Brigitte van der Zanden

Introduction, Chapter 1. The central question of this thesis is how public health in border regions is organised and made workable as a field of policy and practice. Depending on the readability of the text, I use both the term ‘public health in border regions’ and ‘cross-border public health’ for this. In both cases, I refer to cooperation in the field of public health between neighbouring regions in different countries. This adjacent border-regional setting forms the central starting point of this thesis. In doing so, I do not proceed from the assumption that this already constitutes a self-evident and coherent domain. Rather, the central question is how this domain takes shape in border regions where the everyday lives of citizens and professionals unfold across national borders, while national and subnational authorities continue to organise responsibilities, competences and information provision. To analyse this question, I combine insights from border studies and infrastructure studies. In doing so, I examine both the significance of borders for governance and cooperation, and the registrations, standards and routines through which public health is organised in practice. Drawing on border studies, I approach borders not only as formal state borders, but also as institutional and administrative arrangements that help determine what is possible in the practice of public health. At the same time, drawing on infrastructure studies, I focus on the categories, registrations, standards, information flows and coordination routines that link policy and practice. It is precisely through these connections that it becomes clear how public health in border regions is organised in practice and made workable. In Chapter 2, we examine how EU policy defined public health in border regions and under what conditions it developed into a European policy task. Our analysis showed that border regions featured prominently within EU public health policy primarily in relation to serious cross-border threats, particularly biological, chemical and environmental risks. In that context, the emphasis was on surveillance, early warning, preparedness and response. Broader European public health policy recognised prevention and health promotion as important, but did not develop them as a specific cross-border public health task for border regions. It thus became clear that, at EU level, public health in border regions gained policy traction primarily when problems aligned with existing infrastructures for early warning, knowledge production and coordination, and when EU institutions could administratively justify action. In Chapter 3, we use a scoping review to examine how the scientific literature described cross-border infectious disease control in European border regions. In doing so, we identified which infectious diseases and border regions were most frequently studied, which problems in cross-border cooperation were described, and which cross-border recommendations for improvement the literature provided. Based on a systematic inventory and thematic analysis of the available literature, showed that this field of research was relatively narrow in scope and geographically concentrated on a limited number of border regions and infectious diseases. The included studies primarily highlighted structural bottlenecks, particularly in the areas of surveillance, monitoring, data exchange, governance, and legal and procedural coordination. The included studies mainly made recommendations to structurally strengthen cross-border cooperation, particularly through closer institutional cooperation, better coordinated surveillance, and improved data exchange. It thus became clear that the scientific literature primarily approached cross-border infectious disease control as an issue of structural alignment and system coordination, while preventive alignment outside outbreak situations remained less developed. In Chapter 4, we examine how public health professionals in the border region between the Netherlands, Germany and Belgium experienced and maintained cross-border cooperation. Based on nineteen interviews with professionals, we analysed the challenges they identified in this cooperation and the work required to keep cooperation, coordination and information exchange going across the border. The interviews showed that public health professionals widely valued cross-border cooperation, but that it was also vulnerable due to differences in national rules, procedures and accountability expectations, and because cooperation often remained dependent on temporary projects and personal commitment. To keep cooperation workable nonetheless, professionals indicated that they were constantly engaged in coordination, organisation, maintaining personal contacts, and making cross-border activities within their own organisations understandable and defensible. In Chapter 5, we analyse the COVID-19 pandemic as a situation in which state borders were once again deployed as a tool for pandemic control. We investigated whether cross-border transmission of SARS-CoV-2 played a significant and substantial role in the COVID-19 burden within four Euroregions along the Dutch-German-Belgian border. Based on a GIS analysis and a space-time cluster analysis of over four million recorded COVID-19 cases between March 2020 and October 2022, it emerged that incidence largely followed national patterns during the period under investigation. Cross-border clustering did occur, but mainly during periods of very high transmission and not as an early or defining pattern in the course of the pandemic. These findings provided no epidemiological justification for extensive border closures as a central measure of pandemic control. Such measures were, however, justified on the basis of nationally bounded surveillance systems, while the consequences were felt most acutely in the everyday cross-border lives of residents in these regions. In Chapter 6, we examine how municipalities in the Meuse-Rhine Euroregion assess the relevance and feasibility of cross-border policy exchange for age-friendly initiatives, and which barriers and facilitating factors play a role in this. Based on semi-structured group interviews with participants from 33 municipalities, we analysed how municipalities within the Senior Friendly Communities project dealt with policy examples and initiatives from across the border. The analysis showed that cross-border policy exchange was rarely an end in itself for municipalities, but was primarily approached as a selective source for the development of local policy. Whether municipalities deemed examples from across the border useful depended on the extent to which they could align them with their own responsibilities, priorities and working methods within fragmented institutional contexts. It also emerged that more sustainable forms of cross-border policy exchange depend not only on local willingness, but also on administrative and organisational conditions that support coordination, translation and continuity. It thus became clear that cross-border public health policy at the local level does not arise automatically from proximity, but takes shape through selection, adaptation and integration within existing policy and administrative frameworks. In Chapter 7, we examine how individual and environmental factors are associated with substance use among adolescents in border regions of the Netherlands, Belgium and Germany. Based on a large-scale survey of school pupils in these border regions, we analysed differences in binge drinking, smoking and vaping, and cannabis use, as well as their associations with psychosocial characteristics and factors in adolescents’ immediate social and physical environment. The analysis showed that various factors played a role, but that peer influence, frequent late-night outings, parental supervision and participation in structured leisure activities were the factors that emerged most consistently across the three national contexts. This chapter thus makes it clear that observed patterns of substance use between countries cannot be understood solely in terms of differences in national policy, but should also be considered in relation to the social environment in which adolescents in these border region grow up. In Chapter 8, we examine how citizen participation in border regions is organised in a situation where there is no shared level of government and no stable cross-border administrative infrastructure is available. Based on a document analysis of four cross-border participation initiatives, we analysed how agendas, participation formats, representativeness and follow-up were organised in the border region of the Netherlands, Belgium and Germany. The analysis showed that coordination between organisations from different countries, requirements relating to funding and accountability, and practical choices concerning standardisation, recruitment and multilingualism strongly shaped these participation processes. As a result, cross-border participation became organisable, but the scope for locally responsive deliberation and the possibilities for broad and balanced representation were also limited. It also emerged that the outcomes were primarily collated, reported and disseminated within cross-border networks, and much less frequently led to joint policy follow-up. Thus, this chapter demonstrates that citizen participation in border regions depends on institutional coordination that enables joint action. At the same time, the lack of a shared agenda, a body capable of receiving and following up on the outcomes, and a common policy framework limits its scope and impact. Thus, this chapter emphasises that public health in border regions does not constitute a self-evident cross-border domain, but must be made organisationally and institutionally workable on a case-by-case basis. Discussion. In this thesis, I have shown that public health in border regions cannot be understood as a self-evident sum of national systems, nor as an already fully developed cross-border policy domain. Public health in border regions takes shape in the way problems are defined, responsibilities are allocated, data are produced and used, and cooperation is maintained in practice. A first lesson is that cross-border cooperation reveals that public health relies on national classifications, registrations, standards and routines that usually remain in the background within a single country and are therefore hardly noticeable. It is only through cooperation with a neighbouring country, where problems, data and responsibilities are organised differently, that it becomes clear that these infrastructures are not neutral, but help determine what counts as a relevant problem, who becomes visible and how policy is made practically feasible. A second lesson is that, for the time being, cross-border public health mainly gains administrative traction when it fits within existing national frameworks of problem definition, mandate, evidence and accountability. Precisely because a stronger cross-border infrastructure with its own mandates and lines of accountability is largely absent, national policy frameworks remain the guiding principle in determining what is administratively manageable, defensible and sustainably organisable. As a result, cross-border cooperation often only progresses when it fits within existing responsibilities and routines. A third lesson is that cross-border cooperation is not a stable given, but remains vulnerable and can only remain functional if continuity, follow-up and coordination are actively maintained across nationally anchored systems. Precisely because cooperation here does not take place within a single shared administrative and organisational framework, but between systems with different responsibilities, procedures and lines of accountability, it requires constant coordination, translation and maintenance. Without sustainable embedding, cooperation and coordination therefore easily revert to temporary projects, personal commitment and remedial work. A fourth lesson is that in border regions there is a persistent tension between the cross-border everyday lives of citizens and the predominantly nationally organised structure of public health. Citizens’ everyday lives do not stop at the border, but the organisation of public health largely does. Consequently, citizens’ living environment does not run parallel to the area within which public health organisations bear responsibility. In the practices I investigated, diseases, crises, policy tasks and administrative categories therefore much more often formed the starting point than the question of how public health connects with lives that, in practice, unfold across borders. The four lessons also lead to recommendations for policy and practice. Cross-border public health requires the systematic mapping of differences in classifications, data, responsibilities and implementation pathways, administrative channels for agenda-setting, decision-making and follow-up, and structural funding and mandates for cross-border coordination. Furthermore, policy and practice should more consistently assess how public health measures affect citizens who live, work, study, use healthcare or maintain social relationships across borders. In addition to recommendations, the thesis also makes a conceptual contribution to border studies and infrastructure literature. For border studies, it demonstrates that cross-border mobility, professional contact and project-based cooperation do not automatically lead to joint policy, implementation and accountability in public health. For infrastructure literature, it demonstrates that public health infrastructures do not automatically move across national borders, but must be actively coordinated, translated and maintained between nationally organised systems in border regions. Based on these findings, the key conclusion of this thesis is that public health in border regions is organised and made workable as a field of policy and practice by continually realigning nationally anchored infrastructures, responsibilities and relationships across the border. Consequently, public health in border regions is not a fixed domain, but a fragile and unfinished field that must be established anew time and again in administrative, organisational and practical terms.