As vaccines are complex technologies that interact with the human body, their development is overseen by regulators in the administrative state. Countries structure the review of pharmaceutical products according to domestic rules and institutional design. As such, vaccines are reviewed as biologic products by regulatory authorities at the domestic level, such as the Therapeutic Goods Administration in Australia or the Pharmaceutical and Medical Devices Agency in Japan. The national basis of vaccine regulation inevitably leads to country-specific processes and timelines and may in some cases lead to different decisions.

Given the strong public health, societal, and economic benefits associated with the availability and widespread use of vaccines, an ideal scenario would dictate that vaccines needed to prevent and mitigate public health crises be treated as R&D priorities. Both domestic and international innovation policies would prioritize their development, and there would be mechanisms in place to ensure an equitable distribution of these vaccines. In practice, that is not the case.

Efforts to govern health globally have broadened considerably since the 1850s in terms of the subjects, goals, participants, and instruments of governance efforts. Originating in a thin, limited set of rules formally agreed by states, the contemporary global health system has evolved into a complex, dense, yet fragmented network involving governance processes both within and outside the health sector, engaging hundreds of state and non-state actors across all countries. Broader global trends shaped health governance, but key features of the current system also owe much to the particularities of specific events: the HIV/AIDS pandemic, West African Ebola crisis, and most recently Covid-19. Can contemporary networked governance processes can add up to a coherent, functional system for protecting global public health, or is more hierarchy needed? The World Health Organization is a central convenor, legitimator, adviser, and political arena in a fragmented system, but has not yet been empowered to assume the role of a directive coordinator. The extent to which major powers will construct a more hierarchical system is an open question in a world that is not yet post-Westphalian nor truly multipolar.

Chapter 1 starts by describing how, shortly after HIV was identified as the cause of AIDS, it became increasingly clear that the virus originated in Africa. Tests of archival blood samples, retrospective confirmation of early cases of AIDS and comparison of the genetic diversity of HIV in different parts of the world all pointed to central Africa, and especially the two Congos, as the probable location for the beginning of HIV’s journey. Studies of HIV subtypes provide the foundation for reconstructing the complex routes followed by the virus across the world. The example of Cuba illustrates how geopolitical events influenced the spread of HIV. The first epidemic of Ebola fever in a bush hospital in the Congo, as well as recent epidemics in the same country and in West Africa, are used to explain the peculiar characteristics of HIV that enabled it to cause a pandemic.

Africa has seen progress and setbacks with regard to the economic and socio-economic development after decolonization until ca. 2000. These are linked to historical and structural challenges, including the economic infrastructure the colonial powers left behind and the unfavourable geography of vast parts of the continent. In the post-colonial phase there has been much economic and trade dependence on the former colonial powers – giving rise to the dependency theory and the notion of neo-colonialism. There was often an unwillingness of the post-colonial leadership to set the course for the economies of their countries. And rentier states developed. Several initiatives – from Africa and beyond – have been proposed to deal with the economic misery, with those of the World Bank and the International Monetary Fund being the dominant ones, pushing African initiatives aside.

The Epilogue does not summarize the already condensed version of African history and politics but offers some wider questions for reflection and asks the readers to engage with African affairs.

This concluding chapter maintains that Liberia’s battle to eradicate Ebola from 2014 to 2016 represented an interface wherein state-, nation-, and peace-building objectives converged. Whereas counterparts across Africa had waged nationalist struggles decades before against European colonialism, Liberian domestic and diasporic actors for the first time collaborated to fight a common enemy, Ebola, outside of themselves. As a direct response to deeply embedded inequalities in primary care, non-government Liberian actors at home and abroad embodied active citizenship by engaging in public health measures that reshaped how we envisage public authority in conflict-affected states. Their relatively successful struggles against an existential threat illuminated how the political economy of belonging to Liberia could be made manifest. This chapter demonstrates further that the 2020 referendum proposition based on Liberia’s Dual Citizen and Nationality Act of 2019 would be moot without reconciling disputes over the meaning and practice of Liberian citizenship amongst actors of divergent social locations and life-worlds. It contends that a Liberian citizenship triad—which frames citizenship as identity (passive), practice (active), and a set of relations (interactive)—could be used as a model for theorising citizenship generally since it moves citizenship from the abstract and Eurocentric to the concrete and Afrocentric.

This chapter traces the imperial history of racial and environmental medical research, the economic drivers behind public health initiatives, and the legacies of colonialism in medical research and public health interventions in Africa. Examining this history of African encounters with development interventions around health provides much-needed context for breaking down misconceptions about African resistance to or ignorance of Western biomedical aid. The development episteme has perpetuated the idea that Africa is a place of disease and that Africans are resistant to treatments and cures. The nineteenth-century ad hoc campaigns to protect Europeans and segregate the sick from the healthy grew into state-sponsored public health programs during the interwar period. By World War II colonial development discourses on African health had shifted from the “white man’s grave” to biopower as states harnessed healthy bodies for productive purposes. Medical studies on declining populations, outbreaks of sleeping sickness or tuberculosis, STIs, and maternity and childcare sought healthcare solutions that would increase the productivity of labor. New hospitals, maternity centers, child welfare centers, and dispensaries brought some people relief and others terror. Scientists and officials used public health interventions and biomedical research to bolster the norms of the development episteme.

Chapter 6 discusses biosecurity in the transfer of human pathogens. In the aftermath of the 2014–2016 West Africa Ebola outbreak, there were thousands of Ebola samples that went unaccounted for as well as virus samples stored in facilities that did not have an appropriate level of biosecurity and biosafety. The chapter reviews the existing global governance mechanisms for addressing this biosafety and biosecurity concern, and the ongoing debate amongst donor countries as to the best path forward. The chapter describes efforts to support the Government of Sierra Leone to find and secure Ebola samples as foreign labs shut down, identifying the challenges of tracking all Ebola samples and their associated data, and efforts to place those samples in suitable inventoried repositories by local health authorities. The chapter concludes with recommendations for governments around the world to ensure that plans, procedures and regulations are in place prior to the chaos of an emergency in order to ensure that dangerous pathogens are handled in safe and secure manners, that data are preserved for research, and appropriate practices are implemented.