Marrying foreign policy and health: feasible or doomed to fail?

We have been assured by both the Minister for Foreign Affairs Alexander Downer1 and the then Minister for Health Kay Patterson2 that interest in global health has increased. Academic studies have also noted growing attention to links between health, foreign policy and security.3 Much of this public interest may be a reaction to the HIV/AIDS and SARS epidemics, which affect Australians now or could do so in the future. However, it is hard to find a comprehensive foreign policy statement on health — global health is not in the index of the most recent annual report of the Department of Foreign Affairs and Trade, and there is no reference to the World Health Organization (WHO); nor does the Internet home page of the Department of Health and Ageing indicate any general policy on global health. Furthermore, until this year, Australia’s aid agency (AusAID) commonly bundled health with education in its reporting.

The important direct influences are easily recognised, as HIV/AIDS in Africa and SARS in Asia demonstrated, with the role of international institutions, notably WHO, as well as the health professions, being central. But foreign policies are commonly concerned with environmental, behavioural and other non-medical influences on health. For example, foreign policy aims to prevent military conflict and the resulting death and injury. While war currently accounts for less than 1% of global mortality,4 threats from nuclear, chemical and biological weapons remain. Moreover, war’s aftermath often has greater health impacts through damage to basic infrastructure — water supply, sewerage, hospitals and other medical services — as post-war Iraq demonstrates.

Much foreign policy activity related to the global environment has health implications, particularly for poorer countries. Australia is involved, for example, with international agreements restricting cross-boundary dumping of hazardous wastes (Basel Convention), reducing the use of ozone-depleting chemicals (Montreal Protocol), and ensuring the safe management of toxic and carcinogenic chemicals (Rotterdam and Stockholm conventions).

Trade negotiations also have health implications. For most economists, liberalised global trading and investment systems are fundamental to economic development, having been basic to gains already made in reducing global poverty and improving global health. While, as Gro Harlem Brundtland rightly says, poor health limits development, poor development also limits health.5 Agricultural trade reform in Europe and the United States would, in particular, greatly benefit developing countries, reducing subsidised competition for their producers and increasing their export market access.

Extreme poverty, a critical cause of ill-health, remains the main international economic challenge for the 21st century.6 Yet, the prevalence of poverty has been substantially reduced worldwide, except in Africa, and, over the past 30 years, life expectancies in developing countries overall have increased substantially. However, for economic development to contribute to health, good governing systems are required; much of sub-Saharan Africa, in particular, which lacks effective governance, gives low priority to human health. Australia has recognised the need to develop good regional governance as well as assist economic development. Thus, Australian aid policy puts “promoting improved governance” as the first of five themes for developing countries.7

Foreign policies also affect complex, and sometimes controversial, health issues, including:

• access to essential drugs for resource-poor countries;

• patents on pharmaceutical drugs, and other trade-related aspects of intellectual property (such as patents on genome sequencing); and

• protection of traditional knowledge and protection from biopiracy (the appropriation and monopolisation of traditional populations’ health-related knowledge and biological resources).

International debate continues over health aspects of trade in genetically manipulated organisms and the use of hormones in meat exports, such as from the US to Europe. Recent concerns in Australia relate to the effects of a free trade agreement with the US: one particular anxiety is that it could adversely affect Australia’s Pharmaceutical Benefits Scheme. It is argued, for example, that the US pharmaceutical industry wishes to reduce the use in Australia of generic drugs, thereby raising health costs.8

Australia’s earlier efforts to advance women’s rights internationally were aimed, among other things, at enhancing the capacity of women in other countries to make their own decisions on family planning and infant health programs, thereby improving family wellbeing and reducing infant mortality. (Similar reasons are behind the World Bank’s targeting of gender equality in its program on the Millennium Development Goals.9) These objectives were reinforced by Australia’s support for international action enhancing the rights of the child; more recent policy changes, however, have limited aid provided to family planning programs.10

Obviously, the effects of direct and indirect health-related policies commonly overlap. For example, in relatively few decades, the life expectancies at birth in China increased rapidly from around 40 years in 1950 to around 70 in 2000,11 and general health improved markedly. The main contributors to this achievement were economic development and better governance. Yet training in health practice and research methodologies, much of it from overseas sources (including Australian and other non-government organisations and aid agencies), was also critical.

Despite longer life expectancies, global health risks from disease have increased. Australia’s total annual aid program has been increased by some $79 million to meet these growing needs, and the proportion being spent on health has risen to some 12%–13% of total aid expenditure, which is above Australia’s past proportions and well above the average for the OECD in recent years.12,13 Furthermore, we are cooperating with the UN, WHO, World Trade Organization, OECD, and the Commonwealth of Nations in paying greater attention to global health.

Nevertheless, despite its humanitarian drivers, Australia’s aid program, like its wider foreign policy, has a large national interest component. National interests suggest that, where possible, we should deal with health problems outside Australia before they have an impact within Australia. We do not want to face problems of infectious and other disease when we travel, nor do we want our armed forces to face health hazards in other countries. That poverty may provide a potential breeding ground for terrorism is well recognised, and we are sensitive to bioterrorism threats. Finally, we do not want items such as food or drugs (legal or illegal) that damage our health to be imported, and Australia’s stated concerns about illegal immigrants also include health fears.14

It is also in our interests that our trading partners, particularly those in our region, are prosperous, especially given Australia’s strength as a commercial supplier of medical services.