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21st Century Global Health Diplomacy

Posted on by Laurie Garrett

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 The perils of pandemics and poor health have never been problems neatly confined inside of national boundaries. Certainly the empires of the Incas, Aztecs, Shona, Yoruba and hundreds of other non-European peoples learned this ugly lesson when explorers and conquistadores from afar brought hitch-hiking deadly microbes to their shores. Following the Black Death of the 14th Century many European societies incorporated forms of “health” provision into essential governance. But no European government in the Middle Ages could separate “disease” from “religion”, as they had no germ theory explaining why suffering and death occurred. As a result, cooperation across borders to control spread of disease inevitably confronted religious and cultural differences between societies. Disease, therefore, furthered tensions, contributed to conflict, and undermined European social cohesion.

During the 17th century, Europe was torn to shreds by the Thirty Years War: the culmination of what had actually been 140 years of violence across the continent and into the British Isles, often under the banner of Catholic versus Protestant domination. Tiny nation-states, even mere city-states battled endlessly, each trying to impose its religion, values and trade advantages upon another.

In the end the bloody carnage was war over sovereignty – what defines a State? When, if ever, does one State have a right to impose its will on another State? The terrible warfare ended in 1648 with the Treaty of Westphalia under which Europe defined shared terms of “sovereignty,” clearly delineated its borders and agreed to peaceful coexistence between religious states. From the Westphalian pact grew a golden era of European development, featuring spectacular cross-border sharing of scientific, medical, artistic and philosophical ideas. Countries created disease control mechanisms, and cooperated to slow the spread of epidemics.

The foundations of world cooperation in health were essentially set in the post-Westphalian environment, spreading from Europe to its colonies. In essence, the concepts of health – where do diseases come from, how are they spread, what should the State do in response – and the responsibility to protect the health of populations were both deemed to be domestic matters, to be determined by each State, separately. Tuscany might deem all disease the devil’s doing, and set up strings of Catholic-run quarantine centers, while Bohemia could define all outbreaks as the evil-doing of Jews and Gypsies, “containing” epidemics thru genocide campaigns. To each European State, his own, as it were. But collaboration between States, both in the form of sharing intellectual insights and in responding to outbreaks and epidemics, was encouraged as an element of European diplomacy.

The idea that health was part of the sovereign identity of a State has always had serious downsides. Rich countries could always afford to provide more hospitals and clean water to their masses than could poor nations. Dictators and cruel leaders could patently deny all forms of public health while squandering national wealth on other matters. And germs carry no passports: Viruses and bacteria do not respect Westphalian boundaries.

During the 1990s, with the fall of the Soviet Union and the rise of Globalization, the weaknesses in the Westphalian notions of health seemed to equal their strengths. By the time Boris Yeltsin was standing atop a tank in Moscow, fending off a would-be communist putsch, the HIV pandemic had successfully spread into every country on Earth, creating the third largest plague in world history. The Westphalian concept of health – embedding disease inside of sovereignty – was part of the problem. Country after country saw HIV coming, but refused outside intervention, insisted the epidemic was the result of some other State’s decadence or immorality, and failed to take steps to stem the virus’ spread until no reasonably effective and humane prevention measures remained.

When effective HIV treatment emerged in 1996, treatment and activist communities directly challenged Westphalian health notions, insisting that every country had two mandates: If rich, share the burden of cost and training for HIV care; if less rich, a nation had to allow outsiders, their drugs, clean needles, and condoms, inside, no matter what cultural and political taboos might be challenged. Both sides of this algorithm have proven politically painful.

By the dawn of the 21st Century this post-Westphalian view of health was the new normal, affecting not only contagious diseases such as influenza, HIV and tuberculosis, but also the very constructs of healthcare delivery and financing. Debate over HIV reached the UN Security Council and sparked two special sessions of the General Assembly. A fantastic increase in the flow of financing from wealthy nations to the poor during the early 21st Century propelled genuine revolutions inside nations, turning their health systems and notions of disease upside down. And within the donor countries the Christian question, “Am I my brother’s keeper?” has been answered in the affirmative for a range of global health concerns.

While health was part of diplomacy for the Westphalian State, it was only so during moments of agreed cross-border sharing of ideas or outbreak control. By 2013 health has become a thoroughly integrated element of overall diplomatic efforts in most of the powerful States, with the United States, in particular, incorporating health-related programming into the daily duty charts of its entire Ambassadorial corps, worldwide. Within the UN system diplomatic efforts now include noncommunicable diseases like cancer and diabetes, as well as a call for universal health coverage.

The concept is still evolving: “health diplomacy” remains an awkward theme, lacking global consensus in both definition and implementation. All global health practitioners and observers are struggling with the political and economic sides of the diplomacy equation, while political leaders remain flummoxed regarding “health” and governments’ obligations to the well-being of their own citizenries, much less humanity, planet-wide.

Novotny and Kickbusch’s compendium of essays helps a great deal. While in the end it poses many questions and leaves the reader still wondering what, precisely, “health diplomacy” may be, the book reveals the facets of debate, and evolving thinking. I very much doubt we will reach any consensus on the boundaries and implementation of “global diplomacy” during my lifetime, but this book will help sort out many of the issues, and guide the debate.

[World Scientific Press 2013]