New roles for global health: diplomatic, security, and foreign policy responsiveness
Authors: Sebastian Kevany
Journal: The Lancet Global Health (2016)

Global health initiatives such as the Global Fund to Fight AIDS, Tuberculosis and Malaria and the US President's Emergency Plan for AIDS Relief (PEPFAR) have, at present, no explicit or formal internal capacity to respond to the overarching diplomatic or foreign policy concerns of either their donors or the broader global community.1Michaud J Kates J Global health diplomacy: advancing foreign policy and global health interests.Glob Health Sci Pract. 2013; 1: 24-28Crossref Scopus (22) Google Scholar To the utilitarian, this respect for professional boundaries is to be welcomed. To the cosmopolitan, the increasingly connected nature of both the causes of, and solutions to, poverty, disease, ill health, and health security—in the context of associated considerations of world peace, non-health security, conflict prevention, and international stability—implies that all entities, individuals, and policies are interconnected, and cannot operate in isolation of each other.2Brown GW Moving from cosmopolitan legal theory to legal practice: Models of cosmopolitan law?.Leg Stud. 2008; 28: 430-451Crossref Scopus (25) Google Scholar As former President of the USA John Fitzgerald Kennedy remarked to the UN during its early idealism: “the long labor of peace is an undertaking for every nation—in this effort, none of us can remain unaligned. To this goal, none can be uncommitted”.3Kennedy JF Address to the United Nations Security Council.http://www.jfklibrary.org/Research/Research-Aids/Ready-Reference/JFK-Quotations.aspxDate: 1963Google Scholar Most recently, the blurring of the line of institutional responsibilities to advance and protect global and international health has been shown by an expansion of military purviews in response to such emergencies as the west African Ebola outbreak.4The LancetNational armies for global health?.Lancet. 2014; 384: 1477Summary Full Text Full Text PDF PubMed Scopus (11) Google Scholar Correspondingly, and in parallel, rationales exist for global health professionals and organisations to work, wherever possible, to resolve diplomatic and foreign policy issues beyond health—with the sine qua non that health outcomes, access to services, and “health for all” remain primary operational goals.5WHOConstitution of the World Health Organization. World Health Organization, Geneva1989Google Scholar Where collateral or downstream effects—of, for example, health systems strengthening initiatives—can advance non-health international affairs to the benefit and satisfaction of both donor and recipient countries, as well as the broader global community, there seems to be no reason why such an expanded de jure and de facto remit should not be encouraged. This has, of course, been happening since the very beginning of global health and international development efforts.6Alesina A Dollar D Who gives foreign aid to whom and why?.J Econ Growth. 2000; 5: 33-63Crossref Scopus (1358) Google Scholar What distinguishes a 21st century approach—an era of increasing levels of transparency, technology, education, interdigitation, and accountability—is the evolution of the implicit to the explicit; of a shift away from the covert use of aid to advance foreign policy and diplomacy (often in suboptimal ways) to an overt system of programme design, delivery, and evaluation that optimises both health and non-health goals in tandem with each other, in the mutual interests of both donors and recipients, and leveraging all available synergies. These considerations inevitably have implications for the type of interventions that are used; if in no other way than by ensuring that cost-effective approaches are also adaptable and responsive to local needs, cultures, religions,7Kevany S Khumalo-Sakutukwa G Murima O et al.Health diplomacy and the adaptation of global health interventions to local needs in sub-Saharan Africa and Thailand: Evaluating findings from Project Accept (HPTN 043)?.BMC Public Health. 2012; 12: 459Crossref PubMed Scopus (27) Google Scholar and other country ownership considerations.8Goosby E Dybul M Fauci A et al.The United States President's Emergency Plan for AIDS Relief: a story of partnerships and smart investments to turn the tide of the global AIDS pandemic?.J Acquir Immune Defic Syndr. 2012; 60: S51-S56Crossref PubMed Scopus (31) Google Scholar Consider international terrorism; a growing threat to which conventional “hard power” responses have had limited success in addressing. What could, or should, global health do about it? Dissociate (as advocated by the Deans of the US medical schools),9Buekens P Medical school deans' letter to President Obama.http://www.jhsph.edu/news/news-releases/2013/Klag%20letter%20to%20President%20Obama.pdfDate: 2013Google Scholar isolate, establish boundaries, and “stove-pipe”? Or accept the possibility that such disciplinary overlaps, and associated consideration of both health and non-health considerations in programme design, delivery, and location, are both benign and inevitable under “smart”,10Kevany S Global health diplomacy, ‘smart power’, and the new world order.Glob Public Health. 2014; 9: 787-807Crossref PubMed Scopus (37) Google Scholar multifarious, and interrelated approaches? To focus efforts only on health outcomes risks, as one report puts it, creating “tense and confusing dualities”11Center for Strategic and International StudiesFinal report of the CSIS Commission on smart global health policy.http://csis.org/event/rollout-final-report-csis-commission-smart-global-health-policyGoogle Scholar when measured against political, diplomatic, or other foreign policy metrics and benchmarks. It could therefore be both appropriate and timely for global health leaders to take the initiative in establishing mutually acceptable parameters for such interdisciplinary engagements before it is too late, and the chance for such inputs has passed. Two recent pieces—one developing an instrument for the establishment and evaluation of diplomatic and foreign policy principles and standards within global health programmes,7Kevany S Khumalo-Sakutukwa G Murima O et al.Health diplomacy and the adaptation of global health interventions to local needs in sub-Saharan Africa and Thailand: Evaluating findings from Project Accept (HPTN 043)?.BMC Public Health. 2012; 12: 459Crossref PubMed Scopus (27) Google Scholar the other proposing a set of codes or soft laws by which global health governance can control and calibrate its inputs to international security and the broader, non-health interests of the global community12Kevany S Diplomatic advantages & threats in global health program selection, design, delivery and implementation: the development and application of the Kevany Riposte.Global Health. 2015; 11: 22Crossref PubMed Scopus (13) Google Scholar—might help to provide the basis for such an approach. For so long reliant on resource allocation instruments such as cost-effectiveness, making narrow metrics the only consideration in assessing programmatic worth or value,13Kevany S. Global health engagement in diplomacy, intelligence and counter-terrorism: a system of standards. JPICT (in press).Google Scholar policy makers now have the option of expanded, holistic assessments of the effects of global health programmes across both health and non-health outcomes. To return to the original example, for how long can the Global Fund—an organisation with growing international influence—attempt to transcend the non-health political, security, and international relation concerns of the global community, which will continue to be implicitly affected by its interventions? Is the illusory virtue of apolitical aid—the very existence of which is highly questionable—worth the cost of avoiding (often minor) modifications to programme design and delivery that enable the harmonised achievement of benign health and non-health objectives? With the ascendancy of the global health diplomacy paradigm,1Michaud J Kates J Global health diplomacy: advancing foreign policy and global health interests.Glob Health Sci Pract. 2013; 1: 24-28Crossref Scopus (22) Google Scholar both bilateral and multilateral donors now have a powerful and unique opportunity to pursue and support noble humanitarian and international relations goals that are closely linked to the high ideals of global health. The development of diplomatic, political, and security, and foreign policy liaison offices—in the manner of the US Office of Global Health Diplomacy—would help to ensure that criteria for positive diplomatic and foreign policy effects are advanced in tandem with world health. By elaborating and making explicit to donors the benign collateral effects of health programmes, global health diplomacy approaches also present an important message to funders: that their investments, as well as pursuing altruistic ideals, also achieve even more “enlightened self-interest”10Kevany S Global health diplomacy, ‘smart power’, and the new world order.Glob Public Health. 2014; 9: 787-807Crossref PubMed Scopus (37) Google Scholar ends such as national security, international relations, conflict resolution, world peace, and the prevention or mitigation of armed conflict—through, for example, improved communications or the establishment of an international presence.14Kevany S Sahak O Workneh N Saeedzai S Global health diplomacy investments in Afghanistan: adaptations and outcomes of global fund malaria programs.Med Confl Surviv. 2014; 30: 37-55Crossref PubMed Scopus (11) Google Scholar At a time when arguments against the augmentation of hard power budgets have become increasingly compelling, if the same aims can be achieved through soft or smart power,15Bipartisan Policy CenterThe Case for Strategic Health Diplomacy: a Study of PEPFAR.http://bipartisanpolicy.org/library/the-case-for-strategic-health-diplomacy-a-study-of-pepfar/Google Scholar we stand on the brink of an era in which global health will become firmly established in the high political pantheon. I declare no competing interests.