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

Stuart Harris
Med J Aust 2004; 180 (4): 171-173.
Published online: 16 February 2004

Abstract

  • Although there appears to be no Australian foreign policy statement on health, much of our existing foreign policy has health implications, ranging across security, economic, political and humanitarian objectives.

  • Humanitarian motives have influenced Australia’s foreign-aid policy, but our aid program, like our wider foreign policy, has a large national interest component.

  • A generalised approach to health and foreign policy activities is difficult given the disparate direct and indirect links between foreign policy and global health issues, and the various official and unofficial interests and responsibilities involved.

  • The greatest benefit may come from the health community making its own judgements on health priorities and seeking to engage in specific terms with foreign policy makers.

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 existing relationship

In many ways, foreign policy and health are already married. Nevertheless, it is more a marriage of convenience than of substance, with limited intramarital conversation.

Much of Australia’s foreign policy has health implications, ranging across Australia’s security, economic, political and humanitarian objectives. However, that interaction is largely indirect. Moreover, foreign policies are generally directed to the national interest, which, regardless of how it is defined, tends to be given priority over international humanitarian objectives.

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.

Mixed motives

Humanitarian motives in foreign-aid policy were substantially behind past contributions by Australia to the worldwide eradication of smallpox and, particularly in our region, poliomyelitis, as well as to the successful training and support of skilled healthcare workers regionally. Furthermore, food aid from Australia supports global humanitarian efforts to limit morbidity and mortality from malnutrition in North Korea, and in meeting Iraq’s food needs and other regional food requirements.

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.

Building the relationship

So, can health be placed more centrally on the foreign policy agenda? Yes, but only with difficulty.

One difficulty concerns priorities. If health is a security issue, how does the health security pay-off compare with that of other security risks? Even within the health field, where is Australia’s greatest health pay-off: more funds for reducing global debt in the poorest countries or more funds for providing specific healthcare infrastructure?

Priority setting in government is, at best, a very imprecise process because of the many competing interests and pressures, the large information gaps, and the fact that most decisions involve marginal changes from the existing situation. Given the disparate direct and indirect links between foreign policy and global health issues, and the various official and unofficial interests and responsibilities involved, activities coming under the rubric of foreign policy and health do not lend themselves to a generalised approach, whether to priority setting or in other contexts. Seeking a common policy focus through a coordinating office or position faces major practical problems of scope, expertise and acceptability.

It may be more beneficial for the health community to systematically determine where it judges health needs are greatest and policies most effective, and to express these in specific terms that lend themselves to engaging in priority setting with foreign policy makers. Even so, a civil society advocacy group or coalition will face a stiff challenge because of the disparate nature of the many foreign policy and health interactions. As specific health-related problems emerge, sharing information and experiences with others (eg, through the Internet) would be helpful.

One established strategy is public reporting to gain attention and provide information. The 2003 Global Health and Foreign Policy symposium raised the understanding of Australia’s role in global health, but the effort needs to be sustained. Similar periodic public assessments of progress in key areas would be one step.

Desirably, humanitarian impulses will remain important in Australia’s international health policies, including supporting research on global health problems. However, success in engaging government is more likely in those areas where our efforts in global health can be shown to benefit the national interest.

The marriage of foreign policy and health, although one of convenience, will last. It can, however, be helped to work better.

  • Stuart Harris

  • Department of International Relations, Research School of Pacific and Asian Studies, Australian National University, Canberra, ACT.

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