傳染病與國際關係理論-一個跨領域的論述與反思

Abstract

不論從傳統國際衛生或新興全球衛生研究觀察，在眾多國際公共衛生議題中，最受國際社會關注的往往是傳染病議題。傳染病的系列議題主要包括疾病爆發、監測、通報、新藥研發、新藥上市商品化、藥物取得以及國際衛生援助等。本論文以傳染病議題為研究對象，尤其聚焦於新興與再現傳染病與被忽略熱帶疾病議題。本論文分別從國際關係領域的自由主義、現實主義、制度主義與世界主義這四個重要理論典範來分別探究傳染病控制、傳染病治療以及國際衛生援助這三個重要面向，並試圖為傳染病議題提供一個跨學科領域的理論論述。 就傳染病控制的疾病監測通報而言，本文透過愛滋病的衛生安全化作為個案分析來反思全球衛生安全這個主流概念的真正符號內涵。本文以為，現實主義所詮釋的全球衛生安全乃是指涉全球衛生的國家安全化，尤其反映西方大國的國家安全利益。現實主義與安全研究社群透過衛生安全化將某些新興傳染病賦予全球衛生安全位階成為高度政治議題，比如著名的「三大疾病」(the big three)。本文認為，全球衛生安全其實並不是現實主義所指稱的傳染病被衛生安全化，而是某些少數被西方大國所選定的新興傳染病被衛生安全化。 就傳染病治療的藥物可及性而言，本文以為，透過自由主義雖可詮釋藥物研發的技術創新以提供有療效新藥來治癒病患，但自由主義卻仍無法合理解釋藥物可及性及衛生資源落差所造成的市場失靈。本文採用制度主義論點，分別從全球衛生治理、全球衛生公共產品與全球衛生協力關係這些制度觀點來檢證熱帶疾病的藥物可及性爭議。本文以為，雖然熱帶疾病的全球衛生協力關係如今逐漸成為全球衛生治理的具體實踐模式，但仍須避免全球衛生協力關係所產生的課責性與合法性這些制度缺失。 就國際衛生援助的大國衛生責任而言，本質上就是一場全球正義與權力利益的責任主體論戰。西方大國透過對國際衛生援助的大量資源投入藉此強調對傳染病議題的重視以及爭取全球衛生領導地位的主導權。本文指出，現實主義對於國際衛生援助是以大國為關注對象，所反映的仍是大國自身的安全、政治及經濟利益。本文以為，從歐巴馬全球衛生宣言來觀察，不僅反映對聯合國千禧年發展目標的政治承諾，也凸顯大國責任已逐漸傾向世界主義援助觀點，呈現一種融合自利主義與利他主義的新興國際衛生援助思維。 本論文的研究貢獻與建議如下。首先，本文採用制度主義與世界主義論點提出新興的全球衛生政治論述，藉以批判與反思主流國關社群所詮釋的國際衛生政治。一方面，全球衛生政治反映新興傳染病與熱帶疾病兩者間的嚴重落差，也凸顯兩者在權力及資源分配上的不對稱性；另一方面，全球衛生政治應該被視為國家與非國家角色這些多元的全球衛生行為體在國際衛生制度下的垂直與水平衛生治理行為，而非僅是國家之間所壟斷的水平衛生治理。 其次，本文發現目前傳染病所面臨的困境是：由於政府與市場的雙重失靈，導致傳染病監測通報與藥物可及性出現重大爭議。面對這些爭議，本文認為制度主義與世界主義比較具有論述優勢。制度主義一方面跳脫出自由主義與現實主義面對傳染病論述的極端化與各執己見，並超越單純只以國家或市場觀點來理解傳染病。另一方面，制度主義加入全球市民社會這個第三部門，透過國家、國際藥廠與全球市民社會組織這三個全球衛生行為體的多元化制度互動，建立新興的全球衛生治理系統來處理傳染病議題。 最後，如果僅透過國際衛生制度與全球衛生協力關係來治理傳染病議題，有時仍無法有效解決傳染病反而創造出課責性、透明性與合法性這些制度風險。因此本文採用世界主義來彌補制度主義的論述困境。由於全球衛生研究是對全球衛生不平等的重視，世界主義對傳染病議題強調全球衛生倫理與全球衛生正義的規範性面向。有鑑於此，本文建議可透過世界主義對世界貧困、衛生分配正義與衛生不平等的道德關注，來填補制度主義無法合理詮釋的全球衛生不平等議題。

Assessing from the perspectives of traditional international health or emerging global health studies, infectious diseases have received considerable attention over these decades in international community. Infectious diseases are usually used to refer to a serious process of involving diseases outbreak, surveillance, notification, research and development of drugs, drugs commercialization, access to medicine and international health assistance. The research objects of this dissertation are those diseases regarding Emerging and Re-Emerging Infectious Diseases (EID) and Neglected Tropical Diseases (NTD) in particular. The author adopts four theories relating to liberalism, realism, institutionalism and cosmopolitanism in the fields of IR and IPE to analyze and examine current infectious diseases debates on diseases control, diseases cure and international health assistance. Given that previous studies had failed to consider theoretical discourses of infectious diseases, this study tries to offer a complete and cross-disciplinary theoretical discourse for infectious diseases. In regard to surveillance and notification of diseases control, this study makes an attempt at adopting HIV/AIDS as a case study to analyze the core meaning of global health security which has been constructed by realism and security scholarship. The study argues that global health security should be interpreted as national securitization of diseases so as to make some specific EID become high politics issue, such as famous the big three diseases. More importantly, global health security doesn’t mean that diseases are health securitized, but rather that some EID which great powers had decided are health securitized on the basis of great power’s power and interests. As far as the access to medicine of diseases cure is concerned, this study has argued that although liberalism can interpret the technology innovation on research and development of drugs as to provide curative effect drugs, it still failed to rationalize the debates over market failure of access to medicine on NTD caused by the gap of extremely international health resources in the world. In order to examine the access to medicine debates on NTD, this study is concerned with these perspectives on global health governance, global health public goods and global health partnerships. This study claims that even though global health partnership for NTD is regarded as a concrete business model in practice based on global health governance, it needs to avoid those democratic deficits that institutionalism fails to justify, such as accountability, transparency, and legitimacy. In matters of great power's responsibilities on international health assistance, this study claims that this controversy is essentially contested on basis of global health justice and power allocation. Great powers place emphasis on infectious diseases and global health by means of drawing attention to increasing international health assistance funding. This study argues that mainstream arguments of realism regarding international health assistance still focused on great power’s security, political and economic interests. As far as Obama's global health declaration is concerned, it not only presents political commitments for UN Millennium Development Goals, but also shows emerging foreign aid thinking based on integration between self-interest and altruism. Rested on the above depictions, this study offers some suggestions as follows: First of all, from the perspectives of institutionalism and cosmopolitanism, this study offers a new discourse about global health politics by criticizing the extant arguments of international health politics that has been illuminated by the mainstream of international relation community. On the one hand, the global health politics is suffering from dual deficits, that is, it not only presents a critical gap between EID and NTD, but it demonstrates an unsymmetrical allocation of health power and resources. On the other hand, global health politics should be characterized as both horizontal and vertical health governance between states and non-state actors. Secondly, this study finds that current diseases dilemma is caused by the double failures, that is, government failure and market failure, and these failures have generated some controversies on disease control and cure dimensions. Facing these controversies, the author is convinced that the arguments of institutionalism and cosmopolitanism will be more persuasive than other theories. For institutionalism, on the one hand, it is able to offer health institutional construction arguments beyond dichotomy between state-oriented realism and market-oriented liberalism. On the other hand, institutionalism tries to construct an emerging system of global health governance which is constituted of states, pharmaceutical industry and global civil society organizations so as to interpret and solve disease’s double failures dilemma. On the other hand, because institutionalism takes global civil society into consideration, an institutional network, in which states, pharmaceutical industry and global civil society organizations interact with each other, will be made for solving the disease’s double failures dilemma. Finally, this study finds that if we attempt to govern the disease issues simply relying on the international health institutions such as global health partnerships, it may be in futility on the one hand, and probably generate some institutional risks, such as accountability, transparency, and legitimacy on the other hand. For this reason, this study makes up for institutional deficits by adopting the perspectives of cosmopolitanism. Given that the emerging global health studies have focused on the issues of global health inequalities, the cosmopolitanism, by emphasizing normative dimensions relating to global health ethics and health justice, will play a complementary role in the global health governance system. Consequently, this study suggests that the theoretical loophole of global health inequalities that institutionalism has made might be filled by the arguments of cosmopolitanism, such as world poverty, health distributional justice, and health equality demands.