Engagement or dismissiveness? Intersecting international theory and global health

ABSTRACT

International relations theorists and global health politics scholars largely fail to communicate with one another. We argue that drawing on insights from classic and contemporary international theory more explicitly will positively augment the study of global health politics. This paper highlights four major theoretical orientations in the international relations literature (realism, neoliberal institutionalism, constructivism, and feminism) and discusses how an understanding of these perspectives can strengthen our understanding of global health policy.

KEYWORDS:

• Realism
• neoliberal institutionalism
• constructivism
• feminism
• international relations theory

Introduction

A robust literature on the intersection of international relations (IR) and global health politics has developed since the 1990s. This research has shown the linkages between these two seemingly disparate fields in a wide range of areas, including global governance, international organisations, international political economy, and security studies. Despite this exchange, there is one area of international relations that has largely remained absent from the study of global health politics—international relations theory. As researchers who work in the intersection of IR and global health politics, we find the lack of engagement between global health politics and IR theory frustrating and analytically limiting. We see potential for numerous fruitful exchanges between IR theory and global health and want to break down the academic silos that have prevented this sort of exchange from happening. The use of theory can structure higher level thinking and facilitate long-term and strategic thinking.

In this article, we call for a more meaningful engagement between global health politics and IR theory. We do not aim to provide to a single ‘right’ answer about which IR theory best explains global health policy; indeed, the authors of this piece do not share a common theoretical orientation. One of us comes largely from a constructivist and English School orientation, while the other has been known to remark that (almost) no interesting international relations theory has been written since the Second World War.¹ Instead, we aim to call attention to how a closer engagement between global health and IR theory may prove beneficial. We cannot go into all of the details of various IR theories, nor can we apply each theory to all global health issues, but we aim to show how grounding our understanding of global health politics in IR theory can provide a firmer foundation for considering these issues as part of longer-term processes. Grand theories of IR may seem out of fashion, but we argue that they provide a foundational basis for understanding the larger world and grounding intellectual analysis. Most IR scholars still position themselves within or at least in opposition to a particular theoretical paradigm, and theoretical work may provide a means for ‘bridging the gaps between different conversations’ (Saideman, 2018, p. 18). While these theories may not tell us whether eradication is the best strategy for dealing with polio, they do offer a lens for understanding the world and how various actors interpret what is happening around them. More specifically, IR theory offers global health a chance to stand back and evaluate its potential roles and overall direction in the tumult of international politics.

There are a number of reasons why social scientific analysts of global health, particular those who study international politics and society, might want to pay more attention to IR theory. Theorists have considered many of the problems, concerns, or ideas we encounter when we examine global health as a phenomenon of political life. The theories around which we centre this paper help to explain both the failures and successes of global health policy. By encouraging global health scholars to pay more attention to IR theory, we want to better understand the structural and social conditions that make successful global health policy possible. At a time when the practice of international politics seems increasingly chaotic and there is open questioning of the value of global health governance systems in powerful quarters, IR theory can provide a grounding for understanding global health politics.

Theory can provide us with ways to think about the political import of those very phenomena, bringing the biological into the realm of social cause-and-effect. Engaging with IR theory reminds us that disease is inherently political. This gap remains in need of addressing, despite previous work by Fidler (2003) and Youde (2005). Though they called on scholars to recognise the intersection between IR theory and global health politics more than a dozen years ago, the gap remains—and we want to re-engage the discussion they aimed to start. In this paper, we draw attention to the ways in which IR theory can serve as an important conceptual lens for understanding responses to global public health issues, and we outline how some of the leading theories of IR offer insights for understanding how and under which circumstances the international community responds to cross-border health concerns. Rather than answering which theories matter, we encourage the reader to consider how IR theory matters for understanding global health.

Some may argue that engaging with the ‘classic’ theories of IR, as we do below, is an outdated method for approaching the world, particularly because the study of IR has moved to what these scholars argue is a more ‘non-paradigmatic, problem-based’ approach. We disagree. While a Kuhnian (Kuhn, 1970) approach or a ‘problems based/issue areas’ tack may seem more prominent (Saideman, 2018) or perhaps even advisable (but see Grieco, 2018), evidence remains for the centrality of the ‘classic’ realist, liberal institutionalist, and constructivist schools of thought, even as they have become ‘more closely intertwined’ (Kristensen, 2018). We also assume that a number of global health analysts reading this article are not necessarily familiar with the historical and sociological roots of IR theory, and so we have chosen to engage with the foundations given by our discipline’s history and sociology.

Theory as a lens

Traditional IR schools of thought offer lenses for guiding action and interpreting responses to issues in global health, yet the global health politics literature has too frequently failed to avail itself of these resources. As a result, the global health politics literature can at times suffer from a lack of analytical grounding that limits its ability to speak to the larger IR literature or to theoretical social science more generally. For example, global health is inherently political, and theory can help us to understand and appreciate the nature of that politics. Cox reminds us, ‘theory is always for someone and for some purpose’ (Cox, 1981, p. 128; emphasis in the original). We can divide theories into two broad categories: problem-solving, which takes the world as it is and aims to address a specific issue; and critical, which questions the institutions and power relations that give rise to the contemporary world (Cox, 1981, pp. 128–129). These insights are particularly valuable when considering global health, as understanding these distinctions can allow us to avoid speaking past each other. Again, we are not necessarily making a case for the primacy of one type of theory over the other, and both forms can perform important roles.

Within the American academy, the majority of IR theory comes from one of four varieties: realism, neoliberal institutionalism, constructivism, and feminism.² While it is beyond the scope of this article to provide an exegesis of the variants of these theories, we provide a brief overview of each as a starting point for analysis. All of these have something to say about the conduct of politics related to health concerns.³ We break these four theories down to their base elements to understand the possible insights they hold for understanding global health politics.

To better understand how the four schools might engage with global health politics, we briefly posit how each might view the Global Health Security Agenda. The GHSA, launched in 2014,

is a growing partnership of over 64 nations, international organizations, and non-governmental stakeholders to help build countries’ capacity to help create a world safe and secure from infectious disease threats and elevate global health security as a national and global priority. (Global Health Security Agenda, 2018)

In three broad categories of action—surveillance, prevention, and response—the GHSA sets measurable objectives to bring international core capacities in line with the 2005 International Health Regulations. The GHSA is also particularly useful for examining theoretical paradigms because it explicitly ties into an issue—national and international security—that has played a prominent role in nearly all prominent IR theories. Its diverse membership and inclusion of both state and non-state actors also makes it particularly advantageous for examining how IR theory understands global health and how global health understands IR theory.

Realism

Realism is a theory of self-help. The world is a dangerous place, akin to Hobbes’ characterisation of life in the state of nature as ‘solitary, poor, nasty, brutish, and short’ (Hobbes, 1651, I.xiii.9). States—which are the only international actors of real consequence—cannot rely on others to protect them, so every state must be ready to defend itself against any and all challengers. As a result, states must exercise constant vigilance, putting their security above other issues (Waltz, 1979, p. 92). A state’s resources, advantages, and skills are valuable to the extent that they contribute to its ability to develop and maintain its defenses and security apparatus. Geography, natural resources, and industrial capacity—all of which are key elements of a state’s power—are important precisely because they directly contribute to military preparedness; their value is proportional to the value they serve to help a state secure itself (Morgenthau, 2005, pp. 133–137). For most contemporary American realists, economic and social concerns play a secondary role. No rational state can prioritise these over security concerns because such ‘low politics’ concerns are irrelevant and unfathomable unless and until a state has adequately addressed its security threats.

From this, realists derive three key implications. First, the international system is anarchic. There is no central government at the world level to keep order and enforce rules. Second, and as a result of the first, the world can be a self-help place; the polity may be left on its own (or at least understands the world like this). Trusting others is a potential recipe for disaster, as today’s ally today may be tomorrow’s enemy. (Alliances, however, can serve as an important consideration toward a state’s security and are not per se bad.) Third, states are the relevant actors in the international system. That does not deny the existence of non-state actors, but realism, at least in its ‘purest’ form, stresses that their influence on international politics is ephemeral and that any power they may possess is because states have ceded that power to them (and can thus withdraw it). Given these starting points, it is hardly surprising that realists tend to have a fairly pessimistic view of the international system (Grieco, 1988). Lebow describes this viewpoint as ‘a brutal arena where states look for opportunities to take advantage of each other’ (2007, p. 55). It is a zero-sum view of the world; if one state is gaining, another must be losing.

Given such a pessimistic view of the international arena, what can realism contribute to our understanding of global health? In the situation of epidemic response, the realist view of the world may not look too far off from the situation facing a state responding to an outbreak. It is great if one state can convince others to help it to fight the problem, but there are no guarantees and no ability to compel that assistance. Instead, we may see borders closed, trade and travel restrictions implemented, and protectionist policies introduced (Osterholm, 2005)—despite international organisations like the World Health Organization (WHO) explicitly and strenuously discouraging states from introducing such restrictions. From a realist perspective, these decisions by states would be individually rational because no state should rely on the actions of others to provide them with protection, and international organisations lack independent power to compel states to take specific actions.

This logic has been applied to real-world situations. During the 2009 H1N1 influenza outbreak, the government of the People’s Republic of China (PRC) banned the import of pork and products from Mexico and the United States (Ricci, 2010, p. 5). The PRC also quarantined 70 Mexican citizens who showed no signs of the disease. Mexican officials strenuously objected, saying that there was no reason to detain their citizens (Lacey & Jacobs, 2009). The Chinese actions exceeded WHO’s recommendations and were technically in violation of the International Health Regulations (World Health Organization, 2010). From a realist perspective, though, China’s decisions make sense. WHO lacks sovereign authority, so its policy recommendations are mere suggestions; they lack the force of law to compel states to do anything. Furthermore, WHO’s interests are not the same as China’s. From China’s perspective, the government needed to take extraordinary steps to limit H1N1’s spread within its borders. China singled out Mexican products and peoples because that is where the virus originated. The Chinese government wanted to maintain its own security in the face of a potential existential threat (particularly in light of dire predictions about the virus’ potential spread and lethality at the time), and it saw little reason to believe that the international community’s recommendations or strategies would adequately protect China. It is not a matter of being difficult or unwilling to ‘play along’ with others; it is an assertion of the fundamental right and duty of a sovereign state.

Realism is not completely foreign to global health politics analyses. Ruger argues that international health relations have largely proceeded along realist lines because they have been motivated primarily by ‘the strategic interactions of self-interested nation-states’ (Ruger, 2008, p. 429). Price-Smith (2009) builds upon realist theory as a framework for analyzing global health because of its explicit recognition of the importance of material-contextual factors. He criticises much contemporary political theory for being overly focused on ideational factors which obscure the vital importance of demography, geography, and material capabilities for understanding responses to infectious disease outbreaks. At the same time, he shies away from a wholesale embrace of realist theory because of its tendency to dismiss the importance of middle and small powers, its disengagement with non-state actors, and the tendency to dichotomise the domestic and systemic levels of analysis.

At first glance, the GHSA may appear incompatible with realism, given its emphasis on multi-state partnerships. At the same time, the GHSA is potentially important precisely because of its emphasis on security. In the case of a global pandemic, the threat does not come from other states (solely, at least) but from the pathogen in question, especially insofar as that pathogen affects the ability of a state to engage in maximising its self-help. The GHSA is analogous to a security alliance of several nations that bandwagon together in order to balance against a larger threat. Given that militaries have often been both highly affected by as well as major transmitters of significant infectious disease threats, action that ameliorates potential martial weakness increases the state’s security in the most traditional sense. At the same time, realists may question how different or transformative an alliance like the GHSA truly is. It may include 64 countries, but its decision-making processes and priority areas will still reflect the interests and concerns of the most powerful states. The GHSA cannot change a state’s fundamental interests, and such partnerships are unlikely to survive if dominant states limit their participation.

Neoliberal institutionalism

Neoliberal institutionalism, the contemporary manifestation of classical liberalism in both domestic and international spheres, approaches the international arena from very different perspectives from realism. While the two theories may appear to share common perspectives, their basic understandings of core ideas differ dramatically—even in areas where they use similar language. Both realism and neoliberal institutionalism assert that the international arena is anarchic, that states are key actors of analysis, and that states act rationally. What these terms mean, though, differs dramatically. Where realists see anarchy as forcing states to be self-reliant, neoliberal institutionalists see it as a threat to cooperation. They ultimately believe that human beings can tame anarchy through cooperation because such cooperative efforts will improve the standing of all involved (Axelrod, 1984). Overcoming anarchy through cooperation allows for increasing the general prosperity, and such gains will not come at anyone else’s expense. Furthermore, neoliberal institutionalism opens up the realm of potentially relevant actors beyond the narrow range of dominant states. Finally, neoliberal institutionalists see states as primarily and rationally most concerned with economic gain and cooperation. It is not the case that neoliberal institutionalism does not care about physical security; rather, it argues that this is a less pressing concern for most states in most instances. By and large, states do not feel existentially threatened in the vast majority of circumstances that they face.

Neoliberal institutionalism argues that the best way for states to achieve their goals is through creating and maintaining international institutions and regimes that facilitate cooperation and create interdependent ties among their members. Institutions help build trust, facilitate agreements, and offer forums for negotiations and dispute resolution. Institutions have some measure of permanency and stability to them. Rather than being ad hoc creations every time cooperation is desired, they offer ongoing opportunities to build connections with others and therefore reduce transaction costs. Institutions promote cooperation, offer incentives for collaboration, and facilitate the provision of public goods. These institutions do not transform their members or their interests; instead, they are tools members use to realise their interests.

Contemporary manifestations of global health governance tend to reflect neoliberal institutional impulses. The WHO, the International Health Regulations, and other institutions and regimes that encourage cross-border cooperation on health matters instantiate this proclivity toward creating organisations to reduce transaction costs, facilitate cooperation, and offer venues in which states can make agreements, resolve disputes, and (ideally) hold each other accountable.

A neoliberal institutional framework may seem particularly well suited to understand that the ebbs and flows of global health institutionalisation follow from eras of peak adherence within the international policy community to this theory’s ideas. The initial impulse for the creation of the International Health Regulations arose during the mid-nineteenth century—a time when British liberal and institutional hegemony was at its peak. It is also highly relevant to note that the International Health Regulations were explicitly premised on reducing barriers to trade and commercial interactions. They were not about health qua health; they were about the potential for disease to interrupt economic relationships. The World Health Organization emerged in the aftermath of World War II when the international community was actively creating an array of international organisations to decrease the chances that such all-encompassing conflicts would reappear. Promoting good health fit into that narrative. On the flip side, periods of international tension and unease undermined the ability of global health governance organisations and institutions to get off the ground. The Alma-Ata Declaration of 1978 pledged international cooperation to ensure access to health services under the slogan Health for All by 2000. Its failure to take off is in many ways a reflection of the heightened Cold War tensions within the international community in the late 1970s and early 1980s (Hall & Taylor, 2003; Youde, 2012, pp. 37–40).

At the same time, neoliberal institutionalist analysis can undersell the factors that motivate and maintain international cooperation on health issues. Ruger (2012) criticises this theory for placing too much emphasis on the structural factors and establishing rules of conduct, but she notes that these elements are tilted toward the interests of economically and politically dominant states. For this reason, she argues, neoliberal institutionalism ‘lacks a shared awareness of a common ethos’ (Ruger, 2012, p. 47) that is vital both for motivating widespread acceptance of the regime and for addressing the most important global health concerns. A focus on institutions without an appreciation of fairness and equity fails to understand the underlying need for an effective global health governance system (see also Kokaz, 2005).

The GHSA fits easily within a neoliberal institutionalist framework. Institutionalism stresses the ‘global’ and ‘agenda’ portions of the GHSA. ‘GHSA aims to elevate political attention and encourage multistakeholder participation, coordination, and collaboration while leveraging previously existing commitments and multilateral efforts such as IHR (2005) and the World Organization for Animal Health (OIE) Animal Health Codes’ (Katz, Sorrell, Kornblet, & Fischer, 2014, p. 233). Because resources available to build health surveillance, prevention, and action systems vary greatly from country to country, and because some of the greatest threats to health have originated from the poorest and least capable countries, cooperative action among the potentially affected actors becomes a sensible way to protect their social and economic concerns. Liberals would also highlight how the cooperative nature of the GHSA and its ability to leverage resources from a variety of different sources will allow for better outcomes than any single state could achieve on its own. If it is in our collective interest to detect disease outbreaks early, then a unified effort will be better than anything an individual state (even a very powerful one) could do by itself.

Constructivism

Constructivism approaches the international system from a fundamentally different perspective than the previous two theories. It dispenses with the state-centrism, the assumptions of rationality, or even the belief in the existence of anarchy. As Wendt (1992) famously averred, ‘Anarchy is what states make of it.’ Constructivists deny the notion that outside observers can preordain or predict state behaviour on the basis of seemingly objective standards. Constructivists argue that we cannot understand IR absent the context—the ideas, interests, and identities that shape how actors see themselves and how they see others. States will frequently shape their behaviour to comply with international norms. They want to act in ways that comport with expectations of legitimate and appropriate behaviour—but such standards shift and evolve over time as ideas, interests, and identities change. These norms do not determine behaviour, but they provide a framework for states to think about how ‘good’ states act. States will generally seek to uphold and comply with good conduct within the international system, and such actions over time build up to become almost automatic and a part of a state’s own identity. These rules and norms, though, only make sense within their context. For example, chess has its own rules about how pieces can move and how you win the game, but those rules only make sense in the context of the chessboard. One could not take the rules of chess and try to apply them to checkers, Monopoly, or poker because they would not make sense in that context (Kratochwil, 1991, pp. 92–102).

That all said, norms and behavioural expectations do not determine behaviour. A state that violates a norm may face little, if any, direct punishment. Failure to comply with these behavioural expectations does not mean that the norm does not exist or that states care little about them. There are laws against drunk driving, but drunk driving still exists. A similar dynamic is at work for states. When states violate rules and norms, but then attempt to justify their actions or explain why they have done so, that is tacit evidence for the existence of the norm. A state would not explain why it failed to meet some expectation unless it acknowledged the underlying expectation itself (Kratochwil & Ruggie, 1986, p. 767). Furthermore, if other states condemn the violator for its actions, that is evidence that the international community holds certain behavioural expectations by which it expects others to abide. Therefore, it is not the violation of a norm itself that is important; it is the response of the violator and those around it that tells us what the international community values and how those values have shifted over time.

These ideas about norms, interests, identities, and how they shift over time have direct relevance for global health politics and governance. Which ideas and identities lead actors to conflict and cooperation? How does the mutual creation of actor and environment bring ‘disease’ into being? How does the shadow of the past shape the current and future understanding of the sort of issue that health poses for the state? For example, states have historically been reluctant to acknowledge that cases of an infectious disease are present within their borders. On a strictly rational basis, this seemingly makes little sense; calling attention to a problem can lead to increased resources and an ability to stop the spread of the disease before it gets out of hand. From a constructivist perspective, though, states may be unwilling to share information about disease outbreaks because of how others might see them. Fortin (1989) describes how the governments of both Haiti and Kenya resisted acknowledging the presence of HIV within their borders because other states responded by introducing travel restrictions or reducing trade. Kenya and Haiti saw their identity shift within the international community because of the virus, and they tried to protect themselves by not sharing that information. More recently, one reason given for the tardiness of China’s response to SARS is that the government feared that acknowledging the presence and spread of this new virus would reflect poorly on the government and the Communist Party’s ability to maintain order (Huang, 2004).

Constructivist theorising about global health has paid particular attention to how framing health issues influences when and how the international community pays attention to them. Rushton and Williams (2012) argue that economic neoliberalism frames health in particular ways that underserve the needs of poor and vulnerable populations and instead privileges the interests (and fears) of developed states. Shiffman (2009) focuses particularly on the issues that appear on the global health agenda, and argues that the prominence (or lack thereof) of any given global health issues is almost entirely a function of how it is framed by its policy community and is largely disconnected from a disease’s actual morbidity and mortality. The material and the ideational interact in complex ways in order to establish what ‘counts’ as global health (McInnes & Lee, 2012, pp. 29–30). It helps to explain why a disease like HIV/AIDS gets far more attention and resources than malaria, even though malaria causes far more illness and death on an annual basis. At the same time, constructivism can help us to understand how normative understandings around global cooperation on health issues shifts over time, like making the establishment and maintenance of disease surveillance systems a key part of global health security (Davies, Kamradt-Scott, & Rushton, 2015).

Constructivism’s take on the GHSA would likely start with the idea of ‘health security.’ Not until the nineteenth century did health become a site of action for international polities, and this has as much to do with the increasing globalisation under industrialisation in that period as the greater articulation of the nation-state form of governance (Harrison, 2012). But the idea of ‘health’ as a subject and/or object of ‘security’ comes from the temporal particularity of the HIV pandemic—particularly that it followed close on the eradication of smallpox and a then-general optimism about humanity’s ability to eradicate or control infectious disease—and the potential that disease raised for political and economic destabilisation in sub-Saharan Africa (Elbe, 2009). HIV, SARS, pandemic influenza, and hemorrhagic fever outbreaks in the ‘90s and ‘00s turned even traditional foreign policy actors like foreign ministries and defense ministries to treat disease as subjects of their action and expertise. The US State Department and Defense Department ‘expanded Cooperative Threat Reduction programs … to address biological threats in Africa, the Middle East, and Asia … ’ (Katz et al., 2014, p. 232). A changed set of perceptions about threat in the world altered the conception of security (Davies et al., 2015), such that nations no longer regard infectious disease control to be primarily the province of health ministries. Constructivism traces how changed understandings of the material world (more and more serious diseases) lead to alterations in ideas (security) and bring about new policy responses.

Feminism

Feminist IR theory aims to shift the analytical gaze away from a singular focus on interstate relations to one that instead pays attention to how transnational actors and structures transform and are transformed by larger structures. In this way, it explicitly incorporates those marginalised groups and peoples who are generally ignored by mainstream IR. Rather than dismiss their importance, feminist theorists present alternative understandings of power and call attention to the effects of this exclusion on global politics. True emphasises that ‘the insights of feminist praxis’ provide a valuable lens for understanding the range of IR issues while also offering an emancipatory possibility for changing the system and building alliances across national, racial, and gender borders (2013, p. 241).

More than the other theories discussed in this article, feminism offers the most direct and sustained focus on the role of individuals on the practice of international politics. It also emphasises how practices within the international system have an effect on individuals—and how those effects are not borne equally across society. By recognising the importance of gender as analytical category, feminism opens a pathway for disaggregating the effects of policy. Enloe (1989) demonstrates how personal identities and private lives play a profound role in making international politics possible and how the traditional lens for understanding IR fail to appreciate the gendered dimensions of nationalism, diplomacy, and capitalist economic production.

Feminist theory moves beyond the traditional analytical categories of IR. The state, for example, is an analytical category for feminism, but it is by no means the primary analytical category. Traditional theories of IR frequently build upon Waltz’ (1959) equating of the state and its pursuit of its rational interests with the behaviour of men. In this way, these theories implicitly equate rationality with masculinity and thus dismissing the importance of women from the international realm (Sylvester, 1990).

Feminist approaches also emphasise that gendered approaches to the study of IR condition the focus of what to study and how to study it. War and security, for example, have traditionally been the objects of the greatest and most prestigious areas of research in IR. Sjoberg and Tickner write, ‘While IR studies issues such as the effect of regime types on states’ propensity for war … feminist theories have shown that understanding global politics relies as much on seeing … household-level political economies as it does on IR’s “traditional” issues’ (2011, p. 2). For these reasons, feminist IR scholars argue that the theory gives much needed attention to the ‘politics at the margins’ (True, 2013, p. 243) in order to demonstrate that international politics is far more pervasive than IR’s traditional focus on war or national leaders. War may cause insecurity, but for the vast majority of people the vast majority of time, the real causes of insecurity are more personal and reflect gender and structural imbalances that harm and threaten a person’s ability to live a life of dignity (Robinson, 2011). The human security framework, with its emphasis on individuals rather than reified abstractions of the state, shares important similarities with feminist theory.

Masculine worldviews condition the study objects of IR and in turn spill over into issues in which they may not be appropriate. Those who seek to manage the effects of disease and promote health often easily fall into the language of warfare and violence to describe their efforts. We speak of ‘fighting’ disease, of ‘conquering’ microbes, and the ‘threat’ of emerging, reemerging, and zoonotic diseases—but ‘the language of warfare risks turning infected people and their caretakers into objects of fear and stigma.’ Diseases themselves are not ‘tearing down the pillars of social order’ in the fashion of war. ‘The greatest dangers come from panicked or coercive responses to disease’ (de Waal, 2014). When we combine the gendered nature of war with the idea of medicine and health as a form of warfare, we detrimentally remove the real people experiencing the effect of these health issues from our analysis.

At the same time, feminism generally avoids trying to present a single corrective framework to replace traditional theories. Instead, feminist IR emphasises ‘richer, alternative models of agency that take account of both production and reproduction, redefine rationality to be less exclusive and instrumental, and … [highlight] the interdependence of human beings with nature’ (True, 2013, p. 255). Feminism functions less like traditional IR theories and more through its ability to offer critical lenses for incorporating intersectionality into the discipline.

Feminist theory has strong and clear connections to the underlying themes of global public health and the causes of ill health around the world. If we consider the social determinants of health, the linkages between social exclusion and ill health are readily apparent. For example, the position of women in a society is one of the clearest and strongest indicators of child health and survival. As a result, improving gender equity is one of the most important interventions necessary for improving public health. This necessarily requires a wide range of strategies, including outlawing discrimination on the basis of gender, improving educational opportunities for women and girls, and investing in sexual and reproductive health services. However, these changes cannot happen solely through a legal framework; they also require larger shifts in cultural understandings that go beyond what legislation alone can achieve (Marmot et al., 2008).

Gender dynamics and the effects of social exclusion manifest themselves in a wide range of health issues. Women and girls make up more than half of all HIV-positive persons around the world, and they are at higher risk for contracting HIV due to sexual violence, restrictions on their sexual rights, and unequal access to health care (Davies, 2009, pp. 76–77). Furthermore, they face higher rates of stigma and discrimination if they become HIV-positive (Wingood et al., 2007). The recent Zika outbreak in South America also highlighted the connections between gender and global health. Zika infections rarely cause significant problems—unless the person infected is a pregnant woman. In that case, there is an increased risk of giving birth to a child with microcephaly, a condition where a baby’s abnormal brain development and significantly smaller than normal head cause various developmental issues. The government of El Salvador, among others, advised women against getting pregnant until 2018 (Ahmed, 2016). Such advice ignores the fact that women's access to contraception is frequently limited, abortion services are illegal in many parts of Central and South America, and the rates of sexual violence are high (Boseley & Douglas, 2016). An official with Amnesty International starkly described the problem, ‘[This advice is] putting women in an impossible place, by asking them to put the sole responsibility of public health on their shoulders by not getting pregnant, when over half don’t have that choice’ (cited in Alter, 2016). The health advice from the government ignores the structural impediments that make the suggestions impractical at best and punishes women for factors over which they have little control. It assumes a degree of agency and autonomy that does not comport with lived experiences. Harris, Silverman, and Marshall (2016) highlight how the health advice regarding the Zika virus places women in an unsolvable paradox.

Feminist theory might emphasise the externalities of the GHSA process. Illness and material deprivation exist hand in hand in our contemporary world. Even within ‘poor’ countries that are the sites of the greatest suffering from disease, women and children, because of their structural disadvantage vis-à-vis men in many countries, will bear even larger costs from disease. The GHSA’s success relies upon resource-rich countries building up the capacities of poorer ones to prevent, detect, and respond to infectious disease outbreaks. Building up those capacities for the medium- to long-term, however, requires the strengthening of the overall health system in these resource-poor countries. If those systems are built with an appropriate consideration of gender and power, they can be leveraged to improve the health of women and children particularly. National laboratory and reporting systems that can detect the appearance and spread of diseases like tuberculosis; or workforce development that includes physicians, nurses, veterinarians, epidemiologists, lab scientists, and animal professionals; or the creation of a functioning mass vaccination delivery system—all pillars of the GHSA—are institutions that with appropriate design can add to the health of women and children, aside from the goal of protecting the global society from pandemic.

Conclusion

We will continue to see disease outbreaks that cross international borders and require some measure of global cooperation to address. IR scholars should ideally be well placed to contribute to understanding how, why, and under what circumstances such cooperation happens. Unfortunately, the relative lack of engagement between the global health politics literature and IR theory limits our ability to engage with global health politics in a deep, meaningful, and theoretically consistent manner. If we want to understand the various responses to a disease epidemic like the Ebola outbreak in West Africa from 2014 to 2016, we can use IR theories to appreciate the circumstances that facilitated and hindered international cooperation. Does the international cooperation to combat Ebola show evidence of an emergent international norm? Do the failures of the World Health Organization in responding to the outbreak highlight the limits of international organisations? Was the reaction to the outbreak conditioned on the fact that it happened in poor countries in West Africa instead of wealthy European states? Why did governments and the WHO describe Ebola as a threat to national and international security, and how did that alter their reactions? These are the sorts of questions that a direct engagement between IR theory and global health can help us better answer.

Through our introductory analysis in this article, we aim to encourage scholars to consider the value in understanding the relationship between global health politics and international relations theory. International relations theory matters. Global health politics matters. Encouraging collaboration between these two fields will be good for both of them.

Acknowledgements

Thanks are owed to panelists and attendees of ‘Security, Securitization and Health’ at the 2016 International Studies Association conference in Atlanta; the Global Health Section of the International Studies Association; participants in the May 2017 ‘Research Symposium on Global Health Politics’ at American University, particularly Jeremy Shiffman for extending an invitation; Radhika Gore of Global Public Health for shepherding the manuscript through the review process; and the anonymous reviewers for critical compliments and suggestions.

Disclosure statement

No potential conflict of interest was reported by the authors.

ORCID

Nathan Paxton http://orcid.org/0000-0002-7602-2842

Jeremy Youde http://orcid.org/0000-0002-5449-1840

Notes

1. We leave it to the reader to identify which is which.

2. ‘Idealism’—most often understood as some form of economic or political pacifism, a la Norman Angell or Woodrow Wilson, respectively—has died out in the American and British Commonwealth academy. While E.H. Carr could pose Idealism (Utopianism in his terms) as a useful foil to Realism in 1939, World War II seems to have done Idealism in.

3. Of course, these four theoretical strands do not constitute the entirety of international relations, and it is not our intention to denigrate or ignore Marxism, English School, post-colonial, or critical theories. We highlight these four because of their prominence within the American academy. The fact that other theories have less purchase within the United States probably says more about the provincialism of how international relations is practiced and studied in the United States.