Ⅰ. Introduction

 

It was on January 30, 2020 that the World Health Organization (WHO) declared a Public Health Emergency of International Concern (PHEIC), as defined in the International Health Regulations (IHR), for the spread of Coronavirus Disease 2019 (COVID-19). Since 2000, PHEIC has often been declared in response to outbreaks of infectious diseases. For example, PHEIC was declared for the 2009 H1N1 influenza in April 2009 and lifted a year and four months later, in August 2010. For the 2014 Western African Ebola virus epidemic, PHEIC was declared in August 2014 and lifted a year and seven months later, in March 2016. For the Zika virus epidemic in the Americas, PHEIC was declared in February 2016 and lifted nine months later, in November 2016. As for COVID-19, the end of PHEIC was finally declared on May 5, 2023, after three years and three months (Gumbrecht et al. 2023); this period was longer than that of previous outbreaks of H1N1 influenza, Ebola, and Zika.

 

What was the background behind the protracted PHEIC? One of reasons was that the COVID-19 virus was highly contagious and caused multiple outbreaks worldwide, unlike the localized outbreaks of Ebola hemorrhagic fever and swine flu. Almost immediately, all countries focused on their own domestic responses, leading to competition for resources such as vaccines and therapeutic drugs. While the strengthening of nationalism in each country during the unprecedented crisis united people within the nation and enabled collective action, it weakened international cooperation (Mylonas and Whalley 2022). Within the territory of each sovereign state, matters regarding how to manage diseases are left to each country’s sovereignty; at the same time, it is essential to control infectious diseases that cross boarders at a global level. As such, health issues that require a global response are called “global health.”[1] When considering global health from the perspective of international politics, an important point is who controls global health issues in what form, in an international society with no world government. Until this point, when talking about global health, many people think of the WHO, which is not, however, the sole manager of global health governance (Kickbusch and Szabo 2014). As I discussed in detail in my previous book (Takuma 2020), stakeholders and actors in global health governance other than the WHO are many, including member states of WHO, pharmaceutical companies, NGOs, and other United Nations (UN) agencies such as the United Nations Children’s Fund (UNICEF) and the World Trade Organization (WTO). The process of controlling global health issues amidst numerous competing interests is called global health governance (Kickbusch and Szabo 2014); its mechanism is extremely complex.

 

Ilona Kickbusch of the Geneva Graduate Institute in Geneva, Switzerland, noted that to fully understand the links and interfaces between the various institutions and processes involved in global health, the spaces of health governance are three: Global Health Governance, which includes institutions and processes of governance with an explicit health mandate, such as the WHO; Global Governance for Health, which comprises institutions and processes of global governance that do not necessarily have explicit health mandates but that have a direct and indirect health impact, such as the UN or the WTO; and Governance for Global Health, which includes institutions and mechanisms established at the national and regional levels to contribute to global health governance and/or to governance for global health, such as countries’ health foreign policy or Council on Foreign Relations of the U.S. According to Kickbusch, all three political spaces are interrelated, and their appropriate management leads to appropriate responses to global health (Kickbusch and Szabo 2014). Ultimately, managing health issues at the global level involves various political spaces. From a global perspective, international norms for responding to infectious diseases, such as various provisions of the International Health Regulations (IHR), were not necessarily followed appropriately in response to this pandemic. In other words, the institutions and mechanisms with explicit mandates, which Kickbusch calls “global health governance,” did not always function properly during the pandemics of the century (Kahl and Wright 2021, p. 3).

 

Historically, global health cooperation had been relatively free from geopolitical trends. Examples include the health cooperation between Japan and the League of Nations in the 1930s and the cooperation on smallpox between the U.S. and the Soviet Union during the Cold War (Takuma 2020). Since then, various authors have argued that global health rarely entered so-called high politics until the end of the Cold War (Labonté and Gagnon 2010; Youde 2016). Meanwhile, since the 2010s, as American hegemony collapses and political tensions between China, Russia, and the U.S. increase, the control of global health issues has no longer been free from these geopolitical trends (Fidler 2020). The intense exchange between the U.S. and China over the source of COVID-19 is fresh in our minds; the Russian invasion of Ukraine has also cast a considerable shadow over the control of health issues at the global level.[2] In this way, the control of health issues on a global level is showing signs of movement that is closely linked to politics (Kickbusch and Liu 2022); the movement for reconstruction is not optimistic. David Levy (2021) from the University of Massachusetts pointed out that the COVID-19 pandemic can disrupt global governance structures and processes that were already in turmoil before the pandemic; it could instead spur the rise of economic nationalism, populism, and voluntary governance (Levy 2021). Since this paper was written during the pandemic, Levy himself indicated the need for longer-term analysis, but the negative impact of the pandemic is undeniable.

 

However, it would be too shortsighted to pessimize the future of international cooperation based on this event. The threat of M-pox (monkey pox) and avian influenza remains high, and with the deteriorating international situation, the possibility of bioterrorism is also a concern. As threats to health become more diverse today, the necessity to cooperate with others outside of our own country continues.[3] Such perceptions are still recognized by many actors, at least in the field of health. In fact, the following illustrates the global consensus: at a Special Session of the World Health Assembly in November 2021, WHO member states agreed to launch a process to develop accord on pandemic management (WHO News 2021); and at the World Health Assembly in May 2022, they agreed to update IHR in a shorter period than originally planned.

 

However, what “others” mean to each nation nowadays is not a form of cooperation with unspecified others in the global arena but rather comrades who share values. While such current situation is good news for the future of international cooperation, it may also create a fragile situation in which one misstep could lead to the fragmentation of the entire world (Kickbusch n.d.).

 

As global cooperation becomes more difficult due to the influence of geopolitical trends, cooperation at sub-levels, such as in regions and between like-minded countries, is becoming more important. As pointed out in my previous book, the U.S. played a major role in establishing postwar multilateralism (Kahler 1992; Ikenberry 2006); the establishment of multilateralism in the health sector was also strongly insisted upon by the U.S. after World War II for its universality in the form of including not only the allied countries but also the defeated countries. Particularly in infectious diseases, including all countries in the framework regardless of their political positions or ideologies is extremely meaningful from the technical aspects of infectious disease control (Takuma 2020, chap. 2), which remains unchanged today.

 

Conversely, ideological divisions and political tensions have become so high that the multilateralism that has continued in the postwar international community can no longer remain as it has been. This perspective is not new in international politics—it is the so-called minilateralism argument. “Minilateralism,” in general, is the idea of a small group of people working together on a specific issue among those who share a common set of values. In 2009, after the global financial crisis, Moisés Naím, editor-in-chief of Foreign Policy, argued in his article that multilateralist efforts had failed and that, instead, minilateralism could be a policy of targeting specific issues and seeking consensus among a small group of people whenever possible (Naím 2009). The point that multilateralism, supported by Western hegemony, is in decline has been made in various areas since then. American University professor Amitav Acharya, in the first edition of The End of American World Order in 2015, wrote that the liberal international order based on the hegemony of the U.S. and Europe is in decline, and in its place, a multilayered order (multiplex world) is emerging in which international organizations, like-minded states, regional bodies, emerging powers, and private actors cooperate while exerting their respective influences.[4] In fact, the number of occasions in which it is mentioned in academic settings has increased in recent years, due in part to the growing number of frameworks for specific countries, such as the Quad and AUKUS, in Asia and the Indo-Pacific region.[5]

 

In the field of health, the fundamental question is how to reconcile such a current situation with the demands of multilateralism in the health sector. As noted above, cooperation with others is essential for the effective management of health issues. Especially in light of the fact that many infectious diseases have been occurring in Asia in recent years, we must find a way to preserve international cooperation in some form.

 

From this perspective, this paper focuses on regional cooperation. In addition to strengthening the response at the national level, many moves were made during the COVID-19 pandemic to strengthen cooperation with neighboring countries and establish new frameworks to solidify cooperation in each region. Geographically close countries often face the same or similar challenges in public health, so naturally regional frameworks are strengthened. Historically, strengthened relations with neighboring countries or intraregional health cooperation precedes the development of global-level frameworks. This paper reviews the progress made in each region during the COVID-19 pandemic, and then proceeds to discuss the possibilities of intraregional health cooperation in a post-COVID era.

 

Ⅱ. Revitalizing Regional Cooperation during the Pandemic

 

After World War II, the WHO established six regional bureaus and developed cooperative relationships among neighboring countries. WHO’s regional offices facilitated information sharing and mutual assistance with neighboring countries, facilitated cooperation among concerned countries, and provided a platform for jointly addressing regional challenges. While these bureaus are positioned as a subordinate organization of WHO, the independence of each regional secretariat has dramatically increased in recent years and even become a political issue (Fee et al. 2016). In fact, staff mobility among WHO regional offices is very low, hindering smooth exchanges when cooperation is needed. Gro Harlem Brundtland, WHO Director-General from 1998–2003, made an unsuccessful attempt to reform the relationship between WHO headquarters and regional offices. Some note that independent regional functions hinder the effectiveness of WHO (Lee 2009, p. 33).

 

Nevertheless, the significance of health cooperation at the regional level is that it complements cooperation at the global level. In fact, the International Health Regulations (IHR2005), which stipulate public health emergency response, also include consideration of regional efforts. For example, in Article 57(3), which establishes relationships with other international agreements, it states, “Without prejudice to their obligations under these Regulations, States Parties that are members of a regional economic integration organization shall apply in their mutual It states that relations the common rules in force in that regional economic integration organization.” In other words, global agreements and regional agreements are positioned to complement each other. In addition, Article 44, Paragraph 3 of the IHR states: “Collaboration under this Article may be implemented through multiple channels, including bilaterally, through regional networks and the WHO regional offices, and through intergovernmental organizations and international bodies.” Again’, we can see how regional and global initiatives are positioned to complement each other (WHO 2005). In fact, some research suggests the use of regional frameworks to compensate for the deficiencies in global efforts to the One Health approach (an approach in which stakeholders work together to address cross-cutting issues related to human, animal, and environmental health) (Elnaiem et al. 2023).

 

The draft of the Pandemic Convention (Zero Draft) released In February 2023 also proposes various articles based on the current state of multi-layered governance. For example, in paragraph 26 of the preface, it states, “Reaffirming the importance of a One Health approach and the need for synergies between multisectoral and cross-sectoral collaboration at national, regional and international levels to safeguard human health, detect and prevent health threats at the animal and human interface, in particular zoonotic spill-over and mutations, and to sustainably balance and optimize the health of people, animals and ecosystеms.” In addition, in Article 2, paragraph 2, which describes the relationship with other international agreements and international instruments, it states: “The provisions of the WHO CA+ shall not affect the rights and obligations of any Party under other existing international instruments and shall There is a description of respect the competencies of other organizations and treaty bodies”. Article 3 of the Convention states that “The WHO CA+ aims to comprehensively and effectively address systеmic gaps and challenges that exist in these areas, at national, regional and international levels, through substantially reducing the risk of pandemics, Increasing pandemic preparedness and response capacities, progressive realization of universal health coverage and ensuring coordinated, collaborative and evidence-based pandemic response and resilient recovery of health systеms at community, national, regional and global level” (WHO 2023). Ultimately, considering the advances in global health governance across national, regional, and global levels, and the mutual complementarity of each level, one of the goals is to eliminate regional and national disparities through international cooperation.

 

Ⅲ. Regional Health Cooperation in Asia

 

Before World War II, the Singapore Infectious Diseases Information Agency of the League of Nations Health Organization existed in Asia, serving as a base for regional health cooperation (Takuma 2023). However, since the end of World War II, political tensions rose between the countries concerned, and no comprehensive cooperation framework has been established within the region. Since 2007, Japan, China, and South Korea have held health ministers’ meetings every year, except 2012, when relations between Japan and China deteriorated over the dispute over the Senkaku Islands. In May 2020, a special meeting of the Japan-China-Korea Health Ministers’ Meeting was held to deal with COVID-19. The countries issued a joint statement on the importance of strengthening information, data, and knowledge sharing among the three countries, promoting further exchanges and cooperation among technical and specialized agencies, and sharing information and experiences to combat COVID-19. However, there was further progress on cooperation, as distrust of China’s response grew, and Japan-Korea relations became strained due to trade issues and the issue of forced labor.

 

Despite this, various innovative regional initiatives have been established during the pandemic, especially with Southeast Asian countries. For example, in 2020, at the request of the ASEAN Secretariat, then Prime Minister Shinzo Abe announced the establishment of the ASEAN Center for Public Health Emergencies and Emerging Diseases (ACPHEED). The ACPHEED, as a regional focal point, aims to strengthen ASEAN’s preparedness, detection, and response capabilities to public health crises and emerging infectious diseases (Japanese Ministry of Foreign Affairs 2020, p. 14). The center aims to improve local medical standards and lead the expansion of Japanese companies into ASEAN. In the future, it has the potential to become a base for cooperation, such as clinical trials, while developing Japanese-made pharmaceuticals. From a geopolitical perspective, infectious disease cooperation with Southeast Asian countries can be an important step in realizing global health security within the “Free and Open Indo-Pacific” concept. In November 2020, at the 37th Summit, ASEAN leaders formally announced ACPHEED’s establishment (ASEAN 2020).

 

In addition, in 2021, Japan’s National Center for Global Health and Medicine (NCGM) began collaborating with multiple research institutes in Asian countries to launch the ARO Alliance for ASEAN and East Asia (ARISE), a clinical trial platform for the Asian region. ARISE aims to lead clinical research in Asia and the world by conducting international joint clinical trials aiming for pharmaceutical approval. They will work on international collaborative clinical trials not only for emerging, re-emerging, and tropical infectious diseases prevalent in Asia, but also for chronic diseases.[6] Although it was initially planned that Japan would provide international medical support to ASEAN countries through ARISE, a mutual cooperative relationship has now been established between Japan and the participating countries, according to those involved (Takuma 2024, chap. 3). Currently, ARISE’s member countries are mainly Southeast Asian countries, with Swiss and American institutions listed as collaborating institutions,[7] but in the future, depending on the budget, it is possible that ARISE’s network could be expanded to regions where joint clinical research and trials are possible, such as East Asia, Africa, and South America (Takuma 2024, chap. 3).

 

South Korea is also actively promoting health cooperation in Asia. In February 2022, Korea and WHO established the WHO Biomanufacturing Training Hub. The hub aims to be a global hub serving all low- and middle-income countries wishing to produce biologics such as vaccines, insulin, and cancer drugs (WHO 2022). As mentioned above, in November 2021, the WHO has set up an mRNA vaccine technology transfer hub in South Africa, as geopolitical conflicts hinder proper equitable distribution of resources. Simultaneously, it was decided to establish an organization to train in the production of biologics such as vaccines. The presence of Korean companies, such as SK Bioscience, is said to have been the key to the selection. Indeed, even after its establishment, training has been conducted in close cooperation with these domestic companies. Currently, Bangladesh, Indonesia, Pakistan, Serbia, and Vietnam, among others, have announced their participation. In the future, this hub aims to welcome participation not only from Asia, but from a wide range of middle and low-income countries.[8] Future developments can be crucial, such as cooperation with the United States.

 

Cooperation between the United States and Asian countries was also strengthened during the pandemic. At the joint press conference after the Japan-United States summit meeting in May 2022, plans were announced to establish a Japan office for the U.S. CDC. Moreover, the U.S. Department of Health and Human Services established a country office in Vietnam in 1998 and has continued health cooperation with Vietnam ever since. In 2014, the U.S. CDC and Vietnam’s Ministry of Health (MOH) signed a new five-year cooperation agreement to build a stronger foundation for Vietnam to prevent, detect, and respond to disease outbreaks. This agreement was made as part of the Global Health Security Agenda (GHSA) launched by the United States in 2014 (US Embassy and Consulate in Vietnam 2014). In November 2022, during the pandemic, the importance of partnership in the health sector between the United States and Vietnam was reaffirmed (US Embassy and Consulate in Vietnam 2022).

 

Cooperation among Quad countries also showed progress. As part of its efforts, the four-nation foreign and security policy framework “Quad,” consisting of the United States, India, Japan, and Australia, has jointly provided vaccines manufactured in India to Southeast Asian countries, supported the expansion of vaccine manufacturing capacity, and provided cold chain support (Japanese Ministry of Foreign Affairs 2022).

 

On February 5, 2024, the US CDC East Asia Pacific (EAP) Regional Office was opened in Tokyo, which will advance global and regional health security by focusing on advanced surveillance, strengthening interlaboratory networks, and strengthening response capabilities to rapidly respond to public health threats. Through this regional office, regional initiatives in which Japan is involved, such as ACPHEED, may be expanded to include wider countries and regions (Morrison and Wolfe 2024).

 

Both cases have happened in the backdrop of geopolitical confrontation. As mentioned above, it has become difficult to build a consensus at the global level, and the distribution of vaccines and medical cooperation have become strategic. Still, measures against infectious diseases are showing signs of progress.

 

Ⅳ. Discussion

 

The structure of global health governance displays signs of multilayering, given the divisions within the international committee and the influence of geopolitical trends. While reaffirming the importance of a global health co-operation framework for establishing rules and norms and making efforts to strengthen it are necessary, there is simultaneously a growing movement to strengthen intraregional health cooperation as a substantive co-operative entity. Given the ongoing health crisis, it is reassuring that a realistic response framework is being established among neighboring countries.

 

In Asia, reflecting political and cultural diversity, no co-operation framework encompasses the entire region, as can be found in Africa or Europe. It would be quite difficult for countries with different political systеms or ideologies to co-operate. On the other hand, it would not be impossible for liberal democratic countries to co-operate with each other on practical matters such as sharing health information or developing vaccines; for example, South Korea and Japan are implementing various initiatives such as those introduced earlier, and connecting them organically would increase efficiency and strengthen health security in Asia.

 

More concretely, this paper makes the following three policy recommendations. The first is co-operation between Japan and South Korea regarding training human resources in Southeast Asia. As mentioned above, South Korea is working to develop human resources through the Biomanufacturing Training Hub. Japan is also deepening its co-operation with Southeast Asian countries through the ASEAN Centre for Infectious Diseases. By linking the efforts of Japan and South Korea, it will be possible to more efficiently develop human resources in Asia.

 

The second is co-operation among the CDCs of Japan, the United States, and South Korea. As noted above, the US CDC opened an Asia-Pacific regional office in Tokyo earlier this year. Japan’s CDC is scheduled to be established in April of next year, and it is expected to work with the regional office of the US CDC to strengthen health security in the Asia-Pacific region. Adding South Korea to the Japan–U.S. partnership will help further strengthen health security in Asia.

 

The third is co-operation in vaccine development between Japan and South Korea. Japan has established an international clinical research network entitled ARISE. If South Korea, which has high technological capacities in the field of biomanufacturing, joined ARISE, it would be possible to develop vaccines within the region, taking advantage of Japan and South Korea’s high technological capabilities and Asia’s population. South Korea has world’s leading biomanufacturing companies including SK Bioscience as well as the International Vaccine Institute in Seoul. Japan, too, has sufficient capacity in developing and producing vaccines, although Japan lags far behind other countries in developing COVID-19 vaccines. Of note, Japanese-made M-pox vaccines were exported to African countries that are combatting this deadly virus. Such co-operation will make Southeast Asian countries dependent on a Japan–South Korea alliance while making them less dependent on Chinese vaccines for the next pandemic.

 

The fourth is co-operative support for African countries. As groups and regions develop substantial co-operation, disparities will naturally emerge between different regions or groups. In particular, active financial and technical support from foreign countries, companies, foundations, and so on is essential for strengthening pharmaceutical manufacturing capacity and surveillance in the African region, and active support and mediation from countries, especially developed countries, is required. One need not mention the need for active involvement in reviewing and strengthening the international collaborative framework Access to COVID-19 Tools (ACT) Accelerator to accelerate the development and production of COVID-19 testing, treatment, and vaccines and achieve equitable results.

 

Various innovative initiatives emerged during the pandemic in Asia. At present, it may not be possible to assert that each initiative is linked organically, reflecting political tensions in the region. Still, if the focus remains on specific items, such as eliminating the gap in access to medicines, potential remains for co-operation between Japan and South Korea, or the Quad and South Korea, to build a regional ecosystеm. For the purpose of strengthening health security in Asia, both South Korea and Japan are encouraged to realize the necessity of their co-operation, and to co-operate with each other, putting aside their immediate interests. ■

 

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[1] Kickbusch and Szabo 2014: Ilona Kickbusch, a leading expert in global health governance research, defines global health as “those health issues which transcend national boundaries and governments and call for actions on the global forces and global flows that determine the health of people”.

 

[2] Furlong 2023: Following the Russian invasion of Ukraine, the World Health Assembly passed a resolution condemning actions of Russia, and the WHO office from Moscow was moved to Copenhagen, Denmark.

 

[3] Kahl and Wright 2021; Dehury 2022. Kahl and Wright point out that we live in where international cooperation is needed more than ever due to increasing threats that transcend national borders, but the intensifying competition among the major powers is making cooperation increasingly difficult.

 

[4] Acharya 2015. Acharya published a second edition in 2018, after Brexit and the election of President Trump. Acharya 2018.

 

[5] Based on the current situation where multilateralism is dysfunctional in various fields and, on the other hand, the framework of a small number of people is becoming more active, this work discusses how minilateralism is becoming more active and its potential: Mohan 2023. Another discussion of the rise of minilateralism in the Asia-Pacific region and its security impact and potential include Singh and Teo (eds.) 2020.

 

[6] National Center for International Medical Cooperation, ARISE (ARO Alliance for ASEAN & East Asia) website (https://arise.ncgm.go.jp).

 

[7] National Center for International Medical Cooperation, ARISE (ARO Alliance for ASEAN & East Asia) website (https://arise.ncgm.go.jp).

 

[8] Interview with a person from the Ministry of Health and Welfare, South Korea, 3 February 2023.

 

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■ Kayo Takuma is Professor of International Politics at the Faculty of Law, Keio University.

 

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■ Edited by Hansu Park, EAI Research Associate
    For inquiries: 02 2277 1683 (ext. 204) | hspark@eai.or.kr