, Volume 51, Issue 1, pp 49–69

Organizational Legitimacy of International Research Collaborations: Crossing Boundaries in the Middle East


    • Faculty of EducationUniversity of Hong Kong

DOI: 10.1007/s11024-013-9221-2

Cite this article as:
Oleksiyenko, A. Minerva (2013) 51: 49. doi:10.1007/s11024-013-9221-2


Cross-border academic collaborations in conflict zones are vulnerable to escalated turbulence, liability concerns and flagging support. Multi-level stakeholder engagement at home and abroad is essential for securing the political and financial sustainability of such collaborations. This study examines the multilayered stakeholder arrangements within an international academic health science network contributing to peace-building in the Middle East. While organizational forms in this collaboration change to reflect the structural, epistemic and political expectations of various support groups operating locally and globally, the legitimacy of the international research and its contribution to the peace-building process last as long as institutional norms of academic enterprise – integrity, impartiality and collegiality – are sustained. This paper analyzes the reconciliatory strategies used by the collaborating health scientists to mitigate organizational turbulence, reduce resource asymmetries and continually build and rebuild bridges across stakeholder communities.


International research collaborationOrganizational legitimacyBoundary managementAcademic health science center


International research is increasingly dependent on the support of stakeholders who control resources across multiple layers of financial and intellectual flows: local, national, regional and global. Multi-stakeholder partnerships are sometimes the only solution to complex societal problems that cannot be managed unilaterally (Gulati and Singh 1998; Reich 2002; Anderson and Steneck 2011). However, the multiple sites that accommodate international research harbor a variety of asymmetries in resource structures, including discrepancies in the availability of intangible assets such as political support, a collaborative environment and/or the sustainability of commitments (Stein et al. 2001; Reich 2002). Research partnerships are susceptible to failure, as internal and external stakeholders feel cognitive dissonance with regard to problem causes, stakeholder responsibilities, project accountability, and desired outcomes (Reich 2002; McCoy et al. 2008).

International research collaborations implemented by academic health science centers in regions affected by conflict illustrate the quandary in stark terms. On the one hand, the multifarious nature of these centers encourages interdisciplinary inquiry, which makes it possible to connect the learning processes of disparate stakeholders and accelerate problem-solving by building bridges between the professional and social spheres (Stein et al. 2001; Skinner et al. 2005). Indeed, in addition to offering immediate life-saving interventions, medical professionals often become engaged in cross-boundary dialogues, some of which have a profound effect on relieving the socio-ethnic and political tensions that fuel armed conflicts and exacerbate acute public health threats (Pedersen 2002; Noyek et al. 2005). Academic mediation is viewed as imparting special value in the emotional palliation of traumatic events, given that it helps those involved to rethink the nature of the tensions, acquire a more rational position in the prevailing debate and get a sense of normalcy amid violent events (Gangrade and Misra 1990; Oweini 1998; Abu-Saba 1999; Gluncic et al. 2001; Skinner et al. 2005). The confluence of scientific, humanitarian and peace-building actions has generated powerful results in dissipating global crises, as demonstrated by the legacies of such international movements as Pugwash, Médecins Sans Frontières, and others (Evangelista 1999; Dechaine 2002).

On the other hand, academic institutions located in peaceful and stable environments often experience justifiable anxiety about the validity of their engagement in regions that present a very real threat of hostage taking, physical disability or mortality for their staff. Similarly, the judiciousness of the academics’ noble intentions can be questioned by their governments, universities and families. Moreover, conflict-affected factions in partnering countries (Dajani and Carel 2002; Ghani and Lockhaart 2008), as well as various stakeholder groups at home, can also challenge the notion of intervention, especially when there are no quick fixes or ready solutions available (Zwi 2004). The public value placed on health, education and/or peace can clash with private interests and claims, negatively affecting the partnership equation and resource commitments, as well as the legitimacy and sustainability of collaborative efforts, which were initially based on noble intentions (Kaul, Grunberg and Stern 1999; Kirk 2007).

External barriers imposed by stakeholders can be augmented by conflicting positions on the roles and responsibilities held by internal gatekeepers in academic health science centers. The academic medical enterprise is simultaneously a scholarly and a patient-oriented institution (Kirch et al. 2005). The strategies of its departments, research centers and labs are shaped by distinctive epistemic norms, organizational cultures and accountability frames that may differ from those of their counterparts in the non-medical fields (Cooper et al. 2007; Macfarlane et al. 2008). By virtue of their practical mission, academic health science centers have to form public healthcare allegiances, and thus prioritize the demands of local patients/taxpayers over any commitments to global problem-solving. The expanding geopolitical dimensionality of academic outreach and multi-level governance of research internationalization adds another layer of challenges to achieving institutional coherence and harmonious stakeholder relationships (Marginson and Rhoades 2002; Beerkens and Wende 2007; Jongbloed, Enders, and Salerno 2008; Jones and Oleksiyenko 2011).

Although the scholarly literature recognizes the growing role of stakeholders in academic enterprises, research on the legitimization of international collaborations in complex multi-stakeholder contexts remains scant. What particular challenges do cross-border research projects encounter in circumstances of varied stakeholder support? How do academics approach issues of legitimacy when collaborative initiatives become strategic to them and their research fields, but not necessarily to the whole academic enterprise or its constituency? How do researchers manage issues of legitimacy in inter-organizational contexts when political turbulence increases or crises occur? How do they mitigate multiple stakeholder concerns in the face of increased risks? Amidst the substantial research on organizational legitimacy, these questions remain largely unanswered, while expectations surrounding universities’ social engagement at home and abroad are on the rise (Khan et al. 2009; Siegel 2010; Tierney 2011).

This paper endeavors to reduce some of the knowledge gaps by examining the strategies behind the multi-stakeholder legitimization of an international collaboration involving medical scholars in Canada, as they reach out to the Middle East and deal with a multitude of political, cultural and religious divides (Noyek et al. 2005; also see Isralowitz et al. 2001; Moore and Aweiss 2008). The analytical framework of this paper is informed by studies on organizational legitimization, which point out the increasing division of university mandates across simultaneously evolving global, national and local responsibilities (Marginson and Rhoades 2002; Jones and Oleksiyenko 2011). The conceptualization is presented below and followed up with an explanation of the study design and a listing of the key findings. Lastly, the paper discusses the major implications of the findings on international partnerships that consider the legitimization process to be a strategic objective.

The Organizational Legitimacy in the Context of a “Glonacal” Agency

The accelerating cross-border movement of people, products and ideas over the last decades has enhanced in equal measure the challenges and opportunities for medical science. The rapid spread and viral complexity of infectious diseases resulting from the increased mobility is counteracted to some extent by the growing opportunities for national governments to collaborate and develop more immediate, coherent and affordable solutions, as well as to implement more effective epidemiological and monitoring systems (Cooper et al. 2007). The changing nature of governance in academic science has both challenged and improved accountability norms, making stakeholders more engaged in the planning and implementation processes (Jones and Oleksiyenko 2011). Indeed, the legitimacy of collaborative initiatives at academic health science centers is increasingly determined by various communities of interest: immediate users, sponsoring organizations, disciplinary networks, and ever more, global agencies (MacQueen and Santa-Barbara 2000; Markle et al. 2007). Medical departments, research centers, programs and research initiatives endeavor to build identities that are recognized and accepted across multiple levels of authority (Moses, Thier and Matheson 2005) and “social worlds” that they serve (Frost, Reich and Fujisaki 2002). The emergence of new scientific fields and boundary-crossing initiatives requires broad support from stakeholders (Oleksiyenko and Sá 2010) who define the rules, budget frames and accountability norms (Ryan and Walsh 2004; Jongbloed, Enders and Salerno 2008).

Previous studies point to the exchange of resources (e.g. financial, informational, intellectual) (Terreberry 1968), organizational survival (Zald and Denton 1963; Pfeffer and Salancik 1978/2003), and value congruency (Clark 1956; Dowling and Pfeffer 1975) as indicators of legitimization. However, organizational legitimacy is increasingly determined by stakeholder recognition and support of ideas and processes as “desirable, proper, or appropriate within some socially constructed system of norms, values, beliefs and definitions” (Suchman 1995: 574). The process of achieving legitimization is challenging because stakeholders tend to develop variable interpretations and perceptions of what is desirable or appropriate (Perrow 1970; Ashforth and Gibbs 1990; Frost, Reich and Fujisaki 2002). An organization’s maturity, complexity and interactive capacities all have an effect on its ability to detect and address problems that have the potential to compromise or erode legitimacy (Dowling and Pfeffer 1975; Pfeffer and Salancik 1978/2003).

Assurances of legitimacy are becoming more difficult to sustain in rapidly changing environments that conflate local, national and global interests and commitments. The “glonacal agency,” which reflects on the simultaneity of demands across the three stakeholder planes (see Marginson and Rhoades 2002), tries to embrace the multi-layered interaction, but is vulnerable to increasing clashes between individual and collective decisions involving governmental, professional and civic stakeholder groups at home and abroad. Within closed environments, the legitimization of such decisions depends primarily on the support of proximate social formations, or “social worlds,” whose values and norms correlate closely with those of the decision-makers (see Pfeffer and Salancik 1978/2003; Star and Griesmer 1989; Gieryn 1999; Frost, Reich and Fujisaki 2002). With the growing mobility of ideas, talents, goods, resources and technologies, the locally bounded “social worlds” increasingly absorb socio-cultural and political patterns generated elsewhere. As constructs dependent on multi-level stakeholder engagement, organizations become vulnerable to environmental turbulence propelled by incompatibilities between the local and the global. This turbulence is augmented by disagreements inside the organization, as well as by the constant pressure on organizations to keep their strategies attuned to the changing goals and priorities of their supporters, who are likewise entangled in the “glonacal” layers of interests and commitments.

In higher education systems, three major structural levels – understructure, structure and superstructure (see Clark 1983) – exemplify tensions between various internal and external stakeholders, who collaborate and compete over policies, funding schemes, projects and accountability norms. While incoherence in values, attitudes and interpretations surrounding joint actions increases, some structural levels become less vibrant or increasingly deficient, and the reciprocity and harmony across the layers of stakeholder support dissipates (Jones and Oleksiyenko 2011). At the understructure level, primarily controlled by academic departments and individual scholars, the legitimization of cross-border initiatives is a process of contestation driven by the inherent disparity of interests promulgated by “academic tribes and territories” (Becher and Trowler 2001). Disparate organizational traditions, epistemic norms and resource streams encourage allegiances in various academic divisions with dissimilar stakeholder groups and networks. Various performance and tenure frameworks place faculty members in divergent commitment modes and role schemes (Bunton and Mallon 2007; Ramsey and Miller 2009). Competition for limited internal resources often generates tensions among various research groups (Mallon 2006). Given that joint actions require that individual interests be sacrificed for the sake of collective benefit, defiance and divergence are likely to emerge in the course of the implementation process (Finet 1993). Resource asymmetries, augmented by variances in researchers’ institutional and stakeholder support schemes, generate internal and external hierarchies that cause some research collaborations to stand out from others.

At the structure level, university executive offices can favor one or another geographic, institutional or individual faculty member’s engagement and thus channel political and financial support respectively. The institutional authorities, however, can concentrate their powers only to a limited extent, given the epistemic contestations and erratic support from donors alternatively favoring local, national and/or global interests (Oleksiyenko and Sá 2010). Academic health science centers, for example, are both local and global knowledge institutions. Medical scientists’ connections with global networks of discovery and innovation are an essential element of their research and practice. However, the health centers’ operational demands are primarily shaped by the needs of local clients, who may have limited understanding of local-global interdependencies and their bearing on their particular medical problem. While the centers’ resource management is driven by the expectations of local clients/taxpayers, health scientists cannot move the whole research agency to the global domain in which some academics may be more interested. Caught between the different levels of the “glonacal agency,” international collaborators in academic health can be perplexed about the strategies for spanning the boundaries of the stakeholders’ “social worlds.” In absence of external sponsorship, academic leaders can give limited support to the global initiatives, even though social and technical competencies in the health sciences become more internationalized (Sá and Oleksiyenko 2011).

At the superstructure level, competing national interests, public-private divides, the emergence of new players, as well as the reinterpretation of established accountability norms, all intervene to thwart the advancement of international collaborations (see Reich 2002; Marginson 2007). Achieving scientific outcomes that are equally salient, relevant and legitimate at home and abroad is often impossible without multi-level stakeholder support for crossing disciplinary, departmental and cultural boundaries and developing reconciliatory frames (Lattuca 2001; Feller 2007). Academic collaborations become dependent on the abilities of researchers to communicate effectively with their internal and external stakeholders, so as to secure political and financial support across multiple decision-making levels. With economic rationales moving to the center of academic decision-making, academic partnerships are becoming subject to organizational strategies involving calculation and calibration of stakeholder relations (Jongbloed, Enders, and Salerno 2008). In view of this, partnership planners try to minimize the inherent differences in the missions and cultures of collaborating organizations in order to offer various professional and governmental stakeholders a more synergistic perspective on the viability of shared objectives and implementation schemes (Austin 2000; Kirch et al. 2005; Ryan and Walsh 2004).

As legitimization of academic collaborations is a highly contested process, the redrafting of boundaries through changes in organizational strategies and stakeholder classifications (Osborn and Hagedoorn 1997; Jongbloed, Enders and Salerno 2008), becomes essential to maintaining bridges between the scientific and non-scientific worlds. “Boundary organizations” and their boundary objects (Star and Greimeser 1989; Guston 2001), which are capable of gaining support across various stakeholder groups, as well as flexible enough to translate disparate values and mitigate risks, are especially important when collaboration legitimacy is prone to constant threats and compromises (Deegan, Rankin and Voght 2000; Massey 2001; Frost, Reich and Fujisaki 2002; O’Donovan 2002; Upshur and Tracy 2004). Placed in international conflict zones, where strains between local, national and global forces intensify, medical research partnerships have to assume complex boundary responsibilities and come up with strategic choices that require careful gradation and structuration of stakeholder support. This is exceedingly difficult to achieve in environments where cross-institutional and cross-cultural communication patterns change unpredictably, disrupting the flow of collaborative tasks, undermining trust and destabilizing partnership relations.

As previous research indicates: the greater the variety of stakeholder interests and expectations, the harder it is to achieve consistency and sustainability of multi-stakeholder commitments and collaborations (Frost, Reich and Fujisaki 2002; Anderson and Steneck 2011). Given that most research initiatives benefit from decentralized academic contexts (Geiger 1990; Sá and Oleksiyenko 2011), a fragmented stakeholder landscape is most likely to keep the legitimization process in a perpetually turbulent condition. What it means in actuality for international research partnerships to stabilize these multiple planes of engagement and to sustain recognition and support across disparate stakeholder groups is an increasingly critical question.

The Study

The case study of the Canadian International Scientific Exchange Program (CISEPO) illuminates some of the connecting and anchoring strategies used by academic collaborators to reconcile stakeholder disagreements in one of the world’s most volatile areas, the Middle East. CISEPO presents an interesting configuration of roles, determined by its status as a “charitable, non-governmental organization (NGO), based at Mount Sinai Hospital in the Peter A. Silverman Centre for International Health, at the University of Toronto in the Dalla Lana School of Public Health and at York University in the Faculty of Health” (CISEPO 2011). As part of the Toronto Academic Health Science Center, a massive health complex managing a half billion dollar annual research budget, CISEPO is compelled to serve both local and national needs. However, the program’s primary mandate is to “promote international development by advancing health education, health care, health care systems, scientific exchange, research and public health” through “cooperative people-to-people on-the-ground activities, social entrepreneurial enterprise and technology and innovation” (ibid.).

Moreover, CISEPO conducts most of its activities in the Middle East, contributing to reestablishing peace and order in a political climate that is historically unstable and prone to outbreaks of violence. The organization uses international science as a vehicle to reduce turbulence in the region and to promote a more open and trustful environment for cross-border exchange and collaboration among medical professionals who hold diverse religious and political affiliations (Stein et al. 2001; Skinner et al. 2005). In parallel, it works towards the reconciliation of divides and tensions between the Jewish and Arab communities in Toronto, the multicultural Canadian city where CISEPO headquarters are located.

Despite the ongoing conflict in the region, “CISEPO has built active partnerships with more than 20 hospitals in the Middle East (12 Israeli, 8 Jordanian, and 1 Palestinian); 10 universities (5 Israeli, 4 Jordanian, and 3 Palestinian); the Royal Medical Service of Jordan; and dozens of Arab and Israeli mother and child health centers and citizen organizations” (Ashoka Foundation 2009). Over the course of thirty years, CISEPO arranged for more than 500 Arab-Israeli workshops that span a wide range of joint educational and research projects. More than 200,000 infants in the region were tested and habilitated for hearing loss as a result of this international collaboration. Moreover, CISEPO built sustainable relations with stakeholders in hospitals, universities and non-profit organizations in Canada and the US, offering an outlet for their ambition “to serve the purpose of global peace.” As the network grew, CISEPO undertook a number of steps to strengthen its organizational framework. Some of these were more successful than others, given that the organization had to maintain a fine balance between individual and collective efforts and responsibilities.

The research questions guiding this study were primarily focused on the tensions that academics experienced in managing support streams with their stakeholders at home and abroad. The study examined the key choices made in regards to stakeholder relations and management of the interdependencies shaped by the geopolitical conditions of the Middle East, as well as those of the mediating country, Canada. One of the aims of the study was to understand how CISEPO built legitimacy for its operations across geopolitical, cultural and professional domains. Issues of organizational development, in view of the limitations of an international collaboration agency in spanning geopolitical and scientific boundaries, have received close attention.

The data for this study were drawn from CISEPO archives and publications, as well as from periodic meetings and interviews with the CISEPO board of directors over the course of 2001-2009. Additionally, interviews with 30 representatives from academic, governmental and non-governmental organizations associated or partnering with CISEPO initiatives were conducted during 2007-2009. The initial drafts of this paper were shared with CISEPO associates in order to verify facts and reduce any discrepancies in the data analysis. This paper integrates findings from other research on CISEPO (see, for example, Stein et al. 2001; Skinner et al. 2005; Scolnik 2007; Skinner and Sriharan 2007; Sriharan et al. 2009), while contributing an important new angle to the discussion: that is, consideration of organizational legitimacy of international collaborations in contexts torn by strife. The “global higher education matrix” used in previous analysis of the internationalization of Canadian university research (Jones and Oleksiyenko 2011) was applied in this study. The relations between global, national and local forces, as well as structural layers of governance (i.e., understructure, structure, and superstructure), as employed in the matrix, were briefly discussed in the previous section. The data were coded, triangulated and categorized for analysis in the case study with the use of standard qualitative method techniques (Miles and Huberman 1994, Yin 2003).


Multi-level stakeholder support at home and abroad was essential to sustain CISEPO’s thirty year long run of cross-border collaborations in the highly volatile context of the Middle East. Over the years, as the conflict escalated or receded, CISEPO undertook a number of carefully designed strategies to interact with various stakeholder groups in a variety of social and professional “worlds” – among them private sponsors and governmental aid programs, academic infrastructures and medical networks, local communities and international agencies – in order to help vulnerable populations in a volatile conflict zone. Above all, its success can be credited to the personal commitment and consensus generated within small clusters in the academic settings of Canadian, American, Jordanian, Israeli and Palestinian universities and their medical faculties. The like-minded teams of medical professionals became essential catalysts for the growth of larger stakeholder networks that helped to sustain knowledge transfer across political and professional borders over decades. The connections across these clusters were multi-layered, with the individual and organizational commitments and capacities intricately interwoven. The following paragraphs pull apart these layers and explain the interdependencies.

Understructure Level: Individual Commitments and Shared Leadership

CISEPO emerged out of a set of individual endeavors undertaken by its founder, Dr. Arnold Noyek, Chief Otolaryngologist at Mount Sinai Hospital, who had been “promoting continuing medical education, professional development and capacity building with universities in Israel since 1972 and with Arab universities since 1982” (CISEPO 2005). A specialist in the area of hearing loss, Dr. Noyek was stuck by the high regional incidence rate of the disease, which affected Israelis, Jordanians and Palestinians alike. Clearly, medical professionals could achieve more to solve the problem if they shared their resources, ideas and findings. However, in the clash of civic and political differences, many local medical professionals were affected by the metaphoric affliction of “lost hearing,” rendering them incapable of communicating with each other. Over the years, the lack of exchange and “simple human interaction” created an environment of deep mistrust. One of the Canadian visitors to the region described the local circumstances as follows:

“The reality is that, in a practical way, you talk to people in Israel and they say, ‘You want me to go and study in Jordan? You’ve got to be kidding,’ or you talk to people in Jordan and they say, ‘You want me to go and study in Israel? Where would I put that diploma? Where would I put on my resume that I got a degree in Israel? I don’t think so…’ Or, you talk to people in Israel: ‘You are telling me that you want a Palestinian to come and study here? How do you know that they don’t want to blow up the research lab and kill everybody in it?’”

Dr. Noyek’s impulse to defy mistrust in the region was reinforced by a “big idea of [creating something] more than a medical initiative” which came into fruition when he was approached at the end of the 1990s by the private office of the late King Hussein of Jordan with a proposal to engage a Canadian organization as an “umbrella” for cross-border health sector collaborations between Arabs and Israelis. An umbrella has featured in the CISEPO logo ever since to signify its “broader mission” – i.e., building peace in the conflict region through health science. The relatively stable Jordanian society, and the royal family in particular, have also remained constant anchors for the Canadian initiatives. However, working in the hostile reality of the lingering conflict of the Middle East has remained a formidable challenge that no amount of royal support could adequately cushion. “Simply going through the checkpoints at the borders between Israeli and Palestinian settlements was a frustrating and humiliating routine.” In the words of the CISEPO founder, working in the region was “like walking under the sniper’s target - [one] would have a feeling of being watched all the time.”

The founder had to make consistent efforts to relieve tensions and cultivate comfortable personal relations among the individuals who were joining the network, an approach which had a snowball effect on in its growth over the years. As Dr. Noyek reiterates, “CISEPO is a person-to-person network; it is hard to call it an organization.” Indeed, communication and support are always familial, personal, and caring. Senior scholars in the network feel responsible for the career promotion of their younger colleagues. As one of the interviewees remarked, “mentoring and sincere interest in, and support to, people’s individual careers have been key motivating factors for many of our members.” CISEPO’s founder made deliberate efforts to promote the value of individual success (largely celebrated through various memos and awards of recognition). He also made a point of highlighting that individual success is often the result of a collective effort. One CISEPO associate sums up the prevailing attitude:

“Academics are horrible in sharing glory, but we share glory. So if it’s an award given – like the Red Cross Award, which we got as part of the Humanity Award… it was for [our director]. But he did not take it and go; he shared, he distributed the award.”

In summary, “leadership is not ownership here,” according to the interviewee. Another respondent adds that:

“…the way we maintain the network is by recognizing the leaders, nominating them for awards and prizes, making sure that they know they are valued and appreciated. We phone them, we keep in touch, we visit, we offer workshops… we do things like that to build their careers, if you will.”

Being part of a network located in a conflict zone also required that special support be given to colleagues who encountered traumatic experiences. Peer-to-peer sharing, empathy-based accommodation and on-going involvement were regarded as critical. One of the network leaders explains:

“…some of the relatives of our partners have been killed in one of the bomb blasts, we’ve had serious crises going on, and yet the network is strong. The network is strong because it was built very carefully and very slowly through different kinds of means.”

In times when personal access to the professional communities in the war zones became more difficult, web-based interfaces evolved to sustain communication and offer support. The Internet allowed for immediate responses, as well as for “an equitable and even-handed flow of information” among the groups in various countries. The proliferation and diversification of info-technologies made it possible to intensify communication through continual “day or night calls,” messaging and “Skyping.” Dr. Noyek also made an effort to convey to his network that the exchange rhetoric should remain respectful of religious or cultural identities and differences. His office circulated greetings on major Muslim, Christian and Jewish religious and civic holidays, which were observed by the network to ensure that “the open recognition and celebration of cultural differences served as a warranty for maintaining healthy relations,” both in cyberspace and in face-to-face interactions, including at international workshops and exchanges.

In the collaborative actions aimed at building peace in a highly volatile region, the interplay of multiple disciplines became essential. As one of the researchers remarks:

“Since we’ve been in the hearing business, then we’d hear things like nutrition, malnutrition with children, and child growth and development. We tend to go out from that link. So we start with our core business and maintain our core business, but as opportunities come up that lead us in different directions, we follow them to a certain extent, but we always come back to the core.”

Another respondent explained that “[the] programs have a dramatic multiplier effect, leading to other joint activities including nutrition, mother and child health, infectious disease and youth health promotion.” Environmentalists, anthropologists, educationalists and computer specialists joined the health scientists to develop comprehensive problem-solving strategies. While multidisciplinary engagement has always been encouraged, selectivity in thematic choices is deliberately limited. One of the interviewees explains:

“Health is a good vehicle, but not all health is a good vehicle. You could not pick something like birth control. But hearing loss is something that had affected all communities [in the region] and was seen by them as a major health concern [that] they needed input [on].”

Even more specifically, children’s health became a key focus in the course of collaboration. As one study participant explained:

“If you can find deaf infants and fix their handicap through hearing aids or cochlear implant surgery prior to the age of two, they can advance normally in the school system and achieve a full education. If the process is delayed, a deaf child has only a 60% chance of the learning capacity of a normal hearing or effectively habilitated child. Hearing loss is such a devastating illness – really, it is a huge health burden, and also a human rights issue because people are excluded from society, they never get a chance to get an education and they are less and less involved.”

Given that habilitation strategies required a wider scope of research on families, communities, and professional groups, CISEPO collaborators were given the opportunity to reach out to a broad range of societal groups, thus establishing links beyond the scientific community. The successful collaborative screening and habilitation of more than 200,000 infants in the conflict zone inspired the network to go beyond “what scientists traditionally used to do: i.e., pure disengaged research.” CISEPO initiatives were noted as:

…bringing together clinical research and field practice to change the way [scientists] do research, as well as to make communities feel that they are immediate beneficiaries of having the research and practice informed by each other.

Overall, the combination of focused science, shared leadership, and trust-building in the cross-border project, has become a cornerstone for rectifying cross-border relations among the “cores” of scientists in each country. Before they were able to become bridges for international collaborations, however, these core groups had to also secure cross-institutional support at home.

Structure: Institutional Boundary-Spanners

The founder worked with the collaborating universities’ senior administrators to ensure that institutional support to participating scientists and the ethics of communication became a priority on campuses. The deans of the four medical schools in Israel: Ben Gurion, Hebrew, Technion and Tel Aviv; as well as those at the Al-Quds and Bethlehem medical schools in the Palestinian Authority, enthusiastically supported Dr. Noyek’s call for impartial communication. When academics or students took sides or publicly expressed their political position, the participating university authorities were prompt in affirming the rights of individual expression, while pointing out the difference between personal and institutional positions. The deans clearly stated that the universities discouraged any kind of religious or cultural intolerance. The personal engagement of the academic leaders was also essential in promoting cross-cultural interactions and enhancing the value of the knowledge network. The deans of the medical schools at the Al Quds and Hebrew universities spent numerous hours together, discussing stakeholder strategies and talking through logistical issues related to cross-border exchanges. The Dean of Medicine in Toronto played an instrumental role in sponsoring international visits, as well as backing research proposals in discussions with university committees and donor agencies. Thus, academic leaders at the institutional level in all four countries worked towards a common goal and fine-tuned the perceptions and expectations of internal and external stakeholders.

As an independent non-governmental organization, CISEPO itself became an important institutional spanner – bringing together universities and hospitals in Canada and the Middle East. In times when the Middle Eastern conflict escalated and university authorities became more concerned about deploying staff or students to the region, CISEPO took responsibility for obtaining the support of foreign embassies and worked on enhanced security regulations, liability and indemnification issues, as well as visa clearance, license verification, banking transfers, evacuation plans and other related matters. As a result, university administrative offices were relieved of the extra responsibilities related to cross-border exchange logistics, for which they had neither sufficient knowledge nor adequate resources, and which were not a legitimate part of their organizational mandates. CISEPO’s NGO status created a buffer that mitigated the universities’ liability risks. In more peaceful times, when the conflict was in recession, CISEPO was able to rely on university support in relations with foreign ministries and funding agencies at home and abroad. That is, it was able to use its affiliated status to tap into the university’s internationalization seed funds and to take advantage of existing fundraising mechanisms to advance its mission.

To avoid the stigma of a “politicized partnership,” CISEPO made efforts to integrate the Middle Eastern theme into wide-ranging scholarly discussions on global health, conflict resolution and peace building across faculties and departments at home and abroad. The creation of a series of seminars that examined issues of peace and health brought together local and international scholars from various ethnic, cultural and religious backgrounds. “American, Australian, Brazilian, Dutch, Egyptian, Israeli, Jordanian, New Zealand, Palestinian, Qatari, Spanish, Swedish, Thai, Turkish and other individuals and institutions from the health sector and scientific world” became regular contributors to CISEPO conferences and workshops. Both Israeli and Palestinian CISEPO members noted that they had a feeling of “joining a broader global discussion among colleagues who shared similar concerns.” Comparative epidemiology emerging from these seminars became essential to understanding the complexity of health challenges in various parts of the world affected by ethnic or religious strife.

Superstructure: Multiformity and Continuity

CISEPO was able to sustain continual cross-cultural engagement with the conflict zone by maintaining its headquarters in the multicultural city of Toronto, a cosmopolitan metropolis with half of its population born outside of Canada. In CISEPO’s peace-building strategy, Toronto emerged as a “new city,” an alternative to the old Jerusalem, segregated by the factual and symbolic walls of its constituent religions, histories and cultures. Toronto’s ambassadorial role was reinforced by the Canadian government’s track-record on multilateralism and peace building, which garnered recognition as far back as 1957, when Prime Minister Lester B. Pearson was awarded the Nobel Peace Prize for his role in the resolution of the Suez Canal Crisis. The multicultural city proved to be an ideal place for scholarly interactions, as it allowed visitors to liberate their minds from the patterns imposed by conflict and to re-imagine an alternative model of a “social world” that could be shared by Israelis, Palestinians and Jordanians. In Toronto, participants from the Middle East were able to envision collaborations with a stable, long-term perspective, rather than on the basis of “sporadic and tense reactions in response to occasional political crises.”

Although there were instances of Toronto-based students or ideologically-minded stakeholders initiating campaigns favoring one or another conflicting side, CISEPO was able to appeal to alternative cultural-behavioral templates. In Toronto, CISEPO deliberately opened up its membership to researchers representing a mix of ethnic backgrounds. Its headquarters were a meeting place for professionals and researchers of Jewish and Arab heritage who were enthusiastic about peace-building and collaborative work in the region. In the Middle East, CISEPO established a number of centers where professionals of various cultural backgrounds could meet, share problems, ideas and solutions, and thus engage in legitimate work related to international research and development.

Toronto’s wealth as a financial center became a source of tangible resources for the international collaborations of the medical academics and peace advocates. Initially, CISEPO engaged the support of local Jewish business people—for example, the backing of Peter Silverman and his family has been essential to the operations of the network for more than twenty years. Arnold Noyek and Peter Silverman also worked together to engage other donors. Silverman’s personal involvement served as leverage to soliciting support from federal agencies, such as CIDA and USAID, as well as from big private American foundations, such as Ford and Rockefeller. To boost American involvement, Arnold Noyek traveled throughout the Great Lakes area to connect with US-based colleagues and garner further backing: for example, he succeeded in engaging the support of the local American Arab communities in Detroit. The fundraising efforts made it possible to finance joint training seminars, scholarships and youth summer camps, bringing together established and aspiring scholars from the Palestinian Authority, Jordan and Israel. Medical researchers in Toronto applied for additional resources for their research projects and used the funds to invite Palestinian scholars to take on visiting professorship posts or to complete their doctoral studies in Canada.

CISEPO scientific clusters in the Middle East also experimented with revenue generation and made efforts to connect the needs of patients with access to the best modern technologies. The Middle East Hearing Association (MEHA), for example, organized the development and sale of solar-powered hearing aids. CISEPO engaged disabled women to produce these hearing aids. According to the 2009 Ashoka Foundation communiqué introducing Arnold Noyek as its new fellow, “Not only [do women] gain access to decent jobs which will heighten their economic status and their self-esteem, but the community as a whole [becomes] responsible for distributing essential hearing aids to populations in Palestine, Israel, and Jordan” (Ashoka Foundation 2009).

The social entrepreneurship project to produce solar-powered hearing aids gave rise to shared economic interest among the region’s medical professionals, their patients, as well as local businesses. The initiative encouraged local stakeholders to seek cohesion in regards to hearing screening, auditory therapy, family support and professional education. In some measure, this allowed CISEPO to extend operations beyond the immediate conflict hotspots in the region. For example, the “Bridging the Silence Program” was launched in North Israel to facilitate “cooperative, cross-cultural and interfaith programming in the health sector to benefit deaf children, their parents, their teachers and societies.” The entrepreneurial efforts in the region were wholeheartedly supported by the Canadian scholars involved in CISEPO, as evidenced by the following statement:

“[The network] has to sustain [itself]. I think you have to be entrepreneurial. We need to cheer and encourage [the association] to get involved with the solar-powered hearing aids and then become a distribution agency for hearing aids.”

The multi-sited “social entrepreneurship” required a significant degree of organizational flexibility. CISEPO encouraged structural diversification and nurtured administrative and budgetary autonomy among the increasing number of its “entrepreneurial” outposts in Canada and the Middle East. The strategy resulted in a cluster of affiliated centers and programs at Toronto’s Mount Sinai Hospital, as well as in teaching hospitals in the Middle East. The structural diversification allowed for the most suitable responses to disparate stakeholder ideas, resources and expectations across various affiliations within the network.

Nonetheless, the strategy of self-sustaining network nodes gave rise to some challenges. In Canada, some participants noted that the CISEPO spin-offs began to compete with each other for the scarce resources available from federal global health programs. Moreover, given that CISEPO partner organization boards were often cross-appointed, many directors felt that they had conflicts of interest. As one of the interviewees remarked, the CISEPO leaders “[were wearing] too many hats to be able to provide effective endorsement to the interests of their home spin-offs.” Increasingly, the participants felt that having a gamut of separate units competing for institutional legitimization compromised the overall aim of offering a focused approach to peace building in the region. To facilitate greater cohesion, the position of an executive director working across various groups was established. However, it was soon discontinued, as the managerial role did not fit in with “a more chaotic but also more flexible decision-making style,” which the academics favored in the unpredictable environment. Instead, the CISEPO founder created an interlocking directorate that coordinated spin-offs’ fundraising and stakeholder relationship strategies. The following arguments stood behind the decision:

“Money is important, but is not and should not be our main focus. If somebody tells you that you need money first and then you can do planning, it’s rubbish. Will and patience should go first.”

“Doctors cannot go with a peace mission to communities if they are divided among themselves.”

“We can be different in how we approach our research projects and clinical practices here, but we stay together in making our values speak across partner organizations with the same voice; that is, every effort should contribute to peace in the Middle East.”

Discussion and Concluding Remarks

The organizational legitimacy of CISEPO’s international collaborations has been driven by a variety of structural, intellectual and cultural assets available at multiple layers of the partnership agency. Despite being a small part of a medical enterprise and a minor player in the global effort to resolve the Middle Eastern crisis, CISEPO was able to coalesce multi-level stakeholder interests, and thus achieve its original goal, i.e., to overcome resentment, hostility and disagreements among the conflicting professional segments of the medical profession in the Middle East and to create opportunities for constructive dialogue and collaboration to address a public health challenge. It found ways to connect global, national, and local forces and established a number of boundary-spanners in the governance matrix (see Table 1), making it possible for the professional medical communities to understand their interdependencies in problem-solving, to find common interests, to build trust and to sustain their commitment to peace-building in the conflict region.
Table 1

“Glonacal agency” and multilayer boundary-spanners







Toronto (multicultural city); Jerusalem (object of disagreement); immigrant communities; local sponsors; political stakeholders; public health themes

Federal/national foreign policies; federal/ national diplomatic positions; Canadian Nobel Peace Prize record; positioning of national science internationally

Academic involvement in/ commitment to peace negotiations; regional stakeholders (e.g. Royal Medical Service of Jordan and the royal family in Jordan); cross-border Canada –US academic linkages; youth summer camps

International interest in peace; global foundations and donor agencies; global recognition of academic contributions (e.g. Red Cross Award, Ashoka Foundation); internationalization of science; global scientific norms and ethical standards


Research universities; CISEPO with multicultural headquarters and projects; Dean’s offices and impartial communication in times of crises; Academic Health Science Centers; spin-offs and interlocking directorate; cross-faculty seminars

Federal/national programs supporting international academic science; liaison officers in the departments of foreign affairs; foreign embassies

Middle Eastern Hearing Association; regional workshops; production of solar-powered hearing aids

International knowledge network; international workshops; otolaryngology as a globally connected scientific discipline; ICT


Founder and other scientists in Toronto and in ME; academic departments and research centers;


engaged/ action-oriented research;

graduate scholarships and research fellowships

Country-based science teams/ projects/ networks; engaged/ action- oriented research

Middle Eastern interdisciplinary cluster; North American interdisciplinary cluster; infant-focused hearing loss habilitation projects

Academic mobility, exchange, award-sharing; collaborative leadership;

multicultural recognition of religious and civic holidays

Note: Adapted and modified from Jones and Oleksiyenko (2011)

The analytical matrix is helpful in understanding the interdependencies among various layers of governance in the legitimization process of the international collaboration aimed at building peace through health in the Middle East. It demonstrates how a partnership agency amalgamates geopolitical, social and cultural contexts, and how boundary spanners emerge as important diffusers of the barriers created in the process of conflict. Moreover, the matrix quadrants explain how organizational forms and institutional norms come together. It also makes it possible to observe overlaps and deficiencies across the levels, and consequently to plan the expansion of the boundary-spanners that have the potential to strengthen stakeholder engagement in critical areas.

In many respects, CISEPO presents itself as an example of a “glonacal agency,” which transcends nation-states, markets and academic professions (Marginson and Rhoades 2002), each of which in isolation is limited in its ability to offer a meaningful intervention in the recurring conflicts. CISEPO’s strategy of building multi-layered organizational legitimacy is closely integrated with the likewise multi-level research missions of its hosting academic health science centers. In situations when a whole medical faculty does not have sufficient power to enable the internationalization of its disciplines (Jones and Oleksiyenko 2011), or when the academic community experiences elevated concerns about liability risks, the smaller units, with their networks and spin-offs, emerge as mediatory forces ensuring continued academic engagement and commitment. CISEPO’s multiple identities as a research unit, an NGO and a knowledge network are important pillars in its multi-stakeholder strategy-making. CISEPO tapped into numerous sources of financial, intellectual and political support across the academic, governmental, industrial and civic domains when Canadian federal government programs were unable to increase expenditures for global health (Jones and Oleksiyenko 2011). CISEPO’s concurrent engagement with all these stakeholders played both functional and symbolic roles within the inter-organizational context of its research projects in the Middle East, where broad acceptance by influential stakeholders across the regions and communities was initially largely absent. As a “glonacal agency,” CISEPO was able to reconcile collaborators’ cultural and individual differences. As an agency with a structure-oriented strategy, it remained focused and selective in the range of disciplines, scientists and stakeholders involved in the highly combustible region.

The combination of structure and fluidity has been important in CISEPO’s case. The interdisciplinary research, entrepreneurial activities and “crucial cross-cultural conversations” served as boundary objects intersecting local, national, regional and global levels of stakeholder interest. Entrepreneurship for social purposes, for example, received acknowledgment from disparate political, economic and cultural groups in the region as well as across the globe and, therefore, made it possible to unite stakeholder interests at multiple planes simultaneously. The collaboration in the Middle East also had a positive effect on Jewish and Arab communities in Toronto and elsewhere, leading to progressive movements seeking out collaborative opportunities. In that regard, boundary spanners were useful in creating bridges across the contesting “social worlds” and producing opportunities for those who were open to alternative attitudes and behaviors. This corresponds with the findings of earlier studies, which point to the value of the communicative and interpretative roles of boundary organizations and/or their objects in reconciling competing or warring forces (see discussions by Tawil 1997; Oweini 1998; Abu-Saba 1999; Gluncic et al. 2001, Frost, Reich and Fujisaki 2002). However, the CISEPO case study underlines the need for a carefully designed and deliberately multi-layered legitimization strategy in order to ensure the sustainability of the reconciliatory processes. Moreover, the case demonstrates that the integration of organizational and institutional frames into the multi-layered stakeholder strategy was essential, as it allowed for the rapid reconfiguration or reinforcement of stakeholder relations in response to conflict recesses and escalations. It also helped to ensure continuity and sustainability by harmonizing the ethical norms and scientific standards embedded in collaborating academic institutions.

Overall, CISEPO provides a number of insights for international research collaborations, particularly those positioned in volatile contexts. Certainly, it shows how important and valuable it is to have a big, credible and noble idea to guide the multi-stakeholder effort. The universal human desire for peace and health laid the groundwork for organizational plasticity and resilience in managing boundaries imposed by cultures, religions and politics. However, a clear structure and unambiguous understanding of the partners’ roles and responsibilities are equally important when the stakes are high and the situation is explosive. This is not to say that CISEPO’s organizational structure is bureaucratic. Indeed, the opposite is true and the founder points out that CISEPO does not easily fit the organizational templates that are familiar to industrial or governmental stakeholders. As an academic entity, it was designed to accommodate fluidity, creativity and stakeholder involvement with speed equal to the rapid changes in the conflict region. While its organizational forms could be modified as needed, its institutional norms and beliefs (e.g., collegiality, impartiality, scientific focus and commitment to the common good) remained firm. Given this vital combination, CISEPO was able to go a long way toward legitimizing cross-border academic mandates among local and global stakeholders.


I am indebted to a number of individuals from whose comments and suggestions this study benefitted. Many thanks to Professors Arnold Noyek, William G. Tierney and Simon Marginson for their valuable insights. I am grateful to the two anonymous reviewers of this journal for their helpful advice.

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© Springer Science+Business Media Dordrecht 2013