Health and Foreign Policy

Check against delivery

Ladies and gentlemen,

It is a great pleasure to be with you this afternoon, and let me thank Dean David T. Ellwood and Dean Julio Frenk for their invitation. 

And to Julio, forgive me for sharing with the audience what happened when I visited Harvard back in June 1998. At that time I came as leader of the Transition Team of Dr Gro Harlem Brundtland, the Director General Elect of the WHO. I came to Harvard to attend a seminar arranged by Chris Murray and Jeffery Sachs on the importance of investing in health to combat poverty. Julio was one of the speakers.

When I left Harvard after this 24 hours visit, I had recruited Julio to Dr Brundtland’s senior management team as head of the Evidence and Information for Policy cluster. I had recruited Chris Murray to be Julio’s right hand. And I had almost recruited Jeff Sachs to chair the upcoming Commission on Macroeconomics and Health.

Looking back, I must conclude that it was a productive visit.

This time, however, my purpose is not recruitment, but the sharing of ideas and dialogue on global public health policies – and what we can do with that knowledge.

Over the years I have experienced and learned how health challenges, health threats and health opportunities matter far beyond health. I have learned how they matter even in the field of security and foreign policy.

In short, that the interdependence created by health is one of the most striking effects of globalisation.

Many decision-makers, however, act as if health issues were secondary concerns in foreign policy. As if global health were a ‘nice to solve’ issue that we could tackle gradually, when times are good. As if paying for health were an expense rather than an investment.

My conviction is that we need to build a far greater awareness of the interconnectedness of health concerns and other areas of politics – including foreign policy. This is my main point today. In particular, I want to make three arguments in this respect:

• First, why foreign policy decision-making must incorporate health issues.
• Second, why health practitioners and policy makers must understand that engaging in foreign policy is a necessary part of solving some of the most pressing global health issues facing us all.
• And third, why we need to build on a variety of ideas, institutions and initiatives that will help promote an interconnected global response to health issues.

*****

Let me start with my first point - The relevance of health for foreign policy.

As I mentioned, there are those who see health issues as not having any real impact on so-called high politics, and solving them is an act of charity, a ‘nice to do’, a soft policy area - humanitarian at best.

I believe this view is out of sync with the reality of today’s emerging globalised world order. In many ways, protecting and enhancing the health of its population is the most important goal for a government.

Too many foreign policy decision-makers overlook the fact that global conditions outside the boundaries of the state have a defining effect on national health – and in the worst case – an effect on national security.

When the mad cow disease ravaged Western Europe ten years ago, states closed their borders. When the pandemic flu spread last year, similar reactions occurred. The opening and closing of borders is no small matter in today’s interconnected world – it is a matter of foreign policy and for foreign ministries.

Consider also the lessons of the SARS outbreak in November 2002. Over the course of several months, it spread to over 25 countries. It severely disrupted travel, trade and activities. Some estimates put its costs for the Asia Pacific region alone at USD 40 billion. It created enormous health policy challenges for individual countries. And it created political pressure at the highest level.

So far, we have luckily avoided a full-blown pandemic. The costs and challenges would be much worse than those of the SARS or H1N1 outbreaks. In 2008, the World Bank estimated that a flu pandemic could kill 17 million people worldwide, cost USD 3 trillion, and result in close to 5 percent drop in world gross domestic product. Just think about these figures.

A simple, universal lesson emerges from these lessons and numbers:

That national borders offer little protection against global health risks.

And that national interests and national economies are dependent on the global health conditions, and – therefore – on the ability of foreign policy to influence these conditions.

In sum – health issues are not peripheral concerns to foreign policy and national interests.

Increasingly, developed countries have understood that they need to adopt a perspective of ‘enlightened self-interest’. Helping developing countries to progress economically, creating conditions of global fair trade, and encouraging respect for universal human rights are valuable goals - just and good in themselves.

What is sometimes forgotten, however, is that a healthy population is an essential factor for the success of policies designed to address these concerns.

Many policy-makers agree that poverty may be a source of conflict, violence and even terror. But then, in order to take this to its logical conclusion, they should take a keener interest in what it takes to combat poverty – not only for reasons of human dignity - but also for reasons of national security.

I have been told that the CIA uses the infant or child mortality rate to evaluate whether a state is moving towards failure. High figures are the best indication of an emerging failed state.

The connection is indeed valid, and precisely for that reason, security pundits should take an interest in what it would take to change an upward trend shown in these figures.

This is, in fact, what the world is doing by pursuing the Millennium Development Goals (the MDGs) – the global strategy agreed by world leaders aimed at halving the number of people living in extreme poverty by 2015. It is no coincidence that three of the eight MDGs are directly related to health.

Many foreign policy decision-makers – and economists - assume that economic development alone will improve health conditions in developing countries. The Sachs Commission Report of 2000, however, provided clear evidence that economic growth is not sufficient. The report concluded that targeted and specific health-oriented initiatives, as well as tied funding, are required to improve health conditions in poor countries. It also concluded that doing so will have a multiplier effect on the impact of economic development policies.

The AIDS pandemic in Africa is perhaps the most striking example of how failing to address health conditions can have massive costs on foreign policy goals. The pandemic awakened the world to the broader consequences - the tragedy in the fact that entire swaths of the productive workforce – the police, doctors, teachers, civil servants and business people – were disappearing, dying – turning children into orphans and weakening the human capital that constitutes the backbone of society.

There political consequences of such a pandemic are clear. Development policies and foreign aid cannot succeed if the public and private labour force isn’t healthy enough to make use of it.

*****

So, yes, foreign policy decision-makers should care much more about health. But let me reverse the argument too: more people in the health care sector also need to engage foreign policy decision-makers.  All too often it is as if health workers shield themselves from other schools of professional and academic thought. We need more interaction.

And this is the core of the second point I mentioned in the introduction: engaging in foreign policy is a necessary part of solving some of the most pressing global health issues facing us all.

My ambition is to use my time as foreign minister to forge new complementarities to the benefit of both global health and global security.

Let me elaborate on this point by means of five concrete observations of this foreign policy-health nexus:

One: States are key players in creating the demand that is necessary to motivate medical research and production essential to health improvements.

It is doubtful, for example, that much progress would have been made on combating the AIDS epidemic in Africa, if Secretary-General Kofi Annan, the UN and governments such as the US had not worked so hard – alongside the WHO - to establish the global fund to fight AIDS, TB and malaria. 

Or take the campaigns for immunisation. Thanks to major efforts by UNICEF and WHO to provide global access to vaccines, coverage was brought from a level of 15% to almost 80% by the 1990s - but then it stalled at that level. By the late 1990s a new coalition of stakeholders, ranging from the UN, the World Bank and the pharmaceutical industry to ‘philanthropy’, represented by Bill Gates, joined forces to launch a new mobilisation for vaccination and immunisation.

This coalition needed a government to manifest the dedication of states. Norway decided to seize the opportunity. We engaged and invested in GAVI – the Global Alliance for Vaccines and Immunisation – from the very beginning in 2000.

GAVI is traditional and modern at the same time. Traditional, because it is a mechanism that mobilises donor funds. But also extremely modern and innovative in the way it disburses resources through a performance-driven system that measures real progress and creates lasting incentives for improving the health system.

In short, government intervention is required to compensate for market failures. The market is important in driving innovation and helping supply meet demand, but this is far from enough to give hundreds of millions of poor people access to essential medicines.

Two: The growth of a global labour market has important indirect impacts on health in developing nations. Many developed countries recruit health care workers from developing countries. This may be a good thing both for host countries and for health care professionals. But one unfortunate effect is that it drains developing countries’ health systems of important human capital.

Given the demographics of an aging western population and labour shortage in certain sectors, this situation is likely to become even more acute. The international community will have to resolve the ethical and policy issues raised by this development.

Three: Intra-state violence and war is one of the most concrete threats to a population’s health. Combat deaths are only the most obvious cost. It is estimated that for every soldier killed, 10 or more civilians die, and many more are injured.

Conflict-related sexual violence has affected the physical and mental health of hundreds of thousands of women over the last decades. It has had serious and lasting consequences for peace, stability and reconciliation efforts.

Moreover, conflicts have devastating effects on health care systems. Before the civil war in Liberia, there were 237 doctors in the country. When peace was declared in 2003, only 23 remained.

That is why addressing conflicts and violence – a key domain of foreign policy – is a crucial health-promoting activity. It could be more effective if foreign policy decision-makers understood this better – and acted at an earlier stage.

Norway led the effort to negotiate a treaty to ban cluster munitions that have unacceptable humanitarian consequences. The treaty was signed in Oslo two years ago. It was a real piece of hard foreign policy negotiations. But the effort – like any other disarmament effort - could equally be characterised as a foreign-policy driven effort with clear public health yields.

Four: Many important health threats must be met by means far beyond the health sector’s domain. Take the tide of chronic diseases – or life-style diseases - now hitting most countries. Facing these challenges also means confronting powerful economic interests, such as the tobacco industry – as the WHO did under Dr Brundtland’s leadership.

Five: The probable impact of global climate change on health. Many of the most dangerous infectious diseases are highly sensitive to climate conditions. Global warming will allow them to expand their range and intensity. This means that many of the countries with the least resources will face additional serious challenges - including a new tide of refugees. As a result, international support and cooperation will become even more important.

*****

So, having made the case for establishing closer links between health and foreign policy, where does this leave us? What more can we do?

First, we need better advocacy to focus attention on the interconnectedness of health and foreign policy.

Dr Brundtland made the point that her problem wasn’t so much dealing with the health ministers; they understood why health was important. Her and our mission was rather to convince presidents, prime ministers, foreign ministers and finance ministers that they too needed to see themselves as health ministers. 

Professions should come together and develop evidence and language that help decision-makers understand the point and the relevance: we need to continually underline – by arguments, experience, and research - the foreign policy implications of global health security. We can demonstrate that investing in health is more than a cost. If well managed, it has a return on investment in both money and human value, many times over.

Second, we need to build support for political initiatives that promote an interconnected global response to health issues.

I have mentioned the Millennium Development Goals – and the review process that we have just completed. This effort, although not perfect, has made a huge difference. The recent G8 commitment to focus on child and maternal health is another splendid example, as is the UN Secretary-General’s global strategy for women’s and children’s health, which has mobilised pledges of almost USD 40 billion.

We can also work as individual states or in smaller groups of states to promote such efforts. Norwegian Prime Minister Jens Stoltenberg’s work on MDGs 4 and 5 is a great example, as is President Obama’s global health initiative.

Today, we see major advances in our combined efforts to address the spread of communicable diseases. Much more needs to be done, however, to mobilise against the slow tide of life style diseases that will kill millions and drain state budgets in the years to come.

Third, all of the many initiatives taken – inside and outside the UN family - will require a closer look at the institutional global health architecture. This must be, I would imagine, a dream subject for any case study here at the Harvard Kennedy School!

Fourth, we need to engage. When I became foreign minister five years ago, I reached out to my colleagues from Brazil, France, Indonesia, Senegal, South Africa and Thailand – countries representing real diversity in terms of experience – and we met on the margins of the UN General Assembly to create the Foreign Policy and Global Health Initiative.

In March 2007, we met again in Oslo to adopt the Oslo Declaration and action plan on global health. It identified 10 key policy areas where we believed the international community needed to better understand the health implications of foreign policy.

The initiative continues to grow in strength. At expert level, the group meets regularly, and is currently chaired by Brazil. Later this week, the UN General Assembly will adopt its annual foreign policy and global health (FPGH) resolution, co-sponsored by a record number of countries, including three important newcomers: the US, China and India.

And finally, we need more knowledge and better documentation. What we now need is an interconnected research model that can create the necessary evidence base and help support our efforts. We need events like this – where foreign policy researchers, public health analysts, decision-makers and medical practitioners come together to discuss challenges and solutions. We need to reach out to a new generation of researchers and policy planners, and integrate these perspectives into their world view.

I am happy to announce today that Norway and the Foreign Policy Health Initiative will be supporting a new collaborative research project involving Harvard and five institutions in Norway, South Africa, Brazil and Indonesia – a collaborative project seeking to better understand the impact of various foreign policy domains on health, and what methods we should use to promote global health solutions in international politics.

We are also exploring the possibility of supporting a joint Lancet and University of Oslo Commission on Global Governance for Health as a way of further promoting cross-disciplinary research and exchange.

These are promising steps, and I am proud to have played a small role in them. But to be honest, nothing could make me happier than if one of you were to stand here in let us say 25 years, and be able to tell the next generation of policy-makers and health practitioners that the achievements of your generation have far eclipsed those of my own.

Thank you.

****

For questions after the speech ; see Harvard's web site.