Divergent campaigns towards global health governance: Canadian and U.S. approaches to the global HIV/AIDS pandemic Jeffrey Ayres Patricia Siplon.

AuthorAyres, Jeffrey
PositionHuman immunodeficiency virus, acquired immunodeficiency syndrome - Report

    In June 2001, delegates representing countries from around the world met in New York City for a United Nations (UN) General Assembly Special Session on HIV/ AIDS. This meeting took place at the start of a new millennium in an international environment where states had grudgingly begun to recognize the huge geographic scale and enormous human toll that the disease had inflicted on developing countries around the world. However, a noticeable division had emerged between delegations over the wording of the draft declaration of the Special Session. The United States (US), siding with the Vatican and Islamic states, struggled to expunge any mention in the draft declaration of groups at particularly high risk of HIV infection. Meanwhile, Canada, along with Australia and various Latin American and European countries, had urged a much more explicit declaration with the stated goal of reducing incidence among those at high risk of infection. Civil society organizations that had earlier that spring contributed to the wording of this draft declaration, but which had been excluded since that time as negotiations took place between delegations in secret, decried these divisions. The non-governmental organization (NGO) Human Rights Watch noted that "at a conference devoted to fighting AIDS, governments must not replicate the silence and denial that have driven the spread of the disease." (1)

    It is hard to overstate the dimensions and consequences of infectious disease, particularly HIV/AIDS, which are crippling sub-Sahara Africa, and increasingly threatening other developing areas of the world as well. However, the response of developed countries to this crisis has been uniformly underwhelming relative to what is needed. As suggested by this division over the wording of the UN draft declaration, the response has revealed radically different approaches to global health concerns between two geographic neighbors and historic allies, Canada and the US. Beyond what have become commonplace rhetorical divisions in international conferences, we can identify other contrasts in the approach each country takes to affordable medications and financial aid provided to some of the hardest hit areas.

    Canada has passed legislation facilitating developing countries' access to affordable generic medications at the same time that the US has aggressively pursued multilateral and bilateral trade agreement protections for the brand-name pharmaceutical industry. Canada has also put most its financial contributions into multilateral vehicles such as the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the World Health Organization's (WHO) "3 x 5" (3 million in treatment by 2005) initiative. The US meanwhile has placed the vast majority of its resources into its bilateral President's Emergency Plan for AIDS Relief (PEPFAR) targeting fifteen countries. Though less obvious, the two countries have also pursued very different policies regarding prevention, in terms of funding priorities and the above noted ideological positions at international meetings, as well as overall development goals in vulnerable countries as well. How might we account for these differences in ideological, financial and policy approaches between Canada and the US to the HIV/AIDS pandemic?


    The global HIV/AIDS pandemic and the international response have major implications for both the study of international relations and the practice of global governance. In addition to the moral imperative of preventing the deaths of untold millions of people worldwide who are either now HIV positive or soon will be, the global pandemic has exposed further gaps in so-called have and have not countries, exacerbating global inequity, gender discrimination and the growing roster of weakening or failing states. Our approach to this issue begins with one of the more enduring analytical and systematic approaches for developing explanations for foreign policy and international relations outcomes: levels of analysis.

    Obviously, there are many other analytic frameworks available for this analysis. Social scientists have examined HIV/AIDS using a variety of policy perspectives and approaches for topics ranging from comparative blood policy (2) to the development of care and support policies for HIV positive persons (3) to the highly controversial issue of supervised injection facilities for controlling HIV spread. (4) Another common set of theoretical frameworks has been furnished by social movement theories, including the political process model (5) and Keck and Sikkink's model of transnational advocacy networks.(6) Social movement theory has been employed to explain AIDS activism via the Internet, (7) the rise of the activist organization ACT UP (8) and the growth of domestic and global AIDS treatment activist movements. (9)

    Despite the utility of the approaches mentioned above, we chose the levels of analysis approach as the one that best allows us to explain a variety of factors operating on multiple levels simultaneously. We think the contrasting cases of the US and Canadian approaches to this pandemic highlight the role of people, power and national interest and international systemic trends in inhibiting or constructing appropriate responses to this pandemic. The levels of analysis approach to the study of international relations helps to identify the different foreign policy priorities of the US and Canada as well as the preferred albeit different international outcomes in each state's response to the pandemic. Historically, the US's penchant for unilateralism contrasts starkly with the Canadian multilateral response. The extent to which the global response to the HIV/AIDS pandemic is likely to evolve into a more robust system of global health governance, we argue, is rooted in a broader clash between power and multilateralism.

    A level of analysis approach provides a comprehensive frame work for classifying factors that account for either a state's foreign policy or broader international outcomes. (10) Depending on the level adopted, one can specify conditions that cause an international phenomenon to occur. In the increasingly complex environment of global health governance responses to the HIV/AIDS pandemic, one may encounter an otherwise bewildering array of states, non-state actors including NGOs, transnational movements, multinational corporations (MNCs), intergovernmental organizations (IGOs) and other regional and global institutions, regimes, treaties, and laws. The levels of analysis approach helps to bracket out this blizzard of information and specifically identify different explanations at different levels for the still unsatisfactory global governance response to HIV/AIDS monitoring, prevention and treatment. Three distinct levels of analysis provide divergent explanations for understanding the approaches taken by the US and Canada to the global HIV/ AIDS pandemic and the competing outcomes that are stalling the construction of a more robust regime of global health governance: the individual, state and international. (11)

    The individual level of analysis focuses on policy-relevant individuals responsible for political outcomes. We can study the personality, perceptions, choices, roles, belief systems and activities of key policy-relevant individuals to understand how individuals influence foreign policy and international events. Key individuals monitor developments external to a state but are also clearly shaped by internal political developments as well as personal considerations. We are especially interested in focusing on several key individuals who have been active in debates and policy-making around the global HIV/AIDS pandemic in both the US in Canada. At the state level, explanations for policy outcomes can be derived from characteristics of the state. An analysis at this level might focus on specifying a number of variables including the structure and nature of the different political systems, interest groups within different states, public opinion, political culture, and broader national traditions.

    Finally, an analytical approach at the international level would locate relevant explanations with the anarchic characteristics of the international system as well as with state relationships to each other and the broader array of international and regional IGOs. The web of interstate relations, the relative power differences between states, the presence or absence or regional or international organizations and their strengths and weaknesses, the patterns of international trade and finance, and the presence of global norms and international law all provide constraints and opportunities at the most analytically broad level to understand variances in policies and international outcomes.

    In the following two sections we consider the influence of all three levels of analysis on the policies Canada and the US adopt to combat the global HIV/AIDS pandemic. First, we assess a variety of possible general influences on AIDS policy, adopting a broad and brief "thick" description, not necessarily all inclusive, to identify individuals and trends at different levels that could be considered as shapers of AIDS policy. Next, we use two cases studies to provide a more detailed discussion of the intervening influences of individuals, actors and events within the states, and international trends and characteristics on Canadian and US global HIV/AIDS policy. The first case contrasts the approaches taken by Canada and the US towards improving access to generic medications for developing countries afflicted by large numbers of people infected with HIV/AIDS. The second case looks at the divergent approaches adopted by each state towards providing greater assistance to developing countries facing the HIV/AIDS crisis. In each case, we see the influence of all three levels of analysis, which help to...

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