"Vaccine diplomacy": historical perspectives and future directions.

International cooperation for purposes of infectious and tropical disease control goes back to at least the 14th century, when early concepts of quarantine were introduced in Dubrovnik on the Adriatic Coast of Croatia [1], [2], and to the later date of 1851, when Europe held its first International Sanitary Conference for multilateral cooperation to prevent the spread of cholera and, subsequently, plague and yellow fever [3]. Such efforts led to a series of international sanitary treaties and conventions and ultimately to the formation of the Pan American Health Organization and the later establishment of the World Health Organization (WHO) [3], [4]. Some scholars trace our current framework for global health diplomacy to the writings of Dr. Peter G. Bourne in his role as special assistant for health issues to US President Jimmy Carter [5] and later (during the first years of the 21st century) to the launch of the Millennium Development Goals (MDGs) and the release of the “Report of the Commission for Macroeconomics and Health”, when global health was placed squarely in the international diplomacy arena [6]. Among the driving forces for these activities was an urgent need for diplomatic collaboration to combat pandemics caused by HIV/AIDS and seasonal and avian influenza, which came with the revelation that such diseases are threats to economic development and both national security and foreign policy interests [7]. There were also practical considerations concerning potential bioterrorist threats and situations that required international diplomacy, such as when Indonesia balked at sharing its time-sensitive avian influenza data or when Nigeria and Pakistan halted polio and other immunization initiatives because of religious tensions [7]–[11]. In 2007, foreign ministers from seven countries—Brazil, France, Indonesia, Norway, Senegal, South Africa, and Thailand—issued the landmark “Oslo Ministerial Declaration” that formally linked global health to foreign policy [12]. At that time, Kickbusch et al. defined global health diplomacy in terms of processes by which governments and civil societies both “position health in foreign policy negotiations” and create new types of “global health governance” [13], [14]. More recently, Kickbusch and Lokeny defined it as a “system of organization and communications and negotiation processes that shape global policy environment in the sphere of health and its determinants” [15]. A key element of modern global health diplomacy is that “no longer do diplomats just talk to other diplomats”, but instead a variety of experts in different areas and disciplines are now brought in to solve timely global health issues [13]. Katz et al. [9] have since categorized different aspects of global health diplomacy to include the following: (1) core diplomacy, referring to “classical Westphalian negotiations” between nations leading to bilateral and multilateral treaties, such as the recent WHO Framework Convention on Tobacco Control and International Health Regulations (IHR) 2005; (2) multistakeholder diplomacy, i.e., negotiations between or among nations and international agencies such as WHO, the GAVI Alliance, United States Agency for International Development (USAID), and nongovernmental organizations (NGOs); and (3) informal diplomacy, which includes peer-to-peer scientific partnerships, private funders such as the Bill & Melinda Gates Foundation, and even some government employees from USAID or the US military working more or less independently in the field due to unique circumstances [9]. Michaud and Kates have identified similar forms of global health diplomacy [16]. Kickbusch and Lokeny have also noted recently that the WHO director-general made frequent mention of health diplomacy in her remarks at the January 2013 executive session [15]. Among the factors responsible for this emphasis are globalization associated with the renewed emphasis on “soft power”, security policy, trade agreements, and policies concerning the environment and international development, as well as the inclusion of health issues as part of the United Nations and summits held by various government organizations and agencies, such as the Group of Eight (G8) and Group of Twenty (G20) nations, the European Union (EU), the Organization of the Islamic Conference (OIC), and the BRICS (Brazil, Russia, India, China, and South Africa) countries [15]. Still another factor is the increasing use of health attaches embedded in foreign delegations and agencies and increasing dialogue with low- and middle-income countries [15]. With regards to the G20 (and their BRICS-country components), I introduced the term “blue marble health” to refer to the unexpectedly high neglected disease burden among the poor living in emerging economies and even some G20 countries, circumstances such that these nations could drastically reduce global burdens of neglected diseases by taking greater responsibility for their own health concerns [17], [18].