Global Health Diplomacy: A Call for a New Field of Teaching and Research

Thomas E. Novotny, MD, MPH, and Vincanne Adams, PhD

"Medicine is a social science, and politics nothing but medicine on a grand scale."

Rudolf Virchow, the nineteenth-century Prussian physician now recognized as the father of modern pathology, is famous for this aphorism. He espoused that social, economic, and political inequality, more than biological causes, were at the root of the 1848 typhus epidemic in Upper Silesia, Prussia. Only political reforms, he felt, could solve the health crises of his day (Taylor 1985).  

The relationship between medicine and foreign relations has a long and complicated history. From missionary medicine to postcolonial efforts to establish health systems, health assistance has been used to help keep armies functional, support some semblance of altruism in colonial governments, and stabilize crisis situations where politics have failed. Politics are often a root cause of health crises, especially in conflict settings resulting in genocide, social violence, and egregious inequality. At the same time, medicine can provide the first steps toward bridging cultural gaps, not only to alleviate human suffering but to defuse international conflict.

This, however, requires political commitment, educational commitment, and resource commitment to maximize the impact of direct humanitarian assistance and long-term development investments. With recognition of the critical interaction between health and foreign policy, today’s global health professionals need to be diplomats as well as providers, investigators, and managers. Given the changes in global health wrought by the new philanthropies and by the egregious failures of U.S. diplomacy in recent years, there is hope for a new approach to global health grounded in sensible, ethical, and informed health diplomacy. This approach requires a full understanding of the political, historical, cultural, religious, economic, and ethical contexts of health assistance and development efforts.

Global Health Diplomacy

This is a field in the making that may provide interdisciplinary training of health professionals to improve delivery of global health services, development assistance, and scientific investigation. Such training will support the U.S. Department of Health and Human Services’s call for global public health preparedness, security, and responsiveness, as well as the larger global health community’s efforts to grapple with the new resources available in international health philanthropy (Garrett 2007). Recently, the U.S. Public Health Service, in its annual professional meetings, has called for increasing the capacity of public health professionals in the skills of diplomacy to serve as a “bridge for peace and security” (Couig 2007).

Although one can identify historical efforts at health diplomacy in missionary, bilateral, and multilateral health aid, the field of global health diplomacy is still poorly defined. Consider the shifts in international relations and health development that make health diplomacy training and research more important today. These shifts include:

1. The Globalization of Infectious Diseases. Although many infectious diseases have always been considered “international” problems (McNeill 1989), there is a shift in intensity and rapidity of the spread of many emerging and established pathogens (Garrett 1995). These conditions suggest a need for new responses that require cooperative efforts across geographic, political, national, and ethnic borders. The effects of epidemics include unseen economic and human consequences, such as AIDS- and war-caused orphans in Africa or impoverishment of Chinese chicken farmers who eradicate their flocks because of avian influenza. These consequences need to be understood as problems of globalization, with a critical need for global governance to manage not only the biologic threats but also the political and social fallout that accompanies such efforts (Fidler 1996). 

2. The Emerging Ethical Vacuum. Although there is growing need for institutions capable of assuring ethical decision making at the local and global levels, very few institutions such as this exist in the developing world. Questions over what is fair and equitable (regarding distribution of resources, obligations, health outcomes) are debated but often unresolved (Farmer 2001, Novotny 2006). Other ethical challenges include protection of human subjects and use of newer technologies (stem cell research, genomics, etc.) (Adams 2006, Emanuel 2004). These ethical challenges require the skills not only of scientists but of ethicists who think at the global level. For example, how can we alleviate the “brain drain” of qualified health professionals from resource-poor countries while still attending to health care manpower shortages in the developed world? There are extraordinary needs for equipoise in global health interventions, with complexities extending beyond bioethics to include politics, history, and economic concerns.

3. Nonstate International Assistance. The new philanthropies and nongovernmental organizations (the Bill and Melinda Gates Foundation, Rockefeller Foundation, Médecins sans frontières, Rotary International, etc.) have altered the traditional missions and relative roles of bilateral and multinational organizations alike in the twenty-first century (Cohen 1999, Garrett 2007). Health professionals must retool their thinking about the relationship between national/state organizations (such as the Centers for Disease Control and Prevention or the U.S. Agency for International Development) and these nonstate organizations. There are also new private-public partnerships, such as the Global Fund for AIDS, TB, and Malaria, with unclear accountability patterns and shifting responsibilities that affect national health sovereignty. The field of health diplomacy must explore the new alignments of governance that emerge from these shifts and help define what critical skills are needed to work within these new relationships.   

In response to these and other global health developments, we identify three possible areas for emphasis in research and training in today’s health science education:

Postconflict Health Assistance

Effective health interventions can serve as a diplomatic tool to reduce violence, inequality, and conflict, no matter how large or small the intervention. Health aid can work where political efforts alone fail. Global health professionals have long understood that in situations of ongoing war, violence, and genocide, health and scientific assistance can improve political outcomes (including nation-building) through both relief efforts and the establishment of good institutional relationships (Jones 2006). Health diplomacy can help create political will for social and democratic reform, especially in the postconflict environment (Adams 1998). Examples of this sort of health diplomacy are numerous (for example, Doctors without Borders, various AIDS advocacy organizations, and faith-based health groups), but there is no systematic training program that focuses on providing these skills to students in the health professions.

Social Determinants of Health

Training in health diplomacy must address the social determinants of health, providing contextual approaches to politics, history, economics, religion, ethics, and culture needed for successful health intervention programs. Reducing global health inequality requires a clear understanding of these contextual issues and a clear vision of mutuality, instead of antiquated donor-recipient power relationships (Farmer 2004). Health diplomacy identifies the key social and political determinants that play a role in successful health development projects as a basis for success. 

Building Global Health Governance

Health diplomacy can promote political solutions as a truly collaborative global effort. Increasingly, there is a need for such political policy-making across nations, regions, and cultural divides for maximum impact on health. Global health objectives have been prioritized as collective activities in the Millennium Development Goals in order to galvanize action by various players (United Nations 2002). An example of this is the L-20 Declaration of 2006, wherein heads of state committed to specific Global Action Plans in health, education, and environment (Bradford 2004). Other recent examples are the Framework Convention on Tobacco Control (the world’s first health treaty) (Novotny 2006), the revised International Health Regulations (Fidler 1996), and the Global Health Workforce Alliance (WHO 2006) Global health diplomacy functions within these instruments of governance to solve health problems as multinational alliances of health organizations and governments. However, this cooperative effort must also be understood in the proliferating NGO and private-public partnerships that operate beyond the state and international channels of health governance (Garrett 2007). 

Effective health diplomacy requires new pedagogy and research priorities, including perspectives on globalization, cultural competence, research translation to the developing world, macroeconomics, and political negotiation. The new cadre of students entering health sciences training institutions today will become leaders in our health system tomorrow. As global health professionals with these new skills, we might anticipate improved leadership at the national level, both in international health and in academic research. The results of this new leadership (which we might call the “Peace Corps Effect”) will be an emphasis on health diplomacy as a tool to support international stability, reduce conflict, and secure economic development across nations through health cooperation.

In order to further define the field of global health diplomacy, we at UCSF have undertaken a new initiative with support from the Institute on Global Conflict and Cooperation (IGCC) at U.C. San Diego (a multicampus research unit) and the U.S. Centers for Disease Control and Prevention. We will hold a workshop of major international health and diplomacy experts in March 2007, during which papers and discussions will be presented with multidisciplinary perspectives. Based on findings from that workshop, we hope to develop a global health diplomacy training program that may be offered in 2008 through IGCC’s summer training programs or UCSF’s proposed master’s program in global health sciences. There are now many new programs in global health education across the United States, as well as an extensive project to develop on-line educational modules by the Global Health Education Consortium (GHEC 2007). Health diplomacy may be a critical new field to address in all these activities, and, as with all good international health interventions, this effort will benefit from cooperative actions. We invite reader input.