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Regionalism, activism, and rights: New opportunities for health diplomacy in South America


Tackling germs, negotiating norms, and securing access to medicines are persistent challenges that disproportionally affect developing countries' participation in global health governance. Furthermore, over the last two decades, the excessive focus on global pandemics and security in global health diplomacy, rendered peripheral diseases that usually strike the poor and vulnerable, creating situations of marginalisation and inequality across societies. However, as the importance of regions and regionalism increases in global politics, and integration ambitions and initiatives extend beyond trade and investment to embrace welfare policy, there are new opportunities to explore whether and how regional commitments affect health equity and access to medicine in developing nations. What, if any, are the possibilities for meso-level institutions to provide leadership and direction in support of alternative practices of global (health) governance? Can regional polities become international advocacy actors in support of global justice goals? This article addresses these questions by analysing regional health diplomacy in South America. The article argues that regional organisations can become sites for collective action and pivotal actors in the advocacy of rights (to health) enabling diplomatic and strategic options to member state and nonstate actors, and playing a role as deal-broker in international organisations by engaging in new forms of regional health diplomacy.

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1 Tarrow Sidney, ‘Transnational Politics, Contention and Institutions in International Politics’, Annual Review of Political Science, 4:1 (2001), pp. 120.

2 Scharpf Fritz, ‘Negative and Positive Integration in the Political Economy of European Welfare States’, in Marks Gary, Scharpf Fritz, Schmitter Philippe, Streeck Wolfgang (eds), Governance in the European Union (London: Sage, 1996), pp. 1539; Moravcsik Andrew, The Choice for Europe (Ithaca, NY: Cornell University Press, 1998).

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8 Tussie Diana, ‘Latin America: Contrasting Motivations for Regional Projects’, Review of International Studies, 35:1 (2009), pp. 169–88; Riggirozzi Pía and Tussie Diana (eds), The Rise of Post-Hegemonic Regionalism: The Case of Latin America (Netherlands: Springer, 2012).

9 Buss Paulo, ‘Brazil: Structuring Cooperation for Health’, The Lancet, 377:9779 (2011), pp. 1722–3; Buss Paulo and Leal Maria do Carmo, ‘Global Health and Health Diplomacy’, Cadernos da Saúde Pública, 25:12 (2009), pp. 2541–41; Wolff Jonathan, The Human Right to Health (New York: W. W. Norton & Co, 2012).

10 See Kickbusch Ilona, Silberschmidt Gaudenz, and Buss Paulo, ‘Global Health Diplomacy: the Need for New Perspectives, Strategic Approaches and Skills in Global Health’, Bulletin of the World Health Organization, 85 (2007), pp. 161244; Fidler David, ‘The Globalisation of Public Health: 100 Years of International Health Diplomacy’, Bulletin of the WHO, 79 (2001); Fidler David, ‘Germs, Norms and Power: Global Health's Political Revolution’, Law, Social Justice & Global Development Journal (2004), available at: {} accessed 28 March 2013

11 Kickbusch Ilona and Ivanova Margarita, ‘The History and Evolution of Global Health Diplomacy’, in Kickbusch Ilona, Lister Graham, Told Michaela, and Drager Nick (eds), Global Health Diplomacy: Concepts, Issues, Actors, Instruments, Fora and Cases (New York: Springer, 2013), pp. 1126.

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13 Gary Cecchine and Melinda Moore, ‘Infectious Disease and National Security: Strategic Information Needs’, available at: {} accessed 14 July 2013

14 Ingram Alan, ‘The New Geopolitics of Disease: Between Global Health and Global Security’, Geopolitics, 10:3 (2005), pp. 522–45. Also McInnes Colin and Lee Kelley, Global Health and International Relations (London: Polity, 2012).

15 Rushton Simon, ‘AIDS and International Security in the United Nations System’, Health Policy and Planning, 25:6 (2010), pp. 25, 495504.

16 See Rushton, AIDS and International Security, p. 499.

17 See Fidler David, ‘Architecture amidst Anarchy: Global Health's Quest for Governance’, Global Health Governance, 1:1 (2007), available at: {} accessed 1 April 2014. Also, Labonté Ronald and Gagnon Michelle L, ‘Health and Foreign Policy: Lessons for Global Health Diplomacy’, Global Health, 6:14 (2010), pp. 219.

18 For a comprehensive analysis of these perspectives, see McInnes and Lee, Global Health. Also Ruger Jennifer Prah, ‘Global Health Justice and Governance’, The American Journal of Bioethics, 12:12 (2012), pp. 3554, and Kay and David Williams, Global Health Governance

19 Davies Sara, ‘What Contribution can International Relations Make to the Evolving Global Health Governance’, International Affairs, 86:5 (2010), pp. 1167–90, 1182. Also Farmer Paul, Pathologies of Power (Berkeley, CA: University of California Press, 2005) and Prah Ruger, Global Health Justice

20 For a discussion about ‘right to health’ and recognition, see Hayden Patrick, ‘The Human Right to Health and the Struggle for Recognition’, Review of International Studies, 38 (2012), pp. 569–88.

21 McInnes Colin, ‘HIV/AIDS and Security’, International Affairs, 82 (2006), pp. 315–26; Curley Melissa and Herington Jonathan, ‘The Securitisation of Avian Influenza: International Discourses and Domestic Politics in Asia’, Review of International Studies, 37:1 (2011), pp. 141–66.

22 Grugel Jean and Piper Nicola, ‘Do Rights Promote Development?’, Global Social Policy, 9:1 (2009), pp. 7998, 92.

23 Enemark Christian, Disease and Security: Natural Plagues and Biological Weapons in East Asia (London: Routledge, 2007).

24 Ruger Jennifer Prah, ‘Global Health Governance as Shared Health Governance’, Journal of Epidemiology and Community Health, 66:7 (2012), pp. 653–61, 658.

25 Fidler, Germs, Norms and Power.

26 See for example, Feldbaum Harley, Lee Kelley, and Michaud Joshua, ‘Global Health and Foreign Policy’, Epidemiologic Reviews, 32:1 (2010), pp. 8292.

27 St Clair Asuncion and McNeill Desmond, Global Poverty, Ethics, and Human Rights: The Role of Multilateral Organisations (New York and London: Routledge, 2009); Cornwall Andrea and Nyamu-Musembi Celestine, ‘Putting the ‘Rights-Based Approach’ to Development into Perspective’, Third World Quarterly, 25:8 (2004), pp. 1415–37.

28 Hayden, Human Rights to Health.

29 Farmer, Pathologies of Power; Rushton Simon and Williams Owain (eds), Partnerships and Foundations in Global Health Governance (Basingstoke: Palgrave Macmillan, 2011); Wolff, Human Right to Health. For further discussion, see McInnes Colin, Kamradt-Scott Adam, Lee Kelley, Reubi David, Roemer-Mahler Anne, Rushton Simon, Williams Owain David, and Woodling Marie, Framing Global Health: The Governance Challenge. Global Public Health, 7:2 (2012), pp. 8394.

30 Tarrow Sidney, Power in Movement: Social movements and Contentious Politics (Cambridge: Cambridge University Press, 1998).

31 Hayden, The Human Right to Health, p. 588.

32 Harman Sophie, The World Bank and HIV/AIDS: Setting a Global Agenda (London: Routledge, 2010), p. 117

33 The Lancet-University of Oslo Commission on Global Governance for Health, ‘The Political Origins of Health Inequality’, The Lancet, 383 (2014), pp. 630–67; Harman, The World Bank, p. 20; Farmer, Pathologies of Power.

34 See Keck Margaret E. and Sikkink Kathryn, Activists Beyond Borders: Advocacy Networks in International Politics (Ithaca, NY: Cornell University Press, 1998); Risse Thomas, Ropp Steven, and Sikkink Kathryn, The Power of Human Rights: International Norms and Domestic Change (New York: Cambridge University Press, 2013 [orig. pub. 1999]). Also Acharya Amitav, ‘How Ideas Spread: Whose Norms Matter? Norm Localization and Institutional Change in Asian Regionalism’, International Organization, 58:2 (2004), pp. 239–75.

35 Risse, Ropp, and Sikkink, The Power of Human Rights.

36 Bliss Katherine (ed.), Key Players in Global Health: How Brazil, Russia, India, China, and South Africa are Influencing the Game (Washington, DC: Centre for Strategic and International Studies, 2010); also Kickbusch, Silberschmidt, and Buss, Global Health Diplomacy; and Onzivu William, ‘Regionalism and the Reinvigoration of Global Health Diplomacy: Lessons from Africa’, Asian Journal of WTO & International Health Law and Policy, 7:1 (2012), pp. 4977.

37 Michael McCubbin, Ronald Labonté, and Bernardette Dallaire, ‘Advocacy for Healthy Public Policy as a Health Promotion Technology’, Centre for Health Promotion (2001), available at: {} accessed 19 August 2013.

38 For a literature review on the place of BRICS in global health governance, see Harmer Andrew, Xiao Yina, Missoni Eduardo, and Tediosi Fabrizio, ‘BRICS without straw? A Systematic Literature Review of Newly Emerging Economies Influence in Global Health’, Globalization and Health, 9:15 (2013), pp. 211.

39 Lee Kelley, Chagas Luis, and Novotny Thomas, ‘Brazil and the Framework Convention on Tobacco Control: Global Health Diplomacy as Soft Power’, PLoS Medicine, 7:4 (2010), pp. 14. Also Almeida Celia, Campos Rodrigo, Buss Paulo, et al., ‘Brazil's Conception of South-South “Structural Cooperation” in Health’, Review Global Forum Update on Research for Health, 6 (2009), pp. 100–7.

40 Jönsson Christer and Jönsson Kristina, ‘Global and Local Health Governance: Civil Society, Human Rights and HIV/AIDS’, Third World Quarterly, 33:9 (2012), pp. 1719–34; also Garrett Laurie, HIV and National Security: Where are the Links? (New York: Council on Foreign Relations, 2005).

41 Jönsson and Jönsson, Global and Local Health, p. 1723.

42 Foreign Ministers of Brazil, France, Indonesia, Norway, Senegal, South Africa, and Thailand, ‘Oslo Ministerial Declaration: A Pressing Foreign Policy Issue of Our Time’, Lancet, 369:9570 (2007), pp. 137–8

43 Magnuson Roger, ‘Non-Communicable Diseases and Global Health Governance: Enhancing Global Processes to Improve Health Development’, Globalization and Health, 3:2 (2007), available at: {} accessed 28 March 2013; Peter Navario, ‘HIV Dollars? Boon or Black Hole?’, Council on Foreign Relations Expert Brief (2009), available at: {} accessed 28 March 2013.

44 Labonté Ronald, ‘Health Activism in a Globalising Era: Lessons Past for Efforts Future’, The Lancet, 381:9884 (2013), pp. 2158–19.

45 Conca Ken, Governing Water: Contention, Transnational Politics and Global Institution Building (London: Routledge, 2005); Hochstetler Kathryn, ‘Fading Green: Environmental Politics in the MERCOSUR Free Trade Agreement’, Latin American Politics and Society, 45:4 (2003), pp. 133; Yashar Deborah, ‘Globalisation and Collective Action: A Review Essay’, Comparative Politics, 34:1 (2002), pp. 355–75. Also, Grugel Jean and Piper Nicola, Critical Perspectives in Global Governance (London: Routledge, 2007)

46 For further discussion, see McInnes, Kamradt-Scott, and Lee, Health: The Governance Challenge.

47 Economic Commission for Latin America and the Caribbean (ECLAC), Panorama Social de America Latina (Santiago: CEPAL, 2012).

48 Macdonald Laura and Ruckert Arne, Post-Neoliberalism in the Americas (Basingstoke: Palgrave/Macmillan, 2009); Grugel Jean and Riggirozzi Pia, ‘Post-neoliberalism in Latin America: Rebuilding and Reclaiming the State after Crisis’, Development and Change, 43:1 (2012), pp. 121.

49 ECLAC, Panorama, p. 14.

50 Ibid., p. 9.

51 Holveck John, Ehrenberg John, Ault Stephen, et al., ‘Prevention, Control and Elimination of Neglected Diseases in the Americas: Pathways to Integrated, Inter-programmatic, Intersectoral Action for Health and Development’, BMC Public Health, 7 (2007), available at: {} accessed 10 March 2013; Pruss Annette, Bos Robert, Gore Fiona, and Bartram Jamie, Safer Water, Better Health: Costs, Benefits and Sustainability of Interventions to Protect and Promote Health (Geneva: WHO, 2008).

52 Barreto Sandhi, Miranda Jaime, Figueroa Peter, et al., ‘Epidemiology in Latin America and the Caribbean: Current Situation and Challenges’, International Journal of Epidemiology, 41:2 (2012), pp. 557–71.

53 Ibid. For a discussion about health inequalities and neglected populations, see Hotez Peter, Forgotten Diseases, Forgotten People: The Neglected Tropical Diseases and their Impact on Global Health and Development (ASM Press, 2008).

54 Oliveira Maria A., Bermudez Jorge Zepeda, Chaves Gabriela Costa, et al., ‘Has the Implementation of the TRIPs Agreement in Latin America and the Caribbean Produced Intellectual Legislation that Favours Public Health?’, Bulletin of World Health Organization, 8:11 (2004), pp. 815–21.

55 So Anthony, ‘A Fair Deal for the Future: Flexibilities under TRIPs’, Bulletin of the World Health Organization, 82:11 (2004), pp. 811–90.

56 Ibid., p. 813; Oliveira et al., Has the Implementation of the TRIPs Agreement in Latin America.

57 SELA (Sistema Economico Latinoamericano), ‘Cooperation Experiences in the Health Sector in Latin America and the Caribbean’, available at: {}, p. 56, accessed 2 August 2013.

58 SELA, ‘Bulletin 150 on Regional Integration in Latin America and the Caribbean’, available at: {} accessed 15 March 2014.

59 Almeida Celia, Campos Rodrigo, Buss Paulo, et al., ‘Brazil's Conception of South-South “Structural Cooperation” in Health’, Review Global Forum Update on Research for Health, 6 (2009), pp. 100–7.

60 Riggirozzi and Tussie, The Rise of Post-Hegemonic Regionalism.

61 UNASUR (2009), Constitutional Treaty (Tratado Constitutivo de la Unión de Naciones Sudamericanas), available at: {} accessed 3 July 2012.

62 UNASUR (2011), Report of the Pro Tempore Secretariat (2011), available at: {} accessed 28 July 2012.

63 Nunn Amy, Da Fonseca Elize, and Gruskin SofiaChanging Global Essential Medicines Norms to Improve Access to AIDS treatment: Lessons from Brazil’, Global Public Health: An International Journal for Research, Policy and Practice, 4:2 (2009), pp. 131–49; Kelley Lee, Luiz C. Chagas, and Thomas E. Novotny, ‘Brazil and the Framework Convention on Tobacco Control: Global Health Diplomacy as Soft Power’ (2010), available at: {} accessed 12 June 2013.

64 Nunn Amy, The Politics and History of AIDS Treatment in Brazil (Netherlands: Springer, 2009); Buss and do Carmo Leal, Global Health.

65 Melo Marcus, ‘Anatomia do fracasso: Intermediação de interesses e a reforma das políticas sociais na Nova República’, Dados – Revista de Ciências Sociais, 36:1 (1993), pp. 119–63, quoted in Shankland Alex, and Cornwall Andrea, ‘Realising Health Rights in Brazil: The Micropolitics of Sustaining Health System Reform’, in Bebbington Anthony and McCourt Willy (eds), Development Success: Statecraft in the South, (London: Palgrave, 2007).

66 McAdam, Dynamics of Contention, p. 142.

67 Author's interview with Mariana Faria, ISAGS Chief of Staff, Rio de Janeiro, 29 September 2012.

68 UNASUR (2009), ‘Constitutional Treaty’ (‘Tratado Constitutivo de la Union de Naciones Sudamericanas’ available at:{} accessed 3 March 2014

69 UNASUR, Plan Quinquenal (2010–15), available at: {} accessed 20 March 2012.

70 For detailed information about UNASUR Thematic Groups, networks and ISAGS, see {} accessed 2 April 2013.

71 Buss and do Carmo Leal, Global Health; Nunn et al., Politics and History of AIDS.

72 Author's interview with Mariana Faria, ISAGS Chief of Staff, 29th August 2012.

73 UNASUR, Plan Quinquenal.

74 Agencia Fiocruz de Noticias, ‘UNASUR Promotes Health Systems in South American Nations’, available at: {} accessed 27 April 2013.

75 Author's interview with Dr Hugo Noboa, Ministry of Health, Quito, Ecuador, 30 July 2012, Quito, Ecuador.

76 ISAGS, Report (January 2013), available at: {} accessed 13 March 2013.

77 PAHO, ‘UNASUR's Role in the Vaccination Against Pandemic Influenza’, Pan-American Health Organisation Immunisation Newsletter, 32:4 (2010); UNASUR, ‘Bulletin: Ecuador and Dominican Republic Agree to Cooperate in the Reconstruction of Haiti’ (4 November 2010), available at: {} accessed 28 March 2012.

78 UNASUR, Salud, Report of the Pro Tempore Secretariat (2011), available at: {} accessed 28 March 2012.

79 UNASUR's Centro de Estudios Estrategicos de Defensa (CEED), Action Plan 2013, Centre for Strategic Studies: UNASUR Defense Council (2013), available at: {} accessed 2 June 2013

80 Author's interviews with Patricia Betancourt and Paula Gonzalez, International Cooperation Office, Ministry of Health in Ecuador, 30 July 2012. Author's interview with former UNASUR Health Council delegate from Ecuador, 6 August 2012; and with Lorena Ruiz, former Coordinator of UNASUR's Technical Group for Access to Medicines, 2 August 2012.

81 Author's interview with Fausto Lopez, Senior Official at UNASUR Health Council, 30 July 2012; and with Senior Official at the Ministry of Health in Ecuador, 30 July 2012.

82 Author's interview with Gustavo Giler, Senior Government Official from Ecuador's Presidency and former delegate of UNASUR Health, 29 August 2012

83 Ibid.

84 For instance, Scharpf Fritz, Governing in Europe: Effective and Democratic? (Oxford: Oxford University Press, 1999); Streeck Wolfgang and Schmitter Philippe C., ‘From National Corporatism to Transnational Pluralism: Organized Pluralism: Organized Interests in the Single European Market’, Politics and Society, 19:2 (1991), pp. 133–64.

85 Acharya Amitav, ‘Comparative Regionalism: A Field Whose Time has Come?’, The International Spectator: Italian Journal of International Affairs, 47:1 (2012), pp. 315, 4.

86 McInnes and Lee, Global Health.

87 Ibid.

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