Global Health: A Pressing Foreign Policy Issue of our Time

Nevertheless, there have also been a number of global initiatives focusing on the intersection between politics and health, because health outcomes are not solely a function of health systems. There are so many other factors at play, which may be social or political determinants that arise from actions within states or globally. With globalisation, the impact of transnational actors – be it states, transnational corporations (TNCs) or civil society – and their actions, in turn, are driven by and founded on global social norms, which tend to reflect and perpetuate existing power relations. The impact on health can both be positive or negative; deliberate or a side effect. There is a need for more transparency in acknowledging these as much, as there is a need for more transparency in recognising public health as a foreign policy issue.

In the 19^th century, European countries attempted to deal with the spread of cholera plagues and yellow fever by negotiating international sanitary treaties. During the Cold War, health became one of the strategies for international competition. The then-Soviet Union, for example, approached the hosting of the Alma-Ata International Conference on Primary Health Care (1978) as an opportunity to demonstrate that socialism could accomplish what other political systems could not. In 1995, at its 48^th session, the World Health Assembly (WHA) agreed to revise the 1969 International Health Regulations (IHR), due to the fact that the existing regulations had a narrow scope. There had been an emergence of new infectious agents, such as Ebola haemorrhagic fever in the Democratic Republic of Congo (DRC) (then Zaire). Also, there was a lack of a formal, internationally coordinated mechanism to prevent international spread. These efforts led to the adoption of the current IHR (2005)^,1 which entered into force on 15 June 2007. It is instructive to note that the principles guiding the implementation of the 2005 IHR explicitly include “full respect for the dignity, human rights and fundamental freedoms of persons” and are “guided by the charter of the United Nations (UN) and the constitution of WHO”. A point of key concern, frequently raised in the application of the IHR, is that of ensuring that restrictions on travel and trade during outbreaks are justified, and that they are not used as political instruments. These restrictions tend to bring more financial harm to affected states and, if inappropriately applied, act as a disincentive to accurate reporting.

Towards the end of the 20^th century, the HIV/Aids pandemic, biological terrorism, the probability of an influenza pandemic, tension between health and trade objectives in international negotiations, the tobacco pandemic and the health consequences of conflict and humanitarian crises all served once again to propel health high up the agenda of the system of international relations and foreign policy.

It is against this backdrop that the ministers of foreign affairs of Brazil, France, Indonesia, Norway, Senegal, South Africa and Thailand, under their Global Health and Foreign Policy Initiative (FPGHI) – launched in September 2006 in New York on the margins of the UN General Assembly –
converged in Oslo on 20 March 2007 and issued a ministerial declaration under the same title: “Global Health: A Pressing Foreign Policy Issue of our Time”.²

The ministers asserted that “in today’s era of globalization and interdependence there is an urgent need to broaden the scope of foreign policy”³. They went further to argue that in spite of life and health being the most precious assets, “we believe that health is one of the most important yet still broadly neglected, long-term foreign policy issue of our time.”⁴ The ministers then committed to and invited others to join in a shared agenda for action, organised around three main themes of “capacity for global health security; facing threats to global health security and making globalization work for all”⁵. More importantly, the ministers, whilst affirming the World Health Organization (WHO) Secretariat and the WHA as the main arenas for global health governance, committed to ensuring that health as a foreign policy issue received greater strategic focus on the international agenda. None of the components of the Oslo agenda were necessarily new, but as David P Fidler observed: “The iconic status the Oslo Declaration achieved thus reflects recognition of how the seven countries captured, in a unique and high-profile manner, the rise of health within foreign policy.”⁶

Whilst there may be varied views on the actual impact of the FPGHI as measured against its agenda for action agreed in Oslo, as well as on the concept of global health security, there is no denying that it helped shine the light on global health and foreign policy, primarily in the UN General Assembly. For instance, it advocated for health-related impact assessments in the examination of foreign policy initiatives. Perhaps one of the greatest achievements of the FPGHI, which will further define its relevance in debates currently unfolding in the context of the coronavirus (COVID-19), is that it became a catalyst for a series of UN resolutions specifically focusing on the interface between foreign policy and health. Prior to this initiative, even though the UN had passed resolutions on health issues such as malaria and HIV/Aids, these were never on the critical interface between foreign policy and health.

COVID-19 – the disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) – has once again raised the wider impact of public health emergencies. It has brought into sharper focus and magnified issues that have been gleaned from other public health emergencies before it, such as SARS and Ebola. Globalisation, with its attendant enhanced speed of travel and communication, has increased the overall interconnectedness of the global community. What started as a health emergency in a city in a province in China has now become a global emergency, with no part of the globe immune to its reach. 

A number of features of this pandemic are worth noting, such as:

• It has overwhelmed even the most well-resourced systems in the world through specific characteristics of the virus, such as its high reproductive rate and the exponential nature of its growth. The speed of national responses has had to contend with the disruption of global supply chains as well as global competition for limited supplies.
• As a novel virus in humans, it demonstrates the extreme vulnerability of humanity and how we are interconnected to the other elements of our earth’s ecosystem.
• The fact that in many countries, the pandemic is imported through travel, has now warranted national lockdowns with severe restrictions on domestic, regional and international travel, making humanity more insular. This has raised the issue of an appropriate balance between the rights and duties of citizens. Sometimes, this is presented as a false dilemma of two systems: autocracy and democracy.
  In other instances, there has been a rise of national and ethnic chauvinism, as well as the fuelling of deeply ingrained prejudices, particularly across colour and race. Not only is there growing “othering” across national boundaries, but this is also bringing major faultlines to the surface –
  especially inequalities within states. Long-held social and religious norms are being reshaped, causing significant social and psychological dislocation. This is more so in the area of bereavement and grieving. 
• The national lockdowns and disruption of travel and major global supply chains are leading to severe contractions in virtually all economies, threatening a global recession. This, in turn, is throwing millions out of employment, ravaging informal economies and forcing many more millions who have no buffers to depend on to join the ever-growing army of the poor and destitute.
• In virtually every country affected, governments and policymakers are having to navigate the delicate balance between the imperative to save lives through containing the further spread of the virus and protecting livelihoods by preventing more damage to the economy, and its consequences.
• Even as global citizens and states grapple with the tensions that have been unleashed, there are important positives. Dealing with a new devastating disease is forcing the global scientific community to cooperate on an unprecedented scale. Experiences and lessons learnt in countries that experienced earlier waves of the pandemic are being shared across the globe. Daily, new information is emerging and being shared to confront an enemy whose course we do not fully understand. Governments, the private sector, philanthropists and wider civil society are drawn into partnerships in a race against time. Multiple and multi-centre drug and vaccine trials are testimony to the significant scientific and technological advances of our times, and a timely reminder that technology and science are collective endeavours.
• The resilience of our existing structures of global governance is being tested. aThe WHO is having to defend its scientific independence against accusations of political partisanship. It is having to bear the brunt of a much wider contestation for global dominance between the United States of America (USA) and the People’s Republic of China (PRC). The USA – the largest contributor to the WHO – is withholding its US$400 million annual contribution to this important global institution, essentially accusing it of protecting China. Right at the moment that all hands need to be on deck to contain a public health emergency, geopolitical and geostrategic tensions are surfacing. Meanwhile, fissures in the European project are re-emerging, just as it tries to pull itself together in the context of Brexit. 
• COVID-19 is reshaping the world. It is redefining the nature of globalisation and accelerating changes in the nature of work. There is no certainly about when the crisis will end; what is certain is that it will usher in a new world. Humanity may only be able to discern its broad contours, but the detail of this new world order is going to be an outcome of relentless contestation across a variety of fronts. Therefore, choices that will be made today will shape our tomorrow. In many countries, it has exposed the limitations of the structure of local economies and exercising of national sovereignty. This is leading to calls for devising strategies for import substitution; the development of local industries, especially in strategic sectors; and the growth of “buy local” movements, aimed at injecting life into national economies. What overall impact this will have on the international trading system remains to be seen.

What started as a public health emergency has had far wider ramifications. It has exposed our inability to protect the most vulnerable in our societies. It has exposed the dangerous characteristics of our international system – xenophobia, isolationism, global distrust and disunity. It has once again confirmed that in an interconnected world, we are only as strong as the weakest link in the chain. Viruses know no borders, and if there is any corner of the planet where they can survive, then they will remain an ever-present threat to all of us. We can bury our heads in the sand and revert to conceptualising this in the narrowest of terms as simply a public health emergency. But we can also confront the economic dislocation it has caused; the threat it is posing, both to national and global stability and security; the political alliances it is both firming and revealing; and the heightened debates on what societies we want to build. As UN Secretary-General António Guterres observed, this is a “formidable test to the global promise to leave no one behind”⁷.

Yet, COVID-19 is affording us an opportunity to reshape our system of international relations by focusing on what would make us stronger – global solidarity underpinned by empathy and respect for human dignity. It invites us to build more resilient communities as the only sure safeguard to a collective future. It teaches us, once again, that we are all vulnerable to public health emergencies. We need inclusive economies, so we can be true to our promise to leave no one behind. Only then can the next public health emergency find us better prepared and more resilient. This requires political will and acts of real statesmanship. It also requires global socio-economic and solidarity movements founded on a genuine understanding of our interconnectedness, both in virtue and in our vulnerability. We need to invest more in reshaping and reimagining our institutions of global governance, enhance their capacities and relevance, and make them more representative. It forces a reconceptualisation of the world we live in and how we interact as a global community of nations. It represents a challenge that is a pressing foreign policy issue of our times.

Dr Ayanda Ntsaluba is an Executive Director of Discovery Limited. Prior to that, he served as Director-General in the South African Department of Foreign Affairs (now the Department of International Relations and Cooperation) and Director-General in the South African Department of Health. 

Endnotes

1. See: World Health Organization (2007) ‘International Health Regulations (2005): Areas of Work for Implementation, Available at: https://www.who.int/ihr/finalversion9Nov07.pdf. [Accessed on 19 April 2020]
2. See: Oslo Ministerial Declaration – Global Health: A Pressing Foreign Policy Issue of our Time’, The Lancet, Volume 369, Issue 9570, 1373-1378, April 21, 2007. Available at: <https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(07)60498-X/fulltext> [Accessed on 20 April 2020]
3. See: Oslo Ministerial Declaration – Global Health: A Pressing Foreign Policy Issue of our Time’, The Lancet, Volume 369, Issue 9570, 1373-1378, April 21, 2007. Available at: <https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(07)60498-X/fulltext> [Accessed on 20 April 2020]
4. See: Oslo Ministerial Declaration – Global Health: A Pressing Foreign Policy Issue of our Time’, The Lancet, Volume 369, Issue 9570, 1373-1378, April 21, 2007. Available at: <https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(07)60498-X/fulltext> [Accessed on 20 April 2020]
5. See: Oslo Ministerial Declaration – Global Health: A Pressing Foreign Policy Issue of our Time’, The Lancet, Volume 369, Issue 9570, 1373-1378, April 21, 2007. Available at: <https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(07)60498-X/fulltext> [Accessed on 20 April 2020]
6. Fidler, P. David (2011) ‘Assessing the Foreign Policy & Global Health Initiative: The Meaning of the Oslo Process’, Chatham House briefing paper, June, Available at: <https://www.chathamhouse.org/publications/papers/view/176331>. [Accessed on 25 April 2020]
7. UN Press Release, Secretary-General Calls on Countries to Prioritize Children’s Safety, Education amid COVID-19 Pandemic, Available at: <https://www.un.org/press/en/2020/sgsm20047.doc.htm> [Accessed on 20 April 2020]