Introduction: Health security and the value of semantic analysis
The rise in spending for global public health in the last decade has been motivated by two concurrent forces: the realization by governments that health, or rather disease, has national and global security implications; and the generosity of citizens and philanthropists responding to health inequities, disasters and emergencies (Fauci 2007; Garrett 2007). Fidler (2007) has labelled this interest as ‘a new global social contract for health’. The paper by Aldis (2008) in this issue raises concerns about the ‘health security’ motive, and has explored the origins and range of interpretations of the terms ‘health security’, ‘human security’ and ‘global public health security’. Aldis highlights several tensions along a continuum of human security, public health and bio-defence that play out in policies and programmes, tensions that may not be explicitly acknowledged by the institutional proponents of ‘health security’, or by the governments receiving donor assistance. The varying interpretations and applications of these terms have far-reaching implications in terms of global health governance, institutional and bureaucratic structures, and negotiation processes relating to current health emergencies.
Common themes cited in the paper include ‘protection against health threats’; new global threats such as emerging infectious diseases and security implications of ‘failed states’; the convergence of public health and military/security interests, as in the use of military resources for disaster relief; and the unaligned goals and objectives between public health goals and foreign policy interests. These issues are highly relevant in light of the pandemic threat and response in Southeast Asia; emerging debates about the trade-offs between targeted, vertical, disease-focused donor aid versus health systems strengthening more generally; and most dramatically, in the current national and global response to Cyclone Nargis.
Aldis concludes that fundamentally absent from the ‘health security’ concept are processes that lead to the cultivation of trust and the promotion of dialogue. Further, the lack of clarity and misapplication of concept will lead to: (1) a distortion of priorities within developing country health systems, leading to their further deterioration and fragmentation; and (2) a breakdown in global cooperation. But are these consequences inevitable, or can we by-pass an intractable debate on health security and move directly toward health systems strengthening and health diplomacy goals? What other trends in global and regional cooperation must be taken into consideration?
Harnessing health security investments in surveillance to strengthen health systems
First and foremost, there is an ongoing need to advocate for broader investments in health systems, including human resource development, infrastructure and delivery. In a recent editorial targeting the Toyako G8 Summit, Reich et al. (2008) call for more effective action on health systems that address some of the concerns raised by Aldis. These include: (1) health systems improvements that provide increased protection for individuals in ways that empower recipients and engage local actors; (2) allocation for funds within existing organizations to balance disease-specific and systems-oriented approaches (referred to as a ‘diagonal’ approach complementing vertical and horizontal approaches); and (3) enhanced learning from interventions that aim to improve health systems. Such a commitment on the part of the G8 would, indeed, help to provide more balance to those investments motivated by health security threats, and facilitate the management of investments by developing countries.
Meanwhile, efforts are being made to harness existing investments, particularly those motivated to ensure International Health Regulations (IHR) compliance, to build stronger surveillance systems, and to optimize the use and deployment of resources that currently exist. Surveillance remains a core function of primary care and of public health systems more broadly. How surveillance functions is a reflection of the overall strength and resilience of the health system at any given level. As many have pointed out (Calain 2006; Fidler 2007; Garrett 2007), global resources through vertical streams have benefited national-level surveillance systems focused on specific diseases, but often do not flow to the surveillance units themselves or are not accompanied by commensurate investments in health delivery. As a result, many poorer countries have been unable to respond rapidly to outbreaks that do not fall within those areas, and are challenged in consolidating data on disease outbreak patterns as a whole. Greater collaboration and consensus among donors, governments and technical partners are being targeted to develop a cadre of health professionals skilled in field epidemiology, informatics and monitoring and evaluation; and further investments in public health laboratory capacity are forthcoming. Relatively low-cost/high-impact policy studies and activities are being undertaken to identify, enumerate and map resources, calculate actual resources in relation to need, and deploy resources more efficiently. Direct communication of findings is needed between surveillance and workforce planning units within Ministries of Health for both short-term and longer-term training and deployment, particularly in low-resource settings.
At the same time, the development and monitoring of core indicators could alert policymakers and the public about the state of their national surveillance system (for example: number of surveillance staff per population, budget allocated for surveillance as percentage of total health budget, number of outbreaks detected, declared and contained, etc.). The promotion by WHO of Integrated Disease Surveillance and Response (IDSR) in Africa, and its application in countries such as China with integrated web-based and step-wise surveillance, offer lessons in how better to operationalize ‘diagonal’ systems. Finally, interest in compliance with the IHR (2005) can be expanded to cover public health surveillance that may be of national or sub-national concern, and that prioritizes both communicable and non-communicable diseases.
Building trust and policy coherence through health diplomacy
While there may appear to be a breakdown in collaboration within the multilateral system, alternative forms of collaboration are emerging in regional bodies, bilateral agreements and private or non-state organizations (Kickbusch et al.2007). Fidler (2007) has referred to this proliferation of multiple actors in global health as resulting in a ‘Tragedy of the Global Health Commons’, since least developed countries cannot adequately support multiple activities that further fragment already fragile capacities. However, where countries have a strong stake and sense of ownership in these agreements, and where they build on geographic, political, economic and cultural affinities, they can bring about unusual forms of cooperation across borders, formulation of normative practices and standards to emerging threats, and economies of scale and efficiencies in resource mobilization.
In particular, regional bodies are gaining greater prominence in resolving health and security threats, where multilateral and bilateral negotiations have faced challenges. The role of the East African Community in supporting the peace process in Kenya, and the emerging centrality of ASEAN in coordinating the humanitarian response to Cyclone Nargis are two recent examples of this growing trend. Regional disease surveillance networks in the Middle East, the Mekong Basin and East Africa were formed by health officials motivated to build trust, and collaborate in disease outbreak detection and response, with the ultimate goal of promoting peace in areas prone to endemic disease, poverty and conflict (Bellagio Call to Action 2007).
The terms ‘health diplomacy’ or ‘medical diplomacy’ offer alternatives to ‘health security’ that make more explicit possibilities for the cultivation of trust and negotiation of mutual benefit in the context of global health goals. Global health diplomacy has been defined as a ‘bridge for peace and security’ (Novotny and Adams 2008); ‘winning hearts and minds of people in poor countries by exporting medical care, expertise and personnel to help those who need it most’ (Fauci 2007); and ‘multi-level, multi-actor negotiation processes that shape and manage the global policy environment for health’ (Kickbusch et al.2007).
National efforts to develop health diplomacy are based on an ‘emerging recognition of the need for policy coherence, strategic direction and a common value base in global health’ (Kickbusch et al.2007). Countries such as Brazil and Thailand that play an active role in global health diplomacy and negotiation on the multilateral and bilateral stages share two key characteristics: (1) they exhibit close cooperation between International Health departments within the Ministry of Health and the Ministry of Foreign Affairs; and (2) they recognize the implications of trade and other foreign policy tools on their population's health. The broader move toward policy coherence is reflected in a call for the establishment of the European Council on Global Health (Kickbusch and Matlin 2008).
The emerging health diplomacy movement points to the need for core capacities in the public health and diplomatic arenas. Among these are an understanding of international relations among public health professionals and greater recognition by diplomats of the population health outcomes of foreign policy. More specifically, training would include perspectives on globalization, social determinants of health and cultural competence, macro-economics and political negotiation (Novotny and Adams 2008).
Finally, communities and citizens are often not considered in the formal policy arena but play an important role in meeting foreign policy goals and in cultivating trust and friendship across national borders, particularly in times of crisis and emergency. Future foreign policy and global health efforts need to ensure dialogue with affected communities and be more intentional in engaging and citizens groups in defining needs and goals.
While it is likely that health security—or at best, human security in its broadest definition—will remain a prominent rationale for developed countries to invest in global health initiatives, a more coherent approach to foreign policy and health diplomacy could result in better alignment between the health security goals of developed countries and health equity and development goals of developing countries, while at the same time recognizing and channelling the growing financial and technical contributions of private citizens, companies and organizations.
The author thanks Kumnuan Ungchusak and David Heymann for their ideas on strengthening surveillance systems; Suwit Wibulpolprasert for his ideas on trust between countries, and collaboration with Ministries of Foreign Affairs; David Nabarro for thoughts on health diplomacy; and Carl Kendall for editorial comments.