Chapter 9 summarizes our theoretical expectations and empirical findings about IO exits. It outlines the implications of IO exit for international cooperation, future research, and policymaking. It also provides additional insight into IO exits that have occurred as regional conflicts have engulfed the world in recent years, exemplified by Russia’s invasion of Ukraine in 2022. The chapter analyzes how IO exits might affect international cooperation as multilateralism is being contested on several fronts. It also discusses that patterns of democratic decline and polarized domestic politics may lead the future of IO exits to be different than the past. Even while this contestation is happening, however, we show that IO exits (as well as threats and reentry) extend beyond current affairs; they have been a relatively steady occurrence over time. We conclude by arguing that despite – and sometimes because of – occasional exits, international cooperation continues through IOs and a robust set of other international institutions. We outline several exciting areas for future research that may be inspired by the findings from this book.

Chapter 4 outlines and tests our argument about the consequences of IO withdrawal for exiting states. We argue that there should be negative reputational and cooperative consequences for withdrawing states because IOs operate as hand-tying, credible commitment devices. International actors might regard withdrawal as backing out of a commitment and a signal that decouples the state from a self-chosen “in-group.” Thus, international actors – such as market analysts and other states – may reduce their trust that a withdrawing state will follow through on other commitments. As evidence, we document that withdrawal is associated with worsened perceptions of political risk and investor confidence. We document how the negative reputational consequences vary based on states’ and IOs’ preexisting reputations. We also show that withdrawal reduces the chance of being elected to the UNSC as a non-permanent member and makes states less likely to sign future treaties with the exiting state. We expect the material consequences of withdrawal to be limited due to strategic selection, substitution, and potential gains. We test these arguments on economic IOs because they represent more than half of all IOs and they can be evaluated consistently. We find that withdrawing states on average suffer limited material consequences.

Why do states exit IOs? How often does IO exit happen? And what are the consequences of IO exit for leaving states? Despite recent attention to individual cases and the importance of membership in IOs, little is known about state exit from IOs across states, organizations, and time. Chapter 1 outlines the common logic of IO exit that links withdrawal and suspension: States often use IO exit as a strategy to negotiate institutional change when mechanisms of voice have failed. We summarize our empirical contributions that rely on a new dataset of IO exit across 198 states and 534 IOs from 1913 to 2022. We show that exit is infrequent, intermittent, and often temporary rather than terminal. Factors related to bargaining help predict IO exit, and exit generates negative reputational and cooperative consequences for leaving states. Nonetheless, IO exit is often an imperfect tool in achieving institutional change. Overall, we correct the view of IO exit as recently increasing. We also show that alternative arguments are not correct: IO exit is not widely occurring because of a backlash against globalization, nationalism/populism, IO authority, or legal rules. Moreover, exit is not inconsequential. We end with a roadmap for each chapter.

Chapter 5 traces the dynamics of our argument about the causes and consequences of IO withdrawal with three qualitative case studies: the US’ withdrawal from the ILO from 1977–1980, Japan’s withdrawal from the IWC in 2019, and the UK’s withdrawal from the EU in 2020. The cases show how states often think of withdrawal as a negotiation tool and highlight states’ long-term striving for “better” institutional arrangements through other mechanisms of “voice” before exit. In each case, we use archival research and media sources to document that the desire for IO change prompted exit, that states used withdrawal threats for negotiation, and that negotiation prior to withdrawal happened but fell short of the state’s goals, leading to withdrawal. In the cases of the ILO and IWC, negotiation continued while the state was a non-member and led to its return in the case of the ILO. The case studies also underscore the effects of withdrawal: Each of the withdrawing states suffered negative reputational and cooperative consequences and sometimes material consequences from withdrawal. International actors chastised withdrawing states, and the withdrawers then engaged in rhetorical stigma management to try to lessen the impact.

Chapter 2 theorizes the causes and consequences of state exit from IOs. We explain that IOs start as being beneficial to member states but may become dissatisfying to some states as preferences diverge, power shifts, or IOs themselves evolve. Leaning on the “exit, voice, and loyalty” framework by Hirschman (1970), we argue that dissatisfied states can voice their discontent but when this does not generate desired results, states sometimes use the process of IO exit to invoke change. Threatening and enacting exit can accelerate a tipping point by presenting states with a potential future without the exiting state, which could reduce institutional benefits. The ability to use exit as a negotiation strategy shifts with a state’s bargaining power as well as institutional constraints. As part of the negotiating process, many exit threats are not implemented and many exiting states return to IOs. But exit is costly: Given that exiting states may be perceived as reneging on an international commitment, they can incur negative reputational and cooperative consequences from other actors in the international community. Exiting states may therefore engage in stigma management. And while institutional change is often the goal, exit is usually an imperfect tool for achieving it.

Chapter 3 outlines and tests our theory of IO exit by applying it to the predictors of IO withdrawal. We argue that many dissatisfied states use the process of withdrawal to broker deals for institutional change in the IO. Many withdrawals are driven by preference divergence from other member states or declining power. Using our IO Exit dataset, we analyze 387 IO withdrawals from 1913 to 2022 across 534 IOs and 198 states. In categorizing the reasons for state withdrawals, we show that two-thirds of IO withdrawals are motivated by the desire to negotiate change rather than by issues that reflect populism, nationalism, or capitulation toward international cooperation. States also use the threat of withdrawal, which supports the notion that exit is a negotiating process with multiple steps rather than a final or singular act. Withdrawal is usually not permanent; half of the time, states return to the IOs they left. States also likely consider costs a priori and avoid withdrawal if the costs are projected to be too high. This prevents many withdrawals from happening in the first place. We do not find consistent support for alternative arguments that backlash against globalization, encroachment from authoritative IOs, nationalism/populism, or legal rules are robust drivers of withdrawal.

Anaesthesia for ENT surgery in children is varied, interesting and challenging. It ranges from grommet insertion and adenotonsillectomy, some of the most commonly conducted procedures in children, to the rare and evolving fields of airway reconstruction and EXIT procedures. Excellent teamwork and situational awareness are crucial to be safe and effective. This is particularly important in airway surgery given the small size of the paediatric airway, which is shared and often crowded with instruments, the sensitive physiology of small children and their frequent and complex comorbidities. Multidisciplinary team meetings and shared decision-making is increasingly important for these complex procedures and also on occasion for commonly conducted ENT procedures where there is a paucity of data around central issues such as postoperative admission criteria in children with obstructed sleep apnoea (OSA) and analgesia after tonsillectomy. Ultimately agreed local guidance should be followed as further investigations continue. An area of particular interest is the development of more effective modes of oxygenation such as high-flow oxygen delivery.

The concluding chapter discusses the implications of Hong Kong’s contentious politics within the global context of democratic backsliding and spontaneous mass mobilizations. We highlight the contributions of our theoretical framework and the implications of Hong Kong’s contentious pathways for hybrid regimes and beyond.

This chapter samples some basic signs of location, such as exit and entry, names of cities and streets of various sizes and styles.

Whether a society adapts to a supply shock or resists it coercively depends on the costs of each action. The more costly is adaptation, the likelier is a coercive response. We consider three kinds of adaptation, each usually costlier than the last: factor substitution, factor mobility, and factor-saving technology. Where substitution is elastic, producers can readily substitute a cheaper factor for one that has become suddenly expensive. Inelastic substitution forecloses that alternative, but often a suddenly devalued factor can exit to a different sector or region where it remains in higher demand. Where neither substitution nor exit is possible, a factor-saving technology or institutions that use a factor more efficiently – e.g., where labor is suddenly scarce, a labor-saving technology – can sometimes be adopted or invented. The puzzle, addressed in the next chapter, is why a new technology does, or does not, arise.

A subset of youth respondents in the study express how disappointment, frustration, and anger color everyday citizenship. They report how unmet promises, corruption, repression, and exclusive politics undermine their sense of citizen belonging and amplify tensions with elders. Such frustration may lead youth to contest citizenship in alternative ways, though most do not choose these paths. A small number exit, as indicated in Afrobarometer data and by our respondents. Some actively contest citizenship through the exclusion of others along ethnic or religious lines – patterns manifest among Ghanaian and Ugandan respondents and evident in survey data. Although some could choose to follow leaders who claim to speak for the people, comparisons of youth support for such populism in Tanzania and Uganda, on the one hand, with their support for the Economic Freedom Fighters in South Africa, on the other, provide inconclusive evidence that youth embrace illiberal populism. A subset channels anger into local and national mobilization, illustrating youth citizens as agents.

There are often claims that competition law does not or should not apply to entities that operate on a not-for-profit basis. Operating on a not-for-profit is not however accepted as a reason to exclude an entities activities from the scope of competition law. Competition law is applied to non-profit providers and this essay identifies a number of ways in which not-for-profit status can influence the way the law is applied. It then considers whether, particularly when not-for-profit entities are competing with for-profit entities, whether and why modifications in the application of the law are justified.

This chapter advances a theory of the citizen-consumer that connects the quality of basic services to trust in government, trust in government to consumer behavior, consumer behavior to citizen political participation, and citizen political participation back to the quality of basic services. When basic services are sound, citizens trust the institutions of government; when basic services fail, citizens distrust those same institutions. People who trust government rely on public services, whereas those who distrust government opt instead for more expensive commercial alternatives. This distrust premium is pure profit to government’s commercial competitors and is paid disproportionately by the politically marginalized. Consumers who use public services have a strong interest in safeguarding quality, so they are politically active citizens, demanding high-quality public services. Consumers who abandon public services in favor of commercial firms withdraw from political life. These distrustful, disengaged citizens demand little from government and oppose public investments. Starved of resources and attention, governments’ service quality declines and a vicious cycle of distrust ensues.

High-profile water contamination crises like the one in Flint, Michigan, shake confidence in US water systems. This chapter examines the links between tap water failure, reduced trust in utilities and government, and increased demand for commercial water. We show that negative experiences with basic service quality erode overall trust in government and increase demand for private alternatives. Analyses of data from three independent national surveys demonstrate that individuals who experience problems with their local water such as dirty, bad-tasting, or low-pressure water service also report lower trust in local, state, and federal government. The relationship between water service quality and trust in government persists after controlling for party identification, race, ethnicity, and socioeconomic status. We also find that tap water failure correlates with increased demand for commercial water sold from water kiosks, privately owned commercial water vendors. Taken together, these findings suggest that basic service failure erodes performative trust in government and increases demand for commercial drinking water.