Until recently, health has only rarely impinged on foreign and security policy. This has begun to change, principally in response to concerns over infectious diseases and bioterrorism. The result is that health is in danger of being absorbed into another agenda — promoting the national interest and defence of the state. These are the traditional goals of foreign and security policy. In the post-Cold War world, however, the possibility of a different approach to foreign and security policy has begun to emerge. This approach holds the potential for a more balanced relationship between health concerns and foreign and security policy.
The events of 9/11, followed quickly by “Amerithrax”, heightened sensitivities over the possible use of disease or biological weapons against vulnerable Western populations.1 As a result, public health systems have fallen into the orbit of security, being seen as a key element in the defence, even as a deterrent, against this form of attack.2 Over a slightly longer period, HIV/AIDS, because of its potential impact on national and regional stability, has also impinged on security debates.3 Concerns raised include the disproportionate HIV infection rate among security forces, the economic burden and the increased social fragmentation caused by the disease, its use as a weapon of war (principally through rape), and reluctance to send or receive peacekeepers due to the risk of HIV infection.4 For example, the risk of infectious disease has reduced the willingness of the United States to engage in peacekeeping operations; and Nigerian forces in Sierra Leone, as part of the West African peacekeeping mission ECOMOG, returned with high rates of HIV/AIDS infection.5,6
The HIV/AIDS threat to Africa resulted in a UN Security Council special session in January 2000. US Secretary of State Colin Powell has drawn particular attention to HIV/AIDS in Africa, and the Bush administration has committed US$15 billion to combating the problem. The spread of acute and potentially epidemic infections more generally, including Ebola, West Nile fever and monkeypox, has also heightened concerns within the foreign policy community over risks to the health and economic wellbeing of citizens and communities. Although the causes of the spread of such diseases are complex, globalisation, including increased population mobility, features prominently in many analyses, placing it firmly within the orbit of foreign policy.
As a result, a relatively narrow conception of the relationship between health and foreign and security policy has begun to emerge, one which is related to harder security issues, such as bioterror and state stability, and which primarily addresses the concerns of the security community. This move has been partly the result of foreign and security specialists beginning to deal with health issues from their particular perspective, but has also been aided by some in the public health community who see these “harder” security issues as a means of getting health onto the foreign and security agenda. The danger of this, however, is that health becomes “securitised”: that the international agenda focuses narrowly on the harder security concerns rather than on broader issues involved in global public health, such as the trade in goods affecting health and health services (including tobacco, pharmaceuticals and medical personnel). Further, there is a danger that, in public debate, health issues become secondary to national security, and, not least, that resources and attention are focused disproportionately on hard security issues rather than on issues of global public health. Compare, for example, the newspaper column space and resources devoted to the “war on terror” with those on the global HIV/AIDS pandemic.
In an important departure from this approach, Ilona Kickbusch (Head of Global Health at Yale School of Medicine and former WHO Director of Communications) has made the case for health as “soft power”.7 Kickbusch draws on the analysis of Joseph Nye (Dean of Harvard’s Kennedy School of Government) of the paradox of American power — that, despite its overwhelming military strength, in the 21st century the US must orient itself more towards the use of soft power than military force. For Nye, soft power is about getting others to want what you want through the use of culture, values and institutions, rather than forcing them to do what you want through the more traditional carrot and stick of diplomacy and force.8 Health may be seen as a soft-power tool in allowing the West’s lead in a variety of areas (including biomedical sciences) to promote global health. This is not to say that health should be used crudely to reward allies and punish enemies, but rather that the promotion of global health may reap dividends in promoting the image held of the West by others. If Kickbusch is correct in her analysis, then the risks of securitisation can be hugely diminished by a soft-power approach. Crucially, however, Kickbusch argues that a soft-power approach allows the US (and, by implication, others) to move beyond the narrow confines of promoting the national interest towards more global communitarian values.7 By implication and intent, this would allow a more balanced relationship to be established between global health and foreign and security policy.
Viewing health as soft power is alluring but hazardous. Aside from questions over whether Nye’s analysis is correct (and, for one, it is a perspective that does not seem to be shared by the current US administration), viewing health as a form of power creates a series of risks. Power is not usually an end in itself, but a means towards an end. Therefore, equating health with soft power raises the question of for what end? In this context, health initiatives, even those undertaken with the best of intentions, may be viewed by some with scepticism as being little more than vehicles for promoting national interests. Worse, such initiatives may be viewed as forms of neocolonialism, of the West exporting or imposing its own (health-related) values on the rest of the world. Furthermore, if health is a form of soft power, then what happens when the national interest conflicts with global health interests? The danger of Kickbusch’s argument is that health remains locked within the foreign and security discourse and that the latter imperatives will hold sway whenever the two come into conflict.
In the aftermath of the Cold War, and with developments such as increased globalisation, the possibility of a different form of foreign and security policy has emerged, allowing for a rather different approach to health and foreign and security policy. Globalisation has rendered boundaries porous, leading to the erosion of sovereignty, albeit at different rates across the globe. States are linked to other states in a complex mesh of relationships, with each dependent on and influenced by events in the others. Narrow conceptions of the national interest have become less relevant, and a more internationalist and communitarian perspective is required. Under these circumstances, a wider range of issues may become part of the agenda. Some of these may be readily identified: poor health may slow economic growth in a region, with implications for the global economy; and illicit trafficking in goods and people may have major health consequences for recipient states. But others are less obvious: the export and promotion by the US of fast food with a high fat content and sugar-rich soft drinks is often seen as a feature of globalisation. Given that these may have negative health consequences, does this make it a foreign policy issue?
Thus, some have argued that, in a globalised world, foreign policy should increasingly be concerned with “good international citizenship” and promoting the common good, particularly shared humanitarian values, rather than traditional realpolitik.9 At various times over the past decade, Western governments (including those of the US, UK and Australia) have been explicit in their argument that foreign policy should include humanitarian obligations that go beyond mere national self-interest. These arguments resonate powerfully with the promotion of global public health. Security policy has also been changing. Not least is a growing recognition of the interrelationship between national security and other “levels” of security, including both the global and the human. In this context, health issues may be security issues not only when they pose threats to the state, but when they risk human and global security. An example of this might be the trade in tobacco: for some exporting states, this is an immensely profitable business and therefore its continuation is in the national interest, but, at the level of individual consumption, the risk is sufficient to make this a human security issue. Finally, foreign policy, particularly in Europe, is no longer the preserve of an elite few, but is influenced by a broader constituency in civil society. In particular, non-government organisations have become increasingly involved in foreign and security issues, bringing a strong humanitarian focus to bear. Although their influence may vary, their profile is such that humanitarian concerns (including health issues) are increasingly a part of the foreign and security discourse.
Health has once again become a foreign and security policy issue. To date, the debate has been largely constructed in traditional terms (the impact on the national interest) and the relationship has been largely unidirectional. But a different representation of foreign and security policy creates an opportunity to reconstruct this debate along different lines, opening up a space in the debate for global health issues to be treated on their own terms and for a more equal relationship between the two policy communities.
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- 2. Prescott E. SARS: a warning. Survival 2003; 45: 207-226.
- 3. Elbe S. HIV/AIDS and the changing landscape of war in Africa. Int Secur 2002; 27: 159-177.
- 4. Elbe S. Strategic implications of HIV/AIDS. Adelphi Paper 357. Oxford: Oxford University Press/International Institute for Strategic Studies, 2003.
- 5. Ostergard RL. Politics in the hot zone: AIDS and national security in Africa. Third World Q 2002; 23: 333-350.
- 6. Chalk P. Infectious disease and the threat to national security. Jane’s Intelligence Review 2001; Sep: 48-50.
- 7. Kickbusch I. Influence and opportunity: reflections on the US role in global public health. Health Aff (Millwood) 2002; 21: 131-141, 132.
- 8. Nye JS. The paradox of American power. Oxford: OUP, 2002.
- 9. Wheeler NJ, Dunne T. Good international citizenship: a third way for British foreign policy. Int Aff 1998; 74: 847-870.
Abstract
Current international instability has promoted health to the foreign and security policy agenda; however, health is narrowly conceived in terms of promoting the national interest and defending the state, particularly from the risks of infectious disease and bioterrorism.
This development involves the risk of global health being co-opted into an international agenda that focuses narrowly on security concerns rather than on broader global health issues.
An alternative construction places greater emphasis on shared humanitarian values in a globalised world. This offers a more equal relationship between health and foreign policy and allows a broader range of issues (eg, trade in goods and services affecting health) to be considered in bringing together global health and foreign and security policy.