations and mass organizations. in the course of the meeting, us vice president al gore claimed that hiv/aids was a security threat because "it threatens not just individual citizens, but the very institutions that define and defend the character of a society. the disease weakens workforces and saps economic strength. hiv/aids strikes at teachers, and denies education to their students. it strikes at the military, and subverts the forces of order and peacekeeping". mcinnes and rushton ( ) argued that the hiv/ aids securitization in was not a successful or complete securitization. however, this article does not intend to examine whether the international hiv/aids securitization has been fully accepted by the target audience. it intends to examine the influences of the hiv/ aids international securitization on the national and sub-national levels in china. in , the bush administration launched the president's plan for emergency aids relief (pepfar), pledging us$ billion from to to "turn the tide against hiv/aids." the who launched the " × " campaign that targets getting million people on antiretroviral treatment by , while the multi-country hiv/aids program of the world bank provided more than us$ . billion for grants and concessional loans to help governments respond to hiv/aids issues. examples included the indian network of people living with hiv/aids, thai network of people living with hiv/aids, asia pacific council of aids service organization in malaysia, and also action for aids singapore, economic reform and growth in china routledge handbook of chinese security. london: routledge bric's growing share of global health spending and their diverging pathways the health care systems of china and india: performance and future challenges evolving health expenditure landscape of the brics nations and projections to rural china, a steep price of poverty: dying of aids: new york times unaids data china's pragmatic approach to aids hiv/aids in china and india: governing health security geopolitics in health: confronting obesity, aids, tuberculosis in the emerging brics economies unleash civil society 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nongovernmental organizations. volunt int j volunt nonprofit org globalization and its methodological discontents: contextualizing globalization through the study of hiv how is health a security issue? politics, responses and issues securitizing infectious disease should hiv/aids be securitized? the ethical dilemmas of linking hiv/ aids and security where are the links? council on foreign relations on the responsibility of the security council in the maintenance of international peace and security: hiv/aids and international peace-keeping operations. united nation security council united nations general assembly united nations general assembly political declaration on hiv/aids: intensifying our efforts to eliminate hiv/ aids. united nations general assembly united nations general assembly aids and security: where are we now? hiv/aids and securitization theory the global fund to fight aids, tuberculosis, and malaria china's evolving aids policy: the influence of global norms and transnational non-governmental organizations china among success stories in global hiv/aids fight: unaids chief. xinhua. peking daily cautions against western threats of aids, drugs: the associated press leexisnexis newspapers . ramiah i. securitizing the aids issue in asia gao qiang, at the hiv/aids high-level meeting of the un general assembly. permanent mission of the people's republic of china to the un state council notice on strengthening hiv/aids prevention and control. ncaids, china cdc 国务院关于进一步加强艾滋病防治工作的通知 [state council notice on further strengthening hiv/aids prevention and control.] 国发 号 [state council document no red ribbon forum redoubles aids fighting bid. china daily keqiang wants tax break for ngos specializing aids/hiv work. south china morning post china after the global fund investment in hiv/ aids programs: does it help strengthen health systems in developing countries? glob health the global fund: managing great expectations china country coordinating mechanism secretariats. the global fund to fight aids, tuberculosis, and malaria people's republic of china: national center for aids/std control and prevention aids funds frozen for china in grant dispute global fund lifts china grant freeze. the body china aids fund for non-governmental organizations making turkey's transformation possible: claiming "securityspeak"-not desecuritization! southeast european and black sea studies estimates of global, regional, and national incidence, prevalence, and mortality of hiv, - : the global burden of disease study the political economy of social organization registration in china this work is supported by a hong kong university research council general research fund grant # . the author would like to thank anonymous reviewers for their useful suggestions. the author would also like to express the appreciation to dr. nicholas thomas for his comments on an earlier version of the manuscript. all errors and omissions are the author's responsibility alone. the author declares that she has no competing interests. springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. the author read and approved the final manuscript. key: cord- - tcikxl authors: paul, elisabeth; brown, garrett w; ridde, valery title: covid- : time for paradigm shift in the nexus between local, national and global health date: - - journal: bmj glob health doi: . /bmjgh- - sha: doc_id: cord_uid: tcikxl nan ► the covid- pandemic has triggered unprecedented measures worldwide, which have often been adopted in an 'emergency' mode and are largely reactionary ► alternatively, covid- needs to be appraised as part of a much bigger health picture, adopting a "systems approach" that enables interactions with other acknowledged and preventable health conditions, which often receive disproportionately low attention ► to do so requires a paradigm shift in global health governance, from a specific reactional paradigm to a systemic, coordinated and preventive paradigm ► it is necessary to adopt a holistic approach to health reflecting both a security approach and a health development approach, tackling upstream causes and determinants, aimed at helping populations reduce their individual risk factors and augment their natural immunity ► such preventive health policies must be tailored to local specificities and local environments, and health systems must be strengthened at the local level so as to be able to respond to population needs and expectations ► the current crisis calls for a paradigm shift in public and global health policies; and in the in the nexus between local, national and global health policies and systems the who declared the novel coronavirus disease (covid- ) an 'emergency of international concern' on january and a pandemic on march. according to who's situation report - , as of april , the epidemic has caused deaths worldwide. while it is seemingly nearing its end in china, where it was first reported, it is still on the rise in europe, in the usa and in other parts of the world, including in many low-income and middle-income countries (lmics). the pandemic has triggered unprecedented measures worldwide. many countries have installed travel bans, confinement and lockdown policies. these responses have been adopted in an 'emergency' mode, and are largely reactionary, aimed at mitigating the spread of the disease while waiting for a specific cure and/or vaccine to be developed. here we do not want to underestimate the risks caused by the pandemic, nor to question the measures taken by the who and governments. but we would like to express our concerns regarding four covid- -related issues, and advocate for a 'paradigm shift'that is, a scientific revolution encompassing changes in the basic concepts and experimental practices of a scientific discipline -to prepare for future crises. a shift in focus: covid- in the broader global health picture it is important to remember other acknowledged and preventable health conditions, when compared with the focus that covid- has triggered at global and national levels. respiratory diseases have been leading causes of death and disability in the world before covid- . it is estimated that, globally, four million people die prematurely from chronic respiratory disease each year; in particular, one million die annually from chronic obstructive pulmonary disease; pneumonia kills millions of people annually and is a leading cause of death among children under years old; each year . million die from tuberculosis; and lung cancer kills . million people a year and is the deadliest cancer. the who estimates that seasonal influenza kills up to people a year. in , an estimated people died of malaria. in , about women died during and following pregnancy and childbirth-that is approximately women each day. in the usa alone, a lower limit of bmj global health deaths per year was associated with preventable harm in hospitals. whereas infectious diseases seem to inspire the most terror among the public and policymakers, noncommunicable diseases are responsible for almost % of all deaths. depression affects million people globally and is the leading cause of disability worldwide, and nearly people die from suicide every year. the global boom in premature mortality and morbidity from non-communicable diseases has now reached a point where some have even suggested it to be a pandemic. moreover, climate change (through increased heat waves and disasters) and atmospheric and environmental pollution are expected to increase deaths and injuries, especially in lmics. in some debates, climate change has become more than a risk factor, with increasing calls for the who to declare it a public health emergency. from a public health perspective, covid- needs to be appraised as part of a much bigger health picture. for instance, beyond the lethality and direct mortality rates of covid- , attention should be paid to the interaction with other pathogens, as well as to the more indirect effects of its mitigation measures. indeed, the pandemic and its containment measures interact with, and impact on, other health conditions and will have system-wide effects, highlighting the importance of adopting a 'systems approach' to its resolution. a paradigm shift in global health governance the global health community, national security agencies and all governments have known that a pandemic like covid- was likely to come, yet global health policy has remained woefully unprepared nor fit-for-purpose. in , the g members proclaimed that ebola had been a 'wake-up call' for the need for better global cooperation. it was also recognised that antimicrobial resistance (amr) threatened to kill million people by , thus demanding urgent action. yet little has been done to address these existing global health governance shortcomings. for example, the lauded g and g response, the global health security agenda (https:// ghsagenda. org/), continues to speak in the terms of costly 'countermeasures' versus prevention and health system strengthening. moreover, the pandemic emergency financing facility (pef) (https://www. worldbank. org/ en/ topic/ pandemics/ brief/ pandemic-emergency-financingfacility), meant to deliver up to $ million in epidemic assistance to curb expansion into a pandemic, sits idle as a complicated 'loan mechanism' at the world bank, available to only a few countries (eg, china and india do not qualify for the money). there is also serious ambiguity about how the pef intersects and/or complements the who's contingency fund for emergencies (cfe) (https://www. who. int/ emergencies/ funding/ contingency-fund-for-emergencies). the cfe is available to more countries for more risks, and more quickly, but represents far less money than the pef (which, in theory, should come after the cfe, if you happen to prequalify for the loan). the 'one health' approach, which was meant to offer a more responsive research and policy agenda to combat zoonotic diseases, remains sluggish at best and underdeveloped in terms of including environmental factors, such as soil and water, which play a crucial part in amr and other threats. in terms of pathogen monitoring and response, the international health regulations, which are meant 'to help the international community and governments prevent and respond to acute public health risks that have the potential to cross borders and threaten people worldwide', are not fully implemented by many countries due to limited financial resources and political will, and have been violated in response to the covid- outbreak. what is more confounding is that many highincome countries like france have failed to fully implement the international health regulations, particularly in their overseas territories. in addition, other disease control mechanisms, like the who global influenza surveillance and response system (https://www. who. int/ influenza/ gisrs_ laboratory/ en/), remain inadequate and underfunded, with too few who laboratories and a market-based model where a global public good (pooled influenza knowledge) is turned into a private good (pharmaceutical profit), with historical inequities in terms of public health. moreover, many countries, like china, are incentivised not to raise the epidemic alarm too soon due to fears of diminished direct foreign investment (like with severe acute respiratory syndrome, h n and now covid- ) and fears that the government will be perceived as weak. these conditions of incapacity at the international level are exacerbated by a weakened who, whose budget has been radically reduced and ring-fenced. for example, the who used to receive three-quarters of its financing from assessed contributions levied on members. however, a change to a zero real growth policy for its regular budget in the s has meant it now only receives a quarter of its budget from member contributions. as a result, the who is dependent on extra-budgetary ring-fenced 'pet project' funding from donors to fill an increasingly shrinking budget. as the money flows to other multilateral health initiatives, the who's authority dissipates, with numerous organisations like the institute for health metrics and evaluation, the bill and melinda gates foundation and médecins sans frontières able to command greater epistemic authority, financial influence and response effectiveness. however, this expansion of initiatives creates a condition of policy fragmentation, which significantly weakens coordinated global public health. one real result of fragmentation of global health governance is an inefficient division of labour, where hundreds of actors such as the who, global fund, president's emergency plan for aids relief, united nations programme on hiv and aids, united states agency bmj global health for international development, world bank, the gates foundation and the clinton foundation (to name only a few) produce parallel programmes or bric-à-brac vertical health silos that have neither generated overall system strengthening in high burden countries nor allowed for effective global health policy. this creates two failures. first, contrary to sector-wide approaches, vertical 'pet-project' global initiatives often fail to promote sustainable long-term local health system strengthening, which is the best preventive defence for disease control (of all types, not just infectious diseases). second, the global level is woefully unprepared for epidemics, since global policy has remained reactionary, symptom-based and dependent on vaccine discoveries without full appreciation of other upstream determinants of disease and access to those vaccines. given the state of global health governance and inadequate investments in health system strengthening-as well as the failure, by many actors, to adopt a 'systems approach' to problem resolution -the spread and danger of covid- is not surprising. what is required, we argue, is to shift global health policymaking from a specific reactional paradigm to a systemic, holistic and preventive paradigm. there is no doubt that this approach will require serious resources, governance reform and political will. nevertheless, the global economic costs of covid- have already reached into at least a trillion dollars. thus, serious efforts to improve global and local health systems would be a small fraction of this cost, with a tried and true cost-saving philosophy that 'an ounce of prevention is worth a pound of cure'. beyond the 'pasteurian paradigm': a holistic view of health the emergency responses to covid- so far are based on the so-called 'pasteurian paradigm', which states that each disease is due to one pathogen; thus, for each disease there is one cure, targeting the responsible pathogen. in this case, laboratories are racing to find the cure or the vaccine against covid- -a vaccine which will come too late for the current epidemic, and will have limited efficacy if the virus mutates in the coming months or years. yet it is easy to see how the more pathogens there might be in the future (which there will be) the less this paradigm makes sense. moreover, the pasteurian paradigm has imposed its preferred research methodnamely, randomised control trials that try to isolate one variable from all possible variables-as the gold standard of science, relegating other approaches as near charlatanism. however, there is a multitude of evidence indicating that beyond a single pathogen, the development of a disease, as well as its outcome, is considerably affected by the physical and social parameters in which it operates, and that this is considerably affected by social, political, environmental and individual factors. this seems widely known by the public as far as chronic non-communicable diseases are concerned, but is also the case for infectious diseases, especially for emerging infections, in which the pathogenic role of social inequalities is recognised. moreover, the traditional frontiers between communicable and non-communicable diseases are being blurred by evidence of 'biosocial contagion'. in this light, the globalised world is now facing a 'syndemic'-that is, a synergy of epidemics that 'co occur in time and place, interact with each other to produce complex sequelae, and share common underlying societal drivers'. covid- is no exception, since its mortality rate varies significantly according to age, sex and comorbidities. as an alternative, we argue that it would be more effective, efficient and equitable to adopt a holistic approach to health. how to tackle the silent killers and how to prepare populations-including the most vulnerable -against future epidemics should be on the top of national and global health policy and research agendas. this should reflect both a security approach (fighting symptomatic issues) and a health development approach (tackling upstream causes and determinants). in doing so, the objectives should not be merely be the response mode, but a more concerted effort to limit environmental factors, protect biodiversity, reduce social health inequities, strengthen local health systems for preventive health, help populations reduce their individual risk factors and augment their natural immunity-notably through various 'healthy behaviours' and diets that are proven to strengthen the general immune system. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] like what recently took place in the field of evaluation of complex systems and policies, a 'realist' revolution of medical research is probably needed to help support this. it is ultimately important that the resulting policies are not copy-pasted from other countries, but adapted to each context, and backed by strong local health systems. by definition, preventive health policies must be tailored to local specificities, including local environments, and health systems must be strengthened at the local level so as to be able to respond to a population's needs and expectations. this is also the case for the response to covid- . viruses and epidemics have always existed, and will always exist, and should be anticipated. coronaviruses are a well-known family of viruses, and even if this one is particularly aggressive, its genome has been rapidly identified. the difference with this epidemic which is causing the semicollapse of health systems is that it has revealed a profound lack of national prevention and preparedness. in response to the epidemic, the most hit countries so far have faced a lack of equipment and critical care beds. in the uk and france, as just two examples, decades of austerity policies and an obsession with evaluating health facilities based on technical efficiency (ie, minimising inputs and increasing outputs) have considerably decreased the capacity of health systems to respond to above-average frequentation. the covid- emergency responses of many states have revealed important inconsistencies. in many european countries, the authorities have adopted a one-sizefits-all policy and imposed the same measures everywhere. more worryingly, some governments-notably in africahave not performed their own adapted risk assessment before copy-pasting strategies from abroad. this is problematic, since it makes little sense to use a predictive model developed from a country where the median age is and translate it to a country with a median age of , without adjusting the parameters. in addition, current policies fail to account for regional or transborder contextual parameters, where either more stringent or relaxed measures could be more suitable depending on geographical determinants. the universal lockdown of a whole country may not be necessary when there are only one or two epidemic outbreaks separated by hundreds of miles, especially if containment is quick and determined. what we suggest, in order to be effective, is that policies should fit each context and be adaptive at the territorial or ecosystem level, versus being unreflectively and uniformly bounded by national jurisdictions. this is the best way to not impose measures that are too coercive, which may face legal constraints and may be counterproductive, eroding public trust and cooperation. in the post-covid- recovery phase, we hope the lessons learnt from local, national and global responses to this pandemic will foster support, by policymakers and by the public, for tailored policy responses that support stronger and more integrated local health systems. in summary, the current crisis calls for a paradigm shift in public and global health policies. we will not be prepared for the next epidemic unless we take bold steps. first, global health policies should not be designed on a response mode to case-by-case threats, but should adopt a systems approach that can support a holistic picture of global disease burdens, risks and health conditions, as well as better consider the system-wide effects of adopted measures. second, countering current fragmentation in global health governance will require a substantial shift in global health policymaking from a reactional paradigm to a systemic and preventive paradigm, with meaningful commitments to human health security. third, there is a need to shift our focus from short-term curative policies based on the pasteurian paradigm, to long-term preventive and promotional policies based on a holistic view of people's health, which notably implies limiting environmental factors, reducing social health inequities, helping populations reduce their individual risk factors and augmenting their natural immunity. lastly, such holistic, preventive policies must be adapted to local contexts and implemented through strong local health systems able to have the 'cushion' capacity to respond to emergencies. twitter valery ridde @valeryridde acknowledgements we thank seye abimbola for inviting us to submit this commentary and for giving us critical suggestions for improvement, and eric muraille for advising on references on immunity. contributors ep and gb both had an initial idea for this paper and joined forces to arrive to this joint paper. they wrote the first draft and vr contributed to improving it. all authors contributed to the development of ideas, commenting on drafts and approved the final version. funding the authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. competing interests ep and vr have conducted consultations for various international and donor agencies. gb and vr have received funding from several research funding agencies. however, this article has been written in total independence of these contracts. patient consent for publication not required. provenance and peer review commissioned; internally peer reviewed. world health organization. coronavirus disease (covid- ) situation report - world health organization the structure of scientific revolutions forum of international respiratory societies. the global impact of respiratory disease -second edition up to people die of respiratory diseases linked to seasonal flu each year world bank group and the united nations population division a new, evidence-based estimate of patient harms associated with hospital care world health organization. noncommunicable diseases time to deliver -report of 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infection realistic evaluation. london: sage the coming plague: newly emerging diseases in a world out of balance. farrar, straus and giroux global preparedness monitoring board. a world at risk: annual report on global preparedness for health emergencies world health organization (acting as the host organization for the global preparedness monitoring board) healthcare resource statistics -beds why a one-size-fits-all approach to covid- could have lethal consequences [internet]. the conversation covid- -the law and limits of quarantine us emergency legal responses to novel coronavirus: balancing public health and civil liberties key: cord- -reoa kcw authors: botreau, hélène; cohen, marc j. title: gender inequality and food insecurity: a dozen years after the food price crisis, rural women still bear the brunt of poverty and hunger date: - - journal: nan doi: . /bs.af s. . . sha: doc_id: cord_uid: reoa kcw the global food price crisis of – had devastating impacts for the world's poorest people, especially for smallholder farmers and in particular for women, who face discrimination and a heavy burden of household responsibility. the international policy response to the crisis saw the launch of numerous new initiatives and instruments, but funding has been insufficient and policies have failed to address the structural deficiencies in the global food system. a dozen years on, in light of climate change and increased conflict, new policies are needed to reorient the food system so that it prioritizes smallholder communities, with a renewed focus on the needs and aspirations of women. . introduction . underlying structural factors and their impacts on women . what led to the food price crisis? . impacts and long-term effects on women smallholder farmers . how effective was the global response in tackling the structural causes of the crisis? . the global response after - . responding to the crisis with business as usual . a lack of coherent governance for global food security . addressing women's food insecurity in a (more) unstable and broken food system . increased challenges for food and nutrition security for women . what changes have there been in the institutional and funding agenda to address women's food insecurity? . closing the gender gap: transforming rather than mainstreaming . conclusion and recommendations . guarantee participation and inclusiveness . increase aid to agriculture . increase national public investments in agriculture in developing countries . ensure women's access to resources, competitive markets and farmers' rights the global food price crisis of - underscored how fragile livelihoods are among the world's extremely vulnerable people, as it drove million people in developing countries into poverty (world bank, ) . in the aftermath of the crisis, in the food and agriculture organization of the united nations (fao) estimated in a that almost billion people worldwide were undernourished (fao, a) . as this chapter will show, the crisis disproportionately affected women. in the un world food programme (wfp) calculated that women and girls accounted for % of chronically hungry people around the world (wfp, ; see also scott-villiers et al., ) . the flurry of policy action in the months and years following the price spike brought some hope that the world's governments were prepared to tackle the structural factors behind the crisis, which had a severe impact on vulnerable people's resilience to shocks. the effects proved especially severe for women small-scale agricultural producers. a dozen years later, despite the international commitment to sustainable development goal (sdg) of zero hunger, too many of the policies that precipitated the food price crisis remain in place (wise and murphy, ) . the united nations food, agriculture, and health agencies estimate that the number of hungry people in the world increased by million in , and rose by million over the preceding years (fao et al., ) . viewing food insecurity through a somewhat different lens, the agencies also a following these estimates of hunger, the committee on world food security (cfs) recommended that fao revise its much-criticized methodology for counting the number of undernourished people. this new methodology included updated population estimates and household surveys on food consumption, and took into account food waste at the distribution level. it was used for the first time in the state of food insecurity security in the world (sofi ) (fao, ) report, and the hunger trends observed showed significant changes. the methodology has been under constant revision since then, with new indicators added to make it more complete. therefore, it is not possible to compare figures across annual volumes of the sofi report. estimated that over billion people ( . % of the world's population) cannot afford a healthy diet (fao et al., ) . women smallholder farmers are among the worst affected, and remain far from realizing their human right to adequate food. looking back in , reconsideration of the long-term impacts of the food-price crisis and the impacts of the policy response is long overdue. it has become clear that we will not achieve sdg , given that the structural causes of hunger remain unaddressed and that additional issues have become more salient since . this chapter will proceed as follows: • reflecting on how the existing challenges faced by women smallholder farmers were exacerbated by the structural causes of the food price crisis; • examining major policy responses from governments and the private sector and analyzing their effectiveness in addressing the structural causes of the crisis; • setting out the lessons learned from the major failures of this policy response; • identifying key challenges and gaps in financial aid to women smallholder farmers and, more specifically, looking at the level of official development assistance (oda) targeted to them since ; and • providing policy recommendations to address all of these issues. the challenges and questions raised by this chapter remain substantial, diverse and context-specific. although we cannot explore these topics exhaustively, we hope to contribute to renewed calls for justice and the right to food for the hundreds of millions of people who remain hungry in a time of plenty. their impacts on women . what led to the food price crisis? the term "global food price crisis" usually refers to one of the biggest price surges (de schutter, ) in a period of extreme volatility for primary commodities, mainly the most widely consumed cereals, which had peaks in the second half of and the first half of and another spike in - . between march and march prices rose %, those of soybeans jumped % and wheat prices ballooned % (fao and oecd, ) . the price of rice climbed fourfold during january-april , as several major exporters embargoed foreign sales of this lightly traded commodity (fao and oecd, ) . b global food prices declined from their peak in june , as the world economy fell into recession (fig. ) . prices remained relatively stable until the first half of and then began rising again, reaching an all-time high in february (fao, ) (fig. ). severe drought in major exporting countries was the key short-term factor contributing to this second spike (trostle, ) . as a study by the institute of development studies conducted for oxfam noted, the rise in prices pushed low-income people, who precrisis frequently spent % or more of their incomes to buy food, further into poverty and increased their difficulties in maintaining basic consumption levels: people for whom securing food has already absorbed a large share of their resources and energies before the food crisis came under intense pressure to alter their relationship to food and thus to the economy-to spend more time earning more money to cover basic provisioning and to extract more value from whatever they consumed. scott-villiers et al. ( ) . in other words, the crisis posed a severe threat to the right to adequate food for millions of people (de schutter, ) . . . a broad variety of causes led to the - food price crisis, and views on the weight to give to long-term trends vary in the literature (scott-villiers et al., ) . nevertheless, as olivier de schutter, then the un special rapporteur on the right to food, observed in , "the disaster which results from the increase of international prices of food commodities is a man-made disaster. the causes are identifiable" (de schutter, ) . the agri-food system and its contradictions contain a number of hidden causes of the crisis, what we call "structural factors": liberalization of agriculture and trade, concentration of distribution and inputs marginalizing smaller production units and decreases in investments in agriculture and development assistance to the sector in a context of increasing climate change. these long-term trends made smallholder farmers more vulnerable to shorter-term "conjunctural factors" experienced in the more immediate run-up to the crisis. these conjunctural factors consist mainly of an evolution of fundamentals of the market-supply and demand (bricas and goïta, ; clapp and cohen, )-and marked an increased level of globalization (scott-villiers et al., ) , creating an even more unfavorable economic context for smallholder farmers. in the decade prior to the crisis and following adoption of the world trade organization (wto) agreement on agriculture of and the world food summit in , there was a major shift in global food and agriculture, with lower trade barriers and more open markets. however, countries with weak market infrastructures and those that relied on a small number of export commodities did not gain from liberalization and faced risks associated with increases in world food prices, which would mean considerably higher import bills, potentially requiring them to spend their foreign-exchange reserves (trueblood and shapouri, ) . for farmers, this shift encouraged less production of traditional food cropswhich frequently were the crops that women farmers produced-in favor of crops for domestic and export markets, increasing their exposure to the volatility of those markets and their dependence on purchased inputs (un women, ) . most low-income countries moved rapidly away from self-sufficiency in food and in turn opened their domestic markets to external produce. from , sub-saharan africa became a net food importer (fig. ) , despite an impressive increase in regional production of major crops. between and , only one-fifth of african food exports stayed in african countries, and % of agricultural imports came from other continents (rakotoarisoa et al., ) . west africa tripled its rice imports in the s (fig. ) (oecd, ) . outside of africa, haiti reduced its tariff on imports of rice-the daily staple for most haitians-from % to %. from near self-sufficiency, the country went to importing % of its rice consumption, and has now become the second largest market for us rice (cohen, ; oxfam, ) . liberalization policies have also facilitated the overwhelming market supremacy of a small number of large companies, from farm inputs to sales of food to consumers. as mckeon ( ) has observed, "corporate power in food chains has continued to grow unabated, with the mega-mergers of major agribusiness multinationals threatening a further concentration'" over the past few decades, four firms, known as the abcd companies-archer daniels midland (adm), bunge, cargill and louis dreyfus-have come to virtually control trade in grain and oilseeds plume, ) . such concentrated market power is often seen in low-income countries that typically have at best insubstantial market regulation. in the agrochemical sector in the late s, the top companies accounted for % of global sales. by , seven companies controlled the same market share (humphrey and memedovic, ) . in , as a result of the mega-mergers that mckeon highlights, three companies (bayer, dowdupont c and chemchina) stood poised to claim a % share of global commercial seed and agro-chemical sales (friends of the earth europe et al., ). however, the ability of these firms to administer the prices of seeds, for example, varies according to crop and country context (cavero and galiá, ; oecd, a) . the rate of growth of public spending on agriculture slowed dramatically during - , and it stagnated in africa. however, spending rose steadily in asia, and doubled during the two decades after . in the absence of public funding, smallholder producers, particularly women farmers, had little ability to bargain with large agribusiness firms, middlemen or credit providers (un women, research is unlikely to address the problems facing low-income farmers, given the unlikelihood of a sufficient return on investment in the shortto-medium term. . . . decreased aid to agriculture the public expenditure trend was not offset by oda to agriculture. the period between and was marked by low food prices and a sharp reduction in aid to agricultural development and investments from oecd countries and multilateral agencies ( fig. ; see also hlpe, ) . most of the aid that there was continued to focus on staples productivity; greater support for fruits, vegetables and legumes could have benefited smallholders (pingali, ) . by , agriculture's share of bilateral aid had fallen to a quarter of its former level, and the trend was similar for multilateral agencies: agriculture fell from % of world bank lending in to just % in - (brock and paasch, ). climate change is resulting in more frequent and more severe heat waves, droughts and floods, which can decimate farm production. its effects contributed to food price increases in - and also in , with severe droughts in australia, canada, argentina and the united states, all major cereals producers (fao and oecd, ) . there were droughts in east africa in , (bailey, . the last of these affected more than million people and resulted in the famine in somalia that killed , people (news centre, crops to weather indicate that global maize and wheat yields between and may have been, respectively, . % and . % lower than they would have been without the effects of climate change (lobell et al., (mittal, )-growth in food crop production slowed from the mid- s. for cereals, which cover over half of the world's farm land, yield growth fell from % annually in the s to a little more than half of that in the s, then increased to nearly % in the s (fao, a). . . . . escalating crude oil prices have led to rising farm production costs in the st century, increases in the prices of fertilizer and oil, which are key farm inputs, have exceed those for agricultural produce (fig. ). this has created further financial difficulties for farmers, as most developing country governments have reduced or eliminated subsidies on inputs and assistance with credit and marketing for smallholders (un women, (world bank, ) , and this was associated with a growing urban middle class. food consumption habits evolved and all regions in the world saw increased meat consumption and thus a rising demand for grains for animal feed (see fig. ). during this same period, global food trade concentrated on just four main crops: rice, maize (this, in particular, is an important animal feed as well as a major direct source of human food in sub-saharan africa and parts of latin america) and wheat, plus soybeans (directly consumed by humans, an input into processed foods, an animal feed and also a source of biodiesel) (mccreary, ) . the trends of dependence on the three major global cereals and on imports for food supplies have been simultaneous and mutually reinforcing. in sub-saharan africa and south asia-which are home to the majority of the world's food insecure people and thus constitute hunger's center of gravity-consumption of these cereals has steadily displaced traditional staples such as millet, sorghum, bananas, cassava, potatoes, sweet potatoes and beans over a long period. the trend was remarked on by people interviewed during the - crisis, who repeatedly mentioned the decline of "traditional" foods due to reduced availability, higher cost and longer preparation time (scott-villiers et al., ) . . . . . rapid expansion of biofuels production the expanded production of biofuels was a key driver of the food price crisis: increased biofuel demand in the united states, due to legal mandates to blend ethanol into petrol, pushed up maize prices and probably also those of soybeans, while eu and european expansion of oilseed production for biofuel led to higher wheat prices ( fig. ; see also headey and fan, ) . governments across the world attempted to reduce dependency on oil, increase the use of renewable energies and halt declines in farm income, and approved legislative instruments that encouraged the biofuels industry. those policies, led mainly by rich countries, created a demand shock in international markets (wise and murphy, ) . during a very short period before the crisis, % of the global maize supply was diverted to the us ethanol program. moreover, biofuels have direct impacts on land use and land rights, compromising food security. the eu's bio-energy policy helped biofuels industries to prosper, but the , km of eu land devoted to biofuels crops in could have grown enough food for million people that year (herman and mayrhofer, ) . . . . . declining stocks a low "stock-to-use" ratio due to low stocks, high demand or both creates upward price pressure (fao, b) . low stocks are a vulnerability factor, especially for countries already at high risk vis-à-vis prices, since reserves provide a buffer against both rising prices and poor harvests (wise and murphy, ) . in - the world cereal stockto-use ratio stood at an all-time low of . % (fao, b). . . . . dollar devaluation depreciation of the us dollar also played a role in food price escalation. in general, a weaker dollar is associated with commodity price increases (fao, b; headey and fan, ) . for countries that tie their currency to the dollar or that have a weaker currency, dollar depreciation makes food imports more expensive (fao, b). . . . . increasing speculation in commodities dollar depreciation also made food commodities attractive to investors, especially as technology and housing "went bust" (clapp, ). the growth of food commodities investment became mixed up with the financial crisis of - , which persuaded many noncommercial traders (whether considered "investors" or "speculators") to move their money away from collapsing stock, bond and property markets and into the commodity futures trade (fao, b) . such large-scale speculation contributes to commodity price volatility and gives inappropriate market signals to agricultural producers (fao, b). from the beginning of the food price crisis, the rice market came under pressure because some governments imposed bans on exports (such as restrictions on non-basmati exports by india, e a leading exporter) (usda/fas, ) and major importers such as the philippines made large-scale purchases, seeking to lock in prices as a hedge against further increases (childs and kiawu, ) . like the diversion of maize to biofuels, all this created distrust on the global markets and exacerbated upward pressure on prices. because of the large amount of international trade in wheat and maize at a time of extremely low global stocks, the price increases quickly spread to many national markets. however, transmission of world market prices to domestic markets varied greatly from country to country: in china and india, domestic prices were virtually unaffected; in brazil and south africa e india lifted this ban, imposed in april , in . during the period of the ban, thailand, pakistan and vietnam, among others, moved in to replace indian exports. it served to keep rice affordable for indian consumers, but adversely affected (albeit marginally) india's foreign exchange earnings. since lifting the ban, india has become the world's largest exporter of rice. the authors are grateful to ranu bhogal of oxfam india for pointing this out. prices increased in line with international markets; but in ethiopia and nigeria domestic prices increased dramatically. in general, according to one analysis, there were "higher price transmission rates for import dependent countries, including rice in senegal, mali, burkina faso, niger… and uganda, maize in malawi and uganda, and wheat in ethiopia" (baltzer, ) . the degree of price transmission was affected by domestic and trade policies in importing countries. f the events of - brought into plain view the cracks in an unsustainable food system that was already having severe negative effects on the basic livelihoods of smallholder farmers (murphy and schiavoni, ) . the structural factors outlined above (liberalization of the agri-food system, concentration in input and output markets, a decrease in public investments in agriculture, declining aid to agriculture) showed how unbalanced the system had become, privileging big agri-food businesses and making low-income people even more vulnerable to the conjunctural factors of the crisis. these short-term factors triggered the crisis and further impoverished the poorest people, denying them their human right to adequate food and nutrition and illustrating the global food system's failures (murphy and schiavoni, ) . rural people, and especially farmers, were on the front line. people living in rural areas are among the poorest in the global south and at the time of the crisis three-quarters of them were living on less than the equivalent of $ a day, and spending up to % of their earnings on food (coon, ) . already precarious rural livelihoods (due to geographic, economic and political isolation, poor access to markets, limited opportunities for work, low productivity and seasonal and long-term migration) (coon, ) amplified the threat of soaring agricultural prices, which affected not only consumers and urban dwellers but also food producers. the overwhelming majority of small-scale farmers are also net food purchasers, with very high exposure to price increases (murphy and schiavoni, ) . in theory, higher prices offered opportunities to farmers who are net food sellers, but price increases for agricultural inputs (fertilizers, fuel etc.) offset this possibility (quisumbing et al., ) . f according to baltzer ( ) , 'much of this variation [in the price transmission patterns] can be explained by price stabilization policies, public policy failure, incomplete market integration, and coinciding domestic shocks.' . . women smallholder farmers have been disproportionately affected because gender inequalities remain very strong in agriculture, women farmers are particularly at risk of food insecurity, especially in times of crisis (fao, ). rural women account for one in four people on earth and on average for nearly half the agricultural labor force in developing countries (fao, a) . women play crucial food-security roles, which include farming, food processing, marketing and ensuring household consumption and nutrition (fao, a) . nevertheless: • they face discrimination and frequently are in a weak bargaining position. in addition, other forms of discrimination (based on, e.g., race, class, caste or religion) often intersectionally reinforce gender inequality (un women, ). • the diminished state role in agriculture in the s and s added to female farmers' marginalization, as it reduced their access to inputs, resources and services (un women, ) . rural women also face unequal power relations within both the household and wider society, which have impacts on many aspects of food security. at the level of society: social inequalities come from socially constructed barriers to accessing productive and financial resources that also hinder social participation and political representation. patriarchal norms leading to power imbalances between women and men create disadvantages for women in agriculture, specifically in land rights (small plots, difficulties accessing ownership, discriminatory inheritance rights), productive resources (no access to credit markets, extension services or inputs), unpaid work, insecure employment and low levels of participation in decision making (sexsmith et al., ) . in the household: cultural practices and intra-household bargaining power can also determine the allocation of household incomes to food and care needs. women's weaker position within the family and social standards that favor boys over girls lead to poorer nutrition among women and girls (fao, a; lourme-ruiz et al., ) . . . . the challenges already facing women smallholder farmers were exacerbated by the food price crisis even though there is as yet inadequate research on the gender differentiated impacts of the food price crisis, it is clear that women bore the brunt of it and came under the most pressure to cope with its effects (quisumbing et al., ) . as hossain and green ( ) have observed: the effects differ by gender…women come under more pressure to provide good meals with less food, and feel the stresses of coping with their children's hunger most directly. these stresses push women into poorly paid informal sector work, competing among themselves for ever more inadequate earnings. the crisis really was a matter of inequalities in achieving the right to adequate food and nutrition, and the short-term factors involved in it exacerbated all the gendered dynamics of the food system (un women, ). discrimination against women at these different levels affects their capacity to respond to shocks and cope with food crises (fao, ; un women, ) . because of the constraints they face in accessing extension services and financial and agricultural resources, limited legal benefits and protection, heavy time burdens and limited decision-making power, women have fewer options for overcoming any crisis and face more risks than men of losing their assets or formal sector jobs. price spikes have particularly negative effects on women heads of household, for several reasons: they suffer labor market discrimination, which confines them to informal, vulnerable and casual employment; they often receive less pay than men doing the same work and they usually spend a higher share of their income on food than male household heads (holmes et al., ) . when looking at intra-household dynamics, it is crucial to highlight women's food-security roles: they usually have the primary responsibility for procuring and preparing food within the household (ford, ) . with regard to nutrition, they play an important role in providing dietary diversity through their vegetable gardens (which are often not considered "agriculture"), and also because they grow a large share of the cereal or root crops that the household consumes (doss et al., ) . during - , improvements in women's education and social status accounted for more than % of the substantial reductions in child malnutrition that occurred (smith and haddad, g ). in times of crisis, poor rural households face losses in assets, productivity and income. men use their income to pay past debt and seek new farm production loans. when women's intra-household bargaining position is weak, g here is the methodology used: 'ifpri…examined the factors that helped reduce child malnutrition by % in the developing world between and . the evidence shows that increases in women's education accounted for % of the total reduction in child malnutrition, by far the largest contribution. improvements in women's status accounted for another %. improvements in food availability came in a distant second to women's education, contributing % to the rate of reduction.' the frequent result is less spending on nutrition and children's wellbeing. indeed, when poor households face a decline in food purchasing power, their coping strategies often include buying cheaper items and moving to less diverse diets, depriving pregnant and nursing women and young children of essential nutrients (holmes et al., ) . women often turn to extreme coping strategies: reducing their food consumption to make more available to others in the family (quisumbing et al., ) , collecting wild food or even migrating in distress or selling assets (holmes et al., ) . during the food crisis in chad, khadija khazali, a widow with seven children from azoza village, said, "we have reduced the number of meals daily, and women are digging in anthills to recover grainsa practice which our community has not had to resort to for a very long time" (ford, ) . women may also take unsafe jobs to boost their incomes, at the expense of their own security and health, e.g. working in mines (quisumbing et al., ) or going into prostitution (cohen and smale, a) . men have more access to social capital and have more pathways out of a crisis, whereas women often face severe time burdens, given the pressure on them to ensure the household's food security. therefore they do not enjoy the same opportunities (ford, ) . men can migrate more easily to find a job in urban areas, and this affects the coping capacity of the women who are left behind: they now must manage the family farm, but may still have to get approval from their absent husbands on key agricultural decisions (coon, ) . the structural causes of the crisis? . . putting food security back on the political front burner the crisis and the subsequent media coverage created an opportunity to put food and agriculture back at the core of global development policies, following years of neglect. after - there was a flurry of action, from countries and regions on the front line of the crisis to oda, multilateral initiatives for reinvestment in agriculture and intergovernmental action, to elevate the place of food security on the global policy agenda. as noted in table , in the first years following the crisis the global policy responses and funding commitments focused on macro-level relief such as support for production, food aid and preventing export bans (quisumbing et al., ) . help million africans get out of poverty by . source: authors' analysis; specific sources for each initiative indicated in the relevant row. the fao was the first institution to react, establishing the initiative on soaring food prices in december , with a budget of $ . bn. this provided countries with technical advice through fao's guide for policy and programmatic actions at country level to address high food prices (maetz et al., ) . then in april world bank president robert zoellick pushed for a "new deal for a global food policy" and established the global food crisis response program (gfrp), with a view to the "expedited processing" of assistance and an initial budget of $ . bn. similar to fao's initiative, the gfrp provided technical and policy advice to severely affected, low-income countries (world bank, ). the first coordinated international response was the high-level conference on world food security, held in rome in june and attended by over heads of state from the global south and north. a group of international organizations produced the comprehensive framework for action (cfa), which was launched at the conference; this called for an additional $ bn-$ bn per year for food aid and oda for agriculture and social protection, and advocated allocating % of international aid to agriculture for the next years. the conference resulted in greater collaboration among the rome-based un food and agriculture agencies, but it also led to greater fragmentation of food-related international institutions as yet more new ones were created. then the world summit on food security in rome in november agreed to the rome principles for sustainable global food security, which called for better coordination and more stable funding (fao, c) . both the group of (g ) "leading" countries and the larger group of (g ) then agreed to food security initiatives, including at every annual g /g summit meeting from to . at the g summit in l'aquila, italy member governments pledged $ bn, but it turned out that a large part of this consisted of recycled promises or even money previously spent. in september the pittsburgh g summit asked the world bank "to work with interested donors and organizations to develop a multilateral trust fund to scale-up agricultural assistance to low-income countries" (g information centre, ). the resulting global agriculture and food security program (gafsp) (world bank, a) currently is providing $ . bn to countries through two windows: one focused on supporting public sector action in developing countries, and the other providing loans, guarantees and equity to the private sector to support investment in agricultural development (gafsp, ). following the second spike of the crisis in , there was an additional set of global responses. this time there was a greater focus on long-term agricultural investments, especially through partnerships with other actors like the private sector, whereas in - the response was mainly through the public sector. reflecting on the policy responses to soaring food prices, de schutter ( ) commented: today, too many [governments] continue to see hunger as a problem of supply and demand, when it is primarily a problem of a lack of access to productive resources such as land and water, of unscrupulous employers and traders, of an increasingly concentrated input providers sector, and of insufficient safety nets to support the poor. too much attention has been paid to addressing the mismatch between supply and demand on the international markets […] while comparatively too little attention has been paid both to the imbalances of power in the food systems and to the failure to support the ability of small-scale farmers to feed themselves, their families, and their communities. . responding to the crisis with business as usual . . addressing supply and demand factors: increasing productivity as a major solution, but neglecting the issue of marginalization the marginalization of whole segments of the population in attaining food security and nutrition throughout the food price crisis made it clear that the main issues were access and inequality, rather than food production. however, the policy discussion tended to focus on the need to double production, both to dampen short-term price increases and also to meet projected population growth through to . efforts and plans tended to focus on this perceived need for increased production, even though supplies were already in substantial surplus (bricas and goïta, ) . between june and july , wfp provided short-term food aid valued at $ . bn, nearly double the $ . bn in agricultural aid mobilized by the world bank, fao and the international fund for agricultural development (ifad) (brock and paasch, ). wfp's big fundraising push sought to compensate for the effects of rising food prices on its ability to procure commodities (golay, ) , but in fact global food aid volumes in - were below those of - , as a direct result of the and price spikes (brock and paasch, ) . although some of the early initiatives did provide resources to smallholder agriculture, not all smallholders benefitted equally. thus, these programs fell short on delivering fully on the promise that smallholder-led agricultural development was back prominently on the development agenda. for example, an actionaid assessment showed that gafsp projects successfully targeted small-scale food producers. some projects emphasized women's empowerment, through income-generating opportunities for women and strengthening women's organizations. however, the study also pointed out that women were not adequately consulted in project design and activity planning, and their under-representation prevented them from receiving information about projects (actionaid, ). in addition, much of the funding provided to address the crisis aimed to promote the growth of productivity in staple grains. this was true of the majority of grants from gafsp and the us feed the future (ftf) program for example, with much less attention paid to horticulture crops (pingali, ) , even though horticulture production had the potential to boost the livelihoods and food security of smallholders, including women farmers (ulrich, ) . as table shows, targeting women was not a priority for most of the initiatives that sought to address the food price crisis. for those that did aim to make gender equality a high priority, such as the cfa, the gafsp and ftf, the impacts were limited because these initiatives focused on enhancing the productivity of "market-ready" farmers, who frequently tend to be male. although the cfs champions tackling gender inequalities in food security and nutrition, some member states have sought to weaken it over the past decades, leaving it with less influence. the g responded to the price spikes by encouraging the development of the agricultural marketing information system (amis). this initiative seeks more transparent commodity markets and information exchange among producer and consumer countries. however, amis has no control over many of the drivers of price volatility, and it is not able to monitor privately held stocks (e.g., those of grain traders) (murphy and schiavoni, ) . equally, it cannot tackle all the major market failures that lay behind the crisis. global policy makers largely failed to enact needed reforms to financial markets to prevent destabilizing speculation in commodity markets, due to pressure from industry lobbyists to maintain the status quo (see, for example, fang, ) . the high-level conference on world food security in , the g summit and the world food summit all pointed to the potential table attention to gender issues in initiatives undertake to tackle the food price crisis. gender focus? no mention of gender inequalities or specific focus on women in the guide. comprehensive framework for action (cfa) recognizes the disadvantages that women face in the food price crisis and their disproportionate vulnerability, especially to the long-term effects. the "menu of actions" recommends that "channeling food assistance via women should be encouraged and opportunities to improve program efficiency should be pursued." global food crisis response program (gfrp) no information found. purchase for progress (p p) takes a "gender transformative approach, directly focusing on women to ensure that they benefit from the project source." hokkaido, japan g summit no mention of gender inequalities. committed to a rights-based approach to support small-scale food producers, gender mainstreaming and ecological sustainability. feed the future the usaid forward policy framework and the feed the future guide, which support ftf operations, emphasize gender equality. the policy framework seeks to ensure women's engagement throughout the project cycle. the guide makes gender a cross-cutting priority, and aims to recognize women's often unsung contributions in agriculture, rights to resources and needs as food producers. l'aquila, italy g summit only one mention of women farmers as food security actors. makes "gender, food security and nutrition" a pillar of cfs work. the committee urged member states to undertake policy reforms to ensure gender equality in achieving the right to adequate food and nutrition, and to include women in food security decision making at all levels. it also asked member states to produce gender-disaggregated data. continued role that food reserves could play in the international response to the crisis (gubbels, ) . in the early s, under pressure from the international financial institutions due to the high cost, many developing country governments had abandoned the use of food stocks to counter physical shortages or reduce price fluctuations (see, for example, devereux, ) . but as prices rose in - , some countries sought to collaborate on a regional basis to create reserves to dampen the effects: new regional stocking systems were set up in west africa by the economic community of west african states (ecowas) and in southeast asia by the association of southeast asian nations (asean) (lines, ) . many governments reacted to the crisis, sometimes without efforts to coordinate their actions. however, many low-income, food-importing countries had limited capacity to respond (golay, ) and they also suffered impacts from the actions of other countries, such as export bans. gafsp directly supports achievement of sdg , encouraging gender equality. beyond increasing productivity and linking farmers to markets, gafsp's sustainable agriculture interventions have an impact on gender equality issues, such as women's agricultural empowerment, job creation on and off the farm and the enhancement of women's and girls' nutritional status. agricultural action plan mostly gender-blind, with a single "add women and stir" line in the action plan: "focus on the ultimate client, especially women." gender-blind: does not address gender issues, and evaluated by fao as "neutral" on gender, with no specific gender component or strategy. no mention of gender. weak on the recognition of women's rights and women's empowerment. source: authors' analysis; see table for specific sources for each initiative. in west africa in the majority of states lowered tariffs and taxes on some cereals, and some decided to control their domestic prices. although such measures can ease the food price burden on consumers, including politically restive urban populations, they cannot ensure efficiency and sustainability or target all vulnerable people, and may be very costly to maintain (cohen and smale, b; hathie, ) . most of the programs implemented after the crisis only targeted cereal production to reach national sufficiency and did not target other segments of the value chain. this strategy was conducted through national agricultural investment plans (naips), which originally were meant to tackle structural constraints and encourage sustainable agricultural growth as part of national development planning processes but which led to dependency on input subsidies and created a higher dependence on external markets (hathie, ) . fao examined the measures taken in more than countries from to , and found that policy decisions paralleled those of - ( fig. ) (see also maetz et al., ) . these measures included support for farmers' access to inputs and facilitating access to credit. however, such policies do not necessarily favor smallholder production, and many of the policies that on paper targeted small-scale producers excluded those considered to be nonviable economically, leaving many out (wise and murphy, ) . moreover, some of the policies emphasized inclusion of small-holders in export value chains without evaluating the environmental and economic risks (wise and murphy, ) . such policies often had disastrous impacts on small-scale farmers, especially on women farmers who relied on production of non-staple crops. these are key sources of micronutrients, but were crowded out by efforts to promote staple production with fertilizer and credit subsidies and price supports. in many instances, this led to increased prices for non-staples, such as fruit and vegetables (pingali, ) . . . . . liberalization of agricultural trade trade-oriented measures evolved as a medium-term trend. some exporting countries still observed export restrictions after to keep their domestic prices low but several countries, in contrast, put in place export facilitation measures (maetz et al., ) . h in addition, some governments lowered tariffs on imported food in order to improve food access (maetz et al., ) . overall, the policy responses did not reverse the direction of global agricultural trade liberalization. governments continued to reduce agricultural tariffs, and many offered preferential market access via bilateral agreements. world agricultural trade grew an average of . % per year during the two decades following enactment of the wto agreement on agriculture, i.e., (beckman et al., . . . . . acquisition of large tracts of land and biofuel policies one consequence of the food price crisis was a scramble to gain control of large tracts of land in developing countries. wealthy-country governments and private companies acquired much of the land in question. between and , the five leading investor countries were malaysia, singapore, cyprus, the united kingdom and china (grain, ; nolte et al., ) . large-scale land acquisitions (in excess of hectares) often dispossessed smallholders (geary, ; wise and murphy, ) . in most instances, these investments focused on export production rather than growing food h these countries included argentina, brazil, chile, ecuador and paraguay in south america, syria and yemen in the middle east and asian nations including china, pakistan and thailand, as well as india to some extent. countries limiting exports included cambodia, china, india, pakistan and vietnam. crops for local consumption, often with little regard to environmental consequences (geary, ) . two-thirds of these acquisitions occurred in countries facing significant food insecurity (geary, ) . usually, investors sought to acquire land in order to produce biofuel crops such as sugarcane, soy and jatropha for export (geary, ) . meanwhile, biofuels policies in rich countries remain largely unchanged. the united states, the main producer of maize-based ethanol, continues to require the blending of ethanol into petrol (bracmort, ) . legislative work to install a ceiling on the share of biofuels coming from food crops has continued at the eu level over the past decade. however, the eu's renewable energy directive (red ii) of still allows member states to burn massive amounts of food as fuel (oxfam international, ) . . . . . national public investments in agriculture continue to fall short food security and agriculture also gained regional and national policy salience after the food price crisis. for example, the comprehensive africa agriculture development program (caadp) (see box ), the comprehensive africa agriculture development program (caadp) (au, a) seeks to promote agricultural development, food security and good nutrition on the continent. it was endorsed at the au's summit meeting under the maputo declaration in (au, b) . from the start, it grabbed headlines by setting a target for every african government to devote a minimum of % of its budget to agriculture. the program is intended to end a long-ingrained habit of dependence on external resources. as a oxfam report noted, "international aid has long represented the bulk of agricultural sector financing in many west african countries. in , it accounted for % of the domestic agriculture budget of niger [and] over % in ghana…." (guereña, ) . oda remains a key source of finance for burkina faso's agriculture budget. i this situation has led the work of governments in unusual directions. thus, "national agriculture co-ordination bodies do exist…, but they serve more to exchange information than to actually co-ordinate interventions on the ground" (guereña, ) . by agriculture's share of public expenditure by african governments was just . %, although the share differed greatly from country to (anisimova, ) , and few have done so consistently. the au agreed to a new agenda in , marking years since the foundation of the organisation of african unity. its call to action for the next years included the following among its targets for african agriculture and agro-businesses by the time of the th anniversary: • achieve zero hunger; • lower food imports while boosting intra-africa food and agricultural trade to % of total agricultural trade; and • increase women's access to land and agricultural inputs, and allocate at least % of agricultural finance to women (au, ) . one year later in , the malabo declaration introduced a system of biennial reviews of countries' achievements under caadp (au, ). the first review, covering and , found that au members' expenditure on agriculture ranged from . % to . % of their budgets. ten countries met the % target, but this was no more than in , when the star performers were zimbabwe, malawi and ethiopia. however, malawi had fallen back from . % in to . %, ethiopia to . % and zimbabwe to . % (au, ). there are concerns that the review process is excessively "state-centric." popular narratives dwell on the argument that if the review process is there to ensure accountability, it must provide for inclusivity and the participation of all stakeholders. j indeed, the caadp framework remains very weak in terms of gender inclusion: the only caadp commitment related to gender is about women's involvement in agribusiness. in other words, the caadp commitments themselves are largely gender-blind. and although the technical guidance of caadp asks countries to collect gender-disaggregated data, there is minimal reporting on how women smallholder farmers are progressing under these commitments. . % of their expenditures that year to the military (world bank, ), despite the role played by conflict in increasing hunger in the region. despite renewed policy attention to agriculture, current public investment levels remain woefully inadequate. the un conference on trade and development (unctad) estimates an annual investment gap in developing country agriculture of $ bn over the period - (out of a total annual sdg financing gap of $ . trillion) (unctad, ). an analysis of national government and aid donor investments in ethiopia, ghana, nigeria, pakistan, the philippines and tanzania was unable to trace the flow of funds to women farmers. it found diversion of resources away from smallholders, and a lack of government capacity to ensure support for small-scale producers (either men or women) (mayrhofer and saarinen, ) . social safety nets put in place by governments are often efficient in targeting vulnerable populations; however, their efficiency is limited depending on the objective (e.g., assistance through cash transfers during lean periods) and there are multiple approaches (a short-term approach providing food assistance or long-term approaches aimed at strengthening resilience and fighting poverty). while donors' efforts to target support for social protection programs based on poverty criteria show decent results (schnitzer, ) , there could be better inclusion of women by adding gender-specific requirements (e.g., direct inclusion of female heads of household or women with children under the age of five). investments in r&d and in infrastructure have often focused on export agriculture and cereals at the expense of food crops oriented toward the consumption of local communities (de schutter, ) . the consultative group for international agricultural research's (cgiar) r&d expenditures on wheat, maize and rice, for example, more than doubled from $ m in to $ m annually during - (pingali, ) . the share of oda dedicated to food security and nutrition (fsn) has remained largely constant (fig. k ) : oecd data show that this kind of aid grew at the same rate as total oda, without major increases in response to the food price spikes. k we use the same methodology as presented in mowlds et al. ( ) to calculate gross oda disbursements for food and nutrition security (fns). we therefore consider all aid reported under agriculture, agro-industries, forestry, fishing, nutrition and development food aid/food security assistance as being aid for fns. while this approach will include some aid that is not specifically targeted to fns and will also exclude some that is, we feel that in the absence of a specific fns classification it provides a reasonable picture of trends in aid in this area. although the $ bn pledge made in l'aquila in did lead to additional oda resources for agriculture, the increase in funds for fsn was modest, as less than one-third of the pledges ($ . bn) represented additional money above spending that donors had already planned. also, the funds promised at l'aquila were one-time pledges, not multiyear commitments of additional money (mowlds et al., ; wise and murphy, ) . as the global economy fell into recession in the second half of , donors turned to austerity measures that limited oda increases (wise and murphy, ) . analyzing two major donors, the eu and the us, over a period of years shows that they are far from delivering. smallholders are central to the eu's international food security policy (ec, ) and its $ bn food facility, launched in , had a specific focus on small-scale producers. however, mayrhofer and saarinen ( ) found that less than one-quarter of eu aid for agriculture between and explicitly targeted small-scale producers. only %- % of eu agricultural funding promoted gender equality, and there was little attention to environmental sustainability. furthermore, with the exception of just year ( due to the food facility), the eu's agricultural oda has consistently supported industrial and export crops with significantly higher budgets than food crops. the destination of oda can also contradict aid effectiveness principles when it does not match policy commitments. in contrast with the eu commitment to target a substantial share of its aid to africa, oda for agricultural fig. ). the us created a -year, $ . bn agriculture, food security and nutrition initiative, feed the future (ftf), after l'aquila. since , the program has continued with funding of about $ bn annually. ftf has attempted to integrate the principles of aid effectiveness, particularly country ownership, into its programming, along with women's empowerment and sustainable natural resource management. its main emphasis is on working with "market-ready" smallholders who have high potential to engage in commercial agriculture, often however at the expense of farmers who have the least access to resources (land, labor, capital). also, the focus is more often on approaches to yield gains that require high levels of external inputs. the gains have been impressive: farm outputs in ftf focus countries over the period - exceeded those of other low-and low-middle-income countries by $ bn (feed the future, ). however, it is not clear whether these gains are sustainable once us aid ends. there also appears to be a real trade-off between aligning aid with national development plans missing out on small is beautiful: the eu's failure to deliver on policy commitments to support smallholder agriculture in developing countries. oxfam briefing paper. https://policy-practice.oxfam.org.uk/publications/missing-out-onsmall-is-beautiful-the-eus-failure-to-deliv-er-on-policy-commitme- . on the one hand and some other aspects of country ownership on the other, such as broad consultation with stakeholders and provision of resources through local systems and actors (muñoz and tumusiime, ) . . . . . growing role for multinational enterprise since the food price crisis, global policy has given more space to the private sector: for instance, the g launched its new alliance for food security and nutrition in africa in may , with a goal of "unleashing the potential of the private sector." developing country governments, bilateral and multilateral aid agencies, and multinational firms have all joined in promoting private investment in agriculture in the global south. but there is a big risk that this emphasis will bypass smallholder farmers (see box ). the g launched the new alliance on the eve of its camp david meeting in . this initiative represents a major scaling back of public funds provided by g countries for global agricultural development, leaving africa much more reliant on public-private partnerships (ppps) and private capital. the alliance has been denounced as "the new colonialism" by some organizations in the region (provost et al., ) . the new alliance has benefited the biggest agribusiness multinationals through legal changes and new investor frameworks in african countries, while family and smallholder farming is to a great extent excluded. of new alliance projects, only three are led by producers' organizations (one each in burkina faso, benin and malawi). the agricultural model supported resembles that of the green revolution of the s and s, i.e., monoculture, mechanization, very heavy dependence on purchased inputs, long distribution channels and production for export. it also puts considerable emphasis on the role of biotechnology. by focusing narrowly on technology-driven productivity gains, this approach misses much of the complexity that underlies hunger, and ignores the ways that the interests of powerful actors affect food and agriculture. there is evidence that the alliance has supported the enactment of laws conferring intellectual property rights to plant breeders; this impinges on traditional farming practices such as saving, reusing and trading seeds (qiu, ) . a uk government fact sheet on the new alliance makes no mention of gender or women's roles in food security (dfid, n.d.), and a new alliance progress report published in points out that only % of smallholder farmers taking part in new alliance projects are women (acf et al., ) . a new trend in development finance is private finance (pf) blending: during the past years, donors and international agencies have increasingly sought to engage the private sector in development, using oda to "leverage" private finance through "blending" the latter with public resources. the data on how much oda is going into pf blending arrangements remain unclear (eurodad, ) . although the absolute figures appear still to be relatively low, it is expected that they will increase rapidly over the coming years. such a financing mechanism could benefit smallholders in low-income developing countries, including women, by de-risking the provision of credit for on-and off-farm activities. for example, ftf in ghana has worked with a local financial institution to expand the provision of microcredit in the northern part of the country, which has higher poverty rates than the national average (saarinen and godfrey, ) . a study of pf blending programs in agriculture found serious data limitations (both quantitative and qualitative). it concluded that "donors have more work to do to ensure that private finance blending is an effective tool for financing smallholder agriculture and promoting inclusive and sustainable transformation in the sector" (saarinen and godfrey, ). the following broad conclusions have been drawn from a analysis by eurodad and oxfam (which is not specific to agriculture and food security). pf blending poses risks to the quality of aid (eurodad, ): • it is less transparent and accountable than other forms of aid. • development finance institutions (dfis) that engage in pf blending often do not operate according to the principles of development effectiveness, particularly country ownership. • so far, there is inadequate evidence on impacts and inadequate monitoring and evaluation. • pf blending opens up the possibility of supporting donor-based commercial interests, rather than local smallholders. this increases the risk that it will support tied aid. blending also could drain oda resources from high priority development programs and is unlikely to offer an effective means to finance development in poorer countries or for the poorest farmers. based on return on investment considerations, pf blending resources tend to go to middle-income countries and are geared toward better-off farmer groups who already have access to resources and knowledge (eurodad, ; see also saarinen and godfrey, ) . a recent study by the overseas development institute (odi) reinforces these concerns. it found that, despite donor claims of high leverage ratios, each $ . of blended development finance from multilateral development banks and dfis in fact leverages just $ . in private finance. the figure falls to $ . for lowincome countries (attridge and engen, ). adaptation to climate change is also an issue that needs high-level funding if the world is to reach zero hunger. the united nations environment program (unep) has found that developing countries' annual adaptation costs could reach $ bn-$ bn by (unep, ), with much of those costs agriculture-related. pearl-martinez ( ) found that adaptation finance still accounts for less than half of all climate finance. only a very small share is targeted to smallholders; in , the figure was just $ m. the food price crisis of - generated a strong reaction and opened the door to civil society and the scientific community to push for a radical transformation of agri-food systems that would take account of environmental, social and health challenges and would promote fairness and sustainability, through balanced governance (bricas and goïta, ) . despite these opportunities, however, the governance of global food security is under threat and its shake-up after the food price crisis has not led to smooth coordination, coherence or convergence among the multiple stakeholders. multilateralism and global governance are more and more hybrid and fragmented: numerous parallel and overlapping initiatives and platforms deal with food security and operate without coordination. so far, they have not proved able to converge to attain sdg (zero hunger), (gender equality) or (combat the impacts of climate change). since the food price crisis, the decision-making center has shifted uncertainly between the cfa, the high-level task force on global food and nutrition security (hltf), the g , the g and the world bank and the international monetary fund (imf), with strong influence from the private sector. the decision-making power of the cfs has been reinforced since its restructuring, but its recommendations to member states remain purely advisory. paradoxically, food security governance has also been more concentrated among just a few actors since the food price crisis. after the crisis, we can identify four relevant types of international agency involved in food security governance: • general political direction: the g /g and the g . these groupings are powerful as they are dominated by richer countries, include all the main aid donors and can take big decisions at moments of crisis. even in the more broadly based g , the representatives of the global south are either bigger countries (e.g., indonesia), members of the brics group (e.g., south africa) or both (e.g., brazil, china and india). africa is represented only by south africa, while small island states, which are extremely vulnerable economically and climatically, are not represented at all. • development aid: e.g., wfp, the world bank, ifad, usaid, eu institutions, such private foundations as the bill & melinda gates foundation and the rockefeller foundation and private ventures like the alliance for a green revolution in africa (agra). the world bank and the imf wield outsized influence on countries through their loans, conditionalities, policy advice and technical assistance, much of which is followed by bilateral aid agencies as well (eurodad, ; stichelmans, dispute settlement mechanism is currently in crisis due to a withdrawal of cooperation by the us, which is seen in some quarters as an effort to undermine the organization (bey, ) . other analysts see us obstruction as part of that country's negotiating posture tied to its trade disputes with china, and note that the us continues to win a substantial share of the complaints it brings to the disputes body (hanke and von der burchard, ; lamy, ) . this fragmentation leads to a lack of coordinated policies and coherent governance, with strong competing perspectives. the un system has promoted a rights-based approach to food security through the cfs, encouraging the implementation of more holistic tactics to achieve the sdgs, advocating for sustainable food systems and agroecology, launching the un decade of family farming ( - ) and, in , adopting the un peasants' rights declaration ( un news, ) . on the opposite side, some aid donors have provided short-term responses that have not always been consistent with long-term needs. and in terms of policy, the response to the food price crisis served to reinforce the emphasis on productivity and producing more food "to feed billion by ," failed to address ecological challenges and the rights and practices of small-scale farmers and practically ignored gender inequalities (duncan and margulis, ) . increased multinational corporate influence within the governance landscape has resulted in a limited interpretation of sustainability. for example, some global supermarket firms include in their sustainability plans the integration of smallholder farmers into their value chains, including training in sustainable agriculture techniques. at the same time, the growing market power of these firms allows them to enforce production standards within those value chains and to determine contract terms (barling and duncan, ) . such private power often contradicts and undermines efforts undertaken by civil society actors and some states to promote a rights-based approach to food security (duncan and margulis, ) , and raises accountability questions. states continue to play a key role in global food security governance across the different platforms of engagement and at multiple scales (duncan and margulis, ) . however, the increased complexity of governance can permit states to pursue contradictory policy goals. they may place food security high on their policy agendas, strongly advocate for it in forums like the g or the g and provide contributions of aid for agriculture, but at the same time they may try to limit the political influence of the cfs and its multi-stakeholder process, prevent institutionalization of the human right to food as a fundamental principle of food security and pursue aggressive trade liberalization policies vis-à-vis developing countries (duncan and margulis, ) . the body that was supposed to give general political direction is the cfs, which was reformed in the wake of the food price crisis to be a broad, multistakeholder platform for food security governance, incorporating civil society organizations, in particular organizations and movements of the people seriously affected by hunger and undernutrition, as part of the decisionmaking procedures with the status of empowered (though non-voting) participants (mckeon, ) . this process is facilitated through the civil society and indigenous peoples' mechanism (csm). member states remain the principal decision makers and accountable stakeholders (mckeon, ) . this structural reform qualifies as a significant effort to address the underlying causes of the food crisis. however, the cfs faces a multitude of challenges, despite evaluations that find its work positive and pertinent; this is symptomatic of a global contraction of civil-society space in all governance platforms. the challenges concern (mckeon, ): • the actors-some governments do not wish to be held accountable; big corporate actors seek a privileged place at the expense of smallholders and civil society organizations (csos). • the process-some states favor technical and institutional solutions that privilege investments over public policies and make extra use of their red lines to prohibit discussion of certain topics. • the finances-inadequate funding of the platform constrains its potential. • the content-the agenda is overly influenced or controlled by a few states with strong vested interests in expanding current agriculture models while civil society voices and farmers organizations are marginalized. it took the csm several years to bring agro-ecology before the cfs, and debate on contentious questions such as food sovereignty, climate change, biofuels and the food and nutrition impacts of international trade liberalization remain taboo. in contrast, the g expanded its area of influence after the food price crisis, seeking to coordinate the global response. the g action plan did not address the root causes of the problem, however, and au countries criticized it for fostering continuing dependence on food imports in an era of volatile global prices. these countries demanded policies to support food self-reliance (wise and murphy, ) . the g includes the governments of some of the world's wealthiest and most powerful countries, as well as those of middle-income and developing countries that have no mandate to speak for other countries. this arrangement poses a problem of legitimacy, especially when the countries representing the global south in the group are major net food exporters, such as brazil (wise and murphy, ) . since the food price crisis the private sector, another key player, has acquired increasing influence over food security governance, adding another layer of complexity to the panorama of actors and decision making. the rhetoric of mobilizing "billions to trillions" to finance achievement of the sdgs (world bank, ) elevates the private sector and private finance to an ever more privileged position. a analysis examined the key elements of the growing influence of agri-food multinationals in discussions on the fight against hunger at a governance level (acf et al., ) and syngenta (now owned by bayer and chemchina, respectively) established or ramped up their philanthropic arms to engage in advocacy in international forums, including the cfs, as well as in discussions on trade and the environment. • multinational firms have proved influential in development discussions through their corporate social responsibility activities. their public relations efforts highlight the convergence of corporate and government interests and priorities. a good example is the food company nestl e's decade-long emphasis on "creating shared value" which, according to the firm, reflects "our ongoing commitment to achieving the un sustainable development goals…." (nestl e, ). • undertakings such as the new alliance and grow africa seek to mobilize private funds to overcome public sector disinvestment in the agricultural sector in developing countries. donors have established these entities to offer the private sector vehicles to promote their approaches, technologies and policy prescriptions. large philanthropies such as the rockefeller foundation and the bill & melinda gates foundation in particular have a great deal of financial clout: between and private foundations spent $ . bn on agricultural development, and % of these funds went to africa. over the same period, private foundations spent $ . bn on agricultural research, primarily on inputs and specifically seeds (mainly hybrids and genetically modified organisms (gmos)) (inter-r eseaux, ). their financial clout and investment mean that they exert influence over the agricultural models that developing countries adopt. organizations that have received substantial foundation funding, such as agra, have sought to shape the design of policies in africa: in ghana, the agra working group on seeds drafted corporateoriented amendments to the national seed policy that were submitted to the ministry of food and agriculture (inter-r eseaux, ). as the influence of private sector actors in food security policy has grown, it has tended to overwhelm that of small and family-owned business. corporate actors usually promote technological approaches to development, including high-external-input agriculture, and generally steer clear of any holistic rights-based approach. multinational firms also structure their own governance along top-down lines, leaving out farmers' organizations, organizations of rural women and women's rights organizations, national private sectors and civil society in general (inter-r eseaux, ). unstable and broken food system the lack of progress on realization of the right to adequate food for all-and specifically for women smallholder farmers-and thus on achieving sdg by results from instability in the factors that contribute to achieving food security, and this has led to food price volatility. all this is largely the consequence of gender-blind political choices that have failed to tackle the broken agri-food system. twelve years after the - food price spike, the main structural factors that marginalized women smallholder farmers have still not been addressed and the most likely food security scenarios do not seem to have become any more optimistic. according to the un report on the state of food security and nutrition in the world (sofi ), the number of hungry people globally rose by million in and by million over a -year period. looking at food insecurity thorough a different optic, the report also found that more than billion people ( . % of the world's population) cannot afford a healthy diet (fao et al., ) . the number of people facing acute food insecurity rose to million in (fsin, ). the number of african countries relying on external food aid rose from in to in (caramel, ) . early projections of the effects of the coronavirus pandemic suggest that it will have catastrophic food security consequences. sofi reports that covid- could add million- million people to the ranks of the hungry, depending on the depth and duration of the resulting global recession (fao et al., ) . the virus, combined with insecurity, extreme weather, desert locusts and economic instability will likely contribute to increased acute food insecurity as well (fsin, ) . violent conflict is the key factor in the severe food crises in south sudan and yemen (fsin, ) . according to the latest intergovernmental panel on climate change (ipcc) report (ipcc, ), there is already evidence of farmers migrating as temperatures increase, exacerbating inequality as those least able to cope are forced to uproot their lives. marginalized communities-including indigenous, pastoral, agricultural and coastal communities-will suffer the most as food and water become less available, health risks increase and their lives and livelihoods are jeopardized. women farmers remain on the razor edge of extreme shocks to the system and in a warming world, with a growing number of hungry people and more conflicts, they face ever greater risks. indeed, according to fao, "women are slightly more likely to be food insecure than men in every region of the world" (fao et al., : ) , especially if they live in rural areas, where poverty and food insecurity are very much linked, and especially in a context of increased reliance on markets and a decrease in subsistence agriculture. current food stresses are linked to prices and access to markets rather than to production (gaye et al., ) , but women are vulnerable in all dimensions of food security: availability, access, utilization and stability. twelve years on, food production has increased and remains adequate to feed all of the increased population in all of the world's regions. per capita food availability has increased globally over the past years (un women, ). nevertheless, climate change and its impacts on agriculture constitute a substantial threat to food availability. fao projects that global average cereal yields will decrease by %- % for each degree of warming . africa and a belt stretching from the middle east through south asia to mainland south-east asia and on into indonesia and the philippines are forecast to be the regions worst affected by disasters caused by natural hazards associated with climate change . this is likely to cause severe harm to harvests and external trade, among other things . it is also forecast to increase food prices, most of all in west africa and india; people's purchasing power is expected to decline by nearly % in west africa and . % in india (fao, ). reduced buying power will have severe impacts on rural poor people . climate variability and extreme weather events can have negative local impacts even when overall national food production figures look good, and this can lead to serious hunger problems in the affected areas . rural people in developing countries, who usually have low carbon footprints (pearl-martinez, ) and depend on renewable natural resources, are acutely vulnerable to climate shocks and natural hazards, which can result in devastating production losses and undermine their food security and nutrition . women have especially high vulnerability as they tend to have less access than men to the resources that can facilitate climate change adaptation, such as social capital, land, finance, credit, health, education, information, mobility and formal employment, and they frequently lack a seat at the decision making table pearl-martinez, ; quisumbing et al., ) . climate change related drought and water scarcity add to their gender-related workloads, such as collecting fuel wood and water (fao, ). even when food is available, poor and marginalized people may lack the resources to access it through purchase or production, and too often neither public social protection programs nor private charity reach them, if these even exist in poor countries (drèze and sen, ) . most often women are expected to find ways to cope with their families' hunger (un women, ) . within concentrated global and domestic value chains, women farmers are at risk because of their weak bargaining position: global food industries and supermarket chains play an increasingly prominent role in food supply, and access to food depends on income, price levels and social transfers, factors over which women have no power or in which they face discrimination (un women, ) . smallholders find that they are being driven out of markets, squeezed by corporate entities on both the input side (seeds, machinery) and the buyer side (traders, food industry, supermarket chains). willoughby and gore ( ) found that in the context of patriarchal norms and social practices, women feel the effects most severely. they are relegated to low-paying and often informal work within agri-food systems, are denied most socioeconomic and political rights and are under the threat of sexual harassment and violence. all these factors constrain their ability to access food. a survey of south african grape farm workers in found that over % said that they did not have enough to eat during the prior month. nearly a third said that they or someone in their family had missed at least one meal in that month (willoughby and gore, ) . when policies have been implemented to give women better access to markets, they have not necessarily been beneficial. entering into market relations usually brings large changes-negative or positive-to the ways that people live. these changes can alter relations within the household, to the benefit or detriment of women. in general, it is widely thought that direct access to income increases a woman's autonomy, but in the household economy it is not always that simple (britwum, ) . within farming households, there are often gender differences in revenue earning from crops. men tend to produce high-value crops, leaving women to cultivate traditional produce which may be rich in critical micronutrients but has been neglected by post-crisis policies that have primarily targeted cereal production to reach national sufficiency. an fao analysis of gender and cash crop production in ghana found that women cocoa farmers are as productive as men. but because they tend to be more cash strapped than male producers, women cultivators tend to use more labor-intensive and less high-tech approaches than men, which adds to their workloads (fao, c) . conflict also has gendered impacts on food security (fao et al., ) : • men tend to do the bulk of the fighting, leaving women in charge of household livelihoods and wellbeing. • violence can directly harm women, and can also reduce their capacity to provide for their families. • conflict related displacement also is a major reason for food insecurity, and affects women and children disproportionately. at the household level, women are frequently the ones who eat least, last and least well. increased poverty in female-headed households affects women's nutrition: to adjust to the decline in their capacity to purchase or grow highquality, diverse foods, they often shift to cheaper and less diverse diets, which frequently lack the key nutrients that pregnant women and young children require. as fao (n.d.) has observed, "more often than not, the face of malnutrition is female." in , global food insecurity rose for the third consecutive year , and women were the most affected: a third of the world's women of reproductive age suffer from anemia, usually due to iron-deficient diets. this also means risks for the health and nutrition of their children (fao et al., ) and has long-term impacts on development. worldwide, anemia is a contributing or sole cause of %- % of maternal deaths. anemic women are twice as likely to die during or shortly after pregnancy as nonanemic mothers . because anemia caused by iron deficiency results in reduced learning capacity and less productive workers, it is estimated to reduce gross domestic product (gdp) by % annually, particularly in african and south-east asian countries (world bank, ) . women's malnutrition frequently stems from poverty and unequal intrahousehold relations. women who have access to financial resources enjoy greater dietary diversity, and in rural areas women farmers who control resources tend to have better-quality diets (lourme-ruiz et al., ) . even when food is available and relatively accessible, people may not fully meet their nutritional needs. in countries where the calorie supply is adequate, there are still high levels of child stunting, e.g., bangladesh, burkina faso, ghana, mali and nepal (dury and bocoum, ; un women, ) . climate shocks, conflicts and social factors that increase women farmers' work burdens put their own health at risk and limit their ability to engage in recommended feeding practices for infants and young children . in many developing countries staples price volatility has persisted, with fresh spikes in and , and prices have remained above the level of the early s. in the face of volatile prices, people shift their income from other necessities to maintain their access to food, and this means that stable prices are a crucial element of food security (fao, ; murphy and schiavoni, ) . instability on the dimensions of food security over the past years has driven the failure to attain the right to adequate food. this is largely due to political choices concerning food security but also to funding, in terms of quantity, quality, targets and accountability. funding agenda to address women's food insecurity? . . an institutional step forward some major institutions have shifted their narratives to factor gender into their policies and strategies. the un agencies in particular have worked toward the empowerment of rural women and have helped reframe the agricultural development narrative. after the food price crisis, the rome-based un agencies developed their own gender strategies: • wfp-in wfp implemented its policy on gender equality for all its programs and projects through an action plan for operability in the field. the objectives were to bring an adapted approach to food aid considering specific needs, increase women's participation in program design, empower women and girls in decision making and protect women from sexual and gender-based violence (wfp, ). • fao-in march fao adopted its policy on gender equality. the objective was to better target women across all programs through disaggregated gender data and norms and standards in project formulation (fao, b). • ifad-ifad's gender strategy implemented in was articulated around three objectives: promote women's economic empowerment, ensure equal participation and influence within institutions and rural organizations and guarantee equity in workloads and in the share of extension services and economic value (ifad, ) . • in the cfs produced gender and nutrition policy recommendations (cfs, ), which included: affirmative action for women. enhancing women's role in food security decision making. enacting legislation to guarantee women's access to resources and services. • in october , fao, ifad, un women and wfp launched their joint initiative on accelerating progress toward the economic empowerment of rural women (un women, ) . it seeks greater leadership opportunities, better food security and higher incomes for women, as well as to foster greater gender awareness. in the face of inaction by governments, the un has taken a step further in legislating around gender inequalities in rural and agricultural sectors over the past years: the committee on the elimination of discrimination against women (cedaw) recognized the myriad challenges facing rural women in , noting that in many cases, the situation has worsened. the committee also indicated that states should therefore ensure, among other things, that macroeconomic policies, including trade, fiscal and investment policies, as well as bilateral and multilateral agreements, are responsive to the needs of rural women and strengthen the productive and investing capacities of small-scale women producers. they should address the negative and differential impacts of economic policies, including agricultural and general trade liberalization, privatization and the commodification of land, water and natural resources, on the lives of rural women and the fulfillment of their rights. the cfs forum on women's empowerment has pointed to significant gaps in policy implementation: countries have at least one law restricting women's economic opportunities, countries exclude women altogether from certain jobs and leave it to husbands to determine if their wives can work. this forum has urged states to uphold their commitments to rural women's rights under the convention on the elimination of all forms of discrimination against women (fao, c) . in , the cfs began work on a set of voluntary guidelines on gender equality and women's empowerment in the context of food security and nutrition. the un declaration on the rights of peasants and other people living in rural areas, adopted by the general assembly in , calls on states to take all appropriate measures to eliminate all forms of discrimination against peasant women and other women working in rural areas and to promote their empowerment in order to ensure, on the basis of equality between men and women, that they fully and equally enjoy all human rights and fundamental freedoms and that they are able to freely pursue, participate in and benefit from rural economic, social, political and cultural development. the world bank's world development report : agriculture for development recognized the importance of smallholder farmers, and especially women. it emphasized the significance of investment in smallholder-led agricultural development for poverty reduction after decades of development processes bypassing small-scale farmers, particularly women cultivators (world bank, ) . in the ensuing years, two broad agendas have emerged, with tools that call for more responsible investment in agriculture and tackling gender inequalities: the voluntary sustainability standards (vss), targeting mainly the private sector, and the responsible investment frameworks in agriculture (rifs), targeting mainly governments. important gaps remain in addressing gender inequality and empowering women farmers, and these tools have to be used in the appropriate context so that they work (sexsmith et al., ) . also in , the bill & melinda gates foundation established a gender policy for the agricultural projects that it supports. this seeks to ensure that women benefit and to track project impacts on women and their children and communities (coon, ) . however, since the food price crisis, there is scant evidence that policy responses have taken gender differentials into account, and research in this area is still patchy. decades of rhetoric about the greater vulnerability of women have borne limited results in policy action. this neglect is reflected in aid expenditures. oecd data show that overall bilateral aid targeting gender equality and women's empowerment as either a significant (secondary) or principal (primary) objective in all sectors combined was higher than ever before in - , corresponding to % of total aid. however, the aid activities marked with the principal objective remained consistently below a total of $ bn per year, representing only % of total bilateral allocable aid from development assistance committee (dac) members in - . dedicated support focused on gender equality and women's empowerment as the principal objective in the economic and productive sectors-which encompass agriculture and rural development-decreased from $ m on average annually in - to only $ m on average in - , representing less than % of aid to these sectors (oecd, b) . nevertheless, it is worth noting that out of that $ m, more than half ($ m) was committed to agriculture and rural development. even though agriculture is the main economic and productive sector for targeting gender equality, making gender a principal objective of aid to agriculture and rural development is still not high on donors' agendas. furthermore, it is important to bear in mind that even when donors tag their aid projects with the oecd gender equality markers, this does not necessarily mean that the projects advance gender equality or empower women. grabowski and essick examined aid projects carrying the markers and found that only two of them actually met all of the oecd's minimum criteria for using the gender equality project marker (grabowski and essick, ) . also, although strong women's rights organizations and movements are recognized as being particularly effective actors in bringing about sustained changes toward gender equality, aid going to these organizations remains extremely modest. in - , an annual average of $ m went specifically to women's nongovernmental organizations (ngos), and women's organizations in developing countries received just $ m of this (oecd, b). in agriculture in - , there was little attention to the gender-disaggregated effects of the food price crisis, including its nutritional impact, coping strategies such as withdrawing girls from school and worsening poverty among female-headed households. the work of agnes quisumbing and ruth meinzen-dick and their colleagues at ifpri (quisumbing et al., ) and fao's ( ) sofi are major exceptions. there is still no access to sex-disaggregated data in food security programs (see box ) (un women, ) . of fao's indicators on food security determinants and outcomes, just one is gender related (anemia among pregnant women) (un women, ) . lack of sex-disaggregated data on rural populations also hampers implementation of cedaw's provisions on the rights of rural women. data are also lacking in terms of donors' actual funding to support women in farming and adapting to climate change, and not all donors systematically report to the oecd creditor reporting system. moreover, oecd gender equality markers only indicate if a project targets gender equality and whether it is a mainstreamed objective or fundamental to a project's design and expected results. the markers do not distinguish the nuances between projects that target resources to women and those that aim to transform gender relations (grabowski and essick, ) . as pearl-martinez notes, because aid recipient countries fail to gather sexdisaggregated data, it is impossible to track whether oda reaches women box collecting high-quality, sex-disaggregated data for better prevention tools: the case of the harmonized framework. l since , the permanent interstate committee for drought control in the sahel (comit e permanent inter-etats de lutte contre la s echeresse dans le sahel, or cilss) has been developing and refining its harmonized framework (cadre harmonis e) for the analysis and identification of risk areas and vulnerable groups in the sahel and west africa. the framework is a tool for food crisis prevention and management, and can identify and analyze zones with populations at high risk of food and nutrition insecurity. the results of these analyses allow the classification of food insecurity on a severity scale and estimates of the most affected populations, as well as projections for lean periods. this tool, targeted at decision makers, could be more qualitative with the inclusion of gender analysis, for example by systematically collecting sex-disaggregated data and evidence. this first step could help characterize food insecurity through a gender lens, and thereby help to better target vulnerable populations. farmers (pearl-martinez, ) . tools exist that can be used to measure gender empowerment, e.g., the women's empowerment in agriculture index, which the us ftf initiative helped create. m such empowerment is essential for transforming rural women's roles in agriculture and food security, as well as for addressing the structural causes of hunger (coon, ) . more investments in agricultural development, even if they target small family farms, do not automatically benefit women and food security. the key questions related to whether agricultural development promotes gender equality include whether women are able to access resources, whether they actually can make decisions about the fruits of productivity and income gains and whether development efforts help them to meet their needs and aspirations (huyer, ) . the international institute for sustainable development (iisd) showed in that men and women do not benefit equally from foreign investments in agriculture (sexsmith et al., ) . though its analysis looks at private investments, some of the faults detailed are also found in publicly funded development programs: • foreign investors tend to reinforce existing inequality in land ownership and control by working only with men who have formal land rights. this can reduce rural women's ability to use common lands to meet household needs. • women frequently have difficulties accessing credit and extension services, and so may be excluded from contract farming schemes. these factors also prevent them from benefitting from agricultural innovations. • investors tend to overlook women's needs and thereby increase their workload, including their unpaid labor. foreign investments can increase household incomes, helping women to ensure that their families are food-secure, but if this requires producing export crops instead of food crops for the household's own consumption, it entails new food security risks, e.g., greater vulnerability to volatile global commodity prices and increased competition. • investment projects reinforce rather than transform gender divisions of labor, with women remaining in insecure and often informal jobs. m for further detail, the weai resource center at http://weai.ifpri.info/. • projects also tend to fail to change women's under-representation in cooperatives and agricultural worker organizations, and particularly in leadership roles in these groups. gender integration in agricultural development and food security policies and programs requires ex ante impact assessment to ensure respect for the "do no harm" principle, considering local social and cultural contexts and how these shape women's ability to participate in development activities. in particular, projects must consider who controls assets within the household and seek to redress inequities. failing to do so will simply reinforce existing gender norms and inequalities (quisumbing et al., ) . poorly designed agricultural development interventions can lead to the increased marginalization of women in decision making. too often, projects require beneficiaries to have minimum levels of education and access to credit, for example, prerequisites that wind up excluding women (dury et al., ) . a gender strategy can help project staff better understand the potential gendered impacts of their interventions, and who is likely to benefit (quisumbing et al., ) . boxes and discuss gender integration efforts in rural development projects in haiti and nigeria. haiti is the poorest country in the western hemisphere and has one of the most unequal income distributions on the planet. agriculture remains central to development in the country, accounting for % of employment and % of gdp. yet poverty pervades the haitian countryside, with % of the population living below the poverty line (compared with an overall national poverty rate of %) (ifad, n.d.; world bank, ). hunger and malnutrition go hand in hand with low incomes: % of all haitian households experience food insecurity and % of pre-school children are chronically malnourished (usaid-haiti, ) . rural women in haiti are especially vulnerable. according to a study for usaid, % of all haitian women are anemic. women are percentage points more likely than men to be unemployed, and on average they earn more than % less than men. in the countryside, rural women have inadequate access to land and participate less than men in high-value agricultural activities. box case study-food insecurity among rural haitian women. n -cont'd this affects the quantity and quality of the food that they are able to consume. in addition, nearly half of rural haitian women should be considered "not empowered," due to their heavy workloads (including many unpaid household responsibilities), lack of ability to make decisions related to agriculture and lack of membership in groups such as farmers' associations or cooperatives (rames et al., ) . in , the us government made haiti one of its ftf "focus countries." according to an assessment of avanse, the feed the future north project in haiti, the project provided women with %- % of the benefits (anglade et al., ) . so avanse can be characterized as "gender-sensitive," in that project staff explicitly sought to mainstream gender and include women and their organizations in activities (avanse, ). however, the project was not gender-transformative, as it did not challenge traditional gender roles in rural northern haiti. it engaged women in what is locally considered "women's work," e.g., small-scale, wholesale marketing of farm produce and the heavy manual labor of building soil and water conservation structures such as terraces and retaining walls. participating farmers at various project sites told the assessment team that "kek grenn fanm" (just a few women) were engaged in growing rice through avanse. the assessment recommended that agricultural development efforts in rural haiti such as avanse make more concerted efforts to consult with women farmers about their needs and priorities, and give them the opportunity to participate in all project activities, including production of all kinds of crops and livestock. box increasing disposable income for women's food security and empowerment in nigeria. food prices in nigeria have trended upwards since (samuels et al., ) , reaching a peak in that negatively affected poor consumers' access to food. in a country very dependent on imports of commodities, the agriculture sector represents a large part of the economy, employing % of working nigerians, mainly as smallholders with below poverty line incomes (matemilola and elegbede, ) . women farmers have less access than male cultivators to land, inputs, paid labor and extension services, and this means that they tend to grow and earn less. in response, many national and international programs have been implemented in nigeria (matemilola and elegbede, ) , but not many have targeted smallholder farmers and women. at a national level, nigeria is far from the % caadp target for agriculture's share of the national budget, with the figure remaining below % as of (mwanzia, ) . very little attention is given box increasing disposable income for women's food security and empowerment in nigeria.-cont'd to specific budget lines for women, youth and marginalized segments of communities. in , gender and youth were lumped together in the budget and only % of proposed projects for them were funded (mwanzia, ) . international initiatives have not tackled this issue either, but some programs, like the one described below, have tried to recognize the productive capacity of female small-scale producers and empower them to significantly reduce food insecurity. since , oxfam has led a village savings and loans (vsl) o program in nigeria, allowing small groups of - villagers to create a common savings fund from which all group members can take loans. one of the main goals of these groups is to increase women's access to financial resources, and eventually to empower women economically, socially and politically. women represent % of program participants. a - baseline study examined the vsl program's impacts on women's empowerment. one of the direct impacts is on community food security. in , some of the respondents, mostly women, reported having fewer than three meals per day in some villages, but in all respondents in all villages reported three meals per day. this improvement can be directly linked to the increased financial capacities of women participants. the following assertion from a woman beneficiary in the village of kebbi shows that vsl allowed her to diversify her household's sources of income, and gave her more choices in buying food to ensure household food security: "before joining the vsl group, i needed to seek permission to buy even soup condiments because the money comes from my husband. but after joining vsl, i am empowered and don't need to seek permission before making little purchases." the program has indeed had a positive impact on joint decision making at the household level because women now contribute fully to expenditures. "i now contribute with money to support my husband, and this is possible because i joined vsl," said a woman from adamawa state. another, from guyuk village, added: "when my husband sells a goat, we discuss how to spend that money. i am very happy, everything has changed." vsl has also contributed to a change of perceptions on women's social role and has reinforced their participation in community political decision making. a woman from kebbi reported: "since i joined vsl, i am being respected by all. often times, i am being included as an executive member of most committees constituted in my community." o the vsl is a methodology invented by care international in . since then, the vsl methodology has been implemented worldwide by several ngos, including oxfam. the authors are grateful to oxfam in nigeria for providing information on the program used here. a study analyzing policy documents in uganda found that the rhetoric of "gender mainstreaming" was well integrated, but that this was insufficient to advance gender equality, given the lack of concrete implementation efforts. the study also found that the documents used mainstreaming in a way that tended to depoliticize gender (acosta et al., ) . multiple food supply and demand factors triggered the food price crisis of - . price spikes also revealed how the structural evolution of the global food system has fomented inequalities in accessing food. the food price crisis denied the right to adequate food to whole categories of people who have suffered long-term impacts. women have experienced disproportionate effects because they face discrimination at both the societal level and within their own households, with profound effects on their right to food. the global response to the crisis has been very visible, with many actors involved and numerous commitments, new initiatives and instruments launched by intergovernmental bodies, countries, global donors and private stakeholders. however, funding has been insufficient and the policy response has mainly targeted production issues instead of focusing on the right to food, especially of women. after years, global food security governance is highly fragmented, with the power of a small number of actors increasing dramatically. those actors include major multinational corporations, the world bank and the imf and the g governments. the voices of the people who have been left food-insecure are seldom heard in policy discussions. funding targeted at women in agriculture is insignificant compared with other official funding, and this public disinvestment opens the door to other actors, such as multinational companies, which have taken a "business as usual" approach and make gender equality in agriculture a low priority at best. especially in light of climate change and increased conflicts, failing to address the structural causes of the food price crisis has put women even more at risk on all dimensions of food security. in order to start tackling these challenges, we offer the following recommendations: • developing country governments and donors should support inclusive agricultural transformation and create an enabling environment for both female and male farmers to exercise their rights. this should include reducing power imbalances and supporting national-level land reforms. • governments and donors must make women's economic empowerment in agriculture a high priority. actions should include greater support for women farmers' organizations and for developing markets for crops that women tend to produce. p • local communities, farmer organizations, rural women's organizations and other relevant civil society actors should be involved in the design of food and agricultural policies. governments and donors need to take a rights-based approach, including ex ante target group identification, ex ante gender analyses and affirmative action addressing the needs of women (e.g., extension services reaching out to them and employing female extension agents). special attention should be paid to ensuring that women participate in decision making at all levels. • policies and funding should support and promote women smallholder farmers in achieving sdg by facilitating the self-organization of women and women's organizations. • donors should encourage multilateral agencies, such as the world bank and ifad, to increase the share of their agricultural spending that supports gender equality. • development aid providers should increase the quantity and quality of aid and support to focus on women smallholders, promoting low-input, climate-resilient practices, particularly soil restoration, crop diversification and water conservation and management. • investments in small-scale agriculture should be combined with and complementary to other initiatives that seek to restore the rights and decision-making power of women smallholder farmers, including initiatives that seek to increase women's access to education and encourage families to share the responsibilities of unpaid care work, as well as legal efforts to give women the same rights as men. • developing country governments should increase public investment in agriculture, with a focus on both women and men smallholder farmers and sustainable, climate-resilient approaches to agricultural p for more on this recommendation, see willoughby ( ) . development, and should include specific line items in their agriculture budgets to support women farmers. • governments should ensure that women farmers' associations and women's rights organizations are able to participate in budget decision making. • african governments should make meeting and then exceeding their caadp pledges on allocating % of national budgets to agriculture a top priority. these budgets should emphasize public investment rather than recurrent spending such as salaries for public officials. • developing country governments should adopt national policies that prioritize food production and discourage the diversion of farmland to large-scale production of crops for export and biofuels. q • governments should create public databases on land ownership and the terms and conditions of large-scale land transactions. • donors should help strengthen developing country governments' capacity to negotiate with investors in large-scale land transactions. • governments should facilitate the participation of civil society, farmers' organizations and women's organizations in the development and governance of food reserves. bilateral and multilateral donors should provide financial and technical assistance to establishment of reserves. • agriculture policies should facilitate women's access to inputs, resources and services. • governments should develop accountability mechanisms to ensure that national and transnational companies do not violate land rights and should ensure gender equality in land governance. • governments should enact or enforce existing competition or antitrust legislation to regulate excessive private power in markets. governments should cooperate on a regional and global basis to enforce competition policies. • national seed policies and legislation on plant breeders' rights should ensure the right of women and men smallholder farmers to save, reuse, exchange and sell seeds. q for more detail, see bernabe ( ) . • developed country governments should increase climate change adaptation financing. • donors should increase efforts to promote gender equality through their bilateral climate adaptation finance by significantly increasing the share of adaptation projects that have gender equality as a principal (dac marker ) or significant (marker ) objective. collect sex-disaggregated data to assess gender inequalities in agriculture • research institutions and agrarian and economic policy forums should seek quality sex-disaggregated data, with strong gender indicators, from all actors, and especially from governments and donors 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partnerships in african agriculture ripe for change: ending human suffering in supermarket supply chains institute for agriculture and trade policy and the global development and environment institute (gdae) world bank framework document for a global agriculture and food security program (gafsp) food price hike drives million people into poverty global food crisis response program from billions to trillions: transforming development finance post- , financing for development: multilateral development finance the world bank in haiti world bank databank the authors wish to acknowledge the assistance of ranu key: cord- -el iy g authors: dinerstein, e.; joshi, a. r.; vynne, c.; lee, a. t. l.; pharand-deschênes, f.; frança, m.; fernando, s.; birch, t.; burkart, k.; asner, g. p.; olson, d. title: a “global safety net” to reverse biodiversity loss and stabilize earth’s climate date: - - journal: sci adv doi: . /sciadv.abb sha: doc_id: cord_uid: el iy g global strategies to halt the dual crises of biodiversity loss and climate change are often formulated separately, even though they are interdependent and risk failure if pursued in isolation. the global safety net maps how expanded nature conservation addresses both overarching threats. we identify % of the terrestrial realm that, if conserved, would reverse further biodiversity loss, prevent co( ) emissions from land conversion, and enhance natural carbon removal. this framework shows that, beyond the . % land area currently protected, . % of land area is needed to conserve additional sites of particular importance for biodiversity and stabilize the climate. fifty ecoregions and countries contribute disproportionately to proposed targets. indigenous lands overlap extensively with the global safety net. conserving the global safety net could support public health by reducing the potential for zoonotic diseases like covid- from emerging in the future. approximately half of earth's terrestrial surface is considered to be in a natural or seminatural condition ( , ) . how does this remaining habitat overlap with global conservation priorities and carbon storage requirements? this paper highlights sites of particular importance for biodiversity where additional conservation attention is needed, and other intact lands of high value for carbon storage and other ecosystem services. it also depicts the coincidence and disparities between terrestrial biodiversity and carbon storage priorities. this spatially explicit output, entitled the global safety net for saving life on earth, is intended to be a dynamic tool to support multilateral, national, and subnational land use planning efforts. while the parallel crises of biodiversity loss and climate change have generally been approached separately, a key solution for two of the most pressing challenges of our time is the same: conserve enough nature and in the right places. analyses designed to protect biological diversity have converged on the need to conserve and connect approximately half the earth ( , , ) . in addition, several studies indicate that above . °c in global average temperature rise, many ecosystems would be unable to adapt and, with increased biodiversity loss, could collapse ( ) . nature-based solutions offer essential means to achieving the global climate objective of staying below . °c ( ) ( ) ( ) . achieving a future in which people and nature thrive is possible, but more ambitious conservation targets will be required ( , ) . to this end, a global deal for nature has been proposed as a time-bound, science-based plan to be paired with the paris climate agreement to save the diversity and abundance of life on earth ( ) . this framework describes a set of science-based targets-organized by country and ecoregion-that would be required to conserve the vast majority of terrestrial plant and animal species. the global deal for nature framework is mutually supportive of policies to address climate change. scaling nature conservation offers fast and cost-effective measures to help stabilize the climate while providing cobenefits from ecosystem services such as the provisioning of clean air and water and the reduction in edge effects that could lead to future disease outbreaks. the need for an ambitious global conservation agenda has taken on a new urgency in after the rapid spread of the covid- virus. global shifts in mammalian population trends reveal key predictors of virus spillover risk ( ) . extensive deforestation in the tropics has led to humans coming into greater direct contact with vector-borne pathogens (e.g., zika virus, which emerged from mosquito carriers in the lake victoria basin forest-savanna) or via mammalian carriers that serve as viral hosts (e.g., hiv virus, which emerged from primates in the northeast congolian lowland forests). as important, achieving the area-based targets to protect all remaining intact and semi-intact terrestrial habitats would be an effective solution to reduce contact zones, helping to limit the chance of zoonotic diseases from affecting human populations in the future. here, using the global deal for nature as a guiding framework, we examine where conservation of the terrestrial realm could be scaled to support biodiversity by securing additional lands to improve the resilience of ecosystems and secure terrestrial carbon stocks, both of which are essential if we are to have a chance of achieving the . °c goal. the global safety net explicitly avoids areas of concentrated human settlement, but it does not exclude resident human populations at relatively low densities in remote areas. we view this as a positive because, in particular, the sustained presence of indigenous communities within intact areas can have long-term benefits for both biodiversity and carbon storage ( ) . this initial version of the global safety net includes spatial layers that, when combined, address expanded biodiversity protection and climate stabilization for the terrestrial realm. we also scope out a preliminary system of wildlife and climate corridors to identify the approximate amount of land that would be required to connect protected areas and intact landscapes. besides mapping and assessing remaining natural habitat, we present tables of optimized contributions by ecoregion and by country required to maximize both biodiversity outcomes and land-based carbon storage. we also show how these targets may overlap with indigenous lands. one potential application of the global safety net is to inform the development of "common but differentiated" targets under the new post- framework of the convention on biological diversity (cbd). it could also help guide land-based mitigation in nationally determined contributions made under the united nations (un) framework convention on climate change. the digital map of the global safety net can be disaggregated by country, ecoregion, and indigenous territory, to shed light on overarching questions: how much does an ecoregion or country contribute to meeting global biodiversity targets? do ecoregions identified as priorities for biodiversity protection also contribute disproportionately to carbon storage? what is the potential role of indigenous peoples' lands in supporting biodiversity protection and climate stabilization? which ecoregions and countries will require the greatest investment in connectivity? at a local scale, the global safety net can serve as a framework to align subnational land use planning efforts with global conservation and climate targets. the reverse is also imperative, as regional conservation planning efforts can replace various parts of the global layers where they are available. we anchored the global safety net with the current network of global protected areas ( ) . this network performs fairly well in representing sites important to narrow-range endemic vertebrates, yet gaps remain ( ) . the global safety net fills in those gaps and targets other elements of biodiversity that need additional conservation attention. we built the global safety net by mapping a comprehensive set of biodiversity elements to determine how much unprotected land needs increased conservation attention. to the extent possible, we included only remaining habitat and avoided agricultural lands. we then assessed where additional conservation measures are needed to achieve climate targets. third, we created a preliminary network of wildlife and climate corridors to connect remaining natural habitat. this target is designed to achieve, by , conservation of unprotected biodiversity. for ease of conceptualization and presentation of results, these data layers can be logically placed into four clusters based on ecological factors, areal extent, or both. these include species rarity, distinct species assemblages, rare phenomena, and intactness. the first cluster, species rarity, is intended to capture species that are naturally rare-that is, they have narrow ranges, occur at low densities, or exhibit both conditions ( ) . the following are the six layers comprising the species rarity cluster: single populations of endangered species [alliance for zero extinction sites (aze); zeroextinction. org], an estimate of range rarity in vertebrates ( ) , ranges of threatened vertebrate species (iucnredlist.org), key biodiversity areas (kbas) ( ) , vertebrate species distributions ( ) , and a new study of the spatial distribution of species rarity in plants ( ) . the distinct species assemblages cluster, intended to capture -diversity-the turnover of plant and animal species communities with distance and along elevational or environmental gradients-includes remaining unprotected habitat of the biodiversity hot spots ( ) and ecoregions of high -diversity ( ) . rare phenomena addresses unprotected landscapes containing rare global phenomena; here, we include areas containing the last intact large mammal assemblages of the terrestrial realm (including species such as large mammalian carnivores that are rare locally but range widely) ( ) . the fourth cluster, intactness, is composed of unprotected parts of the last of the wild in each ecoregion ( ) and other wilderness areas ( ) that provide potential macrorefugia for wildlife and representation of fauna. to identify important carbon stores, we used a map of total carbon biomass-a composite of above ground, below ground, and soil carbon ( ) . we first identified ecoregions above metric tons (mt) of total carbon biomass per hectare, which is the median level across the terrestrial ecoregions. we then overlaid the high carbon storage areas with areas selected under target to determine overlap with important carbon reservoirs. where coverage from target was insufficient to meet climate objectives, we mapped additional areas containing high carbon stocks, designated as tier climate stabilization areas (csas). we also mapped tier csas, places that contribute to carbon storage and drawdown ranging between and mt of total carbon biomass per hectare. ecoregions with median total carbon density per hectare of < mt were not included in this analysis. connectivity is a time-bound issue of global consequence, yet most conservation plans fail to address potential climate corridors or interecoregional connectivity ( ) . pressures on remaining natural habitats from land clearing and infrastructure development are so intense that options to maintain connectivity that exist today may disappear within a decade. currently, only half of the . % of the current roster of terrestrial protected areas are connected ( ) . if managed or restored to allow species movement, a system of comprehensive wildlife and climate corridors could connect the world's remaining intact habitats and enable adaptation in a rapidly changing world. to this end, we conducted the first global scoping exercise on connectivity and then checked against mapping studies of corridors delineated at national, ecoregional, and regional scales and published in the peer-reviewed literature or adopted by national agencies in various countries. the biodiversity layers underpinning the global safety net add . % ( , , km ) of unprotected land surface to the . % currently protected (table and fig. ). this addition includes . % for species-based approaches (clusters to ) and . % for habitat intactness (cluster ). together with protected areas, these areas encompass . % of the terrestrial realm where nature conservation should be a primary objective in the near term (fig. ). areas identified for increased conservation attention under target are concentrated in ecoregions that contribute . % to the . % increase ( table ) and countries (table and table s ). the inclusion of some large, unprotected kbas in a few nontropical forest ecoregions and countries, for instance, sahelian acacia savanna and russia, respectively, contributed their higher ranks in cluster by size. overall, conserving target would increase representation by ecoregion across all major biogeographic realms and ensure continued storage of . million megatons of carbon (see target below). widely used optimization approaches for global priority setting to map species rarity add only , , km or . % of new area to the . % already protected (table and fig. ). overlaying the first global data layer of rare plant species distributions with rare and threatened vertebrates adds but . % ( , km ) to the . % total for species rarity. while the amount of land is small, these areas are highly concentrated and irreplaceable for species conservation. unprotected areas containing distinct species assemblages draw from ecoregions that add , , km or . % to the total of . % for enhanced protection (table and fig. ). rare phenomena (intact large mammal assemblages) contributed . % ( , , km ) to the . % increase. the greatest extension by area to increasing global biodiversity protection comes from the inclusion of intactness (fig. ). these areas comprise over . million km of unprotected habitat or . % of the total land surface ( table ) . grouped together, rare phenomena and intactness are primarily found in the taiga and tundra ecoregions in siberia and northern canada. russia and canada and species-rich habitats in brazil, the united states, australia, and china contain almost % of the total area that could be added by targeting intactness while also conserving the most carbon (tables and ). we identified currently unprotected high-carbon areas that must be conserved to meet global climate targets. a by-product of conserving areas high in biodiversity value is that most, but not all such areas, also store the most carbon (fig. ) . in ecoregions where the median total carbon density is above mt/ha, a total of , , km of terrestrial area storing , , megatons of carbon require increased conservation attention for carbon storage. ninety-two percent of this area is already captured in target ( fig. and table s ), underlining the interdependence of carbon and biodiversity and the importance of these lands to achieve the dual goals of biodiversity conservation and climate stabilization. to bridge the gap for adequate carbon storage beyond areas identified in target , the remaining , , km or . % of earth's land surface was selected as tier csas in target ( fig. ). in addition, we identified , , km of unprotected land, or . % of earth's surface, as tier csas. together, tiers and csas add , , km of currently unprotected lands, or . % of global land area, to the global safety net. these land areas store an estimated , megatons of carbon (table ) . indigenous lands ( ) contribute extensively to carbon storage. greater than % of all mapped indigenous lands ( , , km ) are tier or tier csas, and together, these areas store > , megatons of carbon biomass. together, the two targets described above and currently protected areas that form the global safety net cover . % of the terrestrial realm as regions to enhance biodiversity protection and carbon storage (table and fig. ). approximately % of the area in targets and is indigenous land ( ) . the overlap is particularly pronounced in high -diversity ecoregions ( %; cluster ), cluster rare phenomena ( %), and cluster intactness ( %). this includes many ecoregions in the tundra, boreal, tropical forests, and xeric biomes (table s ). we map results on a finer scale across five biogeographic realms-neotropic, nearctic, afrotropic, palearctic, and indo-malayan (fig. , a to d). all mapped layers are available for online viewing at www.globalsafetynet.app. the scoping exercise on connectivity revealed the relatively small percentage of land that would be required to connect all intact areas. the percentage drops by almost half if the areas set aside for conservation under targets and are achieved. connecting all current terrestrial protected areas via potential wildlife and climate corridors (using . km as an average corridor width) adds , , km or . % of the terrestrial realm. connecting proposed global safety net areas (targets and ) would require substantially less total area for corridors to connect all intact terrestrial habitats if all targets are met. connectivity varies greatly by biome, biogeographic realm, and within each realm. in general, tundra and taiga still retain excellent connectivity, less so in tropical forests outside the congo basin, amazonia, and new guinea, and xeric formations. the most fragmented biomes requiring extensive corridors to achieve connectivity are temperate grasslands, tropical dry forests, and tropical grasslands. recent reports of tipping points and accelerating feedback loops related to climate change have profound implications for the need to scale nature-based solutions ( , ) . furthermore, new climate models highlight the important role of halting land use-driven climate. a holistic solution is emerging that will accelerate both efforts: conserve at least half and in the right places ( , ) . the global safety net provides a pathway for using nature-based solutions to unite the two work streams. the spatial coincidence of areas important for biodiversity conservation and carbon storage has long been suspected but is strongly confirmed here. the ecoregions and countries that score high for rare phenomena and intactness (clusters and ) conserve , , megatons of carbon, equivalent to . % of the total carbon present in natural habitats ( table ). the gains in carbon storage achieved by adding protection of rare phenomena, a single layer, is comparable to carbon storage levels in the . % of land that is currently in protected areas. by focusing conservation effort intensely on high -diversity ecoregions, large mammal assemblages, intact areas, and wilderness, the payoff for climate stability is enormous. the global safety net framework presented here contrasts with the classic questions posed by conservation biologists: "how much is enough to save the biodiversity of each biome or ecoregion?" and "how do we protect all species globally in optimization approaches that conserve the greatest number of endemic or threatened species in the smallest area?" these concerns become less relevant under the extensive land conservation requirements of a . °c climate pathway. the various global priority-setting approaches should be viewed as noncompeting: all are necessary to reverse biodiversity loss and stabilize the global climate system. a hopeful outcome of this framework and its implications for conservation is that every stakeholder and group can unite under the goal of staying below the dangerous threshold of . °c in global average temperature rise, beyond which it would likely be too late to achieve most of the biodiversity goals set forth in the convention on biological diversity. one overlooked area of research that should inform future iterations of the global safety net is the restoration opportunities on degraded lands ( ) . these degraded landscapes could be restored to address both climate and biodiversity concerns. further, reconnecting forest corridors in degraded lands could offset emissions that will occur before a moratorium on land-based emissions is reached. focusing restoration efforts on degraded lands that can serve as wildlife corridors could help achieve other objectives, such as the bonn challenge ( ) . similarly, massive tree-planting programs, if designed using native species and planted to restore corridors, riparian and coastal vegetation, and upper watersheds, could contribute to stabilizing climate and restoring connectivity. major opportunities exist for restoration of forests using native plants. ecoregions such as the atlantic forest of brazil, several forest ecoregions in madagascar, and the western ghats of india are currently underrepresented in this version of the global safety net, which is focused on protection of remaining habitat. restoration opportunities should drive future iterations and allow for monitoring of recovery efforts. a prime example is the mid-elevation forests of nepal, previously one of the more deforested and degraded ecoregions, where intensive community forestry programs have led to nearly doubling forest cover in years ( ), increasing carbon stocks from . to . megatons. the overlay of mapped indigenous territories with spatial targets to reveals an extensive overlap of % and underscores the central role that indigenous peoples and their lands play to preserve biodiversity and regulate earth's atmosphere ( , , ) . another observation is echoed by other conservation biologists who have examined maps of indigenous lands and global biodiversity priorities: a % area-based target for protection by , as advocated by many groups to the convention on biological diversity, effectively already exists when accounting for indigenous lands, should effectively conserved lands be formally acknowledged by governments as other area-based effective conservation measures (oecms) ( ) . in short, the " × " target is far less ambitious when viewed through this perspective. many conservation organizations, indigenous peoples, and local communities have called for an area-based target of "at least %" under the convention on biological diversity. explicit in these calls is to allow for the protection of the land rights and traditional management practices of communities most at risk to food insecurity, the negative impacts of land degradation, and climate change. there are reasons to support the notion that a global safety net encompassing approximately % of land area is achievable. addressing indigenous land claims, upholding existing land tenure rights, and resourcing programs on indigenous-managed lands could help achieve biodiversity objectives on as much as one-third of the area required by the global safety net. simultaneously, this focus would positively address social justice and human rights concerns. in addition, economists are examining pathways for scaling conservation and restoration across all land jurisdictions ( ) . new research from the world economic forum ties half the world's gross domestic product-$ trillion dollars-directly to nature and its services ( ) . the recent covid- crisis has demonstrated the ability of the world's governments to mobilize trillions of dollars, and there are a number of proposals emerging to tie environmental restoration and climate response to economic recovery. csas offer one framework to move beyond the incrementalism of protected area designation over the past couple of decades. last, a key finding of this study is that species closest to the brink of extinction or where rare species concentrate could be protected by an addition of only . % more land area if allocated to the right places and well managed. that target should be achievable within years. the connectivity analysis offers a template to build from and engage local and regional entities in designing programs centered on restoring connectivity. this effort could merge with global habitat restoration and native tree-planting initiatives now under way. investments needed for the establishment and management of additional protected areas and restoration of degraded lands, while substantial, are small compared with enormous fossil fuel subsidies. the estimated $ . trillion per year in fossil fuel subsidies are expected to decline as the paris climate agreement is implemented, making government resources available for restoring, rather than destroying, our global climate system. today, the emergence of a strong advocacy for science-based targets offers hope of an accelerated timeline for delivery far faster than we might expect. national-level leadership to champion the global safety net and, by extension, the global deal for nature, could ideally come from the list of countries where increased conservation attention is most needed (table ) . russia, brazil, indonesia, and the united states have an outsized role to play and abundant internal resources to do so. leadership could also come from countries such as costa rica, peru, namibia, and others, creating their own national safety nets that incorporate the landmark conservation plans of each nation's constituent ecoregions, including adjacent marine ecoregions. in the united states, one could envision a california safety net or maine safety net built from enhanced terrestrial and marine ecoregion plans. the global safety net could also inform country-scale conservation and development plans, supporting un conventions through an overlap analysis with outputs of the country emissions gap reports ( ) . similar to the paris climate agreement, and in alignment with the sustainable development goal (sdg ), a global deal for nature calls for common but differentiated contributions by every nation on earth toward the collective goal of protecting ecosystems, halting land degradation, and stopping biodiversity loss. most conservation efforts and land use decisions are local or regional in nature, and implementation of the global safety net will occur from the ground up, by district, state, province, and nation. saving biological diversity and stabilizing the climate will require increased conservation action, but the tools and designations will vary by place and must be locally appropriate. countries and indigenous communities will use a variety of designations from international union for conservation of nature (iucn) category protection levels, to oecms, to csas managed for retaining vegetative cover and preventing emissions. while our analysis makes a distinction between areas managed for biodiversity and those additional areas managed for climate stabilization, a target could still be reached if land were designated as a csa and managed for priority species. in the current environment, we could also envision intact areas set aside under a pandemic prevention program. these natural habitats would be managed and protected to avoid conversion and reduce human contact with pathogens that lead to zoonotic diseases in areas of high risk. protecting wildlife in these pandemic prevention areas from overhunting, restricting access to bat caves and roosts, could also reduce the potential for more catastrophic outbreaks. future iterations of the global safety net should incorporate additional biodiversity metrics (including marine and freshwater species) and layers that could help inform food and water security. current and future energy and transportation infrastructure should also be included. connectivity analyses should be refined by ecoregion to account for the habitats and species populations requiring connectivity and to account for likely climate impacts. to this end, we have designed this version of the global safety net to be updated by adding new data layers and allowing for dynamic analyses via google earth engine ( ) , so that targets may be adjusted in real time as changes in land use occur. future iterations can also incorporate higher-resolution ecoregional plans, recent spatial data on arable land, agricultural productivity, yield gaps, energy needs and resources, water balance, and the most recent climate models and various carbon maps. ultimately, these evolving maps can refine pathways for conserving earth's land surface to save the diversity and abundance of life, to produce enough food for humanity, and to stay within the bounds of a safe operating space to ensure the well-being of future generations. for the global safety net to be politically achievable requires broad engagement from civil society, public agencies, communities, and indigenous peoples. yet, it is also essential to state clearly that the formulation of the global safety net in no way is intended, is not based on, and does not advocate taking current agricultural land out of production, removing indigenous or other people from lands, or implying that % of all terrestrial ecoregions be conserved. in particular, with regard to indigenous peoples, the global safety net reaffirms their role as essential guardians of nature. currently unprotected high-carbon areas with median total carbon > mt/ha overlap extensively ( . %) with areas selected under target , highlighting the importance of these lands for biodiversity conservation and climate stabilization. other areas important for biodiversity but of lower carbon value, i.e., < mt/ha, are also shown. additional csas, including tier and tier csas, are also selected to bridge the gap for adequate carbon storage beyond areas identified in target . the level of planning and foresight that is needed to properly scale nature conservation requires the emergence of a worldview that embraces the notion of stewardship at a planetary scale. decades after the famous motto "think globally, act locally" was coined, the global safety net offers a possible solution to today's converging socioecological crises, from local to global. human societies are late in the game to rectify impending climate breakdown, massive biodiversity loss, and, now, prevent pandemics. the global safety net, if erected promptly, offers a way for humanity to catch up and rebound. many species are naturally rare, that is, they have narrow ranges, occur at low densities, or exhibit both conditions ( ) . other species may once have been widespread and common, but as a result of human activities such as habitat conversion, overhunting, or invasive species, now have limited ranges or few remaining individuals. conservation biologists have devoted considerable effort to mapping narrow range endemic and threatened species. most of these data layers are generated using optimization approaches to conserve the maximum number of species in the smallest area possible. almost all conservation priority mapping to date is informed by -diversity-the number of species present in a given area. much neglected is -diversity-the turnover of plant and animal species communities with distance and along elevational or environmental gradients. the turnover effect creates distinct species assemblages, a conservation priority in its own right. high levels of -diversity are characteristic across tropical moist forest, tropical dry forest, tropical grassland and savanna, tropical montane grasslands, mediterranean climate shrublands, and some of the tropical xeric biome. many of the high--diversity ecoregions have undergone extensive conversion and are recognized as biodiversity hot spots ( ) . this cluster addresses unprotected landscapes containing rare global phenomena. here, we include areas containing the last intact large mammal assemblages of the terrestrial realm (including species such as large mammalian carnivores that are rare locally but range widely) ( ) . some of these large polygons also overlap with terrestrial large-mammal migrations of the most wide-ranging large-mammal species, perhaps the most endangered ecological phenomenon on earth ( ) . the latter element is not comprehensively mapped on a global scale but could be added to this category. other rare ecological and evolutionary phenomena, not included in this formulation, are aggregations of breeding species, sites of adaptive radiations across multiple taxa, and migratory stopover sites. some of the polygons selected in layers to and and encompass these incompletely mapped elements of biodiversity. kbas, for example, include many migratory stopover sites and breeding aggregations of birds. maps of wilderness and intact forest landscapes show that structurally intact habitats are increasingly rare ( , ) . large intact habitats contain ecological features that cannot be conserved in the small polygons characteristic of ecological elements in the first two clusters. to this end, we included the last of the wild in each ecoregion ( ) and wilderness areas ( ) . the current version of the global safety net is formulated from biodiversity layers (fig. s , a to k, and table s ). we partitioned two of the above datasets to calculate a median pixel values: iucn rangesize rarity raster (median = . ) ( ) and small-range vertebrates raster (median = ) ( ) . for both datasets, only pixels greater than or equal to the median values were used. in the case of rare plant species, to be conservative, we excluded pixels containing only one to two rare plant species. the rationale here is that some of these are known from one to a few specimens. all raster data were converted to vector data (polygon) for further analysis. we overlaid each of these biodiversity data layers with all terrestrial protected areas ( ) to remove areas already set aside for conservation. to remove double counting, we subtracted any overlapping areas with previous datasets. for example, all azes are included as kbas. we ingested resulting layers into the google earth engine to derive remaining habitat in each layer using percent tree-cover maps ( ) in forested ecoregions (except boreal forests) and excluded globally significant patterns of human land use and populations ("anthromes") in nonforested ecoregions ( ) [see ( ) for detailed methods]. we selected all nonoverlapping unprotected areas within each of layers to and only the remaining habitat for layers and as contributions toward target . for layers to within "species rarity," we added a -km buffer around all unprotected sites except layer , rare plant species, as the size of a "rare plant pixel" was ~ , km . to estimate carbon storage potential by biodiversity layer to construct (fig. , table , and table s ), we first overlaid a map of total carbon biomass ( )-which includes above ground, below ground, and soil carbon-with terrestrial ecoregion boundaries ( ) to derive the median carbon density for each ecoregion. to determine csas, we selected ecoregions with a median total carbon density > mt/ha as candidates for tier csas. ecoregions with a median total carbon density between and mt/ha were designated as tier csa candidates. ecoregions with low levels of carbon density (< mt of total carbon per hectare) were not selected as potential sites for additional csas. we then selected all remaining habitat outside protected areas after removing any overlap with the biodiversity layers to derive the polygons for tier and tier csas. on the basis of the best available literature, we designed wildlife corridors to meet the ecological requirements of the most wideranging species that must disperse as part of their life histories and climate corridors that would allow species movement up and down mountainsides, along riparian corridors, or across human-dominated landscapes ( ) . the connectivity analysis was a computationally intensive analysis that included producing a cost-distance matrix, weighing land cover classifications, buffering, and processing. the cost-distance matrix surface was developed as a surface intended to represent varying levels of resistance for wildlife to move along a landscape with regard to vegetation cover, slope, roads, and other land uses. while future iterations should be more specific to ecoregions and local fauna, for this first global scoping phase, we used continents as the unit of analysis and corridors were modeled considering variables that are potentially important for the gene flow of terrestrial species generally. we weighted both variables and classes, depending on the type of data, so that higher weights were given for factors that have higher costs. land cover data were obtained from the european spatial agency with a spatial resolution of m and was reclassified considering the degree of anthropized areas. urban areas and water bodies were excluded from the modeling. roads, railways, and mining areas were buffered. the design of the corridor network and the links between core areas was done with the linkage mapper toolkit of the circuitscape project (www. circuitscape.org). a full description of the methods is available from the authors. here, we identify five potential sources of variation in our results that could be improved in future iterations of the global safety net. we also point to how variants in methods or data sources differ from other, recent efforts to map global biodiversity ( , ) . the total land surface we used to produce the global safety net is based on earth's entire terrestrial area excluding antarctica, which amounts to , , km . much of antarctica includes rock and ice, and the tundra ecoregions on the continent do not contribute to the key targets of the global safety net. the total land area calculated by this method is closely comparable to that adapted by the world database on protected areas from which they derive the . % terrestrial coverage that is the standard used in other biodiversity analyses in preparation for the convention on biological diversity. as a result, the global safety net does differ from other studies-allan et al. ( )-that use a larger total terrestrial area estimate of about , , km . the % of earth's terrestrial area that allan et al. ( ) call for increased conservation attention amounts to million km . in contrast, the . % of earth's terrestrial area included under global safety net for currently protected areas and target totals . million km . when applying layers to of cluster , we used the original polygons provided by the authors of each dataset. as a result, these four data layers include varying amounts of nonhabitat within each selected polygon. we did not apply habitat suitability modeling to refine these datasets as it would further fragment these critical areas for narrow-range and rare species, which could have detrimental effects for biodiversity conservation, especially where some of these adjacent nonhabitat areas are prime candidate for restoration or reconnecting via wildlife corridors. for those reasons, we used the original polygons, including nonhabitat areas, in our analysis for cluster . the inclusion of nonhabitat areas is essentially moot because of its limited spatial extent: summing the entire area of nonhabitat from layers to adds only , km (or . % of the total land surface of earth to the . % selected for cluster ). we suggest removal of nonhabitat is best performed at the ecoregion scale by local experts and done on a case-by-case basis. a goal for the global safety net is to identify near-term opportunities to achieve the global nature conservation target, i.e., areas where additional protection can have the most effective conservation outcome. thus, we focused on suitable natural habitat remaining without the need for major restoration. we therefore selected only intact or semi-intact habitat remaining outside currently protected areas to derive potential contributions to the global safety net from layers to (clusters to ) and from additional areas for carbon storage (csas). we overlaid the global safety net with the most recent global map of lands managed or controlled by indigenous peoples ( ) to determine the extent to which such lands overlap with the existing network of protected areas. the intent was to illustrate the role such lands could have in enhancing biodiversity protection and carbon storage if this were the intention of peoples managing such areas. two sources of variation are noted: (i) many indigenous peoples' lands remain unmapped. blank areas merely indicate that no publicly available datasets currently indicate the presence of indigenous peoples from those areas; the map, however, should not imply absence of indigenous peoples. (ii) the scale at which indigenous lands are mapped in is based on multiple public datasets varying greatly in spatial resolution ( ) . for example, polygons in the sahara and in the tundra ecoregions are much larger and more coarse grained than those mapped within the united states and the brazilian amazon. total carbon was mapped as metric tons per hectare for each pixel (pixel size ~ . km at the equator) ( ) . we used the zonal statistic tool in arcmap . . to calculate median total carbon value for each of earth's terrestrial ecoregions ( ) . as a result, the values for median total carbon density per ecoregion include pixels that are classified as protected areas, remaining habitat outside protected areas, and nonhabitat (e.g., cities and agricultural lands). to estimate the total carbon that could be safeguarded via additional protection of lands under targets and , we multiplied the carbon density of the ecoregion by the area of remaining habitat for each data layer in that ecoregion that could contribute to the global safety net. however, our approach implies that the total carbon added in certain ecoregions may be overestimated or underestimated. for example, in an ecoregion where the majority of the habitat is protected, the median total carbon density per hectare for the ecoregion could be higher than the carbon density per hectare of the habitat remaining outside protected areas. alternatively, in an ecoregion containing a large expanse of nonhabitat (urban areas or converted lands for agriculture), the median total carbon density for the ecoregion might be lower than the carbon density of the habitat remaining outside protected areas. managing the middle: a shift in conservation priorities based on the global human modification gradient conservation attention necessary across at least % of earth's terrestrial area to safeguard biodiversity bolder thinking for conservation biodiversity and climate change: transforming the biosphere natural climate solutions contribution of the land sector to a . °c world degradation and forgone removals increase the carbon impact of intact forest loss by % svenning, % land conservation and climate action reduces tropical extinction risk by more than % an attainable global vision for conservation and human well-being a global deal for nature: guiding principles, milestones, and targets global shifts in mammalian population trends reveal key predictors of virus spillover risk vertebrate biodiversity on indigenous-managed lands in australia, brazil, and canada equals that in protected areas how to protect half of earth to ensure it protects sufficient biodiversity the biology of rarity: patterns, causes and consequences measuring forest biodiversity status and changes globally developed by the kba partnership: birdlife international, international union for the conservation of nature, amphibian survival alliance, conservation international, critical ecosystem partnership fund, global environment facility, global wildlife conservation, natureserve, rainforest trust the commonness of rarity: global and future distribution of rarity across land plants persistence of large mammal faunas as indicators of global human impacts are we capturing faunal intactness? a comparison of intact forest landscapes and the "last of the wild in each ecoregion sixteen years of change in the global terrestrial human footprint and implications for biodiversity conservation mapping co-benefits for carbon storage and biodiversity to inform conservation policy and action protected area connectivity: shortfalls in global targets and country-level priorities a spatial overview of the global importance of indigenous lands for conservation the projected timing of abrupt ecological disruption from climate change amazon tipping point: last chance for action achieving the paris climate agreement goals global restoration opportunities in tropical rainforest landscapes mapping and understanding changes in tree cover in nepal: to importance of indigenous peoples' lands for the conservation of intact forest landscapes airborne laser-guided imaging spectroscopy to map forest trait diversity and guide conservation submission from civil society on the discussions of the thematic workshop on area-based conservation measures how to pay for saving biodiversity nature risk rising: why the crisis engulfing nature matters for business and the economy google earth engine: planetary-scale geospatial analysis for everyone global decline in aggregated migrations of large terrestrial mammals the last frontiers of wilderness: tracking loss of intact forest landscapes from high-resolution global maps of st-century forest cover change anthropogenic transformation of the biomes conceptualizing and designing corridors for climate change we would like to thank d. basiero, n. burgess, s. butchart, s. garnett, c. jenkins, r. noss, s. pimm, a. plumptre, and two anonymous reviewers for comments on the manuscript. we thank the kba secretariat and unep-wcmc for sharing several data layers used in the analysis. supplementary material for this article is available at http://advances.sciencemag.org/cgi/ content/full/ / /eabb /dc competing interests: the authors declare that they have no competing interests. data and materials availability: all data needed to evaluate the conclusions in the paper are present in the paper and/or the supplementary materials. additional data related to this paper are available at www.globalsafetynet.app concurrent with publication and may be requested from the authors. key: cord- -kepbz authors: galaz, victor; Österblom, henrik; bodin, Örjan; crona, beatrice title: global networks and global change-induced tipping points date: - - journal: int environ agreem doi: . /s - - - sha: doc_id: cord_uid: kepbz the existence of “tipping points” in human–environmental systems at multiple scales—such as abrupt negative changes in coral reef ecosystems, “runaway” climate change, and interacting nonlinear “planetary boundaries”—is often viewed as a substantial challenge for governance due to their inherent uncertainty, potential for rapid and large system change, and possible cascading effects on human well-being. despite an increased scholarly and policy interest in the dynamics of these perceived “tipping points,” institutional and governance scholars have yet to make progress on how to analyze in which ways state and non-state actors attempt to anticipate, respond, and prevent the transgression of “tipping points” at large scales. in this article, we use three cases of global network responses to what we denote as global change-induced “tipping points”—ocean acidification, fisheries collapse, and infectious disease outbreaks. based on the commonalities in several research streams, we develop four working propositions: information processing and early warning, multilevel and multinetwork responses, diversity in response capacity, and the balance between efficiency and legitimacy. we conclude by proposing a simple framework for the analysis of the interplay between perceived global change-induced “tipping points,” global networks, and international institutions. global environmental change can unfold rapidly and sometimes irreversibly if anthropogenic pressures exceed critical thresholds. such nonlinear change dynamics have been referred to as ''tipping points''. evidence indicates that many global environmental challenges such as coral reef degradation, ocean acidification, the productivity of agroecosystems, and critical earth system functions such as global climate regulation display nonlinear properties that could imply rapid and practically irreversible shifts in bio-geophysical and social-ecological systems critical for human well-being (steffen et al. ; rockström et al. ; lenton et al. ) . the potential existence of ''tipping points'' represents a substantial multilevel governance challenge for several reasons. first, it is difficult to a priori predict how much disturbances and change a system can absorb before reaching such a perceived ''tipping points'' (scheffer et al. ; scheffer and carpenter ) , a fact that seriously hampers, and even undermines preventive decision making (galaz et al. a ; barrett and dannenberg ) . it has also been argued that even with certainty about the location of a catastrophic ''tipping point,'' present generations still have an incentive to avoid costly preventive measures, and instead are likely to pass on the costs to future generations (gardiner , see also brook et al. ; schlesinger ). second, the transgression of ''tipping points''-such as those proposed for coral reef ecosystems due to ocean acidification-can have social-ecological effects that occur over large geographical scales, creating difficult ''institutional mismatches'' as policy makers respond too late or at the wrong organizational level (walker et al. ). third, institutional fragmentation has been argued to seriously limit the ability of actors to effectively address perceived ''tipping point'' characteristics due to inherent system uncertainties, information integration difficulties, and poor incentives for collective action across different sectors and segments of society (biermann ; galaz et al. ) . research initiatives such as the earth system governance project have made important analytical advances the last few years ). this progress is particularly clear in research areas such as institutional fragmentation, segmentation, and interactions; the changing influence of non-state actors in international environmental governance; novel institutional mechanisms such as norm-setting and implementation; and changing power dynamics in complex actor settings (young ; biermann and pattberg ; oberthür and stokke ) . the mechanisms which allow institutions and state and nonstate actors to adapt to changing circumstances (by some denoted adaptiveness) are also gaining increased interest by scholars (biermann : ; young ) . another stream of literature elaborates a suite of multilevel mechanisms that seem to be able to ''match'' institutions with the dynamic behavior of social-ecological systems (dietz et al. ; folke et al. ; cash et al. ; galaz et al. ; pahl-wostl ) . despite an increased interest, however, few empirical studies exist that explicitly explores the capacity of international actors, institutions, and global networks to deal with perceived ''tipping point'' dynamics in human-environmental systems. as an example, recent syntheses of critical global environmental governance challenges in the anthropocene identify important ''building blocks'' for institutional reform, yet do not elaborate governance mechanisms critical for responding to nonlinear environmental change at global scales kanie et al. ) . this is troublesome considering that the human enterprise now affects systems with proposed nonlinear properties at the global scale (steffen et al. ; rockström et al. ) and that the features of global environmental governance-i.e., institutions and patterns of collaboration-required to address ''tipping point'' changes are likely to be very different from those needed to harness incremental (linear) environmental stresses (folke et al. ; duit and galaz ) . while some of the challenges explored here have parallels to attempts to understand the features of international responses to international social nonlinear ''surprise'' phenomena such as financial shocks and other global risks (e.g., claessens et al. ; oecd ) , we are particularly interested in the ''tipping point'' dynamics created by coupled human-environmental change. there is an increasing need to empirically explore and theorize the way state and non-state actors perceive, respond to and try to prevent large-scale abrupt environmental changes. this is a challenging empirical task for several reasons. first, because the definitions of ''thresholds,'' their reversibility, and their scale remain contested issues. there is currently an intense scientific debate on the most appropriate way to define and delineate the correct spatial (local-regional-global) and temporal (slow-fast) progression of thresholds (for example, see brook et al. , as well as debates about the '' -degree'' climate target, hulme in knopf et al. ) . second, because the number and types of potential ''tipping points'' relevant for the study of biophysical systems at global scales are too large to be quantifiable, this makes it difficult to draw general conclusions from a limited set of cases studies. third, while the governance challenges associated with ''tipping points'' have been studied extensively for local-and regional-scale human-environmental systems such as forest ecosystems, freshwater lakes, wetlands, and marine systems (see plummer et al. for a synthesis), governance challenges associated with global scale or global change-induced tipping point dynamics are seldom explored despite their identified urgency (young : ) . in this study, we analyze current attempts by three global networks to address perceived ''tipping points'' induced by global change, here exemplified by the combined impacts of loss of marine biodiversity and ocean acidification, pending fisheries collapse, and infectious disease outbreaks, respectively. while these ''tipping points'' are in many ways different, they have one important thing in common: they are all globally occurring phenomena where the interplay between technological change, increased human and infrastructural interconnectedness, and continuous biophysical resource overexploitation creates possible ''tipping point '' dynamics (see definition below) . this is what we here denote as ''global change-induced tipping points.'' it should be noted that the precise dynamics of the ''tipping points'' in each of the three cases differ and unfold at multiple scales ranging from local to regional and global (see table for details). despite this diversity, the phenomena studied here all pose similar detection, prevention, and coordination challenges for social actors at multiple scales of social organization (as elaborated by, e.g., adger et al. ; pahl-wostl ; galaz et al. a; young ) . hence, they provide interesting and preliminary insights into the sort of multilevel governance challenges associated with nonlinear global change-induced change. our ambition is twofold: firstly, we investigate how these global networks attempt to identify, respond to, and build capacity to address global change-induced ''tipping points.'' we do this by identifying and empirically illustrating four working propositions that theoretically seem to be essential for understanding adaptiveness in global networks in the face of ''tipping point'' changes. secondly, we explore the interplay between perceptions of human-environmental ''tipping points,'' international institutions, and collaboration patterns here operationalized as global networks. this perspective allows for a more cohesive view that combines both exogenous (i.e., perceived ''tipping point'' dynamics) and endogenous (i.e., information sharing mechanisms) factors (sensu young ). we will return to this point in the end of the article. note that, our ambition is not to ''test'' the proposed features in a statistical sense, but rather to combine in-depth analysis of the case studies, with tentative suggestions that bring to light a number of intriguing and poorly explored issues. while the selection of cases does not provide the generalizability of larger-n studies, it does allow us to examine how the theoretically derived propositions play out in the three different cases, and also provides an opportunity to explore around the potential interplay between variables and causal mechanisms. our ambition in the longer term is that the analysis presented here can underpin more systematic cross-case comparisons (cf. gerring ) . in some cases, this comparison could be done with ''tipping points'' which play out only in the social domain such as financial crises or responses to transnational security threats (e.g., world economic forum ). we define ''global networks'' as globally spanning information sharing and collaboration patterns between organizations, including governmental and/or non-governmental actors. each individual participating organization is not necessarily global, but the network as a whole is essentially international and aims to affect what is perceived as global-scale problems (c.f. monge and contractor ) . our analytical approach is relational as it focuses on broad patterns of collaborations among actors in global networks, and on how patterns of collaboration and modes of operation relate to these networks' abilities to address ''tipping points.'' it is particularly concerned with multiactor agency to understand changes in collaboration over time (emirbayer and goodwin ) . hence, the approach here differs and is complementary to other approaches such as ''epistemic communities'' and ''regime complexes.'' in the first case, the functions and membership of global networks are more diverse than those for epistemic communities as the networks of interest in this paper span beyond knowledgebased collaborations (haas , see however cross for a wider definition). the analysis here also has some similarities to the studies of ''regime complexes'' (orsini et al. ) ; however, our emphasis is not on the interplay between regimes or institutions (principles, norms, rules, decision-making procedures), but rather on the constellation, interplay, and functions that emerge between actors from a network perspective. while we do not quantitatively measure collaboration patterns, nor quantitatively assess governance outcomes or relationships between such outcomes and various characteristics of the studied global networks, our network perspective complements previous analyses of international environmental regimes (e.g., young ) as it examines the evolution and function of globally spanning network collaboration patterns and their embeddedness within more formal rules (cf. ansell ). various definitions for ''tipping points'' have been identified in the literature. its theoretical origins can be traced to dynamical systems theory in the s and s, and has influenced a wide set of disciplines the last decades. earth system scientists, for example, have explored nonlinear phenomena at different scales, with different degrees of reversibility and alternately defined these as ''tipping elements,'' ''switch and choke points,'' or ''planetary boundaries'' at a global scale (lenton et al. ; rockström et al. b; steffen et al. ) . ecologists on the other hand find increasing evidence of ecosystem changes that are not smooth and gradual, but abrupt, exhibiting thresholds with different degrees of reversibility once crossed (scheffer et al. ; scheffer and carpenter ) . while ''tipping points'' thus refer to a variety of complex nonlinear phenomena (including the existence of positive feedbacks, bifurcations, and phase transitions with or without hysteresis effect), they also play out at different scales (from local to global) in very complex, poorly understood , and contested ways (brook et al. ) . lastly, we believe there is an irreducible social component in identifying, elaborating, and organizing around the existence of ''tipping points.'' the role of mental models, cognitive maps, belief systems, and collective meaning making in decision making has a long history in the study of agency in politics (benford and snow ; campbell ) and natural resource management (lynam and brown ) . these aspects related to perceptions clearly also play a role as scientists, governments, and other actors discuss and sometime disagree on their possible existence and appropriate responses (galaz : ff) . the important connection between mental models and goal-oriented action are causal beliefs-perceptions of the causes of change-and about the actions that can lead to a desired outcome (milkoreit : f) . it should be noted, however, that this study explores the processes of collaboration that occur after social actors implicitly have agreed upon causal beliefs associated with perceived ''tipping points.' ' we thus recognize the multifaceted and complex nature of the term. however, as our goal is to understand how global networks address a diversity of ''tipping points'' induced by global change, we opt for a definition that relates to phenomena exhibiting nonlinear and potentially irreversible change processes in human-environmental systems, which require global responses (see table ). this definition is intended to capture global changeinduced phenomena, which due to nonlinear properties such as synergistic feedbacks (c.f. brook et al. : ) have the potential to affect large parts of the world population (c.f. lenton et al. ). our definition is akin to the ''tipping elements'' identified by lenton et al. ( ) , but we chose to make a distinction for two reasons: ( ) because we explicitly acknowledge that the dynamics that create the tipping points in focus comprise both natural and social processes; ( ) the tipping points addressed here span beyond those of relevance for the climatic system in focus in lenton et al. (ibid) . the empirical analysis includes case studies of three global networks ( fig. ) that with varying degrees of outputs and outcomes (sensu young ) explicitly attempt to respond to global change-induced ''tipping points'' (table ) . by ''explicitly,'' we mean that they all acknowledge and mobilize their actions around the notion of potentially harmful global change-induced ''tipping points.'' while this selection does not capture cases where ''tipping points'' exist, but global networks fail to materialize (c.f. dimitrov et al. ) , the ambition has been to include cases that reflect a diversity of global change-induced ''tipping point'' dynamics, with global network responses as common features. as noted by mitchell ( ) , the complexity of human-environmental systems makes outcomes of international environmental collaboration hard to measure directly, since these often have indirect and non-immediate impacts (mitchell : ) . to operationalize the analysis, we thus focus on the outputs and outcomes produced by the actors as they attempt to (a) anticipate, (b) prevent, and (c) respond to perceived ''tipping points.'' again, our ambition is not to ''test'' the propositions, but rather to use the case studies to empirically explore how global networks attempt to respond to ''tipping point'' challenges, pose novel important questions, and explore how to potentially pursue these questions systematically. ocean acidification is likely to exhibit critical tipping points associated with rapid loss of coral reefs, as well as complex ocean-climate interactions affecting the oceans' capacities to capture carbon dioxide. the global arena for addressing these interrelated aspects of marine governance is characterized by a lack of effective coordination among the policy areas of marine biodiversity, fisheries, climate change, and ocean acidification. this has triggered collaboration between a number of international organizations within the global partnership for climate, fisheries and aquaculture (henceforth pacfa). currently, this initiative includes representatives from the food and agriculture organization (fao), the united nations environment programme (unep), worldfish, the world bank, and additional international organizations , see also fig. ). the need for early and reliable warning of pending epidemic outbreaks has been a major concern for the international community since the mid-nineteenth century. early warning and coordinated responses are critical in order to avoid transgressing critical epidemic thresholds at multiple scales (heymann ) . a multitude of networks with different focus and functions (such as surveillance, laboratory analysis, and pure information sharing) have emerged the last two decades as a means to secure early warning and response capacities across national borders. these networks (henceforth global epidemic networks) also span across organizational levels and include among other the world health organization (who), the world organization for animal health (oie), the food and agricultural organization (fao), the red cross, doctors without borders. these networks facilitate responses to epidemic emergencies of international concern by providing early warning signals, rapid laboratory analysis, information dissemination, and coordination of epidemic emergency response activities on the ground (galaz the data used in this article are drawn from previously published studies (see ''appendix ''), but complemented with additional documents, and restructured with a focus on the four working propositions presented below. all cases used the same methodology, combining document studies, simple network analysis, and semi-structured interviews with key international actors (a total of about interviews for all cases). interviewees have been selected strategically to reflect an expected diversity of interests, resources, and role in the network collaboration of interest. the empirical material was restructured and complemented to capture ( ) the perceived risk of ''tipping points'' with cross-boundary effects, including major uncertainties, threshold mechanisms, and time frames of relevance; ( ) the global nature of the problem, including the aspects of institutional fragmentation; ( ) emergence of the network and evolution over time; ( ) current monitoring and coordination capacity of the network; ( ) the most important outputs and outcomes of the network. a detailed, fully referenced and structured compilation of the cases is for space reasons, available as ''appendix .'' several attempts have been made to identify how governments, organizations, and international actors attempt to not only maintain institutional stability, but also flexibility in the face of unexpected change (duit and galaz ) . studies of crisis management (boin et al. ) , network management and ''connective capacity'' in governance (edelenbos et al. ) , the robustness of social and organizational networks (dodds et al. ; bodin and prell ) , complexity leadership (balkundi and kilduff ) , and the governance of complex social-ecological systems (ostrom ; folke et al. ; pahl-wostl ) all provide important insights into how social actors try to respond to unexpected changes. based on these streams of literature, we extract four working propositions to guide the analysis of the empirical material. these propositions should not be viewed as allembracing principles for ''success,'' but rather as suggested and empirically assessable governance functions at play as international actors aim to detect, respond, and prevent the implications of ''tipping point'' environmental change. the propositions also allow a concluding reflection of the interplay between international institutions, global changeinduced ''tipping points,'' and global networks. as a number of research fields-ranging from studies of social-ecological systems (holling ; folke et al. ; galaz et al. b) , crisis management (boin et al. ) , global disaster risk reduction (van baalen and van fenema ), and high-reliability management of complex technical systems (pearson and clair )-have explored, the capacity to continuously monitor, analyze, and interpret information about changing circumstances seems to be a prerequisite for adaptive responses. these information processing capacities are for example identified as critical by, e.g., dietz et al. ( dietz et al. ( : in their elaboration of the features of governance, which support adaptiveness to environmental change; van baalen's and van fenema's ( ) analysis of global network responses to epidemic surprise; and by boin et al. ( : ff) and their synthesis of information processing capacities, which allow state and non-state actors to respond to crises (see also comfort ; dodds et al. ) . we therefore propose that the ability of global networks to anticipate and reorganize in the face of new information and changing circumstances will depend on access to information about system dynamics and the ability to interpret these to facilitate timely coordinated response. global networks and global change-induced tipping points as a number of studies in a diverse set of research fields suggest, responding to changing circumstances often requires drawing on the competences and resources of actors at multiple levels of social organization, often embedded in different organizational networks. for example, folke et al. ( ) explore the need to build linkages between a diversity of actors at multiple levels to be able to successfully deal with nonlinear social-ecological change (see also pahl-wostl ); pearson and clair's ( : ) synthesis of organizational crises identify resource availability through external stakeholders as key for successful responses (see also boin et al. ; van baalen and van fenema ); galaz et al. ( a: ) synthesis also indicate that cross-level and multiactor responses are key for overcoming institutional fragmentation in responses to abrupt human-environmental change; and edelenbos et al. ( ) explore the features of ''connective capacities,'' which allow coordinating actors to constructively connect to actors from different layers, domains, and sectors. therefore, we propose that global networks need to build a capacity to coordinate actors at multiple levels and from different networks as they attempt to respond to potential ''tipping points'' of concern. it also seems reasonable that responses could focus on producing either a set of outcomes (regulation, polices, or supporting infrastructure) or outputs (behavioral changes with direct impacts on the system of interest, including coordinated action) (young ). the predictability of the timing and location of rapid unexpected changes is often limited. hence, it is difficult to know beforehand exactly where and what kind of resources may be needed. as several scholars across disciplines have noted, developing and maintaining a diversity of resources is one way to help prepare for the unexpected. for example, moynihan's ( : ) analysis of learning in organizational networks indicates that the maintenance of actor and resource diversity in networks is fundamental for reducing strategic and institutional uncertainty (see also koppenjan and klijn ) . bodin and crona ( ) explore the role of social networks in natural resource management and note that actor diversity is key for not only effective learning, but also provides a fertile ground for innovation. social-ecological scholars such as folke et al. ( : ) , low et al. ( ) , and dietz et al. ( ) also make a strong case for institutional and actor diversity as a prerequisite for coping with environmental change and as a factor that allows actors to quickly ''bounce back'' after shocks. these proposals bear resemblances with ideas inspired by cybernetic principles about the need to understand the impacts of ''requisite variety'' in governance, that is, the informational, structural, and functional redundancies that emerge as the result of inter-organizational collaboration in governance networks (jessop ) . it also has parallels existing studies about complexity leadership in network settings (balkundi and kilduff ; hoppe and reinelt ) . to simplify the analysis, however, we focus less on the role of individual leaders, their cognition, and strategies, but rather on common structural properties and aggregated behavior across the cases. hence, we propose that global networks need to secure long-term access to a diversity of resources (human and economical), organizational forms (e.g., non-governmental to international organizations), and types of knowledge (e.g., scientific and context dependent) to be able to secure a capacity to monitor and respond in the longer term. these resources could comprise both physical and infrastructural investments (e.g., joint publications and monitoring systems), and immaterial resources, like information databases and access to expertise through relations to a diversity of actors. this third proposition does not suggests that the network necessarily maintains the resources itself (which may be difficult given its inherently distributed nature), but rather that it maintains the capacity to access a portfolio of resources of different kinds, and the collective ability to adaptively use these. a last feature that has been identified across disciplines as critical for multiactor responses seems to be legitimacy. ''legitimacy'' is a multifaceted concept with multiple proposed sources (downs ) . here, we refer to legitimacy as the ''generalized perception or assumption that the actions of an entity are desirable, proper, or appropriate'' (suchman , ) . as young ( ) summarizes it, the ''[m]aintenance of feelings of fairness and legitimacy is important to effectiveness, especially in cases where success requires active participation on the part of the members of the group over time.'' legitimacy relates not only to the ability of actors to follow appropriate rules or procedures (input legitimacy) but also to deliver expected results in the face of perceived urgent issues of common interest (output legitimacy) (van kersbergen and van waarden ) . moynihan ( ) also notes that trust based on perceived legitimacy plays a key role in the coordination of multiple networks by reducing strategic uncertainty (pp. ). we therefore propose that the perceived legitimacy of the main coordinating actor(s) will be critical for the operation of global networks in this context. with these propositions to guide our analysis, we now turn to examine how the three cases of global networks attempt to anticipate, prevent, and respond to global changeinduced ''tipping points.'' summary of results . information processing and early warnings interestingly, all cases feature the role of a few centrally placed actors responsible for continuous data gathering and exchange of information. this is both related to monitoring of specific aspects of a system (e.g., number and location of epidemic outbreaks, or reports of iuu fishing), as well as to the compilation and analysis of other types of knowledge exchange (e.g., policy documents, technical guidelines, and scientific information). the mobility of iuu fishing vessels and associated products requires network members to be able to instantly coordinate action in order to stop illegal activities. the ccamlr-iuu network has developed mechanisms for obtaining, processing, and sharing of information related to iuu fishing operations and trade flows, where the ccamlr secretariat serves as an important network hub (Ö sterblom and bodin ). this network benefits from several well-established compliance mechanisms developed over time, including an electronic catch documentation scheme and information collected from satellite monitoring of vessel activities . non-state actors also contribute to monitoring by reporting suspected vessel sightings or trade flows (Ö sterblom and bodin ). all information collected is reviewed annually by ccamlr, where consensus decisions are taken to blacklist suspected vessels or impose other sanctions. similar features can be identified for information processing in global epidemic networks. severe problems with national reporting of disease outbreaks spurred a new generation of internet-based monitoring systems in the mid- s, including the global public health intelligence network (gphin) hosted by health canada, combining internet datamining technologies and expert analysis, as well as global and moderated epidemic alert e-mail lists and platforms such as promed and healthmap.org (galaz ) . these systems have vastly increased the amount of epidemic early warnings processed by key international organizations such as the who and the food and agricultural organization (fao). these organizations are key actors through their capacities to continuously assess, verify, and disseminate incoming epidemic alerts. the rich flows of information and elaborate verification mechanisms in these two networks are very different from those identified for pacfa. information flows in this network are considerably less formalized and instead center on establishing dialogue between centrally placed individuals who act as points of contact in different international and regional organizations. the importance of trust-based communication between coordinating actors is important for pacfa as alliances are forged to link international negotiations, scientific knowledge and local knowledge, and field projects . here, therefore, information processing is not about monitoring a particular system variable (i.e., number of infected cases or reports of illegal fishing vessels), but rather on achieving coordination benefits for its members. hence, while information processing is important in all cases, it differs in content and function between the networks. the fact that the first two networks respond to well-defined problems (inception of illegal vessels in one region and the isolation of disease outbreak) and the last to more complex global challenges (i.e., global interlinked bio-geophysical dynamics) seems to make an important difference. while multilevel governance is a common feature of environmental polity in general (winter ) , governing ''tipping points'' requires a capacity among centrally placed a examples of detection, coordination, and apprehension of vessels or corporations suspected of iuu fishing. the vessel ''viarsa'' was detected in the southern ocean by the australian coast guard and suspected of illegally fishing of patagonian toothfish. after the longest maritime hot pursuit in maritime history ( , km) and substantial diplomatic coordination, the vessel was seized after the combined effort from australian, south african, and uk assets. the charges were eventually dropped. b examples of detection and response to emerging infectious diseases of international concern. the first signs of a new flu a/h n (''swine flu'') could be found early in local news reports posted on healthmap. it was one report by the early warning system gphin that alerted the who of an outbreak of acute respiratory illness in the mexican state of veracruz. this induced several iterations of communication between mexico and the who ( ), as well as sharing of virus samples to us and canadian medical laboratories ( ). at this stage, the who also issued several recommendations to its member states ( ). this initiated a chain of national responses (some clearly beyond who recommendations), including thermal screening at airports, travel restrictions, and trade embargoes ( ). the suspected causative agent of a/h n induced stronger collaboration between who, fao, and oie, and the expansion of associated expert groups to include swine flu expertise resulting in continuous recommendations to member states ( ). v. galaz et al. actors, to rapidly pool resources from participating network members at multiple levels. figure is based on two case analyses (see ''appendix '' for details) and illustrates these multilevel collaboration and information sharing processes. national delegations to ccamlr integrate several types of actors, including ngos and fishing industry representatives, who in turn are also members in asoc, the antarctic southern ocean coalition (a global ngo network) or colto-coalition of legal toothfish operators (an industry network). this network can coordinate actors within matters of days and involve rapidly mobilizing capacity to apprehend illegal vessels (fig. a) . global epidemic networks are also nested in a larger global network landscape, with a similar ability to rapidly react to epidemic early warnings, including the identification of the sars coronavirus, analysis and response to an unknown form of influenza in madagascar, and prevention of epidemics of yellow fever in côte d'ivoire and senegal. which national, regional, or international organization that becomes the central coordinator depends on the disease agent and location of interest. however, the who global outbreak and response network (goarn) and the fao emergency centre that facilitates coordination for transboundary animal diseases (ectad) (fig. b ) are well-known key coordinating players. while the pacfa network does not respond to rapidly unfolding system dynamics per se, it tries to identify political opportunities in international policy arenas as a way to prevent ''tipping points'' related to marine systems and biodiversity. hence, the coordination challenges across multiple levels are similar as those identified for the other two networks, but with a different focus. for example, while a overall network aim was initially to influence international climate negotiations in copenhagen to integrate marine issues, the path toward this goal consisted of multiple coordinated actions at multiple levels (from assessing potential adaptation needs locally, communicating these, and influencing national delegations at side events to cop ). this required a capacity among a core group of actors (fao) to tap into resources and knowledge across levels and networks, including international scientific institutions (such as ices), international organizations (world bank), and place-based research ngos (worldfish) ). maintaining response capacity over time requires maintaining access to diverse resources and competences. all three cases examined here have evolved through time by strategically expanding the membership of the network to increase their ''portfolio diversity.'' ccamlr hosts and funds strategic training workshops in regions where effective response capacities have been viewed as lacking (e.g., in southern africa and malaysia). several member countries cooperate extensively around offshore monitoring and training, in order to improve the joint enforcement capacity of the network (Ö sterblom and bodin ). actors within the network-coordinated nationally, between organizations or between groups of countries-also continuously develop suggestions for new and revised policy measures to address iuu fishing. global epidemic networks have stretched over time as the result of an explicit strategy to expand international surveillance and response networks, particularly in epidemic hotspot regions where surveillance is weak (e.g., asia and africa) and for diseases perceived as critical for the international community (such as avian influenza). the expansion is both strategic and crisis-driven, and involves continuous capacity building through workshops, conferences, and guidelines (e.g., heymann ) . similarly, pacfa has expanded membership in parts of the world where representation is missing and where tangible field presence could prove useful for attempts to link local governance to global institutional processes. it has also included member organizations of various types-from ngos to scientific organizations-as an explicit strategy to increase skills and resource portfolios. this has also proven as a fruitful way to create a platform for exchange of knowledge, ideas, and information among members. this seems to improve the network's capacity to coordinate local responses (such as improved local marine governance in the face of ocean acidification) and integrate scientific advice into negotiation texts for international policy improvement ). the synthesis indicates that issues of legitimacy are constantly being debated in all networks, but that their responses differ. in general, however, centrally placed actors seem to build legitimacy by strategically enhancing the diversity and number of members, increasing the degree of formalization in what originally were informal collaboration mechanisms, and by encouraging the entrenchment of the networks in various un organizations. cooperation within ccamlr to address iuu fishing emerged in a context where there was a significant risk of fish stock collapse, but where governments were unable to effectively act due to political sensitivities and constraints posed by consensus mechanisms in the network (Ö sterblom and bodin ). controversial and unorthodox methods for conveying the importance of addressing iuu fishing were instead developed by a small ngo-fishing industry coalition in the mid- s (Ö sterblom and sumaila ). a few governments in parallel also began exerting diplomatic pressure on member states of the commission that were associated with illegal fishing, for example as flag, or port states or with their nationals working on board iuu vessels or as owners of associated companies. this has at times resulted in substantial controversy and heated debate between member states about responsibilities and the role of ngos in ccamlr. joint enforcement operations in the southern ocean have been described as pushing the edge of international law (gullett and schofield ) , and suspected offenders have stated that they do not recognize existing territorial claims in the ccamlr area as legitimate (baird ) . continuous improvements of conservation measures and decision-making processes in ccamlr have proven important for securing legitimacy of procedures. legitimacy issues are also addressed by making commission reports available online (except for background reports and reports containing diplomatically sensitive material). the pacfa has also struggled to balance legitimacy and efficiency. as the goal to influence the unfccc process emerged, the ambitions of pacfa also become more explicitly political. this created tensions in the network between actors wanting to achieve tangible outcomes (and thus output legitimacy), and those concerned with overstepping their respective organizations' mandate (thus maintaining input legitimacy). a clear fault line with respect to this was observed between central international organizations and those representing sciencebased organizations in the buildup to the climate negotiations in copenhagen . while most of the activities initially evolved through the work of a few centrally placed actors with modest formal support from the fao and its member states , the network has become increasingly formalized and recently became a un oceans-taskforce, which is likely to increase the network's input legitimacy in the un system. addressing the risks of novel infectious disease outbreaks has been very high on the political agenda for the last decade, especially in the face of recurrent outbreaks of novel animal influenzas with the capacity to infect humans. information processing and global networks and global change-induced tipping points coordination work is currently supported through the revised international health regulation (ihr). however, this cooperation model orchestrated by the who has also raised severe issues of both input and output legitimacy, especially issues such as the role of scientific advice and the influence of pharmaceutical companies; vaccination recommendations associated with the last pandemic outbreak (''swineflu'' a/h n ); and unequal global access to treatments. this has led to repeated calls for governance reforms aiming to increase transparency, effectiveness, and benefit sharing. it should be noted that border protection issues, primarily associated with the fear of new terror attacks after september in the form of intentional releases of novel diseases, have triggered substantial investments in global epidemic monitoring and response networks for disease outbreaks. analogous national security concerns in australia after the national elections in the year of , and the bali bombings in , likely contributed to an increased political opportunity to invest substantially in monitoring technologies for the southern ocean, as border protection became ''securitized'' (Ö sterblom et al. ). in addition, international cooperation and exchange of information between compliance officers has increased substantially after the terrorist attacks in new york city in . the expansion of the studied two networks described here thus appears to be linked to the securitization of the issue areas, which may have important implications for their perceived legitimacy in the future (c.f. curley and herington ). here, we examined three globally spanning networks that all attempt to respond to a diverse set of perceived global change-induced ''tipping points.'' as the analysis shows, the working propositions have highlighted several interesting functions worth further critical elaboration, associated with the attempts to govern complex, contested, and ''tipping point'' dynamics of global concern (summarized in table ). in short, we have illustrated how state and non-state actors (here operationalized as global networks) attempt to build early warning capacities and improve their information processing capabilities; how they strategically expand the networks, as well as diversify their membership; how they reconfigure in ways that secures a prompt response in the face of abrupt change (e.g., novel rapidly diffusing disease, illegal fishery) or opportunities (e.g., climate negotiations); and how they mobilize economical and intellectual resources fundamentally supported by advances in information and communication technologies (e.g., through satellite monitoring and internet data mining). but crises responses are only one aspect of these networks. between times of abrupt change, centrally placed actors in the networks examined are involved in strategic planning aiming to bridge perceived monitoring or response gaps, capacity building needs, and secure longer-term investments. maintaining legitimacy seems to be critical also empirically for the ability of global networks to operate over time. preventing the transgression of perceived critical ''tipping points,'' however, requires not only early warning and response capacities, but also an ability to address complex and underlying human-environmental drivers that contribute to the problem at hand (walker et al. ). it is important to note that none of the networks studied here have neither the ability nor the mandate to directly address key underlying drivers such as climate change (e.g., for ocean acidification), land-use changes (e.g., associated with changed zoonotic risks), or technological change (e.g., contributing to increased interconnectedness and the loss of marine biodiversity). hence, it remains an open question whether global networks as the ones studied here will ever be able to collaborate if stipulated goals become more conflictive and complex, due to interactions between global drivers such as technological, demographical, and environmental (galaz ). yet, it would be a mistake to discard global networks as mere ''symptom treatment.'' the issues elaborated here not only exemplify how interacting institutions affect humanenvironmental systems at global scales (gehring and oberthür ). the cases also display how global networks attempt to complement functional gaps in the complex institutional and actor settings in which they are embedded. the perceived ''sense of urgency'' (i.e., avoiding the next pandemic, coping with potentially rapid ecological shifts in marine systems, or avoiding large-scale fish stock collapses) seemingly triggers the developed mechanism for obtaining, verifying, and sharing of information about, e.g., illegal vessels through its secretariat. ngo's and licensed fishing industry play key roles in complementing information action involves using political opportunities to bring marine issues on top of international policy agendas, and secure support and funding action involves rapidly coordinating crossnational and multiexpert teams to analyze and respond to epidemic emergencies of international concern action involves rapidly mobilizing national and international agents and assets to apprehend illegal vessels. emergence of global networks created by concerned state and non-state actors. figure illustrates this proposed interplay between international institutions, perceptions of ''tipping points,'' and global networks. by shaping state and non-state action, international institutions play a critical role in affecting the creation of potential global change ''tipping points'' (a in fig. ) (young (young , . these perceived ''tipping points'' also create mixed incentives (b) for collective action. while coordination failure is likely due to actor, institutional, and biophysicial complexity (young ) , the perceived urgency of the issue can also create incentives for action among international state and non-state actors, and spur the emergence of global networks based on common causal beliefs (b). these networks can support the enforcement (c) of existing international institutions through their ability to process information and coordinate multinetwork collaboration, as well as create the endogenous and exogenous pressure needed to induce changes in international institutions. as young notes, these sort of self-generating mechanisms can help build adaptability (d) and combat ''institutional arthritis'' (young , ) . for example, the emergence of novel zoonotic diseases (such as avian influenza) is intrinsically linked to the effectiveness of a suite of institutional rules at multiple levels, e.g., though urbanization, land-use change, and technological development (interplay). the potential of these diseases to rapidly transgress dangerous epidemic thresholds creates incentives for joint action, in this case through the emergence of global early warning and response networks, despite malfunctioning formal institutions (e.g., ihrs before the year ). as nation states agreed to reform the ihrs in , the revisions built on technical standards, organizational operation procedures, and norms developed by who-coordinated networks years in advance (adaptability) (heymann ) . a similar mechanism seems to be at play for illegal, iuu fisheries. as the regional mandate of the existing international governance institution for iuu fishing proved insufficient (interplay), and the perceived threat of potential detrimental ''tipping points'' was perceived as valid (incentives), state and non-state actors increasingly developed their networks to operate at the global level, thereby drastically improving the enforcement capacities of existing international rules (Ö sterblom and sumaila ). international actors trying to prepare for the possibly harmful human well-being implications of ocean acidification and rapid loss of marine biodiversity, also illustrate this triad. as these actors perceive the possible transgression of human-environmental ''tipping points'' (incentives), they coordinate their actions in global networks to increase their opportunities to bring additional issues to existing policy arenas created by international institutions (adaptability). at the same time, these institutions fundamentally affect the biophysical, technological, and social drivers that affect the ''tipping points'' at hand (interplay, e.g., the convention on biological diversity, climate change agreements under the unfccc, and the united nations convention on the law of the sea). the analysis is only tentative of course, especially considering the small number of cases, the contested nature of ''tipping points,'' and the need to explore additional working propositions. for example, we have not elaborated the cognitive and leadership processes leading up to a joint problem definition among the collaborating actors, nor a number of associated issues such as transparency and accountability in complex actor settings. however, the analysis brings together a number of theoretically and empirically founded propositions worth further attention. more precisely, how state and non-state actors perceive and frame global change-induced ''tipping points,'' the unfolding global network dynamics, and how these are shaped by international institutions (fig. ) remain an interesting issue to explore further by scholars interested in the governance of a complex earth system. acknowledgments this research was supported by mistra through a core grant to the stockholm resilience centre, a cross-faculty research centre at stockholm university, and through grants from the futura foundation. h. Ö . was supported by baltic ecosystem adaptive management (beam) and the nippon foundation. Ö . b. was supported by the strategic research program ekoklim at stockholm university. b. c. was supported by the erling-persson family foundation. we are grateful to colleagues at the stockholm resilience centre, and to oran young, ruben zondervan and sarah cornell for detailed comments on early drafts of the article. pacfa is based on official web page (http://www.climatefish.org/index_en.htm) and galaz et al. . the network around iuu fishing in the ccamlr area is based on Ö sterblom and sumaila ( ). note that not all members of ccamlr http://ccamlr.org/pu/e/ms/ contacts.htm are actively engaged in reducing iuu fishing as this is an organization tasked with multiple issues related to natural resources in the southern ocean. appendix : summary of case studies and template for data collection here, we briefly summarize the case studies and the protocol for data collection. data have been collected through semi-structured interviews, literature reviews, and surveys (see individual articles for details, i.e., galaz , galaz et al. b , Ö sterblom and sumaila , Ö sterblom and bodin . all cases used the same methodology, combining document studies, simple network analysis, and semi-structured interviews with key international actors (a total of about interviews for all cases). interviewees have been selected strategically to reflect an expected diversity of interests, resources, and role in the network collaboration of interest. the material has been structured and complemented with additional published and ''gray'' literature to elaborate the five overarching subjects below. these five subjects were identified during a series of author workshops and aimed to provide a structured overview of the perception of the problem to be addressed, the emergence of the network studied, as well as its function, effectiveness, and perceived legitimacy. original data sources and detailed methods are available in the literature cited. ( ) what is the risk of a global change-induced ''tipping point''? a. what is the ''tipping point'' of interest? b. over which time frame does it operate and what is the response capacity required? c. what social and ecological uncertainties exist? d. what underlying social and ecological mechanisms increase the risk of ''tipping point'' behavior? ( ) why is global coordination needed? ( ) how did the global network emerge and evolve? a. how did the network emerge? b. which key actors/organizations were responsible for this development? c. what existing networks/governance features did these actors/organizations build on? d. how did the network develop over time and what is the current trajectory (how is capacity maintained and developed)? e. in what political context did the network emerge and develop? f. to what extent were they supported, or counteracted by state actors and/or other institutions? g. how is it coordinated (and what are the pros and cons of coordination)? h. what framework (legal or otherwise) is regulating network activities (and what are the pros and cons with the framework/lack of framework)? i. how are transparency issues addressed? j. what is known about the perceived legitimacy, fairness, and biases of the network? k. what are the primary tools of action for the network? ( ) how is monitoring, sense-making, and coordinated responses enabled? a. what are the monitoring capacities of the network (is both ecological and social monitoring conducted)? b. how does the network achieve sense-making around ''tipping points''? c. how does the network enable rapid and coordinated responses? d. what role does information and communication technologies play in monitoring, sense-making, and response? e. what are major barriers for a continued evolution of the network? ( ) what outputs and outcomes can be attributed to the network? a. what are the major outputs from the network? b. what are the most important outcomes from the network? case . pacfa: global partnership on climate, fisheries, and aquaculture oceans capture approximately one-third of anthropogenic emissions of greenhouse gases. this process is changing ocean chemistry, making oceans more acidic, with potentially enormous negative consequences for a wide range of marine species and societies as a result of losses of ecosystem services. recent research suggests that ocean acidification is likely to exhibit critical ''tipping points'' associated with rapid loss of coral reefs, as well as complex ocean-climate interactions affecting the oceans' capacities to capture carbon dioxide. the global arena for addressing these interrelated aspects of marine governance is characterized by a lack of effective coordination among the policy areas of marine biodiversity, fisheries, climate change, and ocean acidification. this has stimulated an attempt to better bridge these policy domains to increase coordination aimed at addressing potential critical tipping points. a number of international organizations primarily involved in fisheries initiated the global partnership on climate, fisheries, and aquaculture (from hereon pacfa) in . currently, this initiative includes representatives from fao, unep, worldfish, the world bank, and additional international organizations (fig. ) . joint outputs include synthesizing information as a way to monitor the status of unfolding nonlinear dynamics, dissemination of information in science-policy workshops, and lobbying international arenas. a. pacfa is working with understanding and communicating the risk of tipping points related to ocean acidification, loss of carbon mitigating capacity of the oceans, and fish stock collapses. these tipping points are closely related to human activities (eutrophication, loss of marine biodiversity, degradation of coastal and marine habitats, and overfishing) with substantial impacts on livelihoods galaz et al. ( ) . b. tipping points related to these variables are possible within decades, but there is currently limited institutional capacity or development to address these integrated challenges galaz et al. ( ) . c. important uncertainties are related to the speed at which ocean acidification is likely to spread, where tipping point is located and what the social-ecological implications of such tipping points are? no agency or institutions is responsible, and the potential institutional development around this issue is also unclear dimitrov et al. ). d. (i) anthropogenic co dissolves in the water and produces carbonic acid that strongly reduces the rate of calcification of marine organisms. (ii) there is a risk that the capacity of the oceans to act as a ''carbon sink'' is undermined through changed carbon cycle feedbacks. (iii) there are also possibilities for rapid collapse of fisheries as a result of multiple anthropogenic stresses (hoegh-guldberg et al. ; cox et al. ; hutchings and reynolds ) . . the problem domain is defined by multiple global environmental stresses (especially climate change and ocean acidification) and cannot be addressed at the sub-global level. the policy domain is characterized by a wide variety of global actors and initiatives galaz et al. ( ) . a. the network has evolved incrementally through informal personal contacts between centrally placed actors in international organizations. one of the networks first meetings of the was held in , in rome, see galaz et al. ( ) . b. the fao, world bank, unep, and worldfish were key for developing the network galaz et al. ( ) . global networks and global change-induced tipping points c. the network emerged after repeated discussions between individuals centrally placed at international organizations. there was a perceived need to coordinate marine activities and connect them to the global climate agenda galaz et al. ( ) . d. the network started with a few individuals and their respective organizations, and has grown over time. pacfa has evolved from a loose communication network, to a formal partnership and recently ( ) became a un oceans-taskforce. it is currently unclear how it will develop over time, but it will likely remain (as a minimum) a communication-based learning and coordinating network. evolution toward tangible joint field projects depends heavily on funding, see galaz et al. ( ) . e. in a context where climate change is high on the political agenda, but where there is a limited understanding of the associated challenges and limited political connection between those challenges. f. the evolution of the network has gained modest support from governments through the fao and its member states. the network successfully coordinated their activities with the indonesian government during the climate negotiations leading up to the meeting in copenhagen (cop ). we have not identified any explicit opposition to the network. g. coordination is assumed by a small number of key organizations, centered around the fao. this institutional affiliation provides the network with legitimacy, connections, and necessary competence. however, it is also vulnerable as much of the coordination is centered around a small number of individuals, see galaz et al. ( ) . h. key coordinator of network has clear mandate by the fao, and its work is embedded in un law of the seas, and the convention on biological diversity galaz et al. ( ) . it should be noted however that ocean acidification and protection of marine ecosystems such as coral reef ecosystems have been denoted as ''non-regimes' ' dimitrov et al. ( ) . the lack of formal regimes or institutions devoted to ocean acidification has however not been identified as a problem by key actors in network. key barriers perceived by the network to further develop their work is rather a lack of funding and political support for the implementation of ecosystem-based approaches in marine systems, see galaz et al. ( ) . i. transparency is limited due to the informal structure of this network, see galaz et al. ( ) . j. a number of issues related to internal legitimacy have been raised by network members especially related to the use of scientific organizations as leverage to influence international policy processes . coordinating actors try to resolve external legitimacy challenges through actively recruiting members that secure a representation of diverse interests in the network, e.g., ranging from international organizations, to scientific organizations and ngo's in the global south. k. political lobbying aimed at influencing policy makers and policy processes through providing science-based synthesis describing the risk of transgressing possible future ''tipping points'' ). a. network members monitor different aspects of problems associated with climate changeocean acidification-marine biodiversity, however, only in a fragmented way. marine ecological parameters are the main focus of monitoring activities ). b. there is an explicit focus on the need for action before critical ''tipping points'' have been transgressed. the network describes this situation as ''self-regulating and buffering processes [could] break down, leading to irreversible consequences.'' this message is part of the information material and technical reports produced by the network. c. the network primarily coordinates its activities around political opportunities. the network deals primarily with knowledge diffusion among its members, attempts to coordinate local coastal marine management or climate adaptation projects, and highlevel lobbying. scientific syntheses coordinated by the network play a key role for this last activity. for example, actors in the network were trying to gain international momentum for their cause and focused all their activities on trying to influence the international climate negotiations in copenhagen , with an ambition to integrate marine issues in those discussions. this required the capacity of all core actors in the network to tap into resources and knowledge, including international scientific institutions (e.g., ices), international organizations (fao, world bank), and placebased research ngos (worldfish, with over a hundred partners, including universities and non-government organizations in the south). these syntheses not only provide an opportunity to bring together insights, but also feed into lobbying at high-level policy arenas ). d. e-mail and web pages are the primary tools for information dissemination and communication in the network e. funding over the long term and a lack of political support for implementing ecosystem-based management a. scientific reports and workshops where members are updated about scientific advances related to marine systems, and climate change and ocean acidification are the major outputs of the network. members also engage in continuous information sharing about relevant meetings. b. the outcomes have hitherto bee limited. the network does currently not have the necessary infrastructure or economic and human resources to engage in large-scale projects related to marine climate adaptation. case . global epidemic early warning and response networks the need for early and reliable warning of pending epidemics has been a major concern for the global community since the mid-nineteenth century, when cholera epidemics overran europe. the fact that there are strong disincentives for individual states to report disease outbreaks (due to associated losses of income from export and tourism) has created severe problems with detecting early warning signals and response problems. this is particularly critical, as coordinated responses are needed in order to avoid transgressing critical epidemic thresholds. a range of networks, from surveillance, laboratory, and expert networks, have emerged to secure information on early warning signals, mechanisms for rapid dissemination of information and coordinating responses. these networks are both global and regional, and include the who, the world organization for animal health (oie), the food and agriculture organization of the united nations (fao), the red cross, doctors without borders, and additional international and national organization. the networks facilitate responses to epidemic emergencies of international concern by providing early warning signals, rapid laboratory analysis, information dissemination, and coordination of activities in the field. a. there is a risk of uncontrolled spread of infectious disease through global transportation networks. complex interacting social (e.g., connectivity through international travel combined with limited infrastructure for public health in parts of the world) and ecological (land-use change, urbanization, habitat loss) drivers interact and may result in the spread of disease (galaz ). b. tipping points where disease becomes a matter of international concern can develop within the time frame of weeks. a global response capacity may be required within days or weeks, depending on disease characteristics (wallinga and teunis ) . c. key uncertainties include: what disease will emerge, when, where will it emerge, how fast can it spread, and how can it be addressed? d. the spread of disease will be increasingly difficult to control if the spread of the disease exceed the basic reproduction number r [ . the basis reproduction number is defined by virulence, transmissibility, and severity (wallinga and teunis ) . . spread of novel infectious disease can become a global pandemic and require coordination among a diverse set of actors, including international organizations, laboratories, health ministries, and ngo's (in locations where international organizations have weak representation). a. international collaboration on infectious diseases originated in (the global influenza network coordinated by the who). there has been a rapid evolution of health-related networks (regional and/or disease specific), especially since the s and s. a coordination mechanism at the who specifically designed for rapid response to infectious disease emerged around and became formalized in (fidler ; galaz ). b. the who is the main coordinator of relevant networks; operation, and collaborating partners depends on disease and location. c. a number of serious disease outbreaks of international concern in the early s (rift valley fever, ebola, anthrax, avian influenza, sars) led to a change in cooperation and the development of a new international legal framework (the ihrs) in . an increased awareness of the potential global nature of pandemics thus enabled better coordination of networks that had developed from the s (fidler ; galaz ). d. the networks have evolved incrementally over several decades, but with a rapid increase from and onwards. this development was stimulated by an increasing international concern and improved funding opportunities from international organizations and the usa (fidler ; galaz ). e. increasing international concerns of emerging infectious diseases from the s and onward, such as outbreaks of avian influenza (years , - ,) and us border protection security concerns related to terrorist attacks (deliberate introduction of lethal infectious disease) after the september attacks in , triggered rapid investments in global monitoring and response networks. these events also contributed to changes in the ihr in (fidler ). f. there is strong international support. however, some countries have also raised concerns. indonesia, for example, supplied h n virus to the who global influenza surveillance network for analysis and preparation of vaccines for the world. the model where commercial companies produce the resulting vaccines was questioned by indonesia arguing that the produced vaccines would be unavailable to the country. in , indonesia decided to suspend its sharing of viruses with the who, a decision that created serious tensions with the international community (fidler ) . more recently, there has also been concerns voiced by a wide set of groups about the connection between the who and pharmaceutical companies as the result of the last pandemic outbreak (''swineflu'' a/h n ) (zarocostas ) . g. coordination is facilitated by international organizations such as the who, fao, and oie. the ability to rapidly receive, analyze, and disseminate alerts and responses is substantially facilitated by this coordination. rapid evaluation is key and is supported by crisis management structures such as early warning and confirmation mechanisms (galaz ). h. the activities are regulated by the ihrs and related technical plans [e.g., who's pandemic response plans (who ) ] provide formal guidance for coordination and action. however, these formal mechanisms are complemented with informal response procedures to maximize flexibility. the informal procedures create flexibility to emerging surprise events, but within a legal framework (who ) . however, responses to emerging infectious diseases such as avian influenza tend to be contested and may be conceptualized differently by different actors depending on national political agendas and cultural contexts (dry and leach ). i. who and associated partners redefine key policies based on criticism and changing circumstances. the importance of such activities has become apparent after controversial events, such as recent discussions about the role of who in issuing a pandemic alert for the outbreak of a/h n (''swineflu''). j. the coordinating actors in the network (mainly who, fao) are generally viewed as legitimate, but concerns have also arisen. events that generated criticism include the association between the network and corporate interests (zarocostas ) and controversy about the best effective means to respond to outbreaks, and the distribution of costs related to these responses (dry and leach ). k. the networks take action through the coordination of information (laboratory analysis, early warning, confirmation) and collaboration around response options on the ground. a. a wide variety of sophisticated monitoring systems are in place and are enabled depending on the disease. the who is collaborating extensively with the canadian gphin, which has created an effective system for early detection of the spread of epidemic disease through web-monitoring. the use of satellite technology is important in some cases and is complemented with information platforms such as healthmap and the moderated e-mail list promed (galaz ) . monitoring centers on reports on disease outbreaks, but underlying drivers (e.g., land-use change and urbanization trends) are not included in such monitoring (galaz ). b. actions and investments are coordinated around pandemic phases, where action at the national and international level is dependent on the current assessment of the current status and spread of the disease (the pandemic phase), but also on the need for actions that maintain spread within certain levels (who ). c. through well-developed formal and informal mechanisms for cooperation, elaborate monitoring systems and large geographical spread and capacity (galaz ). d. information and communication technologies are crucial in all aspects of coordinated network responses, ranging from early warnings to on-the-ground responses. who regularly sets up videoconferences and secure web pages to facilitate rapid scientific collaboration on urgent epidemic issues (galaz ) . e. there are concerns that reduced future funding will hamper current monitoring and response infrastructure. there are also concerns that additional funding and political interest for investigating in general (preventive) health infrastructure is lacking in many developing countries (iom and nrc ) . critics have raised the issue that the focus is perhaps too much on disease of international concern, thereby obscuring other and more urgent national epidemic needs (dry and leach ) . a. the network has generated a large number of reports and technical documents (e.g., and the who weekly epidemiological record available online: http://www.who. int/wer/en/). continuous national, regional, and national meetings are being conducted for information sharing and capacity building (both disease specific and with regional focus). b. outcomes are difficult to measure as evaluation criteria are contested. there are several successful case studies where unprecedented rapid international responses have been reported, especially for severe acute respiratory syndrome (sars) in . a synthesis by (chan et al. ) shows that international support in epidemic contingencies over time has become more timely due to changes in the ihrs and improved surveillance. case . illegal, unreported, and unregulated fishing and the commission for the conservation of antarctic marine living resources when illegal, iuu fishing for patagonian toothfish emerged in the southern ocean in the mid- s, it was perceived that if unchecked, it would lead to the collapse of valuable fish stocks and endangered seabird populations (table ) . illegal overfishing around south african sub-antarctic islands consequently resulted in a collapse of these stocks, in turn resulting in estimated losses in the order of hundreds of millions us dollars. the toothfish market is essentially global, where products are caught around the antarctic, landed in the southern hemisphere, and primarily consumed in the usa, japan, and europe. the fact that actors involved in iuu fishing are also dispersed globally necessitates coordination between states on all continents. the regional mandate of the existing international governance institution, ccamlr (commission for the ccamlr), initially proved insufficient to address this global challenge. as a response, state and non-state actors increasingly developed their networks and are currently operating at the global level (fig. , si) . continuous coordinated international responses around adjacent islands have resulted in a dramatic reduction in iuu fishing. states now have a well-developed mechanism for coordinated monitoring and response when new actors, markets, or iuu fishing are emerging in the southern ocean. a. the scientific committee of the commission for the ccamlr has repeatedly warned for the imminent risk if collapsing valuable fish stocks and the extinction of globally threatened seabirds throughout the southern ocean (sc-camlr , sc-camlr . this has caused serious concern in the commission and threatened perceived critical commercial and environmental interest. passing regional tipping points for these resources would represent a failure of ccamlr to live up to the convention on the camlr, which explicitly state that these resources should be protected for the benefit of mankind. b. tipping points related to fish stocks and seabirds was expected within years, and a coordinated response was required before such tipping points were passed (Ö sterblom and sumaila ). c. key uncertainties include where iuu fishing (in the southern ocean) emerge next, where the products are landed and which actors and states would be involved in such activities (Ö sterblom et al. )? d. a failure to regulate coastal fisheries and fishing capacity has resulted in collapsing fish stocks combined with an overcapacity of existing fishing fleets. such fleets will move elsewhere (further south, further offshore, and fishing at larger depths (pauly et al. ; swartz et al. ) , which may result in iuu fishing (agnew et al. ). such iuu fishing dramatically reduced naturally long-lived and late maturing fish and seabird populations to low levels in the southern ocean (sc-camlr ; Ö sterblom et al. ; miller et al. ). . the problem is global as iuu vessels are highly mobile across large geographical areas. these vessels may change their flag state, call sign and other identifying markers to avoid detection and apprehension (Ö sterblom et al. ) . iuu actors use loopholes in international legal frameworks to their advantage and adapt faster than formal institutions develop (Ö sterblom and sumaila ; Ö sterblom et al. ). a. the network started to emerge from as a result of the scientific information provided to the meeting of ccamlr that year (sc-camlr ). b. the australian government, together with ngos from australia and norway, collaborated with licensed fishing industries to collect initial information (fallon and kriwoken ). c. the global network evolved from ccamlr, an organization with a regional mandate. the rationale for the network to start cooperating informally was a perceived inability of governments to take actions before tipping points would be passed (Ö sterblom and bodin ). d. the network used ccamlr as a basis for action and developed starting with a small number of countries, which invested substantially in monitoring and enforcement, policy making and diplomatic demarches (Ö sterblom and sumaila ; Ö sterblom and bodin ). a small number of ngos also cooperated to collect and spread information, in collaboration with licensed fishing companies (fallon and kriwoken ) . over time, an increasing number of states and non-state actors became involved in collecting and sharing information and formalizing cooperation (Ö sterblom and sumaila ). members of the network have carried out training workshops in strategic locations. strategic capacity building has been directed toward regions with limited capacity but where ports have been used for offloading iuu catches. e. depletion of coastal fish resources shifted commercial fishing enterprises, but also political interests, toward the high seas (beyond the nautical mile zone). this led to increasing global policy concern about iuu fishing and could also be politically connected to border protection security. this was evident in australia and the usa, particularly after the september attacks in new york city in , the tampa affair and the bali bombings in (Ö sterblom and sumaila ; constable et al. ). f. addressing iuu fishing has been a key challenge for ccamlr as some member states have been associated with iuu fishing, e.g., as flag, or port states or with their nationals working on board iuu vessels or as owners of iuu companies. this has at times resulted in substantial controversy and heated debate (Ö sterblom and sumaila ). g. ccamlr has a well-developed mechanism for obtaining, processing, and sharing of information (from state and non-state actors) through its secretariat. non-state actors are improving the effectiveness of monitoring and enforcement, by for example reporting on suspected vessel sightings, and by creating peer-pressure directed at states and corporations associated with iuu fishing (Ö sterblom and bodin ). h. an international convention (camlr) is regulating the activities within ccamlr, and governments are also bound by global legal agreements (un-fsa ) and codes of conducts (fao ) . information sharing has been facilitated by ccamlr protocols specifically designed to address iuu fishing. ccamlr provides an operational and transparent platform for cooperation but new measures can be hampered by the need to arrive at consensus. i. all commission reports are published online but background reports, including reports on diplomatically sensitive issues, are only published at a password protected web site for delegates j. disputes about some sub-antarctic islands (notably between argentina and the uk) represent a long-standing conflict. arrested iuu operators have expressed the opinion that exclusive economic zones in the southern ocean are illegitimate. several nations have clear benefits from fishing and also conduct expensive monitoring and enforcement. there are no benefit or burden sharing mechanisms in place (Ö sterblom and sumaila ). k. operational management, coordinated response, and policy making are the primary tools for action. countries collaborate to monitor and enforce compliance and form alliances to develop new policies (Ö sterblom and bodin ). a. cooperative international scientific surveys document the dynamics of fish stocks (constable et al. ). this network around ccamlr to address iuu fishing monitor fishing vessel activities and trade flows (Ö sterblom and bodin ). b. the scientific committee reports annually on the estimated levels of iuu catches and estimate the risk of tipping points, both in relation to fish stocks and seabird populations. a corresponding committee for evaluating compliance-related information review, at an annual basis, related social information (trade flows, vessel activities, etc.) (Ö sterblom and bodin ). c. the secretariat serves as an important hub in the network by coordinating information flows. responses are coordinated through either rapid engagement of partners to secure the seizure of a catch or vessel (between states), cooperation to perform alternative investigations (the fishing industry) or information campaigns (ngo community), or political lobbying for new policy tools (Ö sterblom and bodin ). d. satellite technology monitor vessel activities and an electronic catch documentation schemes provide information on trade flows (Ö sterblom and bodin ). forensic accounting is an important tool for criminal investigations, which has been pioneered by us agencies and applied in convicting cases associated with iuu operations in the ccamlr area. e. financial costs (monitoring is very expensive) depends on a small number of actors, governance capacity is limited in several countries used as port or flag states, and political will may influence the capacity of ccamlr to adapt to new challenges. a. ccamlr have developed a number of compliance mechanisms over time and is increasingly developing formal and informal governance mechanisms in order to effectively respond to iuu fishing in the southern ocean (Ö sterblom and sumaila ). b. continuous coordinated international responses around sub-antarctic islands and beyond have resulted in a dramatic reduction in iuu fishing (Ö sterblom and bodin ). nested 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cuttingedge themes, and research strategies who processes on dealing with a pandemic need to be overhauled and made more transparent key: cord- -vd etd authors: tucker, jennifer l.; anantharaman, manisha title: informal work and sustainable cities: from formalization to reparation date: - - journal: one earth doi: . /j.oneear. . . sha: doc_id: cord_uid: vd etd informal workers produce economic, social, and environmental value for cities. too often, policy elites, including those promoting sustainable cities, overlook this value, proposing formalization and relying on deficit-based framings of informal work. in this perspective piece, we bring critical research and community-produced knowledge about informal work to sustainability scholarship. we challenge the dominant, deficit-based frame of informal work, which can dispossess workers, reduce their collective power, and undercut the social and environmental value their work generates. instead, thinking historically, relationally, and spatially clarifies the essential role of informal work for urban economies and highlights their potential for promoting sustainable cities. it also reveals how growth-oriented economies reproduce environmental destruction, income inequality, and poverty, the very conditions impelling many to informal work. rather than formalization, we propose reparation, an ethic and practice promoting ecological regeneration, while redressing historic wrongs and redistributing resources and social power to workers and grassroots social movements. worldwide, about two billion people work informally, more than one-half of non-agricultural employment in most regions of the global south. informal work includes a range of income-generating activities outside of state labor protections and the wagerelation. these workers generate value and contribute to the realization of the sustainable development goals (sdgs). for instance, grassroots recyclers provide essential urban-environmental services, diverting waste from landfills and enabling recycling, while street vendors support food security as they bring life, vibrancy, and protection to urban spaces. , formal economies rely on and appropriate this value. for instance, waste pickers reduce the cost of public waste management services by diverting recyclables away from landfills. informal firms produce goods cheaply, reducing costs for formal, capitalist firms who depend on these inputs. yet, in many places, urban policy frames informal work as problematic or even criminal. desiring reform, policy makers and city officials invest formalization with supercharged powers to reduce poverty, increase productivity, clean and order urban space, and produce self-reliant economic subjects. the international labor organizations' (ilo) centenary declaration for the future of work prioritizes formalization, , whereas the sdgs, particularly sdg , assert that formalizing the informal will produce economic growth and decent work (safe and adequately paid work that respects labor and human rights). but while policy elites push formalization, the economic reality is moving in the opposite direction. the characteristics associated with informal work-low pay, job insecurity, and temporary, contract-based employment without benefits-are becoming generalized, as seen through the ascendance of the gig economy. despite persistent desires for formalization among policy elites, informal work is a permanent feature of contemporary economic life. informal workers produce economic, social, and environmental value for cities, value that is often underestimated or overlooked because informality challenges mainstream assumptions about what work looks like. indeed, informal work is excluded from dominant economic imaginaries, widely shared assumptions of economically productive activity. the dominant economic imaginary associates work with a regular wage paid by an employer in a private establishment, rather than in public space, even as the work of so many looks very different. using the term imaginaries reminds us that core economic assumptions are ideas made up by people. economies are made real in and through social relations in human societies. they are always cultural and contextual. feminist geographer gibson-graham coined this term critiquing the restricted ideas of valuable work and corresponding notions of valuable people that currently dominate. commonly, informal work is defined by what it lacks. this deficit lens of informal work persists because policy elites ignore critical and community-based research on informality and overlook the knowledge and capacities of informal workers. the deficit-based frame of informal work can dispossess workers, reduce their collective power, and undercut the social and environmental value their work generates. new modes of thinking and acting can, in turn, animate new economic imaginaries and relations. building on our research in india and paraguay, amplifying critical informality scholarship and centering the knowledge produced by workers' organizations, we assert that by thinking historically, relationally, and spatially, and redistributing power and resources to workers, we can move beyond formalization to a frame that centers decent work, ecological health, and reparation for uneven legacies of harm. only when it redistributes resources and power to informal workers will formalization help address social and environmental inequities. although we write to sustainability theorists and practitioners, we emphasize that the main protagonists of transformation must be social movements led by frontline communities, that is, the communities who are both most harmed by the crises of climate, covid- , and economic injustice, and therefore have most at stake in realizing alternative worlds. in this article, we analyze why dominant economic imaginaries devalue informal work, assessing the implications for sustainability initiatives. we then outline our proposals about thinking historically, relationally, and spatially. we emphasize that moving toward sustainable cities requires understanding the dynamics of racial capitalism, which produces both poverty and environmental degradation. we offer reparation as a framework to guide the action of development practitioners and scholars, illustrating our argument with existing practices and transformational proposals. we conclude by reflecting on the hard road ahead, underscoring the need to resource, support, and learn from frontline workers' organizations and social movements. indisputably, the st century is characterized by worsening ecological crises alongside a deficit of decent work. although our focus is informal work, we note that waged employment does not necessarily protect against poverty, as million us workers classified as the ''working poor'' can attest. moreover, reducing poverty by expanding decent work has historically intensified environmental exploitation. nearly all countries with national ecological footprints within the sustainability threshold have very high levels of working poverty, indicating that the traditional means of alleviating poverty through economic growth produces environmental degradation. admirably, the sdgs seek to decouple decent work from ecological extraction, promoting both livelihoods and sustainability. however, the transformative potential of the sdgs is compromised by an economic imaginary that misreads the key drivers of both poverty and environmental degradation and ignores empirical and theoretical research demonstrating that economic growth cannot be decoupled from environmental degradation in today's economies of extraction. [ ] [ ] [ ] [ ] studies finding modest success in a few exceptional countries to decouple economic growth from greenhouse gas emissions do not consider other forms of environmental degradation, such as land use change and unsustainable freshwater extraction. indeed, the sdgs remain captive to ''fairytales of eternal economic growth,'' a mindset decried by youth climate activist greta thunberg at the un climate summit. the sdgs privilege technocratic planning and propose win-win scenarios, downplaying the trade-offs between economic growth, social development, and environmental protection. furthermore, the sdgs ignore compelling evidence that redistribution, not growth, is the key. , in their current form, the sdgs are a trojan horse, smuggling in unpopular and problematic neoliberal economic policies, including the erasure and enclosure of informal livelihoods. scholarship over the last years has offered changing perspectives on the nature and value of informal work. , early dualist frameworks proposed that modernization would expand formal employment and starve the informal sector. since then, researchers have documented intense linkages across supply chains that crisscross sectors designated as formal and informal. there is great variation between domains of informal work, from unregistered ''petty commodity producers,'' supplying cheap inputs into capitalist production processes and reducing costs for formal firms ; to own account operators, such as waste pickers and street vendors; to informal employees, such as day laborers or domestic workers. following insights from critical anthropologists, geographers, and planning scholars, we argue that the informal and formal are relational categories whose boundaries are determined by culture and power, pointing to deeply intertwined domains of economic practice. [ ] [ ] [ ] although we find informal and formal to be analytically imprecise categories, we retain them here because of their political significance in policy making to draw lines between valued and devalued economic activities with consequences for both workers and sustainability initiatives. in spite of this research, the dominant economic imaginary devalues informal workers as unproductive and problematic. informal work is compared against the yard-stick of the ''standard employment relationship,'' signifying a unionized, waged worker, despite calls to decenter the wage. , yet secure, well-paid employment with benefits is the exception, not the norm, a form of work limited to so-called developed countries for a few postwar decades. , the deficit-based definition of informal work holds across deep ideological divisions. neoliberal economists see low productivity and ''low levels of human capital,'' labor scholars emphasize the lack of state protections, such as social security or workplace protections, whereas orthodox marxists see the lack of class consciousness and historical agency because of their structural location in economies of ''informal survivalism.'' the tenacity of the deficit definition echoes dynamics that render invisible other value-producing domains, such as women's unpaid household labor, social reproduction more broadly, the essential inputs of nature and noncommodified economies of reciprocity. informal work produces economic, social, and environmental value that sustains lives and urban environments. at the same time, formal economies rely on and appropriate this value. this article explores this central contradiction: the informal is framed as problematic and targeted for reform even as formal economies benefit from and appropriate the value produced by informal workers. to sketch a counter-story, we underscore the considerable creativity of workers facing calamitous state disinvestment in collective wellbeing. at the same time, we do not romanticize these economic words. informal livelihoods are complex and contradictory, combining individualism and community, care and exclusions, competition and collaboration, autonomy and drudgery. , formalization is shorthand for a range of policies seeking to align economic activities with the law, either changing legal codes or reforming behaviors. this can include decriminalizing informal work, licensing businesses, requiring tax compliance, enforcing labor and environmental regulations, promoting certain kinds of spatial order, or eliminating competition from firms or workers with lower costs of business because of noncompliance. however, legalistic formalization projects, rooted in eurocentric urban knowledge, fail to understand the diverse realities of most cities. whereas legalist policy frameworks value rule-following for its own sake, critical researchers demonstrate the anti-poor biases of law, the criminalization of poverty, and tendencies to leave the legal transgressions of elites unpunished. urban life in many cities is marked by dealmaking and provisionality. residents use, sidestep, and transgress legal codes depending on situational exigencies and a ''transversal'' relationship to law. contrary to expectations, formalization does not necessarily solve problems for informal workers, nor make those economic activities more valuable. formalization deriving from a legalistic, deficit-based framing can dispossess workers of livelihoods, reduce workers' collective power, reiterate stigmas associated with informality, and undercut the social and environmental value that informal work generates. if projects devolve risk and responsibility for providing basic services without resourcing worker organizations, formalization can increase the exploitation of informal workers. , the emphasis on formalization in the sdgs reflects the role of powerful, well-funded civil society organizations, largely from rich and middle-income countries , and too often lacking representation of workers. official ''invited spaces of participation'' often limit dissent, discourage critical examination of underlying economic imaginaries, and carry unspoken, exclusionary codes of acceptable behavior that reflect elite norms, values, behaviors, and codes of dress. not uncommonly, policy elites interpret expressions of worker power as illegitimate, such as waste pickers blockading dumps to protect their livelihoods. , yet often, contentious politics are needed to interrupt the status quo and offer alternative political imaginations. to illustrate the importance of informal work, we draw examples from street vending and waste work. in diverse cities, grassroots recyclers toil in difficult conditions while facing intense stigma, quotidian harassment, and even deadly violence. , yet their labors build functioning value chains for recyclables, generating income for themselves and materials for other markets as they also enable environmental behaviors among elites and provide the only opportunity for recycling in many cities. [ ] [ ] [ ] [ ] [ ] [ ] although there is great variability, the informal sector can rival formal sector material recovery rates. informal sector recyclers have irreplaceable knowledge crucial to maximizing value in waste. , [ ] [ ] [ ] [ ] indeed, policy elites now herald informal recycling as already-existing circular economies critical for sustainability transitions. similarly, street vendors enable access to cheap food despite battling a host of ''everyday challenges.'' their work contributes to sdg : making cities and human settlements inclusive, safe, resilient, and sustainable. furthermore, informal livelihoods provide crucial incomes, critical to sdg : zero poverty. worldwide, waste picking sustains some million people, while similar numbers work as street vendors. but informal work means more than an income. informal economies are complex systems of redistribution; community networks that can be tapped in times of need. in contexts of state disinvestment and chronic job scarcity, informal worlds provide a buffer against outright destitution. indeed, against stereotypes, most monetary transfers that keep poor communities afloat occur within poor communities, not between the rich and the poor. for instance, a montevideo recyclers coopera-tive transferred a share of their collective daily earnings to members unable to work due to sickness or care-taking obligations. in times of crisis, informal responses offer ''collective security mechanisms,'' , illustrated by street vendors providing food to communities under a strict covid- curfew in india. while informal care networks help cities recover from disasters-both slow-moving and spectacular-intensifying inequalities are challenging these systems of social provisioning. finally, we emphasize that the conditions of waged work are not universally preferable to informality. the once-a-month payday, inflexible work schedules, and long hours of waged work can clash with the pressing daily needs of those living precariously. in rio's largest dump, waste pickers valued the flexibility, autonomy, and sociability of the dump, cooking together, socializing, and adapting schedules to their needs, working more when necessary and less when possible. building just and sustainable cities requires reexamining how the informal is conceptualized and acted upon by mainstream development actors. we propose decentering formalization as a primary goal of initiatives such as the sdgs and organizations such as the ilo. for formalization to address social and environmental inequities it must redistribute resources and power to informal workers. this can be realized through an ethic and practice of reparation, which seeks to reimagine and recreate socioecological relations from a full acknowledgment of the injustices of the past as they live into the present. , we advocate reparation over justice because dominant, liberal notions of justice center the individual, foreclosing consideration of histories of harm and denying the need for collective redress. we articulate three modes of thinking to reconceptualize informal work and animate an alternative, ethical economic imaginary: thinking historically, thinking relationally, and thinking spatially. yet, it is not enough to think differently. urban economies come into being in and through webs of social relations that tie people to particular modes of laboring, living, creating, and consuming. thus, we also argue for concrete actions oriented toward social and environmental justice: redistributing wealth and power, strengthening worker's organizations, and recovering politics from technocratic capture. this approach underscores the interlinked nature of liberatory thought and action, or praxis. , these ways of thinking and acting are diametrically opposed to dominant academic and policy-making trends in which informal workers are treated as ''passive objects of study'' or which operate through benevolence, a stance which reproduces racial and imperial hierarchies of power. this agenda cannot be designed and executed from the top down and must emerge through an authentic collaboration with workers. such collaborations are only possible by expanding our notions of the agents of urban and sustainable development, which, in turn, requires radical humility on the part of ''experts,'' while valuing workers' knowledge, power, and political forms. without such a reframing, historically marginalized groups might well be excluded, exploited, or expelled from clean and green cities. [ ] [ ] [ ] [ ] thinking historically thinking historically clarifies racial capitalism's core logics of accumulation, appropriation, and exploitation as incompatible with decent work or sustainable societies. decent work and ll one earth , september , clean environments for some have always required oppressions, exclusions, and exposure to harm for others. , racial capitalism as a frame explains how capitalism incorporates and depends on the ''devaluation of nonwhite bodies.'' from its beginning, capitalism tended to ''differentiate-to exaggerate regional, subcultural, and dialectical differences into 'racial' ones.'' , thinking historically with racial capitalism demonstrates the common patterns through which exclusion, exploitation, and disposability are racialized processes, even if racialization works differently for mexican immigrants in the us, members of scheduled castes such as dalits in india, indigenous guatemalans, or afro-brazilians. indeed, racialized groups are more likely to engage in undervalued and invisibilized forms of work (as are women), including care and informal work. today, covid- has launched the term ''essential workers'' into our public vocabularies, making visible how essential work is often underpaid and under-protected. thinking historically shows how capitalist economies treat essential workers as disposable by constructing myths that devalue or render invisible their work. from enslaved africans picking cotton in the us south to reclaimers recycling the waste of consumer capitalism, a core logic twins the essential and the disposable. this lethal logic organizes formal and informal economies. in indian cities, most frontline, essential workers keeping the city clean during covid- lockdowns are dalit, scheduled castes and tribes, or muslims. [ ] [ ] [ ] yet, the state fails to equip them with adequate protective gear. striking amazon workers also report inadequate health protections at facilities with outbreaks, and have responded by organizing over job actions in the us in march to june . meanwhile, amazon ceo jeff bezos amassed an additional $ . billion during weeks in march and april as the pandemic took hold. these examples illustrate that treating people as disposable is not an aberrant behavior of a few bad apples but a common, accepted means to reduce costs and concentrate profits. indeed, in the us, the standard employment relation was made through racial and gendered exclusions. the wagner act-the cornerstone new deal expansion of labor protections-excluded both domestic employees and agriculture workers, legally barring both groups from organizing. these exclusions were a ''proxy to exclude most black employees'' in the south as they also reflected biases devaluing ''women's work.'' congress excluded these workers in an explicit compromise to appease the racism of conservative southern legislators. looking further back, the rise of the waged worker as the presumed norm and aspirational horizon of all has a long, bloody history. early industrial capitalism needed people willing to work for a wage in brutal factories. in england, this required the enclosures movement, two centuries of dispossessing peasants of commonly held lands and criminalizing ''poaching'' and other means of self-provisioning. this long history normalizing the wage also rendered informal work ''invisible to science.'' similarly, self-sufficient indigenous communities steadfastly refused waged work. forcing participation in waged work required centuries of sustained settler violence: land theft, the criminalization of indigenous culture, and attacks on community means of subsistence, for instance, the intentional decimation of buffalo in the us plains states. , indeed, racial capitalism refuses to recognize non-capitalist lifeways as legitimate or pro-ductive. marking these communities as ''uncivilized'' or ''indolent'' helped justify violence and dispossessions. current land grabs and other processes of rural dispossession create mass migration to cities and urban populations seeking a foothold in informal economies. indeed, many waste pickers in bangalore are migrants from bengal, dispossessed of their land-based livelihoods by urban expansion and neoliberal development. capitalist firms also appropriate unpaid or devalued inputs, a processes of ''cheapening'' land, labor, care work, and the fruits of nature, such as food and energy. some appropriations are overtly violent: theft of indigenous land, plantation-based slave economies, or ongoing murders of indigenous land defenders in latin america and beyond. others are harder to see as cheapening rests on abstract ideas of value and its lack. for instance, capitalism appropriates the ''free gifts'' of nature: energy, natural resources, and raw materials. these ecosystem services-uncounted, invisiblized but absolutely necessaryare valued at %- % of global gdp. the free services of nature also partially absorb the wastes of consumer capitalism. the global atlas of environmental justice tracks more than , cases of communities fighting to protect land, water, forests, and livelihood from economies of extraction and privatization. the sdgs, for their part, propose delinking environmental destruction from economic growth, ignoring capitalism's core logics of appropriation and cheapening. furthermore, capitalism insulates markets from public accountability because of the abstract idea that private-sector economic decision making is separate from matters of public concern. cut off from democratic control, the private sector peruses short-term profitably for elites over collective wellbeing and the sustainability of life on earth. relational thinking shifts our practices of study and intervention ''from 'the poor and poor others' to. relationships of power and privilege,'' a framing we borrow from the relational poverty network. it also helps us see the economic, social, and environmental value of informal work and the ways it subsidizes formal economies. the forces that reproduce environmental destruction, inequality, and exclusion are multiscalar and multidimensional: deregulated economies, tax rebellions by the privileged, corporate tax-evasion and off-shoring, and uneven landscapes of investment (and disinvestment). [ ] [ ] [ ] fifty years of neoliberalism-a variant of racial capitalism characterized by austerity, deregulation, and financialization-has undermined the redistributive function of the northern welfare states and hamstrung burgeoning social state capacities across the global south. economist robert reich calls this the ''succession of the successful,'' as rich communities renege on contributing to public goods, turning instead to privatized housing, education, and health that most families cannot afford. the tentative and uneven gains in reducing inequality in the postwar decades have been swept away by the rise of the superrich, in which the top % controls more wealth than the bottom %. yet, from sociological ''cultures of poverty'' research to social entrepreneurship bootstrap schemes aimed at reforming the poor, much scholarship and action persists in blaming the poor for their poverty or focusing interventions in poor communities, leaving ll one earth , september , untouched key domains responsible for inequality and environmental harm. thinking relationally helps show how capitalism predictably produces poverty and inequality, the very forces that make informal economies necessary. given this, generating decent work and building sustainable cities requires transforming structural economic forces that much exceed the bounds of a particular informal economy. relational thinking highlights how informal workers provide ''invisible subsidies'' crucial for the social reproduction of capitalism, from waste pickers metabolizing post-consumer waste to the businesses in dharavi, an informal settlement outside mumbai, recycling plastic, tanning leather, weaving fabrics, and producing pottery worth as much as $ billion each year. relational thinking also demonstrates the connections between spaces of poverty and landscapes of wealth. middle class and rich consumers depend on the cheap, often informal labor of the monetarily poor, who clean homes, build high rises, metabolize waste, and lower consumption costs by lowering the costs of production. thinking relationally draws attention to the resource-hoarding, overconsumption, and disproportionate political power of the rich as major drivers of environmental harm. it also underscores how the modest welfare gains in the post-war era in north atlantic countries relied on massive wealth transfers from the global south (previously colonized) to the global north (in most cases, imperial powers). egyptian economist samir amin tracked one of these transfers, called unequal exchange. in addition to declining terms of trade, workers earning low wages in the global south buy expensive goods produced by higher paid workers in the global north, and vice versa, such that northern countries capture uncompensated value from the global south. in , the estimated value of this south-to-north transfer was $ . trillion, more than times the value of foreign aid moving in the other direction. on a more local level, poor communities are targeted as sources of revenue through official and extra-legal channels. a us department of justice report found that police officers in ferguson-under pressure to meet citation and arrest quotas-targeted black residents for minor, even fabricated infractions in what one anthropologist called a ''shake-down operation.' ' in other cities, street vending necessitates non-compliant activities. in response, officials harass and evict vendors, demanding bribes, imposing fines, and confiscating merchandise. in cochabamba, bolivia, these practices are so common that vendors call police officers ''the hungry ones'' (los hambres). relational thinking exposes how the rule-breaking behavior of state officials (and elites) is often tolerated, whereas the necessary infractions of the poor are criminalized. finally, thinking relationally clarifies the sources of environmental harm, thereby identifying which countries and which social groups bear responsibility for redress and reparation. , environmental justice research demonstrates that political-economic processes concentrate environmental harm in poor, racialized communities, protecting spaces of privilege. emphasizing the scale of environmental harms, ecologists and environmentalists propose we are in a new geologic age, the anthropocene, in which anthropogenic climate change and environmental destruction are earth-transforming features and system-wide threats. but culpability is not evenly distributed. environmental destruction and climate catastrophe result from our political-economic system, not an undifferentiated ''humanity'' or a timeless, unchangeable human nature. it is the consumption of the middle classes and elites that produces dirty cities and a majority of urban greenhouse gas emissions. the consequences of climate catastrophe concentrate in the global south, even as the global north is historically responsible for producing most carbon emissions. instead of the anthropocene, it is more honest and politically enabling to call our era the capitalocene, a frame that names the culprits undermining the conditions for human society. , thinking spatially thinking spatially sheds light on the social processes that allocate authorization and formalized status. elite groups, usually richer and whiter, have more social power to write their interests into law and more power in contests over the best uses of urban space. spatial thinking helps identify the underlying struggles to control space and economy that often drive formalization projects. state officials manage vendors with a range of laws, codes, tacit agreements, and other unofficial strategies. , too often, vendors are viewed as encroachers or criminals while punitive state policies disregard their needs. media accounts and city officials describe vendors as outsiders or as an ''invasion'' from which the city must ''retake'' space, pursing policies which expel the urban poor from desirable urban spaces. exclusionary policies are pervasive and evictions constant and violent. unfortunately, formal recognition does not always protect street vendors. in monrovia, officials harassed vendors even after a memorandum of understanding extended formal recognition. relocating vendors to formalized markets can also have negative effects. , in bogotá , relocated vendors gained better working conditions, but the move weakened their organizations and their incomes fell. in ciudad del este, paraguay, a municipal formalization project divided vendors, demobilized vending associations, and exposed vendors to ''dispossession by formalization.'' behind any campaign to ''clean the streets'' are competing ideas about the best uses of urban space. these visions are not neutral or objective. captive to the growth imaginary, market forces and state policies define ''highest and best use'' as activities that increase property values or create profit opportunities for formal firms. the dominant economic imaginary associates work with private spaces, coding public spaces for recreation, cars, pedestrians, and shoppers. consequently, urban zoning and regulatory practices often fail to support public space as sites of work. however, informal workers often must work in public. when vendors break the rules to work, they then are accused of being predisposed to unlawfulness, an accusation that codes structural inequalities as a question of culture or individual disposition. spatial imaginaries go beyond constructing public work as problematic. in the us, until the early s, sidewalks and streets were multi-use spaces. sidewalks supported working vendors, circulating pedestrians, celebrating residents and politically active citizens. in los angeles, the notion that sidewalks should prioritize pedestrians solidified through anti-immigrant campaigns targeting the livelihoods of chinese vendors. across latin america, colonial spatial imaginaries construct particular racial groups as belonging to particular spaces: cities are for whites and mestizos whereas indigenous communities are imagined as belonging to rural areas. in bolivia, officials racialized space, interpreting popular markets as unruly, rural incursions into cities, a precursor to attempts to remove or criminalize them. in ecuador, similar policies sought to expel indigenous ecuadorians from quito's historic center, ignoring that rural communities needed the income earned by their family members in the city. policing the line between work, nuisance, and crime is also about asserting control over valuable resources. as resourcestrapped cities move to ''modernize'' and formalize recycling, they often privatize waste management, privilege capital-intensive waste management systems, and enclose the materials that are claimed by waste pickers as livelihood inputs. [ ] [ ] [ ] this ''rational-modernist model of urbanization'' can create a ''vicious circle of competition'' for resources. formalization also requires framing trash as valuable, that is, adopting the knowledge work of waste pickers who saw value where officials saw trash. indeed, the discursive construction of the informal as a problematic space in need of reform is a precursor to imagining sites that can be enclosed and privatized. in contrast to official logics, street vendors and waste pickers value urban space by how it sustains life. when vendors and waste pickers carve out spaces for livelihood they are producing important urban commons, claiming urban space for ordinary workers. indeed, the challenge of informal workers in many places is precisely that they question growth and market-driven notions of what public space should be for and who should decide. from formalization to reparation thinking historically, relationally, and spatially clarifies the processes that co-produce both precarious work and ecological harm. decentering formalization, we advocate for reparation as an ethic to orient the actions of development practitioners and policy makers. our debt here is to the black radical tradition, scholars and activists proposing collective redress for the unspeakable violence and thefts of slavery, legacies that live into the present. [ ] [ ] [ ] following w.e.b. du bois, the ethic of reparation activates memory against the forces of willful forgetting that deny history and deep relationality. we are inspired by the black radical tradition's expansive, future-oriented political imagination and its call to remake economic and social relations from the roots up. ''reparation ecologies'' add an imperative to heal the false nature/society divide, locating socio-economic relationships within living ecologies. both lines of thinking emphasize redistribution: of resources, land, work, and the labors of care. although formalization targets workers or the economies that sustain them for reform, the field of action promoted by reparation is much broader, including the forces producing inequality and environmental harm. reparation acts horizontally, centering communities most harmed by fomenting worker power, repairing historic injustices, and redistributing social power and resources to the grassroots. reparation can also help us acknowledge the long history of assent to exploitation that structures scholarship and practice. the moment is ripe for clear thinking and bold action. the convulsions to work and life precipitated by covid- offer a rare opportunity to enact transformational change. of course, entrenched structures of race/class power are invested in extraction economies, wielding considerable resources to push for exclusionary, unsustainable modes of urban development. only empowered social movements led by frontline communities have the force to contest these elite power structures. for this reason, we call on development scholars and practitioners to invest in worker power, embrace contentious politics, relinquish power over knowledge production, and develop accountable relationships with grassroots social movements. against assumptions that informal workers are unorganizable, and despite many challenges, informal worker organizing is powerful. , collective action takes many forms, from member-based organizations (mbos) to workers organizing from other identity roles, such as mothers or migrants. informal workers organize for different demands: protecting access to markets, defending public resources, expanding citizenship rights, demanding social protection, or advocating for infrastructure improvements. , , indeed, collective action by informal workers changes urban policy. in ahmedabad, india, the organization self employed women's association (sewa) helped pass the protection of livelihood and regulation of street vending act while in lima, vendor organizations won pro-vendor policy at the city and national level. organizing by waste pickers forced a sea change in how policymakers understand these workers. once universally viewed as a nuisance or a criminal element, today, the un frames informal waste workers as ''any city's key ally.'' a study of latin american countries found that worker organizing was fundamental to establishing inclusive recycling policies. reversing trends of privatization, several latin american cities have partnered with waste picker organizations for doorto-door waste collection. in brazil, ''solidarity recycling'' includes over worker organizations as partners in the national solid waste policy. the city government in bangalore, india recognizes informal recyclers with occupational identity cards while organizing in durban cut out middlemen and increased income for reclaimers by %. development organizations should resource informal worker organizations, promote supportive regulatory environments, and support the urban commons built by informal workers. this requires resisting the razing instinct of rational-modernist urbanization that tears down informal spaces, instead upgrading in situ, safeguarding community ties, and respecting the rights of the poor to live centrally and participate in urban life. specific action plans must emerge in collaboration with grassroots organizations, such that here we seed ideas for reparative policies, rather than propose blueprints. worker-run cooperatives improve livelihoods whereas mbos build collective power. across levels of government, policy makers should resource these organizations, invest in mbo bargaining capacity, and seize opportunities to open up spaces for negotiations in diverse forums: everyday, ad hoc, and policy and statutory negotiations. , when cities reorganize waste systems, they can meaningfully include grassroots recyclers, pay waste pickers for services, , and provide work spaces. redistribution-across scales-is foundational to reparation, as it recognizes that markets unjustly concentrate wealth, neoliberal policies under-resource public goods while actually existing electoral politics concentrate social power. public budgets are statements of social values. currently, states overinvest in the military, jails, and policing, or in building infrastructures that cater to the consumption desires of elites. we must continue to insist that the resources for just and sustainable cities exist. cities must prioritize public provisioning of systems of care and ''universal basic services'' such as housing, healthcare, childcare, education, and sanitation. , redistribution can help re-value informal and other forms of invisibilized work, reducing inequality. inequality drives unsustainability, both by promoting conspicuous consumption and forcing poor people to over-exploit resources. , thus, addressing inequality through redistribution is critical to achieving environmental sustainability. here, we highlight some bold proposals scaled to the enormity of today's existential challenges: universal basic income, the global green new deal, the red deal, and care incomes. by delinking labor, income, and development, these reparative policies foster more just ways of organizing work, time, and life. in , reverend dr. martin luther king promoted a guaranteed income to further racial justice and activate the creative powers of human labor freed from the compulsions of (low) waged work, a call echoed five decades later by pope francis in his easter address. these ethical injunctions are now backed by evidence from finland, where modest income supports improved wellbeing and life satisfaction. envisioned to emancipate the economy from fossil fuels, the global green new deal offers concrete plans to decarbonize the economy while redressing the historic injustices that concentrate vulnerability to climate harms in poor countries and communities by insisting that climate culprits finance the transition. visionary indigenous organizers go further with a red deal that defunds prisons, policing, and militarism, freeing up the resources for indigenousled visions of ''liberation, life, and land,'' invoking decolonial calls for ''a world where many worlds fit.'' feminist degrowth scholars propose care incomes, payments to recognize and compensate the socially reproductive work that sustains life and community. currently ignored in gdp accounting, care work is largely carried out by women and marginalized social groups and thus care incomes have the potential to redress historical exclusions and benefit informal workers. [ ] [ ] [ ] conclusions today, life-sustaining earth systems are under existential threat. as covid- devastates informal livelihoods worldwide, mass layoffs plunge unprecedented numbers of workers into economic hardship. ethical economic imaginaries undergirding new realities are thus an urgent necessity. sustainable development initiatives such as the sgds admirably seek to promote both environmental sustainability and decent work. yet, promoting poverty alleviation and ecological wholeness through economic growth is like trying to squeeze water from stone. these approaches are seductive. they promise to decouple growth from environmental damage through innovation as they promote policies that leave inequalities in wealth and social power largely untouched. they ignore that inequality is a key driver of environmental harm. thus, we insist, our pathways forward must recognize the co-constitution of poverty, inequality, and unsustainability. the necessary transformations are daunting. challenging entrenched structures of elite power is so difficult that some caution incremental change and propose only band-aid solutions to ameliorate some of the most acute forms of suffering caused by racial capitalism. against this limiting pragmatism, we argue for transformational change and encourage sustainability scholarship and practice to take an active role in promoting reparation. policymakers and sustainability researchers should learn from the critical and community-produced research on informality. we must move beyond formalization and diagnose the shared drivers of decent work deficits and environmental degradation. thinking historically, relationally, and spatially reveals how the value produced by informal workers subsidize urban economies and ecologies, even as racial capitalism predictably reproduces job scarcity, income inequality, and poverty, the very conditions that impel many to informal work. ethical economic imaginaries combined with ethic of reparative action can offer pathways toward sustainable, equitable cities by investing resources in the only social force capable of contesting elite power structures: workers and social movements on the frontlines. women and men in the informal economy: a statistical picture waste pickers and cities sidewalk, st edition (farrar street vending and public policy: a global review informal sector or petty commodity production: dualism or dependence in urban development? 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(the avery review a conceptual framework on informal work and informal worker organizing organizing in the informal economy: a challenge for trade unions organising women workers in the informal economy collective bargaining by informal workers in the global south: where and how it takes place solid waste management in the world's cities. water and sanitation in the worlds cities aná lisis de políticas pú blicas para el reciclaje inclusivo en amé rica latina the emergence of ''solidarity recycling'' in brazil: structural convergences and strategic actions in interconnected fields ecological routes to urban inclusion: theorizing ecological citizenship through informal waste work urban recycling cooperatives: building resilient communities (routledge) waste pickers' cooperatives and social and solidarity economy organizations postura de wiego sobre el cierre de vertederos (wiego) preparing informal recycler inclusion plans: an operational guide (inter-american development bank) trabajadores por la ciudad: aporte de las mujeres a la gestió n ambiental de los residuos só lidos en amé rica latina the case for universal basic services unpacking the urban infrastructure nexus with environment, health, livability, well-being, and equity inequality and sustainability inequality, cooperation, and environmental sustainability cuarta declaració n de la selva lacandona (the revolutionary clandestine committee) within and beyond the pandemic. demanding a care income and a feminist green new deal for europe. undisciplined environments (undisciplined environments collaborative feminist degrowth: pandemic as an opening for a care-full radical transformation (degrwoth) from pandemic toward care-full degrowth trajectories of the earth system in the anthropocene the authors thank the two anonymous reviewers, as well as john stehlin and lani marina tsinnajinnie for their feedback on the ideas presented in this perspective piece. we also owe a debt of gratitude to the informal workers, grassroots communities, and frontline organizations who have shared their time and insights with us, in both paraguay and india. key: cord- -aowxr authors: stoeva, preslava title: dimensions of health security—a conceptual analysis date: - - journal: glob chall doi: . /gch . sha: doc_id: cord_uid: aowxr discussions of the politics and practicalities of confronting health security challenges—from infectious disease outbreaks to antimicrobial resistance and the silent epidemic of noncommunicable diseases—hinge on the conceptualization of health security. there is no consensus among analysts about the specific parameters of health security. this inhibits comparative evaluation and critique, and affects the consistency of advice for policymakers. this article aims to contribute to debates about the meaning and scope of health security by applying baldwin’s ( ) framework for conceptualizing security with a view to propose an alternative framing. asking baldwin’s concept‐defining questions of the health security literature highlights how implicit and explicit assumptions currently place health security squarely within a narrow traditionalist analytical framework. such framing of health security is inaccurate and constraining, as demonstrated by practice and empirical observations. alternative approaches to security propose that security politics can also be multiactor, cooperative, and ethical, while being conscious of postcolonial and feminist critique in search of sustainable solutions to existential threats to individuals and communities. a broader conceptualization of health security can transform the politics of health security, improving health outcomes beyond acute crises and contribute to broader security studies’ debates. discussions of health security periodically climb up the global political agenda, mostly in response to global health-related concerns and challenges-from public health emergencies of international concern and pandemics, e.g., h n , ebola, zika, and the covid- pandemic, [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] to concerns about antimicrobial resistance, defined by the world health organisation (who) as a fundamental threat to human health, development and security, [ ] and the "silent" noncommunicable disease pandemic. [ , ] academic interest in and appetite for health security analysis has not abated either, as indicated by recent "lancet" contributions. [ , [ ] [ ] [ ] [ ] the response to the global conceptualizations of health security emerged over time in response to specific health challenges, political and institutional developments. [ , ] academic analysis has broadly (with a few exceptions) sought to fit health into mainstream security studies paradigms instead of using health to broaden security debates through reflection on practice and the engagement of emerging security paradigms. there is a notable reliance on the securitization framework promoted by the copenhagen school [ ] to explain the rise to prominence of health concerns in security politics, but that, it will be argued here has supported, validated, even justified a narrow, privileged view of health security. in his overview of the multiple meanings of health security, mcinnes argues that just like "security," "health security" is "essentially contested" and it is therefore not possible to reach an agreement on the meaning and application of the term. [ ] he observes that the different framings of health security are "not amenable to a single set of agreed criteria" because they have been constructed to serve a particular purpose, are premised on different sets of assumptions, have different uses and privilege diverse interests and agendas. [ ] such observations, however, default on the need for systematic discussion and critical reflection on the way health security has been conceptualized, or the interests that such conceptualization might be serving. the following brief review of the most common health security conceptualizations in historic context highlights the limited engagement with existing specialist knowledge both from across the spectrum of security studies paradigms including critical security studies, postcolonial and feminist approaches, with specialist knowledge of foreign policy, foreign policy analysis, governance, and global health governance or with key developments in practice. the failure to engage with the broader spectrum of existing knowledge constrains the diversity of discussions, interdisciplinary dialog and learning, as well as the possibility of progressive policy impact. links between national security and infectious disease outbreaks were initially identified by us analysts in the mid to late s. [ ] [ ] [ ] [ ] [ ] [ ] the promotion of health in developing countries was included in us national security strategies (nss) in - . [ ] [ ] [ ] infectious diseases were described as a significant challenge in low and middle-income countries, contributing to a slowdown in economic growth. the us "nss a national security strategy for a new century" was the first such document to state that health problems "can undermine the welfare of us citizens, and compromise our national security, economic and humanitarian interests abroad for generations." [ ] health issues of particular interest to the united states included food-borne diseases from imported foodstuffs, new and emerging infectious diseases and hiv/aids. the bush administration re-iterated concerns about the threats posed by biological weapons and pandemic health threats but did not prioritize health-related security as much. [ ] considerations about national and global health made their way back into the us nss in and under the obama administration. pandemic disease was considered a threat to "the security of regions and the health and safety of the american people." [ ] the first uk national security strategy published in claimed it was premised on a broader conceptualization of national security that included "threats to individual citizens and to our way of life, as well as to the integrity and interests of the state" [ ] and listed infectious diseases (particularly the threat of a global influenza pandemic) and bioterrorism as national security concerns. the uk national security strategy defined the risk of a severe influenza pandemic as one of the top three civil emergencies risks. [ ] while the qualification "broader conceptualization" is intended to refer to a move away from concerns of defense and military security, the narrow focus on bioterrorism and communicable disease is symptomatic of traditional, state-centric thinking about security from acute threats originating outside of it. fidler ( ) provides detailed analysis of the practical ways in which the linkages between public health and national security have emerged. he concludes that the realpolitik perspective on national security is driving the development of the concept of public health security in the united states despite three other possible formulations-common, human and ecological security. [ ] rushton ( ) also observes that health security continues to be framed in narrow traditional terms as national security and underpinned by particular concerns of interest to rich industrialized states, which shape a narrow discourse that largely disregards the needs of the global south. [ ] mcinnes adds that "health issues are not identified as national security risks by reference to an explicit set of criteria but rather have arisen in an ad hoc manner and been agreed to intersubjectively by key national and international actors." [ ] these observations inadvertently contribute to normalizing dominant political discourses about the paramount nature of the national interest, the centrality of the interests of powerful states and the relevance of only acute health threats to security thinking. national security is often considered the key objective of foreign policy. hiv/aids was framed as a foreign policy problem by the clinton administration's interagency working group on emerging and re-emerging infectious diseases' report "infectious disease: a global health threat," and the national intelligence council's report "the global infectious disease threat and its implications for the united states." fidler's analysis, however, mistook us' foreign policy focus on emerging and reemerging communicable diseases and bioterrorism for a global trend and a normative shift, claiming that health had achieved "pre-eminent political value for st century humanity." [ ] kickbusch ( ) argued that the us had shaped the international agenda to fit in with its national interests and priorities and in doing so had preferenced a "unilateral hegemonic approach" to multilateral cooperation. [ ] the implications of us leadership in shaping the international health security agenda remain understudied, and yet critically relevant to what is included and excluded from that agenda. the political recognition of health issues as a matter of foreign policy by other states was marked by the oslo ministerial declaration on global health and foreign policy (ministers of foreign affairs of brazil, france, indonesia, norway, senegal, south africa, and thailand, ) and the adoption of un general assembly resolution / , which "recognizes the close relationship between foreign policy and global health and their interdependence and… urges member states to consider health issues in the formulation of foreign policy." [ ] the reason given for linking health policy with foreign policy at the international level was that health problems of global magnitude were deemed to require cooperative solutions. the international community continues to struggle, however, to find such cooperative state-led solutions, as illustrated by the response to the ebola crisis [ ] and by the current response to the covid- pandemic, which has broadly been marked by states leading individual responses. considering the inclusion of health issues on states' foreign policy agendas as novelty, of course, ignores a long tradition of state cooperation dating back at least to the th century. [ ] the analysis of health concerns as issues of national security and foreign policy suffers from some prominent shortcomings. discussions of foreign policy and health make virtually no reference to analytical frameworks from the field of foreign policy and foreign policy analysis, failing to draw on its methodologies, paradigms and empirical knowledge. in other words, the presence of health on foreign policy agendas and its construction as a threat to national security is observed in practice, but not sufficiently interrogated in analytical terms. furthermore, studies often assume generalizability beyond one state (most commonly the usa), which has skewed analysis and aligned it almost exclusively with dominant paradigms of great-power politics, failing to reflect on how health features in the foreign policy agendas of a broader spectrum of states. health concerns have been conceptualized as international security challenges in a number of high-level policy pronouncements. in her role as director general of the world health organisation (who), gro harlem brundtland argued that health was an underlying determinant of development, security, and global stability and that in an interdependent world the functional separation between domestic and international health policy lost its meaning. [ ] brundtland advocated international cooperation in addressing health-related global threats because "[a] world where a billion people are deprived, insecure and vulnerable, is an unsafe world." [ ] these observations are poignantly relevant years on in the fight against the covid- pandemic. further recognition of health issues as "threats to international peace and security" is evident in un security council resolutions. security council resolution ( ) acknowledged the growing impact of the hiv/aids pandemic in africa on social instability and emergency situations, and stressed that if left unchecked, it "may pose a risk to stability and security." [ ] this historic resolution was followed by two others-resolution ( ) and ( ) respectively on hiv/aids and ebola. the eu security strategy ( ) is another example of framing health as an international security threat. it links infectious diseases to poverty, economic failure, political problems and ultimately violent conflict, [ ] and also notes the threat posed by the potential rapid spread of new diseases and the devastation caused by the hiv/aids pandemic. the concept of international security has been discussed almost in passing in the security literature by buzan ( ) , describing it as focused "on the sources and causes of threats, [with its]… purpose being not to block or offset the threats, but to reduce or eliminate them by political action." [ ] this definition is in contrast to his discussion of national security, which focuses on "reducing the vulnerabilities of the state… by increasing self-reliance, or by building countervailing forces to deal with specific threats. [ ] the concept of 'world security" is in the words of ken booth "more encompassing than the notion of international security… [including] the structures and processes within human society… that work toward the reduction of the threats and risks that determine individual and group lives." [ ] both concepts-of international and world security-are very relevant to thinking about mechanisms to reduce health insecurity, but are rarely used by analysts to frame interrogations of the nature, scope and focus of health security politics. it is curious that there has been so little conceptual analysis of these political statements pronouncing health as a global/international security concern. health security as an aspect of human security has received the least attention in the health security literature. health is one of the seven areas identified by undp's "human development report" ( ) as pertinent to human security. much contemporary analysis, however, focuses on the mechanisms through which health affects human security, and not on the political or policy implications of promoting and pursuing human security, or indeed on what such health security policy might look like. health as a human security issue is broadly defined and premised on who's definition of health as "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity." [ ] this in turn means a broader view of the range of relevant health threats-going beyond communicable diseases and bioterrorism, to include for example noncommunicable diseases, neglected tropical diseases; as well as considerations about the social determinants of health. this view considers "the many other health challenges faced by more vulnerable groups who are amongst those most affected by the burden of disease." [ ] proponents of this approach further note that health threats are experienced most acutely by marginalized groups and communities and that gains in health anywhere in the world benefit everyone everywhere. [ ] takemi et al. argue that a human security approach can contribute to improvements in health because it focuses on the needs of communities, recognizes people's vulnerabilities and strengthens the interface between protection and empowerment. [ ] critics have argued that human security does not have sufficient political traction, [ , ] building on critiques of the concept as being too broad to serve as a guide for academic research or governmental policy making. [ ] while the term "human security" might have lost political traction, however, the value of promoting human-centered security is deeply embedded in existing human rights norms and humanitarian law, as well as doctrines such as the responsibility to protect. this calls for further substantive analysis of the positioning of health security in a broader normative and political context. as the commission on human security has suggested individual and state security need to be considered as complementary-an avenue for analysis that remains largely unexplored. [ ] all the different framings above share a conscious or an unconscious drive to embed public health concerns into existing frameworks for thinking about security. as barkawi and laffey posit, however, "security relations today [sic] are about the contradictions between old security logics and new security problematics." [ ] health security politics provide an accurate illustration of these tensions between understandings of security as a zero-sum game between great powers and the everyday realities of challenges posed by disease and ill-health, affecting the life and well-being many across the world. these tensions, however, cannot be reconciled by the old security theories, premised on old security logics, because they are partly the cause of the problem. analysis, instead, needs to draw on practice and emerging security paradigms. new frameworks for analyzing security politics include, but are not limited to cooperative security, [ ] [ ] [ ] [ ] [ ] multiactor approaches to security politics, [ , ] ethical security studies. [ ] these are particularly relevant to analyzing health security politics, which, as will be discussed, include complex interactions between public and private actors, aim to address issues that transcend national borders, and affect individuals and groups more acutely than states. a synthesis between alternative security approaches and empirical insight would provide a solid foundation for a more pragmatic understanding of how the political realms of health and security intersect and indeed interact. conceptual clarity is key in situating analysis, generating comparable findings, and facilitating understanding of commonality and diversity, argues baldwin. [ ] it is the first step in facilitating meaningful scholarly engagement and the development of policy proposals that are "comparable with each other and with the policies of pursuing other goals" and can easily be evaluated by end users. [ ] the questions that define the concept of security are: "security for whom? security for which values? how much security? from what threats? by what means? at what cost?" [ ] this framework is applied here with a view to highlighting implicit and explicit assumptions made about the nature and scope of health security politics in the existing literature. some of the questions from baldwin's framework have been used to frame discussions of health security already in two influential works by simon rushton-"global health security: security for whom? security from what?" [ ] and security and public health. [ ] there are two main issues with these worksfirst, rushton's analysis, as will be discussed below, is cautious and does not push conceptual boundaries far enough to explore the outer limits of health security; and secondly, these works only partially engage with baldwin's framework, meaning that rushton's analysis does not give us a ° view of the implications of assumptions made in relation to each aspect of the concept of health security. mainstream theories of international relations (ir) and security studies assume the state as the main referent object of security. [ ] current health security analysis is also predominantly premised on this assumption. while some studies assert it explicitly, [ , , ] most do so implicitly by either discussing security only in relation to health threats that challenge states' strategic interests, [ , , ] or by examining health as a foreign policy or national security concern, both of which are by definition state-centric. [ , , , ] the main consequence of focusing on the state as the sole referent object of security is that only a narrow set of health problems, which are perceived to cause acute state instability, state failure or destabilize other interstate relations, qualify as relevant security challenges, while many others remain ignored, excluded, and understudied. direct threats to state security are perceived to emanate from diseases that cause large-scale morbidity and mortality, cross national borders and affect populations, rather than just individuals. [ ] it has been argued that such diseases are destabilizing for states only in extreme circumstances-by affecting the health status of military personnel or peacekeepers, [ ] by undermining state structures and political stability, by exacerbating existing political instability, or by impacting the labor force and the economy, and reversing years of economic development. [ ] [ ] [ ] even in these situations, however, the impact of ill-health would be most acutely felt by individuals and communities. diseases (both communicable and noncommunicable) pose an existential threat to individuals, affecting their own and their families' sense of daily security, stability, predictability, well-being, economic, and development prospects, in a way that cannot be experienced at state-level. what is more, ill-health is the most relevant existential threat to people with out of the top causes of death worldwide being healthrelated, [ , ] which makes a strong argument for promoting human-centered security. baldwin argues that conceptually, and for purposes of specifying the concept of security, individuals, states, the international community can all be considered relevant referent objects of security. [ ] but while such analysis is central to gaining a more accurate and nuanced understanding of dynamic and evolving security problematics globally, existing security, and international relations paradigms are poorly equipped for such multiscalar analysis. traditional ir theories consider the preservation of the sovereignty, autonomy, and territorial integrity of states as core values to be secured. [ ] [ ] [ ] the raison d'etre of the state is to protect itself from external invasion or transgression, they argue, and it is only by ensuring its own security that the state is able to guarantee the security of its people. baldwin argues that in practice, other values are sometimes added to the national security agenda and that the values, which are being pursued by security politics ought to be clearly specified, so as to assist analysts in evaluating their relative importance and resource needs in comparison with other policy objectives. [ ] importantly, baldwin further argues against specifying security objectives in absolute terms, because absolute security is unattainable, which justifies his next question about the degree of security sought in a particular issue area. political and normative developments in international politics demonstrate that the spectrum of values that states have agreed to secure is growing. this is illustrated by the emergence of concepts such as human development, [ ] human security, [ ] responsibility to protect. [ ] [ ] [ ] increasing attention has been paid to the protection of civilians in inter-state conflicts through the growing body of international humanitarian law. states have further committed to seeking individual criminal responsibility for acts of genocide, war crimes and crimes against humanity by accepting the jurisdiction of the international criminal court and thus offering further protection for people from the exigencies of uncontrolled power. [ ] the influence that these norms and values are having on security policy is understudied by both traditional and critical security studies. these norms demonstrate a shift in values toward securing and protecting individual life and population well-being, alongside traditional state security. most analyses of health security do not engage in depth either with this evolving international normative context or with security studies paradigms that are more human-centered. health security studies struggle to effectively reconcile the values pursued by public health-i.e., the protection and promotion of the health of communities and traditional security studies-identified as existential threats to states. [ ] the values to be secured according to this literature, therefore, continue to be the stability and integrity of states-by means of preventing internal instability and state vulnerability that may be caused by high morbidity and mortality, and external instability caused by state failure and conflict. since assumptions about what values ought to be secured are implicit in the health security literature, the implications of these choices for security policy have not been sufficiently evaluated. at first glance, this question might appear futile and its answer obvious-surely, more security is always better. baldwin clarifies its significance-"[i]n a world in which scarce resources must be allocated among competing objectives, none of which is completely attainable, one cannot escape from the question 'how much is enough?" and one should not try." [ ] morgenthau sets out the realist position on this question: "all nations must allocate their scarce resources as rationally as possible" to guarantee national survival. [ ] offensive and defensive neorealists agree, but disagree on whether state security is best achieved through gaining the "appropriate amount of power" [ ] or through the maximization of power relative to other states. [ ] in practice, increasing spending on the pursuit of some values invariably means reducing spending on the pursuit of others. in a world where most states are not "great powers," the scope of security politics is richer and much more nuanced than presented by ir theories. the question of "how much security" has not been addressed at great length in the health security literature. the literature has broadly operated on the assumption that should health-related issues be "securitized" successfully, they will get the resources needed, which is in line with traditional security thinking on the issue. the scale of resources committed to addressing health crises, however, has so far been decided on an ad hoc basis, primarily by donors (public or private), and has often reflected the perceived proximity or scale of a health threat to national security as argued by rushton. [ ] thus, for example, a recent round of replenishment for the global fund to fight hiv/aids, tuberculosis and malaria saw donors pledge nearly $ billion. [ ] these diseases carry a similar burden of morbidity and mortality as some noncommunicable diseases, which have not received nowhere near as much funding. [ , [ ] [ ] [ ] [ ] [ ] nuclear defense spending in the uk and us, for example, far outweighs pandemic-preparedness spending, as highlighted by the current coronavirus pandemic. further analysis of the theory and practice of framing health security challenges is therefore urgently needed, with attention drawn specifically to existential threats facing individuals and communities. threats to security are traditionally defined as being external to the state, predetermined by the anarchic structure of the international system, and military in nature. [ ] the sharp decline in violent interstate conflicts and conflict-related deaths, however, as noted by the human security report project, [ ] threatens to deprive these studies of an object. does this mean, then that states and people are secure? one could hardly say so. with the majority of conflicts taking place within states and involving at least one nonstate armed group, [ , ] (with the intensification of violence against civilians, increasing intractability of conflicts and the spread of violent conflict to middle-income countries (iraq, syria, ukraine), assumptions about the nature and causes of conflict are continuously being challenged. [ ] the human cost of these conflicts is currently born extensively by civilians. [ ] in addition to conflict, people across the world lead daily battles for survival against disease, poverty, malnutrition, environmental degradation, climate change, lack of access to clean water, safe food, basic health services, against political oppression, gender-based violence, and so on. in this context, baldwin's argument that there is no reason to limit the concept of security to narrow, vague references at the expense of referring to practical threats that are comported with common usage, [ ] is particularly relevant. the health security literature has broadly kept in line with traditional security approaches on this question as well, by focusing analysis primarily on issues with a crossborder impact on national security, which has led to an overall narrow focus on health-related causes of insecurity-namely, emerging and re-emerging infectious diseases (erids) and bioterrorism. [ , , , ] some scholars have acknowledged that this focus is too narrow, proposing the inclusion of other issues such as internal state instability and illicit activities and an increased engagement of health security with public health and not just with the concerns raised by the foreign policy and security communities. [ ] this, however, is only a marginal broadening of the agenda, which fails to engage with two central questions-the protection of individuals and communities from danger, hazard and risk; and the much more complex question of whether security policy is just about negative security "security from" or whether consideration should be given to positive security as "security to." [ ] mcsweeney also talks about the importance of considering "structural" threats, namely, the unintended consequences of social action [ ] -the structure of the global economy, the pattern of power relations and dependencies within it, the profound influence of the food, tobacco and alcohol industry on government policy, gender inequality, levels of relative and absolute poverty, income inequality, etc. this is not to say that the health security literature is not cognizant of these, just that they have not been explored systematically and in sufficient depth, because too much attention has often been focused on dealing with acute threats. sovereignty grants states legitimate monopoly over the use of violence. employing the sovereign authority of states to respond to security problems is usually synonymous with the threat or use of military force or other types of coercive action. baldwin argues that the "specification of this dimension of security is especially important in discussions of international politics" and expresses concern that tendencies to define the field entirely in terms of the threat and use of military force "can prejudice discussion to favor of military solutions to security problems." [ ] improving and securing health, for example cannot be achieved by military means, even though military personnel and logistics can and have been utilized in emergency responses. pursuing security through nonmilitary means requires a human-centered focus and cooperative approach, where states engage not only with each other but also with a broad spectrum of nonstate actors. in security politics the state is increasingly becoming one actor among many, but with a key facilitating function in delivering security to individuals and communities. responses to health security challenges involve a broad spectrum of public and private actors, including intergovernmental organizations, inter-agency cooperation, civil society organizations, philanthropic foundations, corporate actors, etc.making for a complex governance architecture and a dynamic combination of various means and resources. the role of this panoply of actors has been explored in the context of global health governance, [ ] [ ] [ ] but not sufficiently so in the context of security politics, where the dynamics of governance interactions are distorted. in addition, promoting and improving health requires investment in infrastructure, education, knowledge development, in lifting people out of poverty, enhancing food and environmental security, all of which require concerted, cooperative efforts. this is a different model of thinking about security politics and appropriate security policy, compared with the zero-sum game, military, confrontational approaches proposed by mainstream security studies. some analysts promote the concept of "cooperative security," [ , [ ] [ ] [ ] premised on the changing nature of security threats as well as changing practices of security governance. this is an emerging fields of security analysis on which health security studies ought to draw more extensively. even though the assumption that security ought to be pursued at any cost is at the heart of traditional thinking about security politics, such conceptualization is unrealistic in most situations. as baldwin points out-"costs always matter." [ ] there are virtually no instances in practice where no restrictions on the means and costs of responding to a threat to security are in place, nor where other values are not competing for or having to be sacrificed in the distribution of scarce resources. this is not a question that has been examined in great detail either in mainstream security studies or in the health security literature, suggesting that analysts have adopted the traditional, exceptionalist frame of thinking about security, whereby a successful "securitizing move," automatically guarantees the availability of "sufficient" funds and resources to address security threats. addressing threats to security stemming from ill-health requires resources that go beyond the cost of medicines, as has become apparent through campaigns dealing with the spread of hiv/aids, tuberculosis, malaria, the fight against polio, and recent infectious disease crises-ebola, zika, and the covid- pandemic. the global health security agenda launched in , by the united states together with other states, who, the food and agricultural organisation and the world organisation for animal health, is one such attempt to promote activities aimed at strengthening "core capacities… of public health systems needed to protect global health security." [ ] analysis of the relative cost of security through the improvement of health and the alleviation of existential threats through the strengthening of health systems can be of particular importance in setting out domestic and global security priorities, but also in raising the required funds. cost is in many situations an inhibiting factor in pursuing particular interventions, despite evidence of the need for the latter. it should therefore always be a significant consideration in any health security policy analysis. mainstream international relations theories do not make a significant distinction between long-, medium-, and short-term security goals. their atemporal approach to security is premised on the assumption that the causes of conflict and insecurity do not change over time, due to the unchanging character of the anarchic international system. [ ] ahistoric realist and neorealist analysis seeks to justify the perpetual need to invest in military resources. in his brief discussion of this aspect of security, baldwin warns that short-term security politics often respond to an immediate threat, but a longer-term strategy for security may well conflict with the short-term approach. [ ] the existing health security literature does not tend to explore medium and long-term policy horizons, despite the pertinence of such temporal considerations to a broader view of health security. the health security literature has mainly taken an interest in current crisis [ , , [ ] [ ] [ ] with the aim of understanding the politics and institutions involved in the responses to these. and while such analysis is important and relevant, conclusions often point toward the need for a medium and long-term planning and investment. improvements in overall health security require much more than pandemic preparedness measures, including investment in the development of healthcare infrastructure, health systems strengthening, training of medical personnel. addressing the root causes of noncommunicable diseases, for example, may not be possible in the short-term, as they necessitate regulation and preventive action, which takes time to negotiate and implement as well as longer term planning and infrastructure investment. thinking about health security in differentiated time frames, therefore, could allow for a broader range of goals to be pursued, for more effective distribution of resources between acute and long-term needs and for pursuing goals of prevention, while also providing care where needed. baldwin's concept of security provides a structured and comprehensive framework for thinking about health security. it promotes systematic thinking about the assumptions and practice of health security politics that is not confined by the rigid ontologies of traditional security paradigms, but is open, flexible, and practice oriented. this conceptual framework enables the combination of rich empirical insight from existing studies of health security with a broader spectrum of approaches to security studies, to not only enhance understanding of political dynamics, but to also generate pragmatic policy options, accommodating of normative considerations. this section sets out new parameters for health security analysis that go beyond the constraints of traditional security studies. these require further analysis of practice and engagement with alternative security frameworks to inform health security policy on how best to address persistent criticisms and shortcomings. baldwin's guiding questions are grouped in three categories-ontological, normative and material considerations, and discussed in turn. concerns about the security of individuals have continuously been embodied in new international legal norms and made part of the global policy agenda over the course of the last few decades. the post-cold war years "exposed the fragility of the state in the face of complex forces within it and of trans-state limitations on its practical sovereignty outside it." [ ] instances of conflict, civil strife, political instability, state fragility, and now of the covid- pandemic are reminders that states are not always able or willing to guarantee the security of their citizens. the dominant view of security as a state-centric concept has been presented by its proponents "not as an option, a choice, but as the only one which is valid and rel-evant… [but] the assumption of security studies which ignores the human dimension is contradicted by the practical dependence of policy-makers and theorists alike on the human individual as the ultimate referent, or subject of security," argues mcsweeney. [ ] the argument in favor of foregrounding the security of individuals and communities in conceptual and theoretical debates is supported by practice. its relevance is particularly obvious in the context of (ill)health, which is probably one of the most prominent existential threats to humans, alongside environmental and food security. if the survival of individuals is not safeguarded, the survival of social structures and institutions loses its significance. contextualizing the security of individuals and groups in relation to and within state security is an area of security analysis that needs further attention in a changing landscape of political conflict-examples include the health security of populations in the context of civil war, failed or fragile states, [ ] [ ] [ ] or the provision of health-services in territories held by nonstate groups, e.g., rebels, guerrilla groups, isis; or the security of women and girl refugees fleeing conflict. [ , ] empirical evidence needs to be brought to bear on understandings of security politics in general and health security in particular. in addition to analyzing the relationship between individual, group, and state security, attention needs to further focus on the "providers" of security, which increasingly include specialized nongovernmental organizations, public-private partnerships, philanthropic foundations, multilateral agencies, and others. it has been assumed that this dynamic governance architecture is still under the control of sovereign governments, but there is little evidence to support that, particularly in contexts of conflict, fragile or failing states such as syria, afghanistan, yemen, south sudan. rushton and williams' "partnerships and foundations in global health governance," [ ] harman's "global health governance," and [ ] jeremy youde's "private actors, global health and learning the lessons of history" [ ] are useful starting points in outlining the architecture of health governance, but further analysis is needed to reflect on the idiosyncrasies of security-focused governance and politics. gjorv ( ) advocates the need to adopt a multiactor security model to explore the patterns of security-related governance, which she argues is prompted not only by normative considerations, but is a reflection of the empirical realities facing security practitioners, illustrating her argument with two examples civilmilitary operations and climate change in the arctic. [ ] baldwin's conceptualization of security demonstrates that restrictions on the referent object of security are superficial. when health-related risks and challenges pose an existential danger, they need to be considered as security risks, in recognition that individual and community security is as relevant a consideration to state security and vice versa. health-related existential threats to individuals and communities are further exacerbated by poverty, political instability, state fragility, conflict, and civil strife. but since state security can both determine and be determined by the security of individuals and communities, and since there are other actors involved who impact or are impacted by such insecurities, a more comprehensive understanding of the politics and frameworks of health security policy making is urgently needed. despite traditional theories of international relations discounting normative considerations in matters of security and national security, such considerations are always present. as discussed earlier, adopting a narrow state-centric, militaristic view of security is both an option and a normative choice, and not the only possible or valid one. this is the premise of much critique from critical security studies, as illustrated by works such as krause and williams, [ ] barkawi and laffey, [ ] booth, [ ] peoples and vaughan-williams, [ ] sjoberg, [ ] wibben, [ ] and shepherd. [ ] some analysts are further advocating consideration of security in terms of both positive and negative security, where negative security aligns more with traditional notions of security as "security from," while positive security is seen as enabling and emancipatory-"security to." [ , , ] such a lens enables values such as human life, life in good health, life with dignity, to be placed at the center of security strategy and policy, which in turn demands that security politics become more inclusive, more protective, less focused on privileged views and experiences of security, more human-centric. framing security as a positive value creates space for considerations such as health system strengthening, the provision of primary care and universal health coverage, the prevention of noncommunicable diseases, to be given greater policy priority, which as analysts have argued would not only improve health outcomes overall, but could also strengthen health responses to acute crises. health is an important value on a global scale, as evidenced by the constitution of the who ( ), the alma ata declaration ( ), the international health regulations ( ), the sustainable development goals ( ), along with the intrinsic value of human life, which is the bedrock of all international human rights norms, treaties, and declarations. if life and good health are the values to be secured, however, state policies would have to go beyond seeking to protect individuals and populations from emerging and re-emerging infectious diseases and bioterrorism and take into account a broader spectrum of health-related existential threats to people. diseases posing significant risks to people in low-and middle-income countries include among others neglected tropical diseases (ntds) [ ] [ ] [ ] and noncommunicable diseases. ntds' burden of disease measured in dalys ranked these diseases fourth after lower respiratory infections, hiv/aids, and diarrheal diseases, preceding malaria, tb, and measles. [ ] "noncommunicable diseases (ncds) are the leading cause of death globally and one of the major challenges of the st century." [ ] an estimated % of all deaths globally in resulted from ncds, the world health organisation (who) reports. over the next years, ncds will cost more than usd trillion, pushing millions of people below the poverty line. [ ] much like other global problems, health insecurity disproportionately affects low-and middle-income countries, as well as the poorest and often most disadvantaged strata of societies in high-income countries. an infectious disease pandemic like covid- further worsens health outcomes by compacting morbidity, exponentially increasing mortality and creating a perfect storm even for the relatively well-resourced health systems in high income countries. securing health and well-being is an important goal in a dynamic portfolio of values that need to be protected. how much attention should be devoted to health overall, and to specific health concerns, or the needs of particular groups within this portfolio, are questions that needs to be examined further and in greater detail, drawing on studies of public health in individual states and across borders. the answer to the question "how much security" is also likely to vary over time. analysis of the relative threat posed by a given health issue to individual, community, and state security is a valid consideration for health security politics-using a structured framework to enable comparative analysis is central to health security analysis. due to the relatively high morbidity and mortality, the covid- pandemic has demonstrated that health threats can be elevated to almost absolute, primary status. actions taken to contain the pandemic have included social distancing measures, limiting travel, shutting down economies, governments promising to pay salaries, support private businesses, etc., which are measures that appear unthinkable in most other cases. in the midst of this crisis, however, it is important to remember that pandemics of such scale and scope are relatively rare and to use covid- more as an extreme example than a baseline one. contrary to traditional security approaches premised on the use of military means, health security (whether broadly or narrowly defined) requires the employment of nonviolent, cooperative measures-including investment, humanitarian aid, development assistance, multiactor cooperation, coordination, sharing of information and expertise, etc. as discussed previously, the cost of addressing health security problems is significant, due to the need to establish and support a functioning health system, to train and retain professional staff, to create infrastructure that facilitates the functioning of the health system, but the cost of inaction is high and puts lives at risk. the challenges posed by public health emergencies of international concern and pandemics can be exceptionally far-reaching and damagingglobally, locally, trans-locally, as illustrated by the current spread of the sars cov virus. the human cost of this pandemic has been unprecedented in recent history, the economic costs are yet to be calculated with more than a quarter of the global population in lockdown, international travel restricted and economies shrinking fast. in a world of scarce resources, the means for securing health and the cost of doing it are pertinent policy considerations, which need to be examined in conjunction with the opportunity cost of both not investing in health security and of investing in a different field. the short-termism and immediacy of conventional security politics is counter-productive in approaching problems such as anti-microbial resistance, noncommunicable diseases, maternal and infant mortality. even responses to public health emergencies of international concern, in the form of communicable disease outbreaks, have demonstrated the need to develop a systematic approach-including properly resourcing the work of the who, investing in health systems strengthening and infrastructure. the report of an independent review committee on the h n response noted that "the world is illprepared to respond… to a global, sustained, and threatening public health emergency" as health capacities were not on a path to timely, worldwide implementation. [ ] the international community collectively and states individually appear to have squandered the time since to prepare for the next global pandemic. the health systems in high-income countries are buckling under the weight of the covid pandemic. concerns are growing over its effects the pandemic will have on low-and middle-income countries. in the conclusion to their discussion of the global response to zika virus, gostin and hodge point out that the apathy and short-sightedness of the international community must change, as the consequences of fast-moving epidemics are comparable with humanitarian crises, climate change, and war. [ ] such analysis and current events clearly illustrate that planning has to include the short-, medium-, and long-term and might be more effectively organized at the global level, as states are better off responding together than individually. to sum up, this discussion of the dimensions of health security demonstrates that health security can be conceived of as focusing on the security of people, communities, and states, if we accept that health security politics are centered on the protection of the core values of life and life in good health. since health security is concerned with issues that both pose an existential threat to people and also threaten and destabilize communities, its significance ought to be ranked relatively high. health security politics need to be viewed both as being embedded within the existing normative context of human rights and as themselves promoting a range of valuesincluding dignity, respect, nondiscrimination, emancipation, and empowerment. the pursuit of health security requires material resources like any other type of security. part of the politics surrounding health challenges center on competition for attention and scarce resources. the resources required for the enhancement of health security can be significant, as they involve developing infrastructure, training health professionals, the delivery of care, ensuring the accessibility of medicines, disease prevention, health promotion, and strengthening health systems. [ ] conceptualizing health security in this way, calls for a more holistic approach to encompass both the important work done through responses to global health emergencies and the need for medium-and long-term policies, because in health, just like in strategic politics, prevention is always better than cure. thinking about health security in a systematic way simultaneously highlights the idiosyncrasy of the health security field compared with other fields of security politics and demonstrates the interconnectedness and overlaps between them. baldwin's concept of security provides a guiding framework, a structured conceptualization through which to rethink the way in which health security has been imagined. the flexibility of ontological assumptions that it provides opens possibilities for health security studies to connect with contemporary security paradigms, defying the stereotypes, and constraints of traditional thinking about security. at the very least, it provides a structured framework that allows for comparative analysis of competing accounts of security politics with diverse paradigmatic assumptions. the framework is able to accommodate not just conceptual debate but observations of and reflections on practice. this article sought to contribute to debates about conceptualizing health security and understanding health security politics. it set out to challenge the use of traditional security paradigms, which obscure the significance of public health threats to individual and community security and well-being. the current covid- pandemic has brought these issues to the fore with a much sharper focus than previous public health emergencies of international concern. the brief overview of the different denominations of health security demonstrated that the grounding of existing analysis in securitization theory and constructivist thought has been driven in part by the desire to validate the claim that health-related challenges were indeed relevant security concerns, and in part by the need to fit within existing debates. overall, as has been demonstrated, health security analysis has remained predominantly anchored to the securitization approach, despite critiques levied at the copenhagen school by critical and feminist scholars. [ ] [ ] [ ] health security analysis has only marginally engaged with related bodies of work in the fields of foreign policy, human security or with alternative security paradigms, which has limited the field's dynamism, critical edge, and ability to influence policy debates. this article applied baldwin's framework of the concept of security to existing conceptual and empirical studies of health security to demonstrate how narrowly health security has been conceptualized and how much more analysis is needed for a better understanding of this complex field. traditional security analysis is broadly inhospitable to claims that health issues are a relevant security consideration, leading some analysts to reject the relevance of health to strategic security instead of questioning whether the way that security is framed and defined is still relevant to political and strategic realities and practice. baldwin's framework helps liberate health security analysis from the dogmatic assumptions of traditional security theories, while at the same time providing a structure for rigorous, comprehensive and comparable conceptual debate. experimenting with novel thinking about the ontological, normative and material considerations in health security can help push the boundaries not only of the health security field, but of security studies overall. particular questions for further research emerge-e.g., about the relationship between individual, community and state security, about the way in which resources are allocated to specific fields of security politics, about the differences in short-, medium-, and long-term planning in health security politics, about ways in which to evaluate the relative importance of competing security challenges, the relationship between perceptions and indicators, and so on. the exploration of these questions, based on a clear, explicitly defined concept of health security will promote more systematic thinking about security politics that is open, flexible, and practice oriented. taking a broader, more holistic and historically grounded approach to understanding the politics of health and security brings its own set of challenges. a comprehensive rather than parsimonious way of thinking would inevitably complicate analysis, as it incorporates more variables and tries to capture more, not less of the political and social complexities of security policymaking. questions about normativity and ethics need to be considered. drawing on knowledge across disciplinary borders is rarely unproblematic, as ontological, epistemological, and methodological differences may hinder multidisciplinary dialog. none of these difficulties, however, are insurmountable, as demonstrated by novel approaches to security studies, on which health security analysis ought to build. the pressing needs to rethink the dimensions of health security has regretfully been validated by the unfolding covid- pandemic. writing in the midst of this crisis, it is difficult to assess what the implications of this pandemic would be for societies, economies, health systems. the issues that the pandemic is bringing to the fore, however, are not new. academics have grappled with and tried to draw attention to some of these for at least the last years. [ ] sars cov , the virus that causes covid- , is a health security threat-make no mistake about it. this virus poses an existential risk to humansit threatens individuals, but impacts on communities and on almost every aspect of societal life-family life, social relations and activities, culture, education, the economy, government. governments around the world are using an unprecedented spectrum of measures to reduce morbidity and mortality, previously unseen in peacetime. the who has repeatedly noted that the response to the pandemic would be most effective if states work together in a spirit of cooperation, solidarity, and care. states need people, businesses (including private health care providers) and voluntary organizations to support the pandemic response, which is an illustration of multiactor security politics coordinated by governments and intergovernmental organizations. there is no doubt that this pandemic will bring about change-the extent and nature of the change is currently unknown. what the pandemic has illustrated so far, however, is the need for health systems strengthening, for deepening of global coordination and cooperation, and a stark need to critically reflect on the way we conceptualize security in general and health security in particular without leaving the individual and communities out. at un global leaders commit to act on anti-microbial resistance the lancet foreign policy and security-towards a conceptual framework for research and policy foreign policy and security-towards a conceptual framework for research and policy managing global health security-the world health organization and disease outbreak control routledge handbook of global health security the coming plague: newly emerging diseases in a world out of balance emerging infections: microbial threats to health in the united states america's vital interest in global health: protecting our people, enhancing our economy, and advancing our international interests the global 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of urban conflict in iraq disease and security-natural plagues and biological weapons in east asia identity and interests: a sociology of international relations secur. hum. rights international theory: positivism and beyond south sudan conflict: violence against healthcare conflict survival critical security studies: concepts and strategies critical security studies: an introduction gender and international security-feminist perspectives feminist security studies-a narrative approach critical approaches to security-an introduction to theories and methods world health organisation, noncommunicable diseases country profiles , world health organisation the global economic burden of non-communicable diseases key: cord- -burm nxm authors: eckmanns, tim; füller, henning; roberts, stephen l. title: digital epidemiology and global health security; an interdisciplinary conversation date: - - journal: life sci soc policy doi: . /s - - - sha: doc_id: cord_uid: burm nxm contemporary infectious disease surveillance systems aim to employ the speed and scope of big data in an attempt to provide global health security. both shifts - the perception of health problems through the framework of global health security and the corresponding technological approaches – imply epistemological changes, methodological ambivalences as well as manifold societal effects. bringing current findings from social sciences and public health praxis into a dialogue, this conversation style contribution points out several broader implications of changing disease surveillance. the conversation covers epidemiological issues such as the shift from expert knowledge to algorithmic knowledge, the securitization of global health, and the construction of new kinds of threats. those developments are detailed and discussed in their impacts for health provision in a broader sense. the term digital epidemiology is in this special compilation defined by marcel salathe as epidemiology that uses data that was generated outside the public health system, i.e. with data that was not generated with the primary purpose of doing epidemiology (salathe ) . arguably a narrow definition, we will use this conceptualization as the starting point for our conversation. the so defined digital epidemiology promises faster detection of disease outbreaks and improved surveillance as well as reduction in administrative and financial burden, among other things. at hand in the following conversation is less the question if those promises are kept. instead we are interested to reflect epistemological/methodological, ethical/legal, social/political, and organizational aspects and implications corresponding to the promise of digital epidemiology. what will be the relationship of traditional and digital epidemiology? will a possible change influence the scope of public health and global health? tim eckmanns, henning füller and stephen roberts discuss political implications of digital epidemiology. digital infectious disease early detection systems such as the promed-mail, global public health intelligence network (gphin), healthmap, the now closed google flu trends or the syndromic surveillance system essence are central elements of global public health surveillance. however, with increasingly digitalized (algorithmic) global public health surveillance systems and related data-driven epidemiological analyses (e.g., digital epidemiology and other research methodologies), there seem to emerge epistemological shifts, as well as methodological ambivalences and diverse social and political effects. you, henning and stephen, both work from a social (or rather political) science perspective on the societal implications of digital epidemiology, which is shaped by multiple imperatives, e.g., of 'global health security' as well the potentials of big data. over the past two decades, i would argue, we have seen an unleashing of the algorithm across practices of health security and surveillance. algorithmically-guided infectious disease surveillance systems have proliferated across global health geographies, seemingly in response to a series of interconnected and complex transformations within global health governance (ghg), as well as the practice of international relations and international security. we have seen the rise of a seeming 'epidemic of epidemics' from the late twentieth century onward, including the emergence of hiv-aids, novel strains of avian and swine influenza, sars, ebola, mers, the zika virus, and the re-emergence of cholera, polio and multi-drug resistant tuberculosis across low and middle income countries (lmics) clinical and public health surveillance practices with their routinised processes of data collection, analysis, and dissemination from national health institutes have increasingly fallen out of pace with the capacity to timely identify the globalised spread of novel and re-emergent pathogens. correspondingly, the rise of the digital era, resultant from technological interconnectivity and innovation, has generated infinite, voluminous and diverse data at a rate never feasible in history. between and , . quintillion bytes of data have been produced continually, every day in the mere span months (ibm ). celebrated for the capacity to connect the operational 'dots' between these seemingly unintelligible and largely unstructured streams of data in the surveillance and identification of infectious disease outbreaks, the algorithm has emerged as salient and novel technology of security in the pre-emption of pandemic threats in the twenty-first century. to firstly illustrate this shift, in late november , the global public health intelligence network (gphin), a semi-automated online health surveillance system, which piloted the use of retrieval algorithms to filter international media sources, identified the early reporting of a form of atypical pneumonia circulating in guangdong province, china. the 'algorithmic gaze' of gphin identified the origins of the severe acute respiratory syndrome (sars) in advance of months of traditional public health and governance authorities. more than a decade following the rapid spread of sars, healthmap, an online health surveillance system, identified again, via algorithmic processing of digital data streams, the emergence of a mysterious hemorrhagic fever occurring in macenta, guinea. healthmap critically captured and presented strategic epidemic intelligence detailing the emergence of the ebola virus disease (evd) on march , days in advance of the official notification of outbreak by the guinean health authorities. digital epidemiology -from expert knowledge to 'knowledge without truth' the increasing integration of algorithmically-driven infectious disease surveillance systems contemporary logics of health security are critical and significant for a number of reasons (roberts and elbe ) . first, reflective of a growing recourse to the harnessing of novel information sources to contain pandemic illness, the who, via the revision of the international health regulations ( ) , has clearly authorised the collection, assessment and utilisation of non-governmental sources of epidemic intelligence and data (article . ), without prior clearance of member-states. (world health organization ) in this regard, the algorithm emerges a new purveyor of varied, voluminous and expedited data sources to be leveraged in the risk assessment of future infectious disease threats. epistemically, what we can see is how the centralisation of the algorithm within security technologies such as digital disease surveillance systems re-contour previous relations and understandings of knowledge production, the practice of surveillance and the regulation of pandemic risk. the cultivation of knowledge to address the contingent within past 'regimes of truth' were largely sustained, as illustrated by foucault by the 'avalanche of statistical numbers' (hacking ) . increasingly however, within these contemporary security technologies, the vs of big data (volume, variety, and velocity) are now being mined, scanned, and reassembled via algorithmic processing of data to produce findings and alerts on the next pandemic. information and 'truths' about the physical world and the contingent threat of infectious disease are increasingly extracted in the forms of signals and signs of the realm of the digital, and no longer solely generated from statistical processes via human analysis. furthermore, as the conceptual work of antoinette rouvroy ( rouvroy ( , rouvroy ( , , has demonstrated, algorithms have emerged within health surveillance technologies as purely 'rational' or 'objective' instruments of forecasting, indifferent to the causes of phenomena and seeking only to accrue maximal reservoirs of data to address that which constitutes the contingent or the uncertain. what this means therefore is information and knowledge generated by these algorithmic techniques now appear to bypass the traditions of human assessment, analysis, hypothesis, testing and trial which were essential to the statistical calculation of the contingent. rouvroy has referred to this dissemination of this new form of understanding future-situated uncertainty as "knowledge without truth", represented in the context of this discussion by disease tracking systems including gphin and healthmap, which have, with upward intensity sought to apprehend infinitely expanding data sources through an intensified recourse to algorithmic-suffused disease surveillance. what is absolutely vital to emphasise here is that amid the widespread deployment of big data analytics and increasingly sophisticated algorithms for tracing the next outbreak, little critical assessment has been formulated by global health security theorists and practitioners on the ramifications 'digital' turn of health surveillance and the implications of big data and algorithmic surveillance practices on individuals, populations and states. thus, these continued shifts towards employing advanced algorithms to make sense of unprecedented amounts of information (leese ) , across practices of contemporary disease surveillance must be continually matched with equally robust interrogations of the unforeseen or unprecedented implications of securitization by algorithms in the realms of ethics, law, politics and society. thanks, stephen for underlining the function of algorithms in current approaches of disease surveillance in global health policies. in addition, i pose that the rationale of an 'emerging diseases world view' (king ) is similarly influential for public health surveillance on a domestic scale. especially in the us, systems of syndromic surveillance have been explicitly employed to answer the challenges of the 'next pandemic' with a new algorithmic form of public health monitoring. going a bit into the details of one specific example of syndromic surveillance, i want to illustrate the problem of "knowledge without truth" stephen mentioned above. the argument is that those systems 'call back' in several ways, influencing both truth claims and practices of public health provision. my empirical example is a study on the use of the "electronic surveillance system for the early notification of community-based epidemics" (essence) in the u.s. national capitol region, an application of syndromic surveillance that received considerable attention as a pilot project (füller ) . technically the essence system provides the server infrastructure to draw together diverse data-sources that are considered indicative for public health. its 'syndromic' approach consists in the integration of several so called surrogate data, signals of diseases or public health problems generated before a confirmed medical diagnosis (velasco et al. ). in the case of essence, such surrogates are for example emergency department chief complaints, daily over-the-counter sales of the two big pharmacy chains cvs and rite aid, reports on absenteeism data gathered from public schools and others. essence claims to provide an unmatched situational awareness partly due to the near real-time nature of those data (collected and reported at least daily). given the amount and unstructured nature of this data, the system employs algorithms to continually search the gathered data-stream for unusual patterns and a gui to visualize and map resulting alerts. if there is an unusual coocurrence of for example the sale of headache pills and school absenteeism in a region, the system will flag out a warning. importantly, the base for this pattern recognition are at no times diagnosed health problems but assumptions generated through the association of different data sets. eventually the system promises to automatically provide an early notification of any unusual public health event before it has been medically diagnosed (fearnley ) . the turn towards infection control and surveillance in public health and the introduction of syndromic surveillance systems have both been contested early on and from several vantage points (reingold ) . the focus here is to point out the performative character of technologies and their related practices in altering the goals and modes of public health provision. my argument centers on the fact that the system is constantly producing health related truth claims. whether it is just quietly monitoringas it does most of the timeor in the rare cases that it is flagging out a public health emergency, the system claims a certain truth about the health of the monitored population. in both cases, the algorithmically produced knowledge becomes performative in different ways. both forms of truth claims illustrate the 'knowledge without truth' problematic stephen already mentioned. on the one hand, those systems introduce a new expectation and a demand to constantly assure the normal state of affairs. new technologies of surveillance are employed to be able to illustrate an absence, to be able to constantly assure that there is nothing to worry about, as kezia barker argues (barker ) . in order to be aware of unusual events, resources, work and infrastructure are invested to extensively monitor the routine state of public health. but this additionally generated knowledge does not provide a qualified, actionable truth about the state of public health. trying to see short-term events, those systems measure against the baseline of the 'normal'. in its usually quiet mode of monitoring, the systems make the implicit claim about a 'normal' , 'well functioning' , 'unproblematic' state of public health, ignoring any long-term and structural health issues. on the other hand, in the case of actually flagging out an incidence, automated monitoring systems such as essence are problematic in their rendering of disassociated facts into medical truths. the threat of an emerging public health event is especially burdening for the executive branch of the local state. decision-makers are pressured to act early, at best before the expected cascading of an infection gets out of control. this expectation makes it tempting to base a decision on the syndromic signals as they are readily available and -through the included mapping tool -often clearly localized. while those signals are explicitly handled as an additional but clearly undiagnosed source of information among epidemiologists and public health experts, for the executive branch they have a tempting appeal of providing a near real-time situational awareness and as such an actionable grasp on the emerging public health event. importantly, using essence as a base for decision-making approaches the signal as if it was an authoritative medical fact instead of just an indicator for the clustering of certain syndromes. the danger of misinterpretation as the algorithmically generated knowledge travels contexts may result in wrongly employed public health interventions with negative social effects. besides the problem of false positives prevalent to those systems (fearnley ) the system always suggests a spatialized source of the problem that may or may not be medically justified. employing public health interventions based on those seemingly objective and localized realities can easily mean the wrong allocation of scarce resources and attention or effect an unjustified stigmatization of a 'problematic' area. from my perspective, as a medical infectious epidemiologist and public health expert who advises on the development of new surveillance systems and who constantly needs to be aware of their effectiveness as well as the consequences of their use, stephen and henning's analyses offer extremely important contributions on how to think about and evaluate increasingly digitized health-and infectious disease control. to add to this, i would, in the following, like to make a few further comments about the epistemic and political aspects of the digitization of infection control. in particular, i am able to speak to activities and experiences at germany's national public health institute, the robert koch institute (rki), and to those at the world health organization (who), where i was within the framework of the west african ebola outbreak ( to ) (owada et al. ) . first of all, i agree with stephen's analysis that there is the risk, as a result of the successive propagation of algorithmic approaches and technologies for infectious disease control, an epidemiology traditionally based on diagnostic findings and controlled statistical processes is becoming increasingly marginalized and, in parallel, the necessary verification loops are being replaced in favour of 'big data' ideologies and trends of dataification. in this context, it seems to me that widespread assumptions that advance the idea that a digital, unofficial infectious disease surveillance and monitoring is quicker than traditional, official information and reporting systems need to be modified. it is true in retrospect that existing digital systems and their associated early warnings could have been faster if their first signals had been correctly named or interpreted at an early stage. at the same time, however, it is mostly ignored that even official state authorities often have knowledge about specific events at relatively early stagesonly that they either initially withhold such information or distribute it in other ways according to the official information/notification systems, e.g. the example of stephen, the authorities of guinea were aware that there was something going on, but they waited with the reporting. so have i experienced it at the who: few countries directly provided all available information to the organization. it can also be observed again and again that official information either minimizes or plays to the media or other entities in a targeted way. in this context, non-state surveillance platforms such as promed or healthmap, for example, should be commended especially for their dimension of political transparency, as they put pressure on governments not to keep information from the public as much as possible. at the same time, however, the increasingly digitized identification, analysis and distribution of epidemiological indications of infectious disease these platforms enable not only leads to increasing likelihood of false positives, but also to specific problems of an immediate, uncontrollable communication of risk. the danger of panic and the great effort required to avoid panic are to be feared. henning provides very important information in this regards. he describes that specific public health actors (here: local health authorities) may be compelled to equate technologically-generated signals with epidemiologically certified public health events, and, on the basis of these unproven indications, initiate public health measures. further, this is also a problematic development from the perspective of resource retention in an already thinly-resourced public health service. early responses and over-reactions from political decision-makers or the media are to be feared in equal measure. in the broader context of the focus and framework of a 'global health security' , such potentially exaggerated perceptions and reactions are tied to perceptions of elevated threats of infectionwhether from (quasi) natural or man-made infection (e.g., in the context of war or incidents of terror)and, consequently, to urgent demands for comprehensive and constant attention, outbreak detection, and further crisis/disaster preparedness measures. as a result of this, infectious disease epidemiology is increasingly being, in my humble opinion, in an irritating way integrated into the national and international security architectures. so it was during the west african ebola outbreak in sierra leone and liberia, two of the three hardest hit countries, that the military was constantly present in the planning of public health measures. e.g. in one situation in sierra leone i remember this resulted in prioritizing quarantining over other public health measurements like community engagement. quarantining is not per se negative but in this particular case turned out very ambivalent as the measure evoked strong resistance among the population and potential new infected individuals increasingly were actively hidden as a consequence. also in non-outbreak times, the cooperation between security forces and public health entities is becoming increasingly narrow. this can be seen, for example, in the global health security initiative, which addresses both the biological threats of pandemic flu and possible threats from chemical or radio-nuclear terrorism. these perspectives as well as the social aspects and subsequent costs of a digitized infection control should be discussed. they are closely linked to the imperatives of constant monitoring and early detection, as well as the similar focus of a 'global health security'. as such, they should be considered with the view not only to the (not new) anticipated restrictions or marginalizations associated with classical, structural and also socially-reformed, areas of public health, as well as to further possible negative costs resulting from of a 'securitized' public health. i would like to hear from you -stephen and henning -especially with regard to these broader health and social policy debates, from your social science perspectives, what is your understanding of 'global health security' in general and of the 'preemptive security logic' , which is often discussed in this context, especially? henning i would suggest to understand "global health security" as a set of preferences and truth claims that are currently framing our understanding of health issues of international relevance. this understanding results from a perspective, that interrogates threat discourses and related policies as a structured but contingent formation of problem descriptions. problems do not exist 'naturally' but they have to be articulated and put on the agenda in a process of social interaction. this approach draws back to michel foucault and his proposal to acknowledge a power/knowledge nexus in general and specifically the power effects of truth claims. according to this, articulating and framing an issue are powerful ways to predetermine the range of thinkable approaches and solutions. by using the term "global health", policy-makers, non-governmental actors and academic observers are drawing together several health problems into a common frame, but also marking this frame as a field of intervention and claiming its relevance. the contours of this frame are still blurry and there exist numerous approaches to define "global health" (brown et al. ; farmer et al. ; fassin ) . there is no accepted definition and "global health […] is more a bunch of problems than a discipline". (kleinman ) the ongoing emergence of a problem field "global health" is an interesting moment then, where new truth claims are put forward and a new understanding of related issues such as 'health' and 'the global' are formed. those newly related ideas are powerful as they are confining the agenda setting and plausible goals and methods of intervention. approaching "global health" from this angle, what is striking from the outset is a strong undercurrent of security. the recent surge of "global health" can be attributed to a confluence of two separate discourses. on the one hand, globalization is increasingly narrated as a health risk. an "emerging diseases" discourse paints the picture of a global spread of infectious diseases due to unparalleled levels of global connectivity and frequency of global travel (barrett et al. ). on the other hand, the concept of national security is being reimagined, facing a new multi-polar and complex world order. today, in order to achieve national security, one has to look beyond military dominance and to take societal issues such as health, poverty but also climate change as security threats into account (redclift and grasso ) . for example in the us, facing the threat of bioterrorism, public health has become a concern for the department of homeland security and international infection control resurfaced as a security issue. both the fear induced by 'globalisation of disease' and the rethinking of national security are underlining a new relevance of global health issues. the resulting tremendous development in global health policies and programs accordingly are often following a security rationale (genest ) . one example is the newly installed global health surveillance mechanisms and the revised international health regulations (ihr) (fidler ) . the recent conception presents global health as part of a security problem rather than as a humanitarian issue. this securitization of 'global health' has already been described in some detail (cook ; king ; pereira ) . here i want to underline the corresponding shift in the perception of threats and its implications. current problems of global health security are often depicted as essentially incalculable. emerging diseases, acts of intentional bioterrorism, food security in an increasingly global connected distribution system, antimicrobial resistant agents, − more than ever we now seem to be confronted with "unknown unknowns". we not only do not know when those events will happen, but we even do not know what the threat is exactly. the reformulated international health regulations (ihr) tellingly have shifted from monitoring a fixed catalogue of diseases to the obligation to warn about anything unexpected. according to the ihr, the national health agencies have now to signal any unspecific "public health emergencies of international concern" (world health organization ) to the who. this specific perception of "global health security problems" as incalculable threats calls for a certain pre-emptive and outbreak-oriented intervention. the implications of the employed "preemptive security" logic have been detailed in critical security studies (de goede and randalls ; lakoff and collier ; massumi ; caduff ) . as those studies have shown, preemption often demands the extension of (technological) surveillance and orients efforts towards the event and away from structural conditions. comparable tendencies have been shown for current "global health" policies, for example an orientation towards containment of an event rather than the search for a broader structural prevention (rushton ) . to sum it up, i would argue that global health is currently presented as a problem and has been put on the political agenda in a way that calls for a very specific answer in the form of a "preemptive security logic". firstly, the underlying truth claims about the problems to solve frame the emerging field of global health partly as security issue. secondly, the incalculability problem evoked in many threat discourses of current global health thinking demands a certain security rationale. the problem of an unknown unknown has to be dealt with preemptively. this way of presenting the problem of global health then implicitly constraints plausible interventions. approaching health as a security issue does often not tackle the actual problems of health on the ground. for example, this approach inclines to invest scarce resources into monitoring and surveillance rather than education and local health infrastructure. in order to reach the goal of more substantial health policies it is important to be aware of this securitization bias in the current problematization of global health. building further on excellent points articulated by henning, this epistemic shift in government and politics towards 'global health security' has been resultant, as i argue, from significant larger geopolitical transformations, and new reconsiderations of security perspective, in a post-cold war era of rapidly proliferating non-traditional security challenges, which extend beyond traditional security correlations of the state/military, are transnational or global in scope, and again, to underscore the centrality of henning's earlier points, which cannot be prevented entirely, only addressed through coping mechanisms and the development of techniques of preemption and forecasting (caballero-anthony ). the rise of global health security and its securitizing processes have transformed the ways in which international relations and global politics are understood, orientated and practiced. in the united nations security council (unsc) adopted resolution (unsc ) which emphasised that the current hiv/aids pandemic, if unchecked, posed a risk to international security and stability, marking the first time in which a health threat was discussed before the un body mandated to maintain international peace and security (fidler ) . years following the seminal security council resolution on hiv/aids, the united nations launched its first and only to date, military mission to combat the spread of an infectious disease outbreak. known as the united nations mission for ebola emergency response (unmeer), the first ever un emergency health mission sought to contain the spiraling west african ebola outbreak following the un security council resolution , which determined that the ongoing outbreak in west africa 'constituted a threat to international peace and security' (unsc ), and we can understand these grand transformations within global politics and international relations as permeated by emergent logics to preempt both occurring public health emergencies and also probable future pandemics. contrastingly, for critical theorists, global health security has emerged as a concept which denotes a novel biopolitical project, or rather, the appearance of a new governmental problem in public health: how to effectively manage 'emerging infectious diseases' at a global scale (lakoff ) . contemporary global health systems are therefore problematized not only by the rapid emergence of pathogens on a global scale, but the risk posed by these circulating pathogens are no longer calculable using tools of risk assessment, which are based on patterns of historical incidence (ibid). in this regard, global health security rationalities, i assert, galvanise and accelerate the facilitation and development of novel techniques and practices of anticipatory or preemptive security, which emphasise the real-time, continuous and cost-effective surveillance of potential disease outbreak and public health emergencies. increasingly, in an era of innumerable digital data sources, the preemption of health risks are managed and analysed via an assemblage of innovative and evolving surveillance practices which combine multiple data sources and disease-tracking techniques, enacted at local, regional and global levels. syndromic surveillance platforms, and digital epidemic intelligence systems including promed-mail, gphin, healthmap, bio-caster, epispider, and the now-defunct google flu trends can thus be conceptualised as new governmental technologies of overarching global health security practices, developed and installed around yet unforeseen events in order to halt or preempt the 'sudden, circular bolting' of pandemic phenomena (foucault ) . collectively then, in my view and building upon the expert points provided by henning, processes of securitization of global health and the rise of preemptive security logics have advanced calls for the deployment of novel security technologies and surveillance apparatuses over the past two decades. these calls have been met with the re-drawing of disease surveillance operations and the launching of new technologies which now seemingly patrol digital datascapes in the surveillance of potential public health emergencies. such novel technologies constitute critical components of an evolving ensemble of new governing practices, knowledges, techniques and rationalities of health security, increasingly influenced by digitised, automated and computerized algorithms. . as components in an emergent socio-technological apparatus of security for the strengthening of global health governmentalities, it is also crucial to consider the ways in which these expanding digital syndromic surveillance systems re-contour previous understandings of the temporalities, form and practice of preemption in the identification of forthcoming pandemics. firstly, the rise of syndromic surveillance technologies for the forecasting of probable disease outbreaks, departs significantly from previous methodologies to identify and further preempt pathogenic threats. as seen with the steady integration of algorithmic programming over the past two decades from promed-mail, to gphin, and to healthmap, syndromic surveillance technologies increasingly draw upon and aggregate open-source data pulled via algorithmic processing from the realm of the digital to inform contemporary practices of health security in the non-digital/physical world. within the politics of preemption, this marks a novel transition towards the harnessing of infinite online data sources, afforded by increasingly sophisticated algorithms to identify unusual data correlations or patterns indicative of a potential disease outbreak. in turn, this represents a process that is distinct and divergent from previous methodologies of health surveillance which utilised clinical and laboratory testing, analysis, observation, and the collation of statistics in order to render visible and intelligible, occurring or emergent infectious disease outbreaks. in the new era of digital disease surveillance, the data warehouse emerges alongside the traditional clinic as a new critical site of surveillance and zone of security praxis in the preemption and surveying of disease risk. further to this, novel techniques to preempt looming pandemic threats via these digital syndromic surveillance systems now also correspond with new problematizations of data and knowledge forms in the securitization of uncertain [pathogenic] futures. unlike previous systems of infectious disease surveillance which were routinely marked by an incompleteness of data in which to understand forthcoming pandemic risks, the deluge of 'big data' of the early twenty-first century has now reversed this problematization of data.. contemporary digital disease surveillance systems and the practice of health security are no longer hindered by a scarcity of data but rather burdened by an excess of infinitely generating, unstructured and diffuse streams of digital data. in order then to preempt and track the emergence of disease outbreaks in a present world that is submerged in data sources, digital disease practices must navigate, as matteo pasquinelli ( ) writes, 'vast data oceans' to detect that which constitutes the anomaly, be it common patterns of behaviours in social media, buying or selling tendencies in stock markets, the oscillation of temperatures in a specific region, or suspicious keywords in disease surveillance networks (ibid). again, in this new practice of 'navigating vast data oceans' , the digital algorithm emerges once more as a strategic, pragmatic and celebrated technology of government with the capacity to apprehend, process and project new insights of disease patterns from troves of digital data which manifest beyond human cognitive and analytic capacities. thus, the politics of preemption in the present era of elevated pandemic threat are intimately intertwined with expanding recourses to apprehending big data sources and employing algorithmic processing techniques to produce advanced alerts, indications and insights of potential pathogenic uncertainties. indeed, during several critical public health emergencies over the past two decades, a combination of big data sources and algorithmic techniques produced meaningful and advanced insights into emergent public health emergencies, including during the early and critical stages of the emergence of severe acute respiratory syndrome (sars) in china and ebola in guinea. however, the success and rise of the algorithm in these health histories should not distract from the imperative for continued meaningful-and indeed critical investigations and interrogations of emergent digital disease surveillance practices which utilize diffuse big data sources and processing of such data streams via algorithm. algorithms are not only famously opaque, but have also been shown to be cantankerous, if not delicate technologies, illustrated famously by a false reporting of a cholera outbreak in the united states by google in , as a result of oprah winfrey picking love in the time of cholera as book of the month in her book club (simonsen et al. ). however, as technology and innovation advance, algorithms are getting smarter, more insightful and more precise, but the growing commonplace of these knowledge producing machines with intensifying technical complexities makes the monitoring and regulation of these data-processing technologies ever the more urgent and vital. the ascendancy of the era of big data and the rise of digital disease surveillance systems have afforded unprecedented new opportunities towards the enhancement and bolstering of disease detection capacities in an era increasingly preoccupied with the emergence of future security challenges-among them pandemic illness. the objective of this discussion has been to provide an overview and highlight the potential gains and benefits yielded by these new data sources and processing techniques, while also emphasising that key ethical, legal, political and societal concerns abound and must not be sidelined in contemporary efforts to accrue maximal data reserves and to effectively track and detect the next pandemic before it occurs. tim dear stephen, dear henning, thank you very much for this inspiring conversation. again, it made clear the necessity of an interdisciplinary and social sciences inspired debate about contemporary epidemiology and public health. for me three insights emerge. first of all, the gains in timeliness and scope of digital epidemiology come at the cost of providing a different type of knowledge. the information provided through such systems is not the same as the traditional expert knowledge based on human assessment, analysis, hypothesis, statistical testing and trials but an algorithmic 'knowledge without truth'. the status of this knowledge may not be totally clear in all the different contexts where it is used. this may result in ill-informed decision making. a driving force for the demand of digital epidemiology is a reformulated conception of global health. a common thread running through the diverse debates about global health policies today is the issue of security. this securitization of global health does frame current policies. 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claims in published maps and institutional affiliations.