Scoping review of international relations theories in health security: A cue for health diplomacy

Background Health security as a domain has gained tremendous importance in the recent past. Emerging and re-emerging diseases globally, coupled with the derailment of the determinants of health mainly the socio-political environment, has made health security a cross-cutting entity in diverse fields including International Relations (IR). With the ongoing global polycrisis, the health-related issues which were previously sidelined as a concept of less strategic importance in the IR field, are now contributing to the shift of the world order. This has instilled an increased participation of IR scholars in the discussions and debates on health security concerns. The field of IR contains numerous theoretical lenses through which scholars analyze such situations, policies, and systems of the world. Methods In this paper, we use a scoping review method to inspect how IR theories have been applied in analyzing health security concerns. Results We observed that various diverging IR theories have been used to deliberate on states’ actions in tackling the recent pandemic and have also been prescriptive about the changing notions of multilateralism and international governing organizations. Realism, liberalism, and securitization were among the most frequently applied IR theories in the context of health security discussions. Conclusions This work provides an impetus to enhance the interaction among interdisciplinary teams leading to evolving solutions that can address issues of global importance in the contemporary world.


Introduction
2][3] With health security becoming the forefront of the discussion in national security and foreign policy concerns, governments worldwide had to balance their act of protecting their people while having a global outlook.This situation was further aggravated by tensions between the USA and China on the origin of the COVID-19 virus, China's contention over Taiwan's accession to the World Health Organization (WHO), and the Russia-Ukraine conflict.There is also a resounding agreement among the countries on the reformation of multilateral systems due to the challenges it brought in mitigating the health and geopolitical crises. 4These situations have ignited discussions and debates among International Relations (IR) scholars who have tried to analyze the world's situations, policies, and systems. 5 scholars generally use the theoretical knowledge base of the field to understand and elaborate on how countries respond to changes and challenges at the global level and navigate inter-state dynamics.Theories are instruments designed to help understand a particular phenomenon that function as a guide for research to explain a specific event or predict the occurrence of something. 6These theories are also utilized by political leaders and policymakers in articulating solutions at the national and international levels which later translate into policies framed to obtain national objectives, which vary in their strategic importance.While states have been the primary focus of IR, the role played by other actors, such as international organizations, civil society groups, and even individuals, has gained prominence in the discourse.However, in the pursuit of peace and security, IR as a field has broadened its horizon by interacting with dynamic fields like global health to analyze how the context of conflicts, development inequity, socio-economic conditions, environmental volatility, and global governance affect health security. 7O defines global public health security "as the activities required, both proactive and reactive, to minimize the danger and impact of acute public health events that endanger people's health across geographical regions and international boundaries."The pandemic magnified national conflicts and challenges impacting the lives of billions globally.In many countries, the crisis turned into a political test. 8The polycrisis nature of the pandemic has created tensions in international relations and health security. 9Historically, health issues largely remained outside the purview of most traditional IR scholarly works as it was treated with lesser strategic significance.However, the importance of discussing health security in the IR field was recognized during the post-Cold War period with the emergence of new security threats, particularly the prospects of pandemics related to emerging/re-remerging diseases and the increased perils of bioterrorism.This led to the issue of health security being dealt with under the ambit of foreign, national, and security policies.Ever since, the aspects of health security have been studied in IR concerning governance, inter-governmental institutions, globalization, diplomacy, and others.
While health-related debates have gradually made their way into IR scholarly works, there is a need for deeper engagement among IR scholars on health.The changing context of the health and foreign policy interface has emphasized health security as a valid concern for IR and could find a place within the traditional boundaries of IR theories.Thus, this scoping review intends to understand how IR scholars have debated and discussed health concerns through a theoretical lens to gauge its potential impact on the international world order.

Methods
A scoping review approach enables us to understand emerging evidence and is regarded as a first step to research evidence development. 10We have followed the framework espoused by Arskey and O'Malley (2005) to inform the methods of this review. 11The PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) checklist was followed to report the review. 11,12ep 1: Identifying the research question The research question was identified by SP in consultation with the subject matter expert (HB) and further refined with the consensus of the research team.Since this is an emerging domain, we inquired about the following research question: "How have International Relations scholars discussed and debated on health security concerns"?Since our objective is to understand the discussions on how these IR scholars have discussed health issues and that the discussion would be informed by a theoretical underpinning in the health security domain, we have adapted the health policy triangle framework instead of other frameworks. 13,14ep 2: Identifying relevant studies Keyword searches were conducted in the English language in PubMed (NCBI), Web of Science (Elsevier), Scopus (Elsevier), and Embase (Elsevier) databases on November 5 th , 2023, to cover a range of literature using the following search terms: "international relations theories" AND "health security".The search strategy used for the study is provided in Appendix 1 of the Extended data. 15We further performed a search on Google Scholar with the aforementioned terms and screened the first five pages (with 10 entries in a page) for possible inclusion.The more detailed search strategy is in an online supplementary document.The search terms were based on the focus of the various IR theories and commonly used terms related to health security.Searches were limited to peer-reviewed journal articles they were not limited to any period.All the records were exported to Rayyan.Ai, a reference management software, and deduplication was carried out. 16ep 3: Study Selection The study selection was carried out at two stages, namely Title-abstract (Ti-Ab) and full-text stages.Ti-Ab screening was conducted by SP, KB, NG, and AI independently while screening at the full-text stage was conducted by SP, AI, and KB based on the following selection criteria: The inclusion criteria comprised of two aspects: (1) the articles needed to reference international relations theories explicitly, and (2) they should extensively apply these theories to offer valuable insights into understanding positions, negotiations, and outcomes in health security.In disagreements, a resolution was sought through discussion and consensus involving a third review author (VD).
Steps 4 and 5: Charting the data and collating, summarising, and reporting the results Three review authors independently extracted information from the articles, utilizing a pre-piloted electronic data extraction form.When discrepancies arose, the two review authors engaged in discussions to reach a consensus.The third author participated in further deliberations if a resolution could not be reached.The records at each review stage are presented in the PRISMA flow diagram.The data synthesis process incorporated principles derived from Walt and Gilson's Health Policy Triangle framework model. 14The framework was employed because it offers a perspective that allows for the analysis of the interactions between actors, context, content, and processes.This framework facilitates an insightful approach to understanding the application and influence of different International Relations (IR) theories in the realm of health security.In this structure, the columns were categorized into distinct components such as "condition" "context" and "content".The gathered data is then synthesized for a theme, along with a comprehensive analysis of the supporting evidence within each theme.

Results
A total of 12,889 records were retrieved from a database search Web of Science (Clarivate) -2802, PubMed (NBCI) -1362, Scopus (Elsevier) -6275, and Embase (Elsevier)-2560.We removed 5227 duplicates from the list of articles.After the screening, 10 studies that met the eligibility criteria were included in the synthesis.We screened 50 records from Google Scholar (from the first five pages) and included 14 records for the synthesis.The PRISMA flow chart which is available as part of extended data, depicts the detailed study selection. 15Characteristics of the included studies and the arguments made by the authors are presented in Appendix 2 and Appendix 3 of the extended data. 15e data synthesis table involved extracting the IR theories discussed during the discussion of health security, health conditions presented in the paper, the context discussed, and the contents of the application of the theory.The detailed data synthesis table is provided in Table 1.The selected studies showed that a few papers used multiple theories in a single study and often presented arguments from various points of view to make a case.The theory of realism, securitization, and liberalism were the most frequently applied theories discussing health security.
The increased relevance of discussions on international relations and health security during the recent COVID-19 pandemic was reflected in our scoping review with a majority of articles focusing on it.These papers primarily deliberated on how states across the world handled the pandemic and how we can anticipate a shift in the existing world order using the existing IR theories.However, one theory that stood out with its application in various global health challenges is the theory of securitization.This theory has been not only applied during COVID-19 but also in HIV, Pandemic influenza, SARS, H5N1, H1N1, infant deaths, diarrheal diseases, tobacco, 'lifestyle diseases', and 'mental health'.The prominent global health concern of non-communicable diseases (NCDs) was discussed in a paper that discussed the role of Postmodernist IR theory in health security.The IR discussions have also taken place on determinants of health such as food, housing, and education through the lens of constructivism.Additionally, social justice and health inequalities concerns have been dealt with by IR scholars.Thus, IR theories have tried to emphasize the relevance of health security's geopolitical and geoeconomic determinants.
The data on the context and content built by a particular IR theory is imperative to understanding the divergence and similarities in viewing health security.The papers that highlight the realist theory emphasize that the liberal world order that promotes global cooperation has failed during the COVID-19 crisis.They view that nations' self-centered and -Difficulty of de-securitizing Securitization highlights the need to prioritize and address unconventional threats.
The statist approach (securitization) demands health initiatives to be associated with foreign or defense policy concerns.
The responses of securitization of health shift the efforts considered being altruistic to one of self-interest.
The ahistoricism of securitization theory and its assumptions of social and international security are analytically divisible and have to be challenged.The constructivist approach stresses the importance of belief structures, identities, and roles.
A consensus on reality is necessary among actors in international politics to provide appropriate responses.

Critical Security Theory 13
Global Health -To investigate the intertwining nature of national health policies and provisions with international considerations.Well-being and individual rights are paramount for the globalist approach (critical security theory) that seeks the advancement of health policies.Health and Social Justice -To theorize (and practice) antihegemonic alternatives to mainstream international relations An egalitarian exchange in international relations fuelled by the collective action of the oppressed is envisioned by modern socialists.Post-Modernist 34

Neo-Marxist
Communicable and NCD -The etiological multifactorial character of the elements involved in disease pathogens -New protagonists are manifesting at the international level, The interest in state problems gets diminished Health protection may be thematically integrated within the concept of security.
The extreme postmodernist vision is when states are pushed towards the removal of economic barriers to trade in the context of the globalization of health where interests of communities, international organizations, corporations, and others become the drivers.

Theory of Hegemonic
Rise and Fall 18 COVID-19 -Use of the proposed conceptual model to predict the future international order The cycle of rise and fall of great powers occurs due to the law of uneven growth causes and the strength of international political currency of economy and military.

Theory of Relational Justice 17
Health Diplomacy -Positioning global health better within foreign policy The theory of relational justice states that there are no simply 'positive duties' to assist, but moral obligations to prevent harm.
self-interest-promoting actions in mitigating the pandemic's risks and the rise of vaccine nationalism were the primary reasons for the lack of practical global cooperation and leadership.They foresee a shift in the US-led liberal world order that has been prevalent after the end of the Cold War.
In contrast to the realists, there is a greater emphasis on the liberal approach as being more relevant to the challenges of COVID-19.Liberals recognized the current world order's limitations and highlighted the need for new geopolitical and geoeconomic players such as the middle-power countries in the East Asian region to enhance cooperation and fill the global leadership void.Despite the national interests becoming prominent in mitigating the pandemic, there has been an unprecedented rise in effective scientific collaborations for addressing the global health challenge.Thus, the liberals emphasize that strengthening cooperation and defying nationalistic measures is vital to tackling future global health crises.
'Securitization theory' has been the most recurring theory of IR that has contributed to the discussions of health security with its application across various global health concerns.The studies using this theory have stressed the importance of the securitization of health, which places 'health' as a foreign and defense policy domain and prioritizes its deliberation and action towards mitigating global health concerns.By making health a foreign policy priority, it challenges the liberal world order with an augmented tendency of states acting in self-interests above a global vision (statist approach).However, it is important to examine whether the securitization of health indeed translates to 'health security'.The analytical demarcation of social and international security of the securitization theory must be addressed as the prolonged securitizing of health threats' has become a concern for efficient resource re-allocation.
The studies that used constructivism theory have used it to understand the reasons for the lack of effective cooperation despite common interests among nations.It emphasizes that an interlinkage between global and national policies is imperative to address health crises.It diverges from the realist and liberal views of the objectivity of states' actions and highlights its subjective and complex nature.According to the theory, the consensus of the reality in which states function affects the state's responses to a common concern and interest.
The critical security theory has been utilized to highlight the need for a globalist approach in which health policies focus on well-being and individual rights.The application of critical and decolonization theory was made to understand the inequitable nature of the world in terms of economic and political power and its effects on the management of the pandemic.With the rise of scrutiny on international organizations and the shift in the world order, liberal institutionalists who examine their determinants have emphasized the importance of domestic regimes and international norms for collective action against global health challenges.Modern Socialist and Marxist Theories were highlighted in a study that endorsed South-South cooperation in health through the lens of social justice.The Neo-Marxist theory, predominantly used to explain health inequity, was also used to explain the divergence in understanding social class.
Health security has also been looked at through the normative theory, which is prescriptive on the existence of effective international agreements and cooperation.However, the study that discusses it also highlighted its limitation of inability to explain the crumbling nature of international cooperation that deterred a comprehensive mechanism to address health challenges.While liberals argued for new developing state actors to cooperate for collective action, the post-modernists argued that such cooperation must also involve the voice of all stakeholders.The discussion of new actors becomes prevalent when the discussions by the theory of hegemonic rise and fall highlight the cyclical nature of great powers and the lack of global leadership in mitigating health risks.This brings importance to why health has to become a foreign policy priority in all countries as deliberated by the theory of relational justice which emphasizes that states should not only assist in treating a health concern that affects them but also in preventing any future harm to other countries.

Discussions
The global health challenge of the COVID-19 pandemic has invariably threatened the primary functions of foreign policy, such as international security, economic stability, human dignity, and social justice.The lapse of the existing global health systems, governing structures, and geopolitical tensions across the world, have made it relevant for international relations scholars to discuss health security and the future direction of the global world order.In this scoping review, we witnessed increased instances of applying IR theories in health security discussions to explain the complex nature of the shifting world order.Various diverging theories have been used to deliberate on states' actions in tackling the recent pandemic and have also been prescriptive about the changing notions of multilateralism and international governing organizations.Additionally, the IR theories have also discussed other health concerns such as communicable and non-communicable diseases, and the determinants of health such as food, housing, education, social justice, and inequalities.Thus, it has become more imperative than ever before to understand how health is evolving into a critical concern in IR.
The contentious issues with the geopolitical dimension are mainly linked to equity and human rights, the sharing of knowledge, technology, and innovation, and the financing of global public goods for health. 8The lack of global solidarity is the major barrier to achieving equity in access to vaccines, therapeutics, and diagnostics.According to WHO Director-General, Dr Tedros Adhanom Ghebreyesus, from the human rights lens, "[t] he enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition".The central principle of the 2030 Agenda for Sustainable Development is to ensure that no one is left behind.For instance, inequity and lack of international cooperation to access COVID-19 tools threatened global public health security.
The involvement of IR theories in discussions on health has evolved post-Cold War caused by the shift in the lens through which policymakers view health.Security discussions during the Cold War period focused predominantly on militarybased national security concerns.According to the WHO Regional Committee for the Eastern Mediterranean, the security dimensions in the 21 st century are characterized by increasing complexity, the fourth industrial revolution, economic polarization, global interdependence in the supply chain, international conflicts, and a wide range of threats, including emerging and re-emerging diseases.The growing insecurity is not adequately addressed by the traditional mechanisms used to pursue national security.In the current scenario, people's security depends on factors beyond a particular state's control and demands a global approach to tackle fundamental issues and mutual vulnerability.The complexity of the global problems and the need for collective action have made it relevant for a multidisciplinary approach to tackle global concerns.
The increased securitization of global public goods and services, such as health, has provided the impetus for IR scholars to contribute to its discussions.The gradual shift of health from being of 'low politics' (humanitarian endeavor) to 'high politics' (national and international security concerns) and its increased discussions in foreign policy matters have provided a perfect segway for applying IR theories in such conditions. 35The results of this study show that the IR theories deliberating on health concerns have disease-specific and system-oriented elements.The theories have been applied to understand the state's action or inaction during a health crisis and relate it to the geopolitical environment in which they function.Interestingly, despite their differences in their approach to tackling a crisis, most theoretical applications concur that the world can expect a shift in the world order after the COVID-19 pandemic.Thus, by looking at geopolitical and geoeconomic determinants of health, the theories have emphasized the need for health to be considered a foreign policy issue.
This scoping review intended to understand how IR theories were applied in health security, why it is relevant in the current geopolitical and health context, and what difference they can make.The results have extensively shown the overlaps and the variance in the theoretical approach to health security.While the wake-up call for IR scholars to deliberate on health security issues became prominent with the COVID-19 pandemic, health as a non-traditional security issue evolved in the post-Cold War era to be included and prioritized in foreign policy.The momentum that health security has gained in the IR space must be further pushed forward by IR scholars using the existing theories in post facto analysis and predicting and prescribing states' actions.Thus, by combining the two disciplines of IR and health, the world can be prepared to tackle a future global health crisis that implies geopolitics.We included studies published only in the English language and we acknowledge this as a limitation.Future studies can include literature from other languages.

Conclusions
This scoping review brings into perspective the need for adopting an interdisciplinary as well as a multidisciplinary approach in bridging the gap between health and international relations.The COVID-19 pandemic brought to the surface that health crisis is not just a single state's problem and demands a global approach to finding solutions to such crisis.Pandemics thereby are a 'global health issue' and very much linked to states 'security' and 'survivability'.This makes it imperative to view and discuss 'health' in the larger confines of IR.Given this, the paper attempts to further expand the security discourse of IR by focusing on 'health' as a core issue of security.Here, the intention lies in creating the scope for further research to bridge the existing gap between 'health' and 'IR'.

Data availability
Underlying data All data underlying the results are available as part of the article and no additional source data are required.

Extended data
Open Science Framework: Scoping Review of International Relations Theories in Health Security: A Cue for Health Diplomacy.https://doi.org/10.17605/OSF.IO/NY9WZ. 15his project contains the following underlying data: Reviewer Expertise: Public health policy I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.
A few minor points will enhance the manuscript: 1.The authors need to clarify if gray literature was examined.
2. The authors could add a few lines on the increasing geo-political influence of India and its' potential role of leadership of the Global South as it relates to international relations and health security.
3. The authors could also discuss the role of South-South collaboration in the new international world order.
4. The authors have touched on 'Modern Socialist and Marxist Theories' and how this could be reconciled with universal human rights, a topic of great interest in liberal democracies.
5. The authors briefly mention "The application of critical and decolonization theory" -they could perhaps expand on how decolonization of global health intersects with security concerns?
Overall, this scoping review brings a new perspective in bridging the gap between health security and international relations.It is clearly important to understand international relations, security, global health, and diplomacy via a theoretical lens.
Are the rationale for, and objectives of, the Systematic Review clearly stated?Yes

Are sufficient details of the methods and analysis provided to allow replication by others? Yes
Is the statistical analysis and its interpretation appropriate?

Are the conclusions drawn adequately supported by the results presented in the review? Yes
If this is a Living Systematic Review, is the 'living' method appropriate and is the search schedule clearly defined and justified?('Living Systematic Review' or a variation of this term should be included in the title.)Yes Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Transplant surgery, Global Surgery, Global Health Diplomacy and development.
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.
The benefits of publishing with F1000Research: Your article is published within days, with no editorial bias • You can publish traditional articles, null/negative results, case reports, data notes and more • The peer review process is transparent and collaborative • Your article is indexed in PubMed after passing peer review • Dedicated customer support at every stage • For pre-submission enquiries, contact research@f1000.com Theory 33 Health inequalities -Examining the key concepts and ideas within Neo-Marxist class analysis -Utilized to analyze and explain health disparities.Neo-Marxist studies reveal a genuine lack of correspondence between theoretical definitions and social class measures.Normative Theory 5 COVID-19 -Grasping global and national policy responses to the crisis -To understand the problem of why states fail to cooperate in the pursuit of common interests The normative theory centers on a moral judgment about what should be.The post facto character of the theory is not able to explain to analysts the patterns and functionality of international cooperation.

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Appendices.pdf (Appendix 1 -Literature Search, Appendix 2 -Reason for excluding studies, Appendix 3 -Data Extraction Table) Garry AslanyanDalla Lana School Of Public Health, University of Toronto, Toronto, Ontario, Canada As a scoping review, this article provides useful overview of theories used in IR and it is applied in analyzing health security.The paper can be further strengthened by clearly outlining which stakeholders in IR (academia, think tanks, governments, lobby groups, NGOs) need to do what differently to adjust to the realities of 21st century and the need for a multidisciplinary approaches in these theories going forward.

Are the rationale for, and objectives of, the Systematic Review clearly stated? Yes Are sufficient details of the methods and analysis provided to allow replication by others? Partly Is the statistical analysis and its interpretation appropriate? Not applicable Are the conclusions drawn adequately supported by the results presented in the review? Partly If this is a Living Systematic Review, is the 'living' method appropriate and is the search schedule clearly defined and justified? ('Living Systematic Review' or a variation of this term should be included in the title.)
Reviewer Expertise: health policy and systems, global health diplomacy I confirm that I

have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.
This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
https://doi.org/10.5256/f1000research.159537.r263573©2024Nordström A.-The article is focused with a clear question as well as results.I have only three comments 1.The fact that health security has been interpreted in different ways in IR -what does that mean?Any implications?Recommendations for the future?2.The article indicates that health treated as a security issue is (or was?) now higher up on the political agenda.It would be useful with some comments on the fact that that interest has now disappeared i.e. lack of sustainable political interest 3. Are the risks and limitations applying an IR perspective and analysis of health?Are the rationale for,

and objectives of, the Systematic Review clearly stated? Yes Are sufficient details of the methods and analysis provided to allow replication by others? Yes Is the statistical analysis and its interpretation appropriate? Yes Are the conclusions drawn adequately supported by the results presented in the review? Yes If this is a Living Systematic Review, is the 'living' method appropriate and is the search schedule clearly defined and justified? ('Living Systematic Review' or a variation of this term should be included in the title.) No Competing Interests:
No competing interests were disclosed.