The Rise of Health Diplomacy

October 17, 2011

Around the world, global health increasingly has become a part of foreign policy agendas and is included in national security, trade, and diplomacy discussions. The SARS outbreak of 2003 and the 2009 H1N1 influenza A pandemic show how quickly emerging infections can spread, costing lives as well as curtailing travel and trade among interdependent economies. One nation's health status and risks can affect not only its own prospects and those of its neighbors, but also those of the entire world.

Nations are integrating health into their foreign policy strategies in today's era of globalization, and are looking to global health diplomacy as a way to accomplish a variety of goals beyond typical health concerns. The increasing number of health actors on the ground, including wealthy donors, has resulted in an outpouring of health assistance in the last decade. These actors have also led to a variety of new assistance mechanisms, including public-private partnerships and global health initiatives. In short, the increase in players has changed the way things happen. Discussions that previously would have taken place between high-level diplomats are now taking place in a variety of different arenas.  For example, this month, Bill Gates, a private citizen whose organization funds global health activities on par with some governments (dispersing more than US$ 17 billion overseas between 2002 and 2006), will meet with national and state officials in Nigeria to discuss polio eradication. This meeting between a private citizen and health officials overseas is a good example of the changing face of health diplomacy.

What exactly is global health diplomacy? This term has many different meanings. It's used for activities ranging from formal negotiations, to an array of partnerships and interactions between governmental and nongovernmental actors.  In a recent article published in the Milbank Quarterly, "Defining Health Diplomacy: Changing Demands in the Era of Globalization" we describe these activities as falling into three different categories of interaction around international public health issues:

1. Core diplomacy - Bilateral and multilateral negotiations between and among nations to resolve disputes and enact formal agreements.  This definition includes international negotiations that fall under the auspices of multilateral institutions such as the World Health Organization (WHO).
2. Multi-stakeholder diplomacy - Refers to international negotiations and exchanges in which various state, non-state, and multilateral actors work together to address common issues, not necessarily intended to lead to binding agreements. This includes partnerships between government agencies (e.g., ministries of health and the US Centers for Disease Control and Prevention (CDC)), public-private partnerships (e.g., Roll Back Malaria or the Global Fund), and activities of organized non-state entities (e.g., WHO and the World Bank).
3. Informal diplomacy - Interactions between public health actors working around the world and their counterparts in the field, including host country officials representatives of multilateral and nongovernmental organizations, private enterprise, and the public. This category has sprung up because of the increasing number of government employees, NGO and private companies, humanitarian workers and researchers, all working in the same space.

Why does this matter?

Today, countries and their representatives (which no longer equates only to foreign service officers, but all working in the field) do not interact solely through traditional diplomatic channels, and the influence of independent actors on foreign policy is substantial. There are various events that illustrate how the outcomes of core diplomacy, multi-stakeholder diplomacy, and informal diplomacy can converge to quicken-and potentially resolve-health crises with international implications. One such example is the continual campaign for polio eradication. Polio remains endemic in only four countries: Nigeria, India, Afghanistan, and Pakistan. Each of these countries has complex challenges. Eradication in these nations is not just about science or money, but will require various types of diplomatic efforts to overcome unique barriers, in order to realize what actually is a global health objective. 

In 2003, the people of Kano State in northern Nigeria began refusing WHO-supported polio vaccination based on rumors that the campaign represented a Western conspiracy to sterilize Muslims. These rumors gained momentum among communities sensitized by the "war on terror." Here was a local health problem that threatened to spill across borders (and, in fact, did result in polio outbreaks all over the region), and was further exacerbated by national and international politics. Traditional diplomatic tools, such as state-to-state negotiations, were not sufficient to resolve what boiled down to a community problem.

The US State Department sought assistance from US leaders and other experts that had been working in the region, including the CDC and the US Agency for International Development. Officials from WHO, other UN agencies, the Organization of the Islamic Conference, and the US government engaged in unusually intense diplomatic efforts with Nigerian authorities to resolve the issue, utilizing expertise from those not normally involved in such actions (i.e., CDC). Ultimately, the negotiations proved successful and helped lead to the resumption of vaccinations.

Polio eradication in Nigeria has remained elusive, and today, the Gates Foundation is continuing the campaign and negotiating with state actors in hopes of finally exterminating the disease -  a clear instance of informal health diplomacy.

No longer is it practical for global health diplomacy to remain an esoteric pursuit for a few specialists. The expanding demands on global health diplomacy require a delicate combination of technical expertise and diplomatic skills, which have not been cultivated systematically among either foreign service or global health professionals. Despite widespread calls for more effective country-level coordination by health actors, formal mechanisms of communication are often fragmented by disease, sector, or bureaucratic silos.  The deepening links between health and foreign policy require both communities to reexamine the skills, comprehension, and resources necessary to achieve their mutual objectives. Both groups' skills and strengths will be necessary to realize the promises of health diplomacy.

Click here to read the full article in the Milbank Quarterly.

Photo Credit: The Gates Foundation, http://www.gatesfoundation.org/photogalleries/Pages/default.aspx#gallery=/about/Pages/timeline-gallery.aspxℑ=7&pager=1&filter