Health as foreign po­li­cy

Kris­tin Ing­stad Sand­berg, Stei­nar An­dre­sen, Sis­sel Hod­ne Steen, Sig­run Mø­ge­dal, Kris­tine Hus­øy Onar­heim, Gra­zi­el­la Van den Bergh About the authors

The global health are­na may appear to be dominated by aid organisations, philanthropists such as Bill Gates and the pharma­ceut­ical industry. What role can the ministries of health and foreign affairs play?

Illustration Su­per­nøtt pop­sløyd

One late-sum­mer day in 1851, delegates from 12 countries were assembled around a table in the French Min­is­try of Foreign Affairs. They had gathered to find a so­lu­tion to prevent the spread of diseases across na­tional boundaries. Chol­era, plague and yel­low fever were the pro­blem. Each coun­try had two representatives present at the negotiations, one me­di­cal doctor and one di­plo­mat (1). This first In­ter­na­tio­nal Sanitary Con­fe­ren­ce was one of the earliest examples of attempts to establish inter­national agreements. Health was thus a pioneering area for global co­oper­ation.

A number of world chal­len­ges related to illness still cannot be addressed with­in the boundaries of individual countries, but require co­oper­ation regionally and internationally. This co­oper­ation has taken many forms, but more than a cen­tu­ry would pass be­tween the sig­ning of the first bind­ing inter­national health agree­ment in 1892 – regulating mat­ters such as quarantine ti­mes for in­ter­con­ti­nen­tal ship­ping – to the sec­ond one, the Framework Con­ven­tion on Tobacco Con­trol in 2003. Du­ring the last decade we have seen a completely dif­fer­ent level of activity, and the concept of health diplomacy is being used to describe the increasingly frequent inter­national nego­tiations on mat­ters pertaining to global health (2).

Nor­way raised its pro­fi­le in 2006, when Jo­nas Gahr Stø­re, Mi­nis­ter of Foreign Affairs, was one of the co-initiators of a new and uni­que initiative to link health and foreign po­li­cy, accompanied by foreign mi­nis­ters from Fran­ce, Bra­zil, In­do­ne­sia, Thai­land, South Af­ri­ca and Se­ne­gal. This group has become well known as the Oslo Ministerial Group, which in recent years has played a key role in set­ting a new agen­da for the role of foreign po­li­cy in the pro­mo­tion of global health (3).

What impact can inter­national negotiations and agreements have in a world where the volume of health-related de­vel­op­ment assistance from the richest to the poorest countries has more than quadrupled since the turn of the mil­len­ni­um (4)? In this art­icle we wish to highlight a new foreign-po­li­cy landscape, where health has emerged as a subject area. We need more knowledge to demonstrate how foreign po­li­cy has an impact on health, but we wish to elucidate how foreign-po­li­cy initiatives can play a role. We will illustrate this topic by referring to the efforts as­so­ci­ated with the Oslo Ministerial Group in particular.

A changing world

At the time of the Pa­ris meet­ing in the 19th cen­tu­ry, the chal­len­ges related to the spread of diseases were inextricably linked to the in­crease in in­ter­con­ti­nen­tal tra­de and the swelling tide of mi­grants. Emigration from Eu­ro­pe to the Ame­ri­can continent was a new and decisive fac­tor, as was the opening of the Suez Ca­nal (5).

In 1999, du­ring Gro Har­lem Brundt­land’s directorship of the WHO, the under­lying factors remained the same, but with a number of spe­cific chal­len­ges. Decades dominated by the se­cur­ity policies of the Cold War and build­ing of alliances were replaced by a far more com­plex world order. The differences be­tween in­dus­tri­al­ised and de­velop­ing countries were no longer as obvious, and the foreign-po­li­cy agen­da grew: Se­cu­ri­ty remained a key issue for all countries, but eco­nomic de­vel­op­ment, tra­de, environmental is­su­es and health were having an in­creas­ing impact on how the countries ex­pressed their interests on the inter­national stage. Foreign po­li­cy was undergoing change.

New chal­len­ges related to diseases emer­ging around the turn of the mil­len­ni­um gave a new impetus to health as a field of foreign po­li­cy. The SARS outbreak in 2003 came as a shock to the accustomed and con­tinu­ous flow of peop­le and goods. How­ever, the issue had been brought to the fore by the pro­blem of HIV/AIDS more than a decade earlier: The mat­ter landed not only on the desk of the health mi­nis­ter, but also in the offices of the foreign mi­nis­ter and the prime mi­nis­ter. How can the population be pro­tected against such threats? Countries such as Nor­way imagined frightening scenarios of an explosive growth in infections from neighbouring areas to the east, while countries such as South Af­ri­ca and Bra­zil found the cost of anti-HIV drugs to be an insurmountable bar­rier. Not least through pressure from civil soci­ety, the mat­ter was put on the UN agen­da, which led to a broad mobilisation across boundaries. Health chal­len­ges could not be addressed only at the na­tional level, but required a global pol­it­ical commitment.

Some interpret these op­por­tun­ities for widespread inter­national co­oper­ation as a dream of «a good global order», but how real are these ideas? The fear of a worldwide influenza pandemic in 2009 served as an unpleasant reminder of the chal­len­ges involved in balancing na­tional and global concerns: The rich countries, such as Nor­way, were quick to establish costly contracts with vaccine manufacturers in order to protect their own populations. They had standing orders for most of the global pro­duc­tion cap­acity. Poor countries and the majority of the world’s population had lit­tle chance to obtain simi­lar quantities du­ring the acute stage, when there was a scarcity of these vac­cines (6).

Health diplomacy

The influenza threat gave an impetus to the inter­national negotiation process Pandemic Influenza Preparedness (PIP) un­der the auspices of the WHO. This process pro­vides a good illustration of how health overlaps with other areas of inter­national pol­it­ics, and what health diplomacy really means.

In 2009, it was not only the distribution of vac­cines that posed a pro­blem. The negotiations started in 2007, when In­do­ne­sia refused to sha­re an influenza virus with a WHO-based net­work of la­bora­tor­ies. The net­work is intended to ensure an op­ti­mal sharing of in­for­ma­tion that can lead to de­vel­op­ment of vac­cines. But, as argued by In­do­ne­sia, if the pharma­ceut­ical industry pa­tents vac­cines de­veloped on the basis of an In­do­ne­sian virus, what will Indonesia receive in re­turn?

As the PIP negotiations progressed, it became increasingly clear that what appeared to be a mat­ter of me­di­cal science, concerning the use of a virus with a potential for caus­ing an influenza pandemic, also included a number of topics in which countries from many re­gi­ons have very differing interests, pol­it­ical ambitions and requirements. The issue of whether manufacturers should be granted pa­tents for vac­cines against pandemic influenza had repercussions far be­yond the negotiations with­in the framework of the WHO, reaching into negotiations in the World Tra­de Or­gan­iza­tion (WTO) and the World Intellectual Prop­erty Or­gan­iza­tion (WIPO).

It was of decisive im­port­ance for a so­lu­tion that the negotiations were raised from the «technocrats», i.e. the health ex­perts, to the level of am­bas­sa­dors, i.e. per­sons who have ac­cess to pol­it­icians in key pos­itions. Even though the core issue was that of disease and vac­cines, the re­pre­sen­ta­ti­ve delegates could not negotiate in isolation from ac­tors in civil soci­ety or bu­si­ness interests, and pol­it­ical concerns therefore assumed a ma­te­ri­al im­port­ance. Du­ring the fi­nal year, the negotiations were di­rec­ted by the Nor­we­gi­an and Mexi­can am­bas­sa­dors to the UN in Geneva, where both enjoyed widespread trust across countries and re­gi­ons. Here, the path was laid for a fi­nal agree­ment and signature in Ap­ril 2011.

Health diplomacy requires joint pro­blem-sol­ving. Negotiators from the foreign ministries are trained di­plo­mats, and are knowledgeable in many and di­ver­se fields. The tech­nical-sci­en­tific health ex­perts, or those who work with de­vel­op­ment assi­stance, are not alw­ays in agree­ment. Often, the ministries of jus­ti­ce and tra­de may be involved. The cases and pro­cesses take their course over sev­eral years, while the di­plo­mats move around. Therefore, agree­ment must be es­tab­lished not only be­tween the delegations from vari­ous countries, but also internally with­in the delegations and across na­tional ministries.

The Oslo Ministerial Group

Foreign po­li­cy has widened its scope to encompass health. Does this mean that countries are now prepared to relate to a new complexity in inter­national pol­it­ics? In a speech held at the Cen­ter for Strategic and In­ter­na­tio­nal Stu­dies in Wash­ing­ton DC in 2009 (7), Jo­nas Gahr Stø­re reflected on this question. Three years pre­vi­ous­ly, Gahr Stø­re and his French colleague Phi­lip­pe Doust Blazy de­veloped the idea for the Oslo Ministerial Group, or The Foreign Po­li­cy and Glo­bal Health Initiative, which is how the group refers to itself. They asked colleagues from five strategically im­port­ant countries, who were well known to them, to join.

The Oslo group is heterogeneous and therefore untraditional in inter­national pol­it­ics, where countries tend to seek each other out on the basis of geographic proximity or similarity of interests (3). The group wrote The Oslo Ministerial Declaration (8), which turned out to be an am­bi­tious consensus document covering topics ranging from migration of health personnel to the threat of climate change. The document is not a plan of ac­tion for the group, but rather an ar­gu­ment in favour of establishing a broad agen­da for global health, with the goal that increased awareness of health will have an impact on pol­it­ical pro­cesses in other sectors of foreign po­li­cy, such as UN-based pro­cesses on hu­man rights and peace-build­ing (8). The idea is summarised as «common vulnerabilities, shared risk and common responsibilities» (9, p.1).

In 2008 the group es­tab­lished a net­work of Geneva-based di­plo­mats and created a new space for informal consultations. Such consultations pro­vided a breath­ing space in for­mal inter­national negotiation pro­cesses, in which the fi­nal document often risks being watered down to the lowest common de­nom­in­ator of agree­ment. The Oslo group became a place where dif­fer­ent pol­it­ical goals and viewpoints could be discussed. The­re is an implicit agree­ment be­tween the seven countries that the group is not an are­na for negotiations, but rather represents an oppor­tun­ity to learn from each other and to un­der­stand and respect each other’s pos­itions. One of the authors of this art­icle (SHS) participated in the PIP negotiations, and experienced how the Oslo group be­- came a decisive resource that hel­ped create a favourable climate for the negotiations.

It is essential for the group that the seven countries not only represent four continents, but also have members in the G8 and G20 and that leading and strong de­velop­ing countries are in the majority. All the countries in the group have played significant roles. South Af­ri­ca, for example, played an ac­tive role in finalising three resolutions on health and foreign po­li­cy in the UN Ge­ne­ral Assembly. South Af­ri­ca occupies a strong pos­ition in the UN and in the group known as the G77, which includes all the de­ve­ lop­ing countries. This grouping was es­tab­lished as early as 1964, and appears in all set­tings where global is­su­es are on the agen­da. In 2010, Bra­zil took over the role of coordinator for the Oslo group. Until then, Nor­way had assumed the main res­ponsi- bility. Just like Nor­way, Bra­zil acts on its ambitions to play key roles in global pol­it­ics.

Health and foreign po­li­cy, so what?

Measuring the effect of the Oslo Ministerial Group is a demanding task in an age when measurable targets constitute the gold stand­­ard for global health initiatives. Insight into how the health diplomacy in Geneva actually works is one of the keys to un­der­stan­ding the Oslo group’s function, a group that has neither allocated funds nor defined milestones, but rather has sought to seize op­por­tun­ities for negotiated solutions wherever they arise. In the longer term the question is whether the group can have an impact in areas where health impinges on other, more trad­itional fields of foreign po­li­cy, such as tra­de, mi­li­ta­ry interventions and hu­mani­tar­ian aid.

The agree­ment with­in the framework of Pandemic Influenza Preparedness may appear spe­cific and tech­nical. Never­the­less, as an example set with­in a wider pol­it­ical context, the agree­ment is a vic­to­ry for global se­cur­ity, inter­national solidarity and the WHO, which is granted a clear, for­mal leadership role by the member sta­tes as a guar­dian of inter­national norms and ru­les for pandemic preparedness. The negotiations are evidence that global policies propounding a holistic, hu­ma­nist perspective are pos­sible in a di­ver­se, although unsettled, world order.

The initiative for health and foreign po­li­cy also in­flu­ences the Nor­we­gi­an debate on global health. Until 2006, the fo­cus was on health-related de­vel­op­ment assistance to the poorest countries and on new global initiatives, such as the GAVI alliance and The Glo­bal Fund to Fight AIDS, Tu­ber­cu­losis, and Ma­la­ria. Gahr Stø­re returned from Brundt­land’s man­age­ment team in the WHO with experience that extended be­yond is­su­es of de­vel­op­ment assistance, including the im­port­ance of taking into account the interconnectedness of all countries with regard to health chal­len­ges. The MFA’s de­ci­sion to put health on the foreign-po­li­cy agen­da raised the discussion on the WHO and its role in the gov­ern­ance of global health po­li­cy. This discussion has a far wider scope than the debate on de­vel­op­ment assistance, since it concerns global health as part of a whole, with­in a foreign-po­li­cy context (3).

If we go back to the first se­ri­es of In­ter­na­tio­nal Sanitary Conferences in the 19th cen­tu­ry, it is inter­est­ing to note that the negotiations were char­ac­ter­ised by uncertainty about the causes of chol­era. This discussion lasted for more than 40 years before the parties could finally agree (1). Since then, there has been a broad de­vel­op­ment of me­di­cal knowledge and of the tools avail­able to doctors. In the present day, we are also aware of the correlation be­tween better li­ving conditions and longer life expectancy. This correlation, known as the social de­ter­min­ants of health, gi­ves rise to questions of how na­tio­- nal and global policies impact health. If this new foreign-po­li­cy landscape is inter­preted as an area where the en­vi­ron­ment, food sup­ply and turmoil in the financial mar­kets are interconnected, could an em­phasis on health pos­sibly be an incitement for untried solutions?

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