Getting political: fighting for global health
Authors: Susan L Erikson
Journal: The Lancet (2008)

What if rather than maintaining the quixotic dream that global health not be political, we trained global-health practitioners to be savvy of international affairs to leverage mechanisms to advantage global health? What if we actively trained global-health partisans—health professionals trained specifically for the rigours of international politics—to smooth the way, work the backrooms, and strategically manoeuvre so that international public-health professionals can do what they do best: public health? What if these practitioners possessed in-depth understanding of foreign policy, international jurisprudence, and global security and were masterful enough to work health to the top of international affairs agendas not just during health crises, but every day? What I am suggesting goes far beyond the usual advocacy that international public-health professionals are already quite good at. I suggest we develop the clout and expertise to influence the course of international affairs. We live in halcyon days of global public health, buoyed by the Gates-Buffett effect,1Okie S Global health—the Gates-Buffett effect.N Engl J Med. 2004; 355: 1084-1088Crossref Scopus (34) Google Scholar but there are some health outcomes that money will not be able to buy, because powerful nations actively pursue foreign-policy agendas detrimental to health. This new approach would be prevention of the highest order. Imagine influencing trade agreements at their inception so that the food security of millions is assured and shortages averted. Imagine knowing enough about world finance to change the international financial institutions' conditions for loans that create health inequities. Imagine health as a human right with legal teeth, replacing the current mechanisms that require nation states to provide protections for their citizens, even when that same state is a perpetrator. Business as usual in these non-health settings has serious international public-health ramifications.2Grown C Braunstein E Malhotra A Trading women's health and rights? trade liberalization and reproductive health in developing economies. Zed Books, London2006Crossref Google Scholar The business of high politics has not traditionally fallen within remit of what is understood as global health.3McInnes C Health and foreign policy in the UK: the experience since 1997. The Nuffield Trust, London2005Google Scholar, 4Drager N Fidler D Foreign policy, trade, and health: at the cutting edge of global health diplomacy.Bull World Health Organ. 2007; 85: 162Crossref PubMed Scopus (46) Google Scholar But it should. Public-health experts regularly champion cooperation as an endpoint toward which we should all be working. Cooperation is inarguably a powerful tool for the management of global health, as the response to severe acute respiratory syndrome proved.5Skolnik R Essentials of global health. Jones & Bartlett Publishers, Boston2007Google Scholar But cooperation as a lone strategy for meeting all global-health objectives is naive when competition between states informs the dominant paradigm, realism, that has shaped relations from Whitehall to Washington for the past century. Realism in international affairs is not about seeing things as they really are, but rather refers to a philosophical doctrine that every international-relations undergraduate learns during their first semester: states are the primary agents in international affairs, states selfishly pursue their national interests, and sovereign states use laws and institutions to pursue these interests.6Klarevas L Political realism.Harvard Int Rev. 2004; 26: 18-23Google Scholar In such a framework, health is expendable when other interests, such as national security, are perceived to be at risk. Contrast the tenets of realism with today's global-health realities: porous national borders; weak and impoverished states struggling to provide health care; the "unruly mélange" of bilateral, multilateral, and non-governmental organisations7Buse K Walt G An unruly mélange? Coordinating external resources to the health sector: a review.Soc Sci Med. 1997; 45: 449-463Crossref PubMed Scopus (87) Google Scholar standing in for states; foreign debt undermining health financing in poor nations; and multinational corporations that successfully defend patent protections for essential medicines. Global-health realities are at odds with the prevailing paradigm. International public-health professionals compound this problem if they have too little understanding of the mindsets (of which realism is only one), histories, and concomitant power structures behind foreign policy and international affairs. International public-health professionals too commonly assume that the value of good population health—to individual societies and to the global community—is self-evident and that they should not really have to work too hard to compete with other agendas. Today's global-health gap is political. We currently do not have enough people knowledgeable and experienced in the everyday politics of international affairs working for advantages that support global-health progress. Global health needs advocates who embrace and understand international realpolitik, of which global health is but a part.8Kickbusch I The need for a European strategy on global health.Scand J Public Health. 2006; 34: 561-565Crossref PubMed Scopus (49) Google Scholar My argument is simple: cultivate foreign policy that helps rather than hinders improved global-health outcomes. This is distinguishable from the promotion of global-health policy,9Lee K Buse K Fustukian S Health policy in a globalising world. Cambridge University Press, London2002Google Scholar which is also necessary. Some global-health victories will depend on how well international politics are played. I declare that I have no conflict of interest.