Yanzhong Huang. “Global Health, Civil Society, and Regional Security.” In A Growing Force: Civil
Society's Role in Asian Regional Security, edited by Rizal Sukma and James Gannon. Tokyo and
New York: Japan Center for International Exchange, 2013, 25–42.

3

Global Health,Civil Society, andRegional SecurityY       H U A N G

G     H        S        T   
H,   represented the most explicit,
and perhaps the only, intersection between health and security. Thatframework, however, produced a very narrow characterization of thehealth-security nexus. Today, the relationship between global healthand regional security can be examined through the lens of three security
frameworks: human security, national security, and international security. First, health problems represent direct threats to several importantcomponents of the human security of individuals as defined by the United
Nations Development Programme, including personal security (due to thepremature loss of life and the stigma and violence associated with certain
health conditions), health security (because of the additional burden healthproblems place on healthcare systems), economic security (as households
and individuals experience a reduced earning capacity and a reduction in
spending on nonfood items due to medical care costs and other related
expenditures), and food security (by negatively affecting the ability ofcertain individuals or households to secure access to food).
Second, health problems pose a threat to national security through theirimpact on a nation’s fighting capabilities (by undermining military readiness) and state capacity (by undermining the national economy, weakening
state institutions, and generating conflicts over access to medicines). The
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YANZHONG HUANG

impact of poor health and infectious diseases on a nation’s regular troops
and general recruiting pool can undermine military readiness and even affect the state’s ability to project power abroad (e.g., “differential immunity”
among troops can lead to an increased risk of fatalities during training andoperational deployment when forces are exposed to diseases for the firsttime). Furthermore, poor health and disease outbreaks could exacerbatesocial and political instability in strategically important countries such as
China, India, or Indonesia. Decision tree analyses suggest that a publichealth issue should be considered a risk to an individual nation’s security
if it has an acute health impact, causing significant death and illness within
the state’s territories. When the outbreak of a disease such as cholera or
HIV/AIDS can be attributed to poor environmental management, poor
health management, or governance problems, a country’s political institutions may be subject to close scrutiny by other countries—as was the casewith China during the severe acute respiratory syndrome (SARS) outbreakin —which, under the new responsibility to protect principle, mightlead to international interference in its domestic affairs.
Finally, health problems can become an international security concern
by undermining the wider stability of international society. In other words,
a local disease outbreak can have “spill-over” effects that impact a broader
area. Decision tree analyses suggest that a public health issue should beconsidered a risk to international security if its transborder spread generates an acute health impact that poses a threat of significant death andillness. Disease outbreaks or disease-related social unrest could cause
massive disruptions to the regional economy, which may have negative
implications for regional security. Social and political instability caused bydisease outbreaks, in turn, may make certain countries more war-prone.
For example, authoritarian rulers or populist leaders may undertake
aggressive action abroad to divert the public’s attention from domestic
political turmoil or embrace hypernationalism to rally the masses andrestore political order. Also, relations between countries could be strainedby self-serving state responses during an epidemic (e.g., quarantines, trade
restrictions, and border closures) or by problems related to transparency,
sample-sharing, or competition for medical and public health tools suchas vaccines or antivirals (e.g., Indonesia’s insistence on “viral sovereignty”).
In the worst-case scenario, infectious disease outbreaks may even affectthe power balance in the international system. As Nicholas Eberstadt’s
model has demonstrated, HIV could alter the economic potential of majorstates and therefore the balance of power in Eurasia.
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Global HealthI               H    -P    
C S O     R    S       Over the past two decades, changes in the political and biological worlds
have profoundly transformed the landscape of global health governance.
The structure of global health governance is taking shape in an age of“nonpolarity” or “unstructured plurality,” featuring “multiple players
addressing different health problems through diverse processes andprinciples.” Among the various players, civil society organizations or
CSOs—nongovernmental organizations (NGOs), philanthropic foundations, and faith-based organizations (FBOs)—have tremendously expanded their involvement in global health governance. In the meantime,
public health governance has entered what David Fidler has called the“post-securitization” stage, in which governance is mainly driven by thepolicy belief that public health problems can be addressed by being framed
as security threats. According to Fidler, “One of the dominant themes ofthe securitization process has been that international cooperation and thenational and global involvement of non-state actors are essential in publichealth governance to achieve security, whether the concept of security inquestion is narrow or broad.”
To be sure, the involvement of civil society groups in global health andin regional security broadly defined is not new. For example, JOICFP(Japanese Organization for International Cooperation in Family Planning)
began to operate health projects onsite in developing countries as early as
the s. What is different today is not only the significant increase in thenumber of health-promoting CSOs but also the high profile and significant influence they have demonstrated over the past decade. The Global
Fund to Fight AIDS, Tuberculosis and Malaria’s Round , for instance,
linked the provision of funding explicitly to the goal of building civilsociety’s ability to assist in combating HIV/AIDS. The Bill & Melinda
Gates Foundation, with the unprecedented resources it has committed
to global health, has actually become a “game changer” in global healthgovernance. The foundation has been spending more on its global healthprogram in recent years (an average of . billion per year in  and) than the World Health Organization (WHO) spends on all of its
programs (. billion per year). The sea change that public healthsecuritism has unleashed presents further opportunities for civil society
groups to exert their influence. More specifically, it expands the politicaland operational space for CSOs as security considerations enter into “agovernance context previously oriented by concerns involving economic
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considerations and aspirations grounded in concepts of human dignity.”
This chapter thus examines the potential and actual roles of health-related
CSOs in three security paradigms: human security, national security, andinternational security.

H    -R      C S O     H    S       
Since the human security framework was specifically developed to highlight the threat of nonmilitary and nontraditional security challenges,
such as those posed by diseases and other health-related problems, there
is no need to belabor the importance of good health to human security.
Reasoning along this line, we can say with confidence that CSOs that arepromoting good health are also contributing to human security. By providing medical and healthcare services, raising awareness of health-related
issues, promoting the privacy and human rights of people suffering from
diseases, and offering financial and legal assistance to affected individuals
and families, CSOs can be instrumental in reducing premature death andassuring human dignity (personal security), improving the performanceof healthcare systems (health security), lowering medical care costs andmitigating their negative impact on household spending on nonfood items(economic security), and sustaining access to food by protecting the healthof breadwinners (food security).
In East Asia, CSOs have played an important role in providing direct
health services to needy groups. Examples include the Healthcare Centerfor Children in Cambodia, Yayasan Kusuma Buana in Indonesia, and
the Population and Community Development Association in Thailand.
Services provided by AIDS NGOs to at-risk groups—e.g., outreach tomen who have sex with men (MSM) for risk reduction education, condom distribution and promotion for commercial sex workers, syringe
exchange for injecting drug users, and treatment and support for people
living with HIV/AIDS (PLWHA)—are particularly effective in lowering
the risk of infection, prolonging the lives of PLWHA, making health andmedical care more accessible and affordable to infected populations, andreducing the stigma and discrimination against PLWHA. Joan Kaufman
has described the situation in China as follows:
In urban areas, numerous AIDS NGO groups have emerged to provide
outreach and education to gay men through hotlines and in bars andbathhouses (AIZHI, Gay Men’s Hotline, Friends Exchange, Chengdu
Community Care Group). Patient support groups have formed, often

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Global Healthaffiliated with urban infectious disease hospitals (Mangrove, Ark ofLove) or as vehicles for raising funds (Positive Art), or to provide antiretroviral (ARV) treatment education and adherence support basedon programs developed by Médecins Sans Frontières (AIDSCARE andChina AIDS Info in Guangzhou). Other groups have been establishedeither to raise money for orphan relief or to provide subsidies andservices to AIDS-affected families (Chi Heng, AOS, Orchid).
Fewer groups exist to work with sex workers or drug users, both illegal,but groups that do operate fill important gaps by providing educationand condoms to sex workers and miners (Panzhiyuan), . . . drug treatment and rehabilitation for drug users (Daytop), or needle and syringe
exchange distribution to injecting drug users (Kuming) [sic].

CSOs, from NGOs to FBOs, also contribute to pandemic preparedness and response in the region. In addition to providing medicine, homecare, and food supplies, a number of civil society groups in Southeast
Asia are involved in promoting education and raising awareness on
pandemic preparedness at the community level. Muhammadiyah, anestablished moderate Islamic organization that was originally created tolead a reformist movement in Indonesia, for example, has been involvedin community-based training in an effort to increase community knowledge and awareness of avian influenza and to strengthen community
surveillance and response capacities. Similarly, some NGOs and FBOs in
Cambodia are promoting education and awareness on pandemics throughinformation leaflets, people-to-people contact, quarantine simulations,and assistance in implementing measures for social distancing. Somealso provide medicine, home care, and food supplies to communities andhouseholds vulnerable to the pandemic.
Not all CSOs operate solely as direct service providers. Advocacy CSOs
representing minority or at-risk groups have been critical in putting pressure on governments and industries to increase funding and access fortreatment and prevention programs, or to treat these groups in a humane
and fair manner. If we agree with Rousseau that social institutions andinequality are the main sources of illness, the efforts by advocacy CSOs,
with their focus on social justice, human rights, and democracy, should
be viewed as an important contribution to the improvement of healthstatus and thus human security. In China, civic groups such as Gongmeng(in the  milk powder scandal), Yirenping (in cases of Hepatitis B discrimination), and Aizhixing (in cases of former plasma donors infectedwith HIV) have helped victims seek legal redress against the government
or companies.
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Of course, advocacy groups are numerous in many other Asian countries
as well. They include Serikat Perempuan Anti Kekerasan in Indonesia,
WomanHealth in the Philippines, and the Korean Federation of Medical
Groups for Health Rights. During the – Nipah virus outbreakin Malaysia, it was a CSO that took the government to task after officials
blamed “illegal pig farm operators”—i.e., ethnic Chinese—for the outbreak. The Federation of Livestock Farmers’ Associations of Malaysia, anassociation of Chinese livestock producers, came to the defense of the pig
farmers and pinpointed the flaws in the state governments’ policies that
had contributed to the outbreak.
Compared with government agencies, an advantage CSOs have enjoyedin service provision and advocacy is their ability to reach and represent
those hard-to-reach, marginalized, and underrepresented groups that areoften the most vulnerable to the negative impacts of health problems. As
Paul Farmer and others have observed, once effective AIDS treatment
became available in the s, community-based organizations and local
NGOs became the backbone of AIDS treatment support in the countryside, where trained healthcare workers are scarce. AIDS Care China, aGuangzhou-based civil society group, assists , AIDS patients withmedication—nearly  percent of the total receiving treatment in China.
During Thailand’s avian influenza outbreak in –, a Bangkokbased foreign NGO, Focus on the Global South, defended the interestsof small farmers who had no access to the policymaking process and who
were being blamed for the outbreak.

C S O     N   S       
There are two primary ways in which CSOs operating in the health field
can contribute to national security. First, as an alternative source of information, civil society groups can help ensure health-related demands arechanneled into the policymaking apparatus in a consistent, systematic,
credible, and timely manner. Because CSOs operate as an intermediate
layer between state and society, they can relate more directly to grassroots problems than can government, and can identify more easily andaccurately those neglected issues or constituencies that require advocacy
or support, thereby improving state effectiveness in addressing various
health-related challenges. In addition, CSOs can use their expertise andexperience to inform the revision or development of normative guidelines and policy frameworks and shape government responses to health30

Global Healthchallenges. One example that relates to both of these functions is thegreater ability of CSOs to involve PLWHA in their activities, which not
only “facilitates the development of credible, acceptable and effective
guidelines” but also “enhances ownership of the process, enables people
living with HIV to hold their governments accountable and forms thebasis for sustained advocacy.”
Second, as an important channel of funding, resources, and organizational skills, CSOs can complement government actors and play asignificant role in health system capacity building, thereby contributing
to socioeconomic and political stability. The – Spanish influenza
did not cause social breakdown or political legitimacy problems in the
United States in part because of the active role played by CSOs; during thesecond wave of the pandemic, community-based civil associations took
over the functions of many of the local governments that had collapsed.
In this case, a robust civil society managed to offset the deficit in the US
government capacity. It is worth noting that despite globalization, building and maintaining public health infrastructure remains predominantly
a government function. Indeed, the development of increasingly demanding international health rules and norms to tackle the global spreadof disease, as embodied in the International Health Regulations (),only highlights and exacerbates the inadequacy and deficiency of healthsystem capacity in low-income countries. By mobilizing additional material and human resources (e.g., volunteers and medical equipment), CSOs
contribute to state capacity building and thus national security. This role
has actually been strengthened in recent years because of the expanded
use of CSOs by states and multinational corporations as direct recipientsof aid and in-kind contributions, such as donated medicines.
In East Asia, the importance of CSOs as an alternative source of information in policymaking is evidenced in state responses to disease outbreaks.
During Malaysia’s Nipah outbreak in –, government officials
initially claimed that the outbreak was caused by Japanese encephalitis.
They were forced to acknowledge that it was caused by a new virus after aforeign epidemiologist working in West Malaysia questioned the government’s claim in an e-mail posted on an online forum for Malaysian healthprofessionals. When the country was facing the threat of HN in May
, Sultan Ahmad Shad called for enhanced cooperation between government agencies and NGOs to provide information to the people on thedangers of this influenza virus and ways to avoid it. In China, CSOs were
the first to alert the general public and the government about the widespread infection with HIV of former plasma donors in Henan Province.
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In addition to promoting transparency and raising awareness, CSOs in
Asia have provided the government with feasible and constructive policy
recommendations and have gained increasing access to health policymaking and capacity building. In Japan, for example, experts note that “advocacy efforts [by health NGOs] since  have uncovered the possibilityof having a direct impact on the policies of the Japanese government, andthe work of NGO alliances since  has moved toward opening up the
possibility for building a dialogue with the government.” Change has
been occurring even in China. A former health minister praised CSOs
for helping promote open and equal discussion among government officials, members of academia, and PLWHA, which was unimaginable 
years ago. In July , the Chinese government and civil society joined
hands for the first time in responding to HIV/AIDS by launching China
Red Ribbon Beijing to share information and pool resources in fighting
the disease. Such state-society synergy is expected to enhance state effectiveness in addressing health challenges and indirectly improve thenational security environment.
In some authoritarian states, health-promoting CSOs are at theforefront of promoting good governance and democracy as well. Statecapacity cannot be considered effective if that capacity is not used in
the interest of society. As an alternative source of discipline, CSOs help
monitor government policy processes and ensure that formally mandated
governmental institutions fulfill their responsibilities appropriately andeffectively. One such example is the China Global Fund Watch Initiative,
which was established in November . As an independent watchdog
NGO, it seeks to promote the development of China’s civil society andensure good governance and public participation by nurturing grassroots
NGOs and building partnership among NGOs, governments, academics,
and private entrepreneurs. In a country where civil society is still in themaking, the proliferation of health-promoting CSOs can be considered“democracy in bud.” As early as April , the reform of the China
Country Coordinating Mechanism (CCM) for Global Fund–supported
programs led to an open, transparent, and thoroughly documented
election of an NGO representative to the CCM. For most of the NGOs
that participated, the election marked their first experience with selforganization. As a result, awareness of the necessity and merits of public
participation among civil society groups was greatly strengthened.
Authoritarian rulers may view the actions of these CSOs as undermining
national security (due to the potential of CSOs to challenge their legitimacy to rule). Insofar as state capacity is concerned, however, efforts by32

Global Health

CSOs to promote democracy and good governance contribute to national
security by curbing the state “capacity deficit” in responding to healthchallenges that have negative security implications.

C S O     I        S       
CSOs can contribute to international security through various means.
First, by encouraging a shift from warfare to welfare, they can mitigate
the traditional “security dilemma.” To increase military spending dramatically, a government will have to ward off competing pressures for higher
expenditures on social services (e.g., pensions, healthcare, and education)and for more public investment in infrastructure. Political pressuresexerted by CSOs for increased public services such as healthcare could
compel governments to continue to increase the share of output spent onthese government services and transfers, which in turn discourages thedramatic rise of military spending. In nondemocracies, such pressures
may not be as strong as they are in democracies. As discussed above,
though, the proliferation and growth of health-related CSOs in authoritarian states can be viewed as part of the democratization process. To theextent that democracies rarely fight with each other, they contribute to“democratic peace.”
Second, CSOs can sometimes be more efficient than government actors in regional disease surveillance with regard to disease outbreaks
that threaten regional peace and stability. In recognition of this, therevised International Health Regulations () authorize the WHO touse information it receives from nongovernmental sources rather thanrelying solely on government-provided information. With a network ofsome , North Korean defectors and their contacts in the North,
the South Korea–based NGO Good Friends proved more sophisticatedthan the South Korean government in breaking down the wall of silencesurrounding the reclusive North Korea and was able to report deaths
linked to the HN influenza outbreak in the North in December .
Third, because of their nongovernmental status, CSOs may be the only
actors acceptable to all sides when states conduct health diplomacy. As
soon as North Korea confirmed an HN outbreak, for example, South
Korea increased funding for humanitarian projects through NGOs supporting infants and improving public healthcare in the North. The movewas construed as an effort to improve ties between South and North
Korea. The “soft power” obtained from wielding such “health diplomacy”
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may provide more incentives for international cooperation on health,which is conducive to regional peace and stability.
Perhaps more importantly, CSOs in one country can link up with
CSOs in other countries of the region to combat common healththreats. In East Asia, many regional CSOs function the same way as
national CSOs in terms of advocacy and service provision. Because theyusually tackle health challenges with regional security implications,however, these organizations may have strong incentives to networkwith other sectors, policy actors, and stakeholders in the region. The
AIDS Society of Asia and the Pacific, for example, aims to reduce thetransmission and impact of HIV/AIDS in Asia Pacific by undertaking
the following tasks:
. Promote opportunities for the discussion of HIV/AIDS issues and theexchange of relevant information and technologies.
. Influence HIV/AIDS policy development in the Asia and Pacific regions
and awareness of the gravity of the regional epidemic internationally.
. Work with different regional sectors and stakeholders in Asia and thePacific towards collective advocacy efforts.

Another regional organization with a different focus is Health Action
International–Asia Pacific, which “actively promotes the concept of essential drugs and their rational and economic use through advocacy, evidencebased research, education and action campaigns.” According to Margaret
Kech and Kathryn Sikkink, such CSOs are part of a “transnational advocacy network” that involves “relevant actors working internationally on
an issue, who are bound together by shared values, a common discourse,and dense exchange of information and services.” Transnational advocacy networks can be particularly useful when domestic CSOs find thatappealing to state authorities by themselves does not resolve problems.
By linking up with international actors (e.g., CSOs in other countries,
international governmental organizations, and foreign governments),
domestic CSOs can often more effectively exert pressure on their own
governments and change the latter’s policy behaviors by encouraging
them to engage in international health cooperation that contributes toregional peace and security. During the negotiations on the Framework
Convention on Tobacco Control (FCTC), for example, the Japan Medical
Association worked with the Framework Convention Alliance to raise attention to and scrutiny of the Japanese government’s pro-tobacco stance.
For fear of being isolated internationally, the government in May made a last-minute decision to adopt the FCTC.
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Other transnational CSOs, such as the Southeast Asia Foundation
for Outbreak Regional Cooperation, seek to further outbreak surveillance and response activities by providing consultation, expertise, andsupport for the implementation and maintenance of the Early Warning
Outbreak Recognition System, which involves four Asian countries(Cambodia, Laos, Indonesia, and Vietnam). In so doing, they provide
useful knowledge of health problems that threaten regional security andhelp to clarify misperceptions and misunderstandings. This is particularly
important when countries in the region are dealing with an unknown andnovel pathogen, which historically has tended to give rise to conspiracy
theories and finger-pointing between countries. CSOs also help ensure
continuity in the provision of health services across borders in ways thatgovernments cannot, which is crucial due to the increased movement ofpeople caused by globalization, natural disasters, and military conflicts.
One such case is Services for the Health in Asian & African Regions(SHARE), an NGO based in Japan that uses its transnational network toensure that migrant workers returning to Thailand from Japan continue
to have access to ARV drugs.
CSOs, including think tanks, can also provide intellectual leadershipand vision in identifying health-related “regional security complexes,”
in designing institutional frameworks for cooperation on health, and inorganizing confidence-building measures. These are particularly important in East Asia, which lacks a strong collective regional identity due tothe heterogeneity of the cultures and the levels of social, economic, andpolitical development, and to the competitive engagement of major powers in the region. Through its health and human security program, theCentre for Non-Traditional Security Studies at Nanyang Technological
University in Singapore, for example, not only aims to raise regionalawareness of the serious threats of infectious diseases but also seeks tobuild linkages among different state agencies and policy communities
in the region in order to develop an integrated approach in responding
to health crises. In order to achieve this objective, the project brings
together an international, multidisciplinary team with experience insecurity studies, public health policy, and epidemiology to study how
global response networks form and evolve and how these distributed
communities interpret and make sense of infectious disease outbreaks.
Likewise, the Japan Center for International Exchange (JCIE), throughits programs related to health and human security, plays an active rolein encouraging thoughtful and collaborative analysis of HIV/AIDS
and communicable diseases in Asia, in encouraging nongovernmental
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contributions to global health, and in establishing and expanding networks of dialogue and cooperation in the region. Similar functions areplayed by other think tanks such as the Health and Global Policy Instituteand the Waseda Institute for Global Health.

A         E         C S O      H    -S        N   
While the engagement of CSOs in public health is not new, the proliferation and prosperity of health-promoting CSOs is a relatively recent
development. The end of the Cold War and the advancement of globalization not only highlighted the nontraditional security challenges that
had been suppressed by superpower struggles but also led to efforts toredefine the security agenda to incorporate health as a high politics issue.
Against this background, the unfolding of the HIV/AIDS crisis served asa catalyst for the competitive engagement of nonstate actors worldwide.
The securitization of health efforts gained further momentum at the turnof the century when the UN Security Council unanimously adopted aresolution to address the impact of HIV/AIDS.
That being said, the breadth and depth of engagement by CSOs in
the health field are uneven across issue areas. A majority of the healthpromoting CSOs work on HIV/AIDS prevention and control, few onother infectious diseases or health system capacity building, and evenfewer on chronic noncommunicable diseases. In China, almost all of thehealth-related NGOs work on one issue area: HIV/AIDS. Few of themwork explicitly on tuberculosis, malaria, or migrant population healthissues. CSOs were also absent in China’s fight against the outbreaks ofsuch diseases as SARS and HN. Among the hundreds of CSOs fighting
AIDS, most deal with MSM and PLWHA. It is interesting to note thatwhile advocacy CSOs in China have been critical of the government’s
policy response toward HIV/AIDS, they were silent in the face of thegovernment’s use of biopower during the  HN pandemic for its own
political agenda. In Japan, while the scope of activity of health-promoting
CSOs is extremely broad, the focus of almost all of these organizations iscentered on directly implementing aid projects on the ground in developing countries or within Japan, and less emphasis is placed on advocacy
work. As a result, in terms of CSO engagement there is simultaneously“under-exploitation” (i.e., many important health challenges fail to receive
sufficient attention) and “over-exploitation” (i.e., competitive engagement
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Global Healthand an absence of coordination in HIV/AIDS prevention and control has
led to a “tragedy of the commons”).
The development and engagement of health-related CSOs also varyacross countries in the region. Overall, CSOs play a more prominent rolein promoting health and security in Japan, Thailand, and Indonesia than in
China, Vietnam, and Laos. The open participation and policy engagementof CSOs in Thailand was directly related to the country’s support for the
inclusion of a substantial voice and responsibility for NGOs in the FCTC.
In Japan, there are about  NGOs that are engaged in the field of global
health, and these organizations (e.g., SHARE, Nippon Foundation, JapanFoundation for AIDS Prevention, Sasakawa Memorial Health Foundation,
JCIE, JOICFP, Japan Committee “Vaccine for the World’s Children,” andWorld Vision Japan) address a wide range of global health challenges
including AIDS, leprosy, polio, parasitic disease control, reproductive
health, and children’s health.
Political institutions account for these differences because they affect the political opportunity structures in which CSOs are embedded,
such as access to key institutions, the presence of influential allies, andchanges in political alignments and conflicts. Thailand’s civil society, forexample, emerged from the democratization process of the s, allowing health-promoting NGOs to alter the political opportunity structurein their favor so that their attempts to frame problems, solutions, andjustifications for political action gained acceptance and legitimacy. By
contrast, some  percent of the NGOs in Mainland China lack legal
status. Nonprofit organizations in China are expected to register with
the Ministry of Civil Affairs (under whose jurisdiction NGOs fall), butthey are not allowed to register without a government-backed agency as
their caretaker. Because few government bodies want to be responsible
for sponsoring independent organizations, most NGOs are forced toregister as for-profit organizations instead. Their for-profit status makes
them subject to government scrutiny over taxes and other administrative issues. Furthermore, NGOs in China are excluded from government
funding and prohibited from raising funds from the public. Since mostenterprises consider it safer to donate to GONGOs (government-backed
nonprofit organizations), other NGOs rely heavily on overseas funding.
But access to even this source of funding is now made increasingly difficult with the introduction of a recent regulation that restricts foreign
donations to independent NGOs. The increasingly difficult operating
environment for NGOs in China forced Wan Yanhai, the director of
Aizhixing, to leave the country in May . In May , the Global
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Fund decided to freeze payments of grants to China for three months,
primarily because of the government’s reluctance to involve genuine
domestic NGOs in the fight against HIV/AIDS.
In dealing with a cross-border disease outbreak, networks of likeminded CSOs can develop and disseminate norms for medical andnonmedical interventions (e.g., quarantine or exit screenings) thatfacilitate coordination and cooperation among national governments.
This becomes particularly important given the discordant measures
implemented by some East Asian countries in reaction to the  HN
pandemic. Health-promoting CSOs can also potentially play a rolein the verification and enforcement of compliance with international
security treaties such as the Biological Weapons Convention. Indeed, aChinese military researcher has even called for the use of CSOs to form
independent investigation teams to identify the sources of biological attacks or bioterrorist threats.
Yet thus far most health-related CSOs in the region are confined tohuman security promotion and their contribution to national and international security is indirect and often symbolic. Again, political environment
matters. In Japan, advocacy receives less priority in CSO functions in part
because of the bureaucratic emphasis on consensus building in reachingdecisions, which makes it very time consuming to move things forward.
Tight state control over information and the lack of checks on state power
in authoritarian states discourages dissenting voices from being heard
in public forums while suppressing the space for CSOs in responding
to major health threats. But we should not overlook other variables. For
one thing, the pattern of international aid to CSOs in Asia may have theunintended effect of narrowing the range of CSO activities in promoting
health and security. International donors (such as the Global Fund, the Bill
& Melinda Gates Foundation, and the US government) have tended to fundprojects that focus on individual diseases (“vertical” approach) rather thanhealth system capacity as a whole (“horizontal” approach). The vertical
approach generally encourages CSOs to work only on certain high-profile
diseases, such as HIV/AIDS. These vertical programs are important foraddressing specific communicable diseases, but they make it difficult for
health-related CSOs to coordinate with each other and with internationaland government agencies in pursuing broader, systemwide public healthobjectives. In countries where government financial support for CSOs
is poor or absent, CSOs become overly dependent on international support and have to tailor their agendas to the donors’ funding priorities.
Overdependence on international aid does not bode well for the healthy38

Global Healthgrowth of civil society groups either. In the absence of government support, for example, funding from the Global Fund has contributed to vicious
competition among various NGOs in China, which in conjunction withthe government’s “divide and rule” approach has resulted in infighting anddistrust among the NGOs. Some NGOs with more funding but poor accountability have gained disproportionately more power than others andhave used that power in a way that jeopardizes the growth of Chinese civilsociety. Not surprisingly, China’s NGOs still lack the skills and experience
to engage the Global Fund as effectively as do more seasoned NGOs inother countries. In this sense, international aid has only complicated thedevelopment of China’s civil society and its ability to scale up.
There is a problem inherent in public health securitism that mightalso explain why many CSOs in the region have not made full use of
their potential. Effective CSO engagement in the health sector must be
built on social capital (i.e., trust), not on public fears. Engaging in areasthat are traditionally not considered security issues might contributeto a “securitized” public health atmosphere that pushes state responses
toward military, police, and intelligence organizations with the power tooverride the civil liberties of particular social groups (e.g., PLWHA). Thisin turn may have the unintended result of jeopardizing human security,and even national security, in the region. This “health security dilemma”
can be compounded by the “security cognition gap” between civil society
and the state. In , while many CSOs pushed for a resolution at the
UN declaring the HIV/AIDS epidemic in Myanmar (Burma) a threat
to international security, China vetoed the proposed resolution on the
grounds that the situation in the country did not pose a threat to international peace and security. Indonesia, the only ASEAN member on the
UN Security Council, echoed China’s stance by abstaining, even though it
agreed that the epidemic “inflicted suffering on the people of Myanmar.”
Similarly, while health-promoting CSOs believe their service and advocacy
work help governments do a better job in tackling health challenges andthereby enhance national security, bureaucrats in the traditional security
and foreign policy cluster may think differently. In China, governments at
various levels often are distrustful of the health-promoting CSOs, viewing
them as organizations with political agendas that potentially threaten thesurvival of the communist state. NGO leaders are often harassed by police
and security officials, with the lucky ones (Gao Yaojie, Wan Yanhai) leaving
the country and the unlucky ones (Hu Jia) ending up in jail. Overcoming
this cognition gap is critical if CSOs in this region are to play a more robust
and constructive role in promoting regional security.
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YANZHONG HUANG

C  
Health-promoting CSOs have played an important role in the regional
security of East Asia. They have contributed to human security by operating as direct service providers and reaching and representing groups
vulnerable to diseases and other health problems. As alternative sourcesof information and discipline, and with the ability to mobilize additional
material and human resources, they contribute to national security by enhancing state capacity and effectiveness in responding to health challenges
that threaten socioeconomic and political stability. They also contributeto international security by forming transnational networks to combat
common health threats with regional security implications. Even so, theengagement of CSOs in health is uneven across countries and issue areas,
and they are yet to take a more explicit security-oriented approach inhandling regional health challenges. In short, there is tremendous unrealized potential for CSOs as health is increasingly viewed through the lensof security in the region.

N. David P. Fidler, “A Pathology of Public Health Securitism: Approaching Pandemics as
Security Threats,” in Governing Global Health: Challenge, Response, Innovation, ed.
Andrew F. Cooper et al. (Aldershot: Ashgate, ), .
. Stefan Elbe, Virus Alert: Security, Governmentality, and the AIDS Pandemic (NewYork: Columbia University, ).
. United Nations Development Programme, Human Development Report  (NewYork: Oxford University, ).
. Henry Feldbaum and Kelley Lee, “Public Health and Security,” in Health, Foreign
Policy, and Security: Towards a Conceptual Framework for Research and Policy, ed.
Alan Ingram (London: Nuffield Trust, ), –; Colin McInnes, “Health andForeign Policy,” in Health, Foreign Policy, and Security, –.
. Responsibility to Protect is a new international security and human rights norm inglobal affairs. Set out by the UN General Assembly in paragraphs – of the“ World Summit Outcome” document, it implies that saving human lives
might in some extreme circumstances override sovereignty. For more information,
see www.responsibilitytoprotect.org.
. Feldbaum and Lee, “Public Health and Security”; McInnes, “Health and Foreign Policy.”
. Nicholas Eberstadt, “The Future of AIDS,” Foreign Affairs , no.  (November/
December ).
. David P. Fidler, “The Challenges of Global Health Governance,” Council on Foreign
Relations Working Paper (May ), .

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Global Health. Fidler, “A Pathology of Public Health Securitism,” .
. Ibid., .
. Fidler, “The Challenges of Global Health Governance,” .
. Bill & Melinda Gates Foundation, “Consolidated Financial Statements, December , and ,” , www.gatesfoundation.org/about/Documents/-foundationfinancial-statements.pdf; and the World Health Organization’s financial statements for the period January , , to December , , http://apps.who.int/
gb/ebwha/pdf_files/WHA/A_-en.pdf.
. Fidler, “A Pathology of Public Health Securitism,” .
. Joan Kaufman, “The Role of NGOs in China’s AIDS Crisis,” in State and Society
Responses to Social Welfare Needs in China—Serving the People, ed. Jonathan
Schwartz and Shawn Shieh (Abingdon: Routledge, ), .
. Centre for Non-Traditional Security Studies, “Pandemic and Security Programme
Report on ‘Pandemic Preparedness in Asia’” (report of the Pandemic Preparednessin Asia Conference, Singapore, January –, ), www.rsis.edu.sg/nts/Events/
pandemicpreparedness/pandemic-preparedness-in-asia-report.pdf.
. Tuong Vu, “Epidemics as Politics with Case Studies from Malaysia, Thailand, andVietnam,” Global Health Governance , no.  (Spring ): .
. Paul Farmer et al., “Community-Based Approaches to HIV Treatment in ResourcePoor Settings,” Lancet  (August , ): –.
. “Red Ribbon Forum Redoubles AIDS Fighting Bid,” Chinadaily.com.cn, July , .
. Bangkok Post, July , , as cited by Vu, “Epidemics as Politics.”
. Christoforos Mallouris, Georgina Caswell, and Edwin Bernard, “How Consultations
by People Living with HIV Drive Change and Shape Policies, Programmes andNormative Guidelines,” Global Health Governance , no.  (Fall ).
. Alfred Crosby, America’s Forgotten Pandemic, nd ed. (New York: Cambridge
University, ).
. David P. Fidler, “Architecture amidst Anarchy: Global Health’s Quest for
Governance,” Global Health Governance , no.  (Spring ).
. Nirmala Ravishankar et al., “Financing of Global Health: Tracking Development
Assistance for Health from  to ,” Lancet  (): –.
. Vu, “Epidemics as Politics.”
. “Malaysian Ministry Denies Alleged Late Action against HN Flu,” BBC Monitoring
Asia Pacific, May , .
. Chika Hyodo and Yasushi Katsuma, The Role and Challenges of Japanese NGOsin the Global Health Policymaking Process (Tokyo: Japan Center for International
Exchange, ), .
. “Red Ribbon Forum Redoubles AIDS Fighting Bid.”
. Jia Ping, “Democracy in Bud: / China CBO/NGO Representative Election,”
China Global Fund Watch Initiative Research Report no.  (May ).
. Keith Crane et al., Modernizing China’s Military: Opportunities and Constraints(Santa Monica CA: RAND Corporation, ).
. Bruce Russett, Grasping the Democratic Peace (Princeton: Princeton University
Press, ).
. “South Korean Daily View Private Groups’ Information on North,” BBC Monitoring
Asia Pacific, December , .

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. Kim Sue-young, “South Increasing Aid to N. Korea via NGOs,” Korea Times,
December , .
. AIDS Society of Asia and the Pacific, “Mission,” www.aidssocietyap.org/mission.php.
. Health Action International–Asia Pacific, “About Us,” www.haiap.org/about.
. Margaret E. Keck and Kathryn Sikkink, Activists beyond Borders: Advocacy Networks
in International Politics (Ithaca: Cornell University, ), .
. H. M. Mamudu and S. A. Glantz, “Civil Society and the Negotiation of the
Framework Convention on Tobacco Control,” Global Public Health , no.  ():–.
. Barry Buzan, Ole Wver, and Jaap De Wilde, Security: A New Framework for Analysis(Boulder CO: Lynne Rienner, ).
. Yanzhong Huang, “Pursuing Health as Foreign Policy: The Case of China,” Indiana
Journal of Global Legal Studies , no.  (Winter ): –.
. The concept of “biopower” was coined by Michel Foucault to model how political
governance increasingly exerts its effects through the control of bodies and populations. See Arthur Kleinman, “Four Social Theories for Global Health,” Lancet ,no.  (May –, ): .
. Hyodo and Katsuma, The Role and Challenges of Japanese NGOs, .
. Fidler, “Architecture amidst Anarchy.”. Kelley Lee and Wayne Kao, “Case Study of Asian Contributions to the Negotiationof the Framework Convention on Tobacco Control,” unpublished manuscript.
. Jutta Joachim, “Framing Issues and Seizing Opportunities: The UN, NGOs andWomen’s Rights,” International Studies Quarterly, no.  (): –.
. “Red Ribbon Forum Redoubles AIDS Fighting Bid.”
. Verna Yu, “NGOs Fight Uphill Battle as Beijing Tightens the Screws,” South China
Morning Post, May , .
. Sharon LaFraniere, “AIDS Funds Frozen for China in Grant Dispute,” New York Times,
May , .
. See Yanzhong Huang, “The  HN Virus: Varied Local Responses to a Global
Spread,” YaleGlobal, September , , http://yaleglobal.yale.edu/content/hn-virus-varied-local-responses-global-spread.
. Ba Jianbo, “Zhongguo fangfan shengwu kongbu xijie duice yanjiue” [China’s research on measures against bioterror attack], Zhongguo xingzhen guanli [China
administration], January .
. Hyodo and Katsuma, The Role and Challenges of Japanese NGOs, –.
. “Gates Rethinks His War on Polio,” Wall Street Journal, April , .
. Author’s interview, Beijing, summer .
. See Stefan Elbe, “Should HIV/AIDS Be Securitized? The Ethical Dilemmas of
Linking HIV/AIDS and Security,” International Studies Quarterly , no.  ():–.
. UN Security Council, “Security Council Fails to Adopt Draft Resolution on
Myanmar, Owing to Negative Votes by China, Russian Federation,” http://www.
un.org/News/Press/docs//sc.doc.htm.

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