Global health diplomacy, health and human security: The ascendancy of enlightened self-interest.

The political, social, economic, and security implications of health-related issues such as emerging infectious diseases or the epidemic of Non Communicable Diseases offer a rare opportunity for professionals in foreign policy and international relations to engage with the health arena and at the same time for global health experts to enter into and intersect with the domain of diplomacy. The aim of this review is to understand and explore the concepts of global health diplomacy (GHD), health security, and human security. For this narrative review, a literature search was done in PubMed, Scopus, and EBSCO for the "global health diplomacy," "health security," and "human security," and full-texts were reviewed. The recent outbreaks of Ebola in West Africa and Zika in South America are pertinent examples of the nature of the human security crisis and the imminent and severe threat posed to human life across the globe as a result of these epidemics. The Commission on Human Security defines human security as the protection of the vital core of all human lives from critical and pervasive threats. We highlight the ways in which health has now become an issue of national security/global concern and also how GHD can aid in the development of new bilateral or multilateral agreements to safeguard the health and security of people in our globalized world. The paper provides a prospective about, and overview of, health and human security that essentially emphasizes the growing interlinkages between global health, diplomacy, and foreign policy.

Introduction

Global health diplomacy (GHD) is relatively a very new field that has yet to be clearly defined, and in terms of International Relations, theory is still early in its coining. The Commission on Human Security (CHS) defines human security as the protection of the vital core of all human lives from critical and pervasive threats. Globalization combined with the acceleration and intersection of knowledge and technology has revamped the conventional ways of conceptualizing the medical, economic, and political means of improving health. In the recent years, the rise of health as a foreign policy concern has indicated an increasing commitment and agreement by a wide array of diverse public and private actors at various levels of governance to the issue of global health. Thus, GHD is defined here as (1) a discipline with transformative potential for furthering human rights dialogue; (2) a platform for providing a framework that allows us a better understanding of global health issues and a better grasp of the negotiations around those issues taking place in many different global governance venues; (3) a paradigm that positions health in foreign policy negotiations;[1] and (4) a concept that is concerned with the design, selection, and delivery of global health interventions and programs in accordance with diplomatic criteria, thereby simultaneously advancing the health of the poor and contributing a health perspective in international relations, peacekeeping, nation building, and other traditional “nonhealth” concerns, including health and nonhealth security. Thus, diplomacy here implies state (and therefore security) interests (increasingly influenced by bilateral, multilateral, and global challenges) that in and of themselves present an argument for state/society complex responses to global health security threats. More broadly, GHD refers to (1) international diplomatic activities that (directly or indirectly) address issues of global health importance and (2) how and why global health issues play out in a foreign policy context.

Methods

A detailed literature search was done on databases namely PubMed, Scopus, and EBSCO focusing on GHD, human security, and health security in an attempt to analyze and understand the concepts. All the articles published after 1995 for which the full-texts were available were included, and a total of 40 papers were included in this narrative review. The information is compiled as per its emergence, role, dynamics, and application in foreign policy to improve overall human security, health security, and human development. The goal of this literature review exercise is to gather pertinent information and document the recent advances in this field and to investigate its link with foreign policy, human security, and health security. This literature review defines certain concepts such as global health, health diplomacy, history of GHD, changing relationship between health and foreign policy, and finally the role of GHD in improving health and human security.

Results

Since the beginning of the twenty- first century, health security concerns such as existence of biological weapons, rise in multidrug-resistant tuberculosis (MDR-TB), and persistence of HIV/AIDS and zoonotic diseases have grown exponentially.[2] As a result of the outbreak in 2003 of severe acute respiratory syndrome (SARS), which highlighted and made more urgent the threat posed by viruses in an interconnected world, the World Health Assembly in 2011 took a decisive step and agreed on the Pandemic Influenza Preparedness (PIP). Conventionally, security has been viewed in terms of protection of national borders, populations, and resources from threats emanating primarily from external and militarized sources. The concept of security has therefore been ostensibly state-centered. It claims as its main aim the protection of the “container” state (and only by extension its citizens) from any external (or in rare cases, internal) security threats; real or perceived. Human security is a broader concept that emphasizes common and global (rather than national) interests and prerogatives. It is about “putting people first.” The United Nations Development Program (UNDP) in 1994 identified seven dimensions of human security: economic, food, health, environmental, personal, community, and political. It also defined human security as ”safety from chronic threats such as hunger, disease, and repression” and “protection from sudden and hurtful disruption in the patterns of daily life.”[3] The CHS adds that human security involves the protection of the vital core of all human lives from critical and pervasive threats. Given that conception of human security, it should not come as a surprise that health security is conceived as an essential element of human security.

In the aftermath of the UN Millennium Summit, an independent CHS was established, chaired by former UN High Commissioner for Refugees Sadako Ogata and Nobel Prize-winning economist Amartya Sen. Its published report “Human Security Now”[4] led to the establishment of an independent advisory group tasked with advising the UN Secretary-General on the promotion of the human security concept.

Global health and diplomatic agendas

Global health is defined as “those health issues that transcend national boundaries and governments and call for actions on the global forces that determine the health of people.”[5] Another proposed definition defines it as “collaborative transnational research and action for promoting health for all.”[6] In other words, global health goes beyond the conventional borders of any state. It is by definition then human-centric. Any danger to its security is, therefore, a human security threat and not necessarily a threat to state security. Global health is concerned with the well-being of world's poorest people, irrespective of where they live. It is also concerned with all strategies for health improvement including population-wide efforts, individual-based healthcare actions, and cross-sectional collaborations: Global health has therefore become, over time, more of an interdisciplinary field, with links increasingly made between health and international trade, intellectual property rights, agriculture, education, and the environment.

Over the past few years, the global health paradigm has received significant attention. Most recently, the World Health Organization (WHO) and the United Nations Security Council (UNSC) both described the Ebola outbreak as one of the international concerns, reaching beyond health, because of its risks both to the security of individuals and to the peace and stability in the region. Both risks called for a global response. Previously, the UNSC had also called HIV/AIDS a “risk to stability and security,” but the resolution 2177 (on Ebola) is the first time that the UNSC formally labeled a public health crisis explicitly as a threat to international peace and security.

Evolution and role of global health diplomacy

Today's global health environment builds on 160 years of history establishing structures to promote health and fight diseases across national borders.[7] The subhistory of GHD can be broken down into five periods: The first International Sanitary Conferences (1839–1900), the first International Health Organizations (1900–1950), the creation of WHO (1948–1977), the Alma-Ata Declaration on Primary Health Care for All (1978–2000), and most recently, during the postmillennium shift toward a multipolar world, a more active role in global health by the financial, diplomatic, and private sectors (e.g., via adoption or support of the millennium development goals [MDGs]). All of this has led, in parallel, to a remarkable surge of interest in the topic of GHD: for example, official GHD offices or departments have been established at the WHO and at the U. S. Department of State, and there has been the emergence of related offices in other governments that are undertaking new GHD responsibilities.[78910]

In the past, the WHO developed several important international agreements including the 2011 Pandemic Preparedness Framework, the 2010 WHO Global Code of Practice on the International Recruitment of Health Personnel, the 2005 revised International Health Regulations, and the 2003 Framework Convention on Tobacco Control (FCTC). Given the global scope of these health codes, regulations, and agreements, more diplomats are now engaged in health negotiations, and conversely, health experts (including NGO advocates) are increasingly being drawn into the realm of foreign policy.[11] The 2011 UN high-level meeting on Non Communicable Diseases, the 2010 UN high-level plenary meeting on MDGs, and the 2010 G8 Muskoka Initiative on Maternal, Newborn, and Child Health have all demonstrated that health is now a critical topic not only for health ministries but also for foreign ministries and heads of states.[12] These new hybrid, synergistic, interdisciplinary dynamics have produced the field of GHD. They are also evident in the 2009 UN Secretary General's Report to the UN General Assembly (UNGA), which explicitly describes the core functions of foreign policy as “achieving security, creating economic wealth, supporting development in low-income countries, and protecting human dignity.”[13]

For GHD to be effective, it must rely on interdigitation: i.e., the bringing together of the disciplines of public health, international affairs, management, law, and economics (among others) to conduct negotiations that shape and manage the global (health and nonhealth) policy environment. The relationship between health, foreign policy, and trade is an example of the cutting edge of GHD: the realization that issues of international trade impinge on both health and diplomacy, often in significant ways.[14] Related issues and examples include international patent deals, vital need to regulate access to vaccines, and essential medicines list.

GHD therefore encompasses broad sets of activities and actors, such as (1) formal country delegations at bilateral or multilateral negotiations on health issues, (2) a combination of governmental and nongovernmental actors negotiating on health-related issues, and although often not considered ''diplomacy'' in the traditional sense, (3) official or semi-official representatives of one country acting in a health capacity in another country [Table 1].[15]

Table 1

Types of global health diplomacy activities

Type	Examples
Formal international bilateral and multilateral negotiations	Those that take place at the World Health Assembly and other multilateral forums and traditional negotiations between donor and recipient countries regarding official bilateral health assistance
	Negotiations around the WHO framework convention on tobacco control
	The U.S. PEPFAR partnership framework agreements on HIV/AIDS between the U.S. government and partner countries
Multi-stakeholder diplomacy	Often includes countries as well as nonstate actors negotiating on health-related issues
	The Global Fund to Fight AIDS, Tuberculosis, and Malaria and GAVI (formerly the Global Alliance for Vaccines and Immunization)
	The 2012 London Summit on Family Planning
Interactions between health actors from one country acting in another country	Include the activities of official and semiofficial representatives from donor countries acting in recipient countries, for example, the USAID, PEPFAR, or contracted NGO staff interacting with officials of the host country
	USAID country staff advocating inclusion of family planning services in Ghana’s national health insurance program
	U.S. Ambassador calling for greater funding of child survival programs in Malawi’s national budget[15]
Barefoot diplomacy	Ad hoc diplomatic duties undertaken by public and global health workers, for which no formal recognition is provided

PEPFAR=President’s Emergency Plan for AIDS Relief, WHO=World Health Organization, USAID=U.S. Agency for International Development

In the context of globalization, as noted above, GHD represents a new type of diplomacy that is necessary for navigating the changing landscape of international affairs and global politics. In the public health context, the emergence of cross-border disease, bioterrorism, shifting geopolitical environments, and the linkages between health, trade, intellectual property, and human rights present stakeholders with a complex matrix of technical and relational challenges.[16] Moreover, regional actors such as the European Union (EU), the African Union (AU), and the Association of Southeast Asian Nations (ASEAN) are intensifying their work at the regional level and placing health higher and higher on their respective agendas. However, the consequences of this intensifying dialog and increasing cooperation go much further than health-creating structures of communication (and, where possible, cooperation) among countries, thereby helping to establish a basis for both building political relationships and strengthening global governance.

Analyses of GHD to date suggest that some global health negotiations, such as the FCTC, have involved diverse actors interacting across public, private, and other sectors. The foreign policy community, however, has yet to reach such an epiphany in relation to global health – though there are encouraging signs. The Group of Eight (G8) countries has addressed health issues to an unprecedented degree over the past decade, and issue-specific meetings, such as the International AIDS Conference and the International Workshop on Influenza Pandemic Preparedness and Control held in 2006, have seen increasing participation of heads of state. Most notably, the Oslo Ministerial Declaration in 2007 marks a significant statement by seven foreign ministers of the need for closer links between global health and foreign policy.[17] There is rising acknowledgment and acceptance that closer interaction between the health and foreign policy communities is both desirable and mutually beneficial.

Discussion

Relationship between health and foreign policy

Health and foreign policy interacts and interrelates differently in different situations, which can be categorized into four arenas.[18] For example, the foreign policy interests and interactions of a country can advance health at a specific moment; however, in other circumstances, the same health may become an instrument of foreign policy. In each arena, a common theme is that national interests can be served but with a different influence and relationship with health. For our purposes, we redefine these four arenas as shown in Table 2.

Table 2

The major relationships between health and foreign policy

1. Foreign policy as detrimental to health: The impact of foreign policy on health can be detrimental when non-health sector policies and international agreements are negotiated but pay little attention to health considerations.[12] For example, in the first round of negotiations on trade-related and intellectual property rights at the WTO, health was completely neglected.[19] Foreign policy in support of national economic interests promoted by multinational corporations can also hinder health actions. Thirdly, health can also be negatively affected by the lack of agreements where they are most needed (e.g., and the absence of health discussions at the 2009 UN climate change conference in Copenhagen)

2. Health as an instrument of foreign policy: Health may be used as a tool to improve the relations between countries in varieties of ways. Such initiatives can also be used to convey a broader message to improve a country’s image at home and abroad. Examples include Cuban medical diplomacy and the oil-for-doctors trade agreement signed in 2000 between Cuba and Venezuela.[20] Agreements between Chinese and African states for health initiatives have also been closely linked to trade, economic, and diplomatic ties. Even the United States’ PEPFAR, the largest health initiative in history for a single disease, was launched in 2003 at the outbreak of the Iraq war. PEPFAR was, therefore, leveraged as a message to the global community related both to altruism and to balancing perceptions of USA at home and abroad.[12]

3. Health as an integral element of foreign policy: This approach is based on the understanding that in the past it was enough for a nation to look after its own health, but that today, that is no longer sufficient.[21] This approach recognizes that, whether in times of peace or war, disease is a major threat to human lives, health, and well-being. Therefore, to ensure national security by including health considerations, there is, currently, a need for strategic approaches at regional and global levels. This then resulted in two key achievements: The IHR and Pandemic preparedness framework (PIP)

4. Foreign policy serves the goals of health: When foreign policy serves the interests of health, a qualitative shift in the relationship between foreign policy and global health occurs. This shift is reflected in the Oslo Ministerial Declaration, prepared by the ministers of foreign affairs of Brazil, France, Indonesia, Norway, Senegal, South Africa and Thailand in 2006. Their goals were (1) to adapt foreign policy to contribute to filling gaps and loopholes in international cooperation in health and (2) to foster cooperation on health-related issues as a useful tool for diplomacy. In this initiative, diplomats rather than health officials took the lead and finalized agreements such as the FCTC, the revised IHR, and the PIP - both of which were all chaired and negotiated by high-level diplomats and not health experts.[12]

PEPFAR=President’s Emergency Plan for AIDS Relief, IHR=International health regulations, PIP=Pandemic Influenza Preparedness, FCTC=Framework Convention for Tobacco Control

Human security and its emphasis

Given the increasingly prominent role of health in global diplomacy, what might be its contribution to broader human security? As noted above, human security is a concept under which the general principles of human rights are interpreted and analyzed at the level of a single citizen. The increasing importance of the individual as the subject, also, of international relations (e.g., through an emphasis on human rights, development of the principle of the Responsibility to Protect, and strengthening of the legal protection of individuals before international tribunals) has shifting issues conventionally belonging to realm of internal state security to the international level of response. Human security, in the international relations context, is a people-centered, comprehensive, context-specific, and prevention-oriented approach to security that contributes to the enhancement of the protection and empowerment of people and communities.[22]

”Human security” was coined within the UN system. Initially, four characteristics of human security were highlighted: That it is universal, people-centered, interdependent, and based on early prevention.[23] Seven interconnected dimensions of human security were also described: economy, food, health, environment, the personal, community, and politics. In 1999, Japan and the UN Secretariat established the UN Trust Fund for Human Security (UNTFHS). Then a group of 13 countries (Austria, Canada, Chile, Costa Rica, Greece, Ireland, Jordan, Mali, Norway, Slovenia, Switzerland, Thailand, and South Africa – then an observer state) formed the Human Security Network (HSN) to promote the concept of Human Security.

What distinguishes human security from traditional security paradigms is its acknowledgment that severe and urgent threats to individuals could originate from nonhuman, nonterrorist, or nonmilitary sources. Global interventions are considered necessary when a threat is pervasive by impacting (1) several dimensions of human security simultaneously and (2) when state-level capacities are insufficient. Common examples are the epidemics of cholera, measles, smallpox, polio, HIV/AIDS, SARS, H1N1, and the recent Ebola virus disease. It also includes threats emanating from the state against its people.

The recent Ebola outbreak in West Africa and the spread of Zika[24] in South America are good examples of a human security crisis, both posing severe and imminent danger to human life in this globalized world. Today, in an interconnected world, bacteria and viruses travel quickly and easily across borders. Local problems thereby become global ones: The Ebola epidemic in West Africa was declared a global threat as it (1) posed danger to human life, (2) affected multiple dimensions of human security as defined by UNDP, and (3) was faced with inadequate state-level response capacities. In addition, the countries most severely affected by the outbreak – Guinea, Sierra Leone, and Liberia – are, also, just recovering from long periods of conflict and instability which were thought likely to re-erupt in the face of an unchecked epidemic. This underlying vulnerability not only hampered those states' ability to effectively prevent, contain, or stop the outbreak but also threatened other areas of human security such as a food crisis and an economic crisis that were precipitated by effects on agriculture and industry.

Taken together, these events illustrate that (1) growing interdependence among nations has challenged the traditional notion of “security” and (2) there is a need for a new notion of security that supplements traditional security – securing not only national boundaries but also the security of individuals and communities beyond and across borders. The CHS emphasizes the focus on three freedoms: freedom from want, freedom from fear, and freedom to live in dignity. For all of these freedoms, health is central and offers a concrete basis for developing human security strategies.

Progress, promise, and accountability for human security

Using the concept of human security in the GHD context is important for two reasons: First, it creates additional ethical obligations to protect individuals from real or perceived health threats, and second, it positions that obligation in the realm of collective responsibility. There has been consistent progress on human security in the global arena.[25] In 2004, the UN launched the Human Security Unit which manages the UNTFHS and supports the UNGA in its discussions of human security issues. UNGA resolution 66/290 (2012) describes the human security approach as one that links peace, development, and human rights and articulates shared understandings to guide its practice.

The language of human security and global health is also increasingly pervasive in foreign policy. For instance, the United States (US) government launched its Global Health Security Agenda in July 2014,[26] a bipartisan effort coordinated with other countries, international organizations, and private actors. Its mandate is to “accelerate progress toward a world safe and secure from infectious disease threats and to promote global health security as an international security priority.” Importantly, the U. S. Government acknowledges “global health security is a shared responsibility that cannot be achieved by a single actor or sector of government.” The Global Health Security agenda illustrates how the discourse of human security – with its emphasis on global security threats, and the collective responsibility to address those threats – has permeated U. S. foreign policy and enabled the articulation of new foreign policy systems such as smart power.[27]

Despite the progress on human security, there remain real limitations to policy implementation. Changing traditional thinking on security to include human security requires the development of innovative global instruments that (1) articulate collective responsibilities to provide human security and (2) increase possible collaboration and commitment across all sectors of international activity. For example, as the on-going Ebola crisis has demonstrated, we lack adequate transnational instruments for addressing human security problems that arise from an increasingly complex, globalized security environment.[28] One reason for this, perhaps, is that health governance is still largely state-centric, bureaucratic, and grounded in international law. Bureaucracies are organized around rules, routines, and standard operating procedures. Standardization generates predictable responses, which makes bureaucracies effective, but rules and routines can also slow them down.[29] For example, the WHO must adhere to the scientific procedures prescribed by the International Health Regulations – a legal framework that obliges states to first report certain infectious diseases to the WHO in order for a public health emergency of international concern to be declared. In April 2014, doctors without borders warned of the unprecedented nature of the Ebola crisis, but WHO, hamstrung by state-based reporting under the IHR protocol, downplayed concerns in part because it received only sporadic data on the number of cases. As a result, the WHO did not declare the outbreak an emergency until August 2014. Thus, paradoxically, the standard operating procedures and legal framework meant to guide the WHO also constrained its ability to act quickly in the face of what would become a global public health crisis.

Another reason why current international mechanisms are insufficient for dealing with these type of threats is that they do not circle back to those affected by human security threats due to inefficient nature of the feedback loop. The UN and WHO are comprised of member states whose elected representatives are accountable to their national constituencies. Conventionally, we think of political accountability as the processes and practices through which elected officials report on, and answer for, their performance to their constituents. To truly develop global instruments for human security, the global community needs to expand the meaning of accountability to reflect the transnational interactions that transcend and breach state boundaries, and that consider opinions of, and feedback to, individuals under threat. They in turn require mechanisms and instruments to make their needs known in a way that elicits an effectual response. People-centered human security needs people-centered accountability, but the major problem is that addressing human security is an “intermestic” and not just a “domestic” or “international” concern. Humanitarian NGOs have been working hard since the 1990s to develop workable standards and principles for accountability to beneficiaries (as well as donors) as a means of improving the quality of humanitarian aid. Learning from their experiences could provide valuable insights into how to shape a people-centered global governance approach to human security, as well as how to embrace closely overlapping prescriptions with principles of smart or diplomatic program design.[30]

Shaping human security through global health governance and diplomacy

Following the Ebola outbreak in West Africa in March 2014, major health and human security alerts throughout the world were put in place. Ebola[31] was declared as an official Public Health Emergency by the WHO in August 2014 and the UNSC (which had last adopted resolutions on HIV/AIDS in 2011 which recognized that the spread of HIV could have a uniquely devastating impact on all sectors and levels of society).

All such health negotiations aim to reach an agreement that can become either legally binding or nonbinding instruments which can have a significant legal and political impact on human security, as well as overlap with GHD. The national, global health strategies of countries such as Great Britain, USA, Norway, France, Germany, Japan, and Sweden also include health security among their goals and priorities: bioterrorism, infectious diseases, and drug resistance are linked to both human security and health diplomacy. Similarly, human development and security can be at least be partially addressed through GHD, including its legal instruments and through other drivers of health policy.

Global health problems involving diplomacy have become more diverse, ranging from pandemic infectious diseases (e.g., HIV/AIDS, influenza, Ebola, Zika), to the sale of unsafe, counterfeit drugs,[32] to the “brain drain” crisis involving health personnel emigrating from low-income countries.[33] The venues for diplomacy also now have unprecedented diversity, involving processes from the August chamber of the UNSC[34] to the private offices of the Gates Foundation.[35] Normatively, global health has also become more diverse as actors widen the ways in which they look at, articulate, and advance their interests – appealing to not only the traditional humanitarian ideals associated with health but also principles grounded in national and global security.

Health problems of all kinds have, therefore, taken on an urgency never before experienced in the long history of international health activities. The overlapping, often competing venues for diplomatic activity give GHD a higher status than that which prevailed when WHO was the unrivaled center of international health diplomacy. The speed of events, and its impact on players, problems, and processes, also affects how diplomatic activities reflect different normative concepts and international legal rules.

Health problems now include concerns related to antimicrobial resistance, emergence and re-emergence, product consumption, environmental degradation, poverty alleviation, and sustainability in national governance and healthcare capacities. Diplomatic processes are also evolving, with new initiatives frequently appearing, and attempts to shift issues among different forums often occurring,[36] not least the role of smart global health programs in advancing, directly or indirectly, diplomatic interests or agendas. GHD seeks to position health in foreign policy negotiations to develop new forms of governance that either (1) stimulate progress within the global health system or (2) help to improve health through the actions of actors in other global policy-making arenas.

The 2010 Report of the UN Secretary-General highlighted the rise of interlinkages between global health and foreign policy. There is, today, even greater scope and need for this inter-linkage which can move both the agendas forward and align with both national and global responsibilities. The report also recognized that associated complexities “require new capacities and skill mixes among health and diplomatic personnel working nationally, regionally and in multilateral institutions.[37]

There is, therefore, a need for governments to respond to these needs and implement comprehensive approaches to bridge professional cultures in a way that responds to a rapidly changing global environment.

Conclusions

Mapping GHD can also help identify patterns of interdependence, interconnectedness, and other characteristics that influence prospects for success or failure in addressing global health problems. Awareness of these patterns will be critical to devising strategies to shape GHD in ways to increase the likelihood of diplomatic success.[38] We see that global health has become more diverse as the actors widened and also the interests appealing not only to the traditional humanitarian ideals associated with health but also to the principles grounded in national and global security.[39]

GHD is also now conducted in multilateral contexts as a method of reaching compromise and consensus in matters related to health so that new agreements promoting values and principles in the face of other interests (e.g., health security, human security) are adopted. GHD has the great potential to promote peace and security.[40] Yet, to date, GHD has had limited success in advocating for health goals within nonhealth settings or vice versa. A complete understanding of the reasons for this, and the scope for furthering this perspective, remains a priority. Should this lead to practitioners of global health and foreign policy working together with better understanding and coordination then health security, human security, and GHD will all improve? In parallel, global health, beyond direct efforts to contain disease, will also advance other realms of human security.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.