Regionalizing Health Security: Thailand's Leadership Ambitions in Mainland Southeast Asian Disease Control.

• Author: Wenham, Clare

Southeast Asia, and Thailand in particular, has often been referred to as a potential "hot zone" or hub of emerging infectious diseases. (1) This has been attributed to a multiplicity of factors including: a greater concentration and connectivity of livestock, persons and products with unsafe animal husbandry practices; (2) a lack of development coupled with population growth and urbanization; (3) problems with effective governance of infectious disease; (4) and increasing interconnectivity in the region due to improved transportation links.

Pandemic potential in Southeast Asia has been framed as a security threat, (5) and Thailand has also recognized the implications of disease for transnational security. Most evident has been the impact of "crisis" events which have changed Thai policy in this area to reflect shifting understandings of disease and security. The first of these was the impact of human immunodeficiency virus infection and HIV/AIDS. Thailand recognized the implications of the virus for the country's national security through its impact on travel and trade. (6) This framing promoted a proactive policy pathway to limit the disease's spread through a series of campaigns such as the 100 per cent condom campaign, (7) scaling up access to antiretroviral drugs, (8) and normalizing discussions of family planning through initiatives like the Cabbages and Condoms restaurant. (9) Accordingly, Thailand has been touted as one of the "success stories" of state responses to HIV/AIDS. (10) However, taking into account the pivotal role of tourism in Thailand's economy, a critical view could consider such efforts in HIV/AIDS control as having been undertaken to protect the country's economic security."

In 2002-03, the spread of severe acute respiratory syndrome (SARS) represented a further key moment for understanding Thailand's infectious disease policy, similar to the "tipping point" it proved to be for regional activity in disease control. (12) Although Thailand only reported a few cases (resulting in two deaths), (13) the government made every effort to promote Thailand as a zero-transmission SARS country. (14) Despite the low impact SARS had on Thailand, it was Bangkok's leadership that was instrumental in summoning the involvement of its regional counterparts in a series of special Association of South East Asian Nations (ASEAN) + 3 meetings culminating in the region being declared SARS free by June 2003. This activity was undertaken in an attempt to limit the damage to the tourism industry and the wider economy, which occurred elsewhere in Asia such as Hong Kong and mainland China.

This focus on economic and national security was further evident in the outbreak of the H5N1 influenza virus in 2004-05. Despite having laboratory confirmation of the circulating virus, the Thai government tried to cover this outbreak up for over three months in order to protect its poultry and tourism industries. (15) This approach was exemplified by Deputy Agriculture Minister Newin Chidchob when he stated: "the chicken industry would have collapsed immediately and the economy would have lost more than 100 billion baht". (16) However, simultaneous to rejecting emerging global health norms of prompt reporting and outbreak transparency, Thailand took to regional activity, seizing a leadership position for disease control, notably by hosting a meeting of ASEAN+3 on how best to control the outbreak, culminating in the production of a Joint Ministerial Statement on Prevention and Control of Avian Influenza. (17)

By regionalizing the risk of disease, Thailand demonstrated that only a collective response would combat its spread. In taking the agency to establish such regional activity, Thailand placed itself at the centre of discussions on how to respond to the threat posed by the disease. Such action is indicative of Thailand's efforts for regional and subregional preponderance in disease control, which have visibly increased in the last 15 years through a range of formal and informal mechanisms, to the extent that Thailand can now be considered a subregional disease governor, arguably extending its own sovereign power in this arena beyond its borders.

Thailand's activity in disease control raises important questions for understanding regional governance of disease more broadly. While recent academic literature has used Martha Finnemore and Kathryn Sikkink's conceptions of norm entrepreneurs and norm cascade in global health governance to explain how ideas and expectations of health security spread among actors in disease control, (18) this article seeks to push this approach one step further by considering the role of individual state agency in the propagation of disease control expectations. Traditionally more powerful regional states have been expected to take care of their own backyard in a necessarily benevolent manner, to provide stability and peace within their geographical spheres of influence. (19) Thailand, as one of the most materially and economically powerful states in mainland Southeast Asia, has arguably become the de facto leader in discussions regarding collaborative subregional disease surveillance and response efforts. This article considers Thailand, Cambodia, Laos, Myanmar and Vietnam as a subregion of Southeast Asia (also known as mainland Southeast Asia). (20)

To some extent, this realizes the requirements of the World Health Organization (WHO)'s International Health Regulations 2005 (IHR 2005) which strongly encourages states to provide each other with technical cooperation and logistical support for capacity building in disease control. (21) While formal regional organizations for disease control have been a regular feature in contemporary global health, such as regional offices of the WHO, Thailand's quasi-creation of a subregional grouping in this informal manner represents a new departure for understanding global health. However, this article argues that Thailand's assertions in disease control are not only undertaken to improve the subregion's health, but also to allow Thailand to protect its own national and economic security from the threat of disease, as initiated through their approach to HIV/AIDS, SARS and H5N1 control.

Using the work of David Lake on hierarchy, (22) and Detlef Nolte on regional power, (23) as a theoretical framework to understand regional governance, this article demonstrates how Thailand has scaled up its disease control activity beyond its borders to assume a position of subregional disease governor. This governance arrangement has been welcomed by Thailand's neighbours in mainland Southeast Asia as it has increased their capacity to respond to an outbreak, and meet their normative obligations to global health security.

Methodology

The findings of this article are drawn from elite semi-structured interviews with a range of policymakers involved in disease control in Thailand, Cambodia, Laos and Vietnam. Interview participants were identified through document and Internet searches, followed by snowball sampling, after making initial contact with an individual in each health ministry. Policymakers were contacted by email and asked to participate in the research, having been sent detailed information about the research project and a list of sample questions. Interviews were recorded, where consent was given, or notes taken. Content analysis was conducted on the interview transcripts, to identify key themes and policy aims from each country. This interview content was then triangulated with policy documents from Thailand's Ministry of Public Health (MOPH) and its subregional counterparts, as well as other global and disease control actors, such as (but not limited to) the WHO, America's Centers for Disease Control and Prevention (CDC) and the Asian Development Bank.

Moving Beyond the Norm Entrepreneurs

Current literature on global heath governance and global disease control focuses on the role of norms in explaining state activity with global health security. Governments are expected to comply with new standards of behaviour for minimizing infectious disease, as codified in the WHO's IHR (2005) and have instigated the necessary structural changes to their national public health provision to reflect this. (24) Based on the work on Finnemore and Sikkink, (25) the assumption is that states act in accordance with global social expectations, and this includes how they should report outbreaks of disease, implement the IHR (2005) and concern themselves with global health security. Working within this norm life cycle, Sara Davies, Adam Kamradt-Scott and Simon Rushton (26) suggest that within the global health space there exist norm entrepreneurs that propose how states should act in global disease control and convince others to commit to a collective security framework. Once several states have accepted a norm proposed by such entrepreneurs, such as improving surveillance and response mechanisms, this norm is considered to have cascaded amid states and becomes embedded within the architecture of global health governance which then becomes the expected behaviour by which all states are judged.

Using such a framework, Thailand could be considered as a subregional norm entrepreneur, as it offers mainland Southeast Asian states an example for how to understand disease--in terms of national and economic security--and a model of technical/financial support for how to implement public health provisions in surveillance, prevention, reporting and response to limit the spread of diseases. However, previous research has demonstrated that Southeast Asian countries have already accepted the need for outbreak transparency and the importance of global health security. (27) Global norms for disease control have cascaded and been internalized from global actors such as the WHO. (28) As such, this framework may not be suitable for understanding the dynamic role of Thailand as a subregional...