26 April 2002 - 28 April 2002

Health as foreign policy

Chair: Sir Maurice Shock and Dr David M Lawrence

(A joint conference with RAND and the Nuffield Trust)

Over the weekend of 26-28 April we met with our partners, RAND and the Nuffield Trust, to examine the links between health issues and national foreign policy interests and the synergies to be obtained through the coordination at both national and international levels of health policies with foreign security and development policies. The scale of the task we had set ourselves soon became apparent when we began to define such wide-ranging concepts as "health" and "foreign policy".

At the outset we heard powerful statements on the role of health in global development. Fear of illness in many parts of the world affected the choices made by people who lacked the sense of security which came from good health. The medical advances in the last decades benefited only a relatively few people world wide while many millions died of preventable diseases. Health was closely linked to development in the less developed countries, health was linked to wealth creation and health was linked to knowledge. Good health standards usually meant a better educated nation. Investment in health and people was the cornerstone of good development. One participant raised the question as to whether establishing democratic institutions in developing countries might be more beneficial to their development than health programmes and suggested that priority might be given to health which was a pre-condition for both successful political and economic development.

We moved on to examine the reasons why health might be considered a core element of foreign policy defined as "all international activity". We agreed, however, that we needed to define "health" more narrowly. Not all health questions were relevant to foreign policy. But major infectious and other diseases including those in animals such as foot and mouth and BSE, had the capacity significantly to affect our national interests. It was also the case that in some parts of the world like Russia and Africa health status indicators such as life expectancy had declined and some of the gains of the past were being lost. Given the many millions of movements across national borders in our globalised world, declining health status in these populations had the potential to make itself felt in many countries. This was the dark side of globalisation.

We looked at some of the reasons why the foreign and security establishments might wish to regard health as an integral part of their policy making and thought that the most persuasive reasons would be those of self-interest. Bioterrorism had an enormous public and political impact. The instability that arose from weak or failed states and inability to achieve economic development were other reasons. We were also urged not to overlook the moral and ethical reasons behind public support for health assistance to countries which were suffering from chronic health problems. The US wished to see itself as a good global citizen. But we were advised that if it came to choice between spending more on domestic policies of direct interest to the voters and spending more on global health policies, the chances were that politicians would get more support for the former than the latter. We hoped, however, that over time and with proper information, enlightened self-interest would prevail. Health had now moved to being a "top table" issue and was on the agenda of the G8. President Bush and Prime Minister Blair also seemed to be engaged.

While we thought it likely that poverty, leading to failed or failing states caused by poor health and economic hardship, could be a contributory factor, there did not seem to be a direct connection between health policies and bioterrorism. No evidential link had yet been established. One participant commented that the terrorists involved with the events of 11 September had not been from the poorest sections of the population but from a disaffected middle class, conceivably motivated in part by envy of higher standards, including health standards, in the West. The greater danger lay in the possibility that failed states could become havens for terrorists or international criminals.

We thought, however, that the link between health and economic development and thus to failed or failing states was a good deal clearer. Health was not, of course, the only factor in the failure of such states but assistance with health problems did seem to be an effective means of helping to prevent countries from becoming unstable. In presentational terms, which had gained importance following the divisions in the international community after the events of 11 September, there were clear advantages for countries which had the greatest health resources such as the USA and members of the EU to be seen to contribute to health programmes which reached out to peoples and countries in great need. The same could be said for the anti-globalisation movement which embraced NGOs, church groups, young people and poor people in low-income countries by showing that globalisation could work for the benefit of humanity as a whole. We also thought that health was integrally linked to global environmental issues and should be considered as a part of that agenda. Global climate change was, for example, having an impact on the incidence of malaria, yellow fever and other infectious diseases. There might also be lessons to be learned from the way in which the environmental movement had succeeded in bringing their concerns to public attention, and even in adopting for trade and other policies which affected health in developing countries the environmental approach of "the polluter pays".

In the course of this discussion we considered the effects of linking health directly with foreign policy choices. It was pointed out that foreign policy was normally decided on the basis of an assessment of national self-interest. If health policy was seen as directly linked to the attainment of specific national goals it could create suspicion and resistance on the part of the recipients. Self-interest, narrowly defined, would also have the effect of excluding Africa from most calculations. Many of us argued that it would be better to preserve the "neutrality of health". Bringing health policies into the overall framework of national foreign and security policies would, however, have the advantage of bringing a longer term perspective to those policies and subjecting them to evidence based evaluation.

It was suggested that it would not be possible to present a single health "solution" to those who were concerned with foreign and security policy. The subject was simply too large. There was not a single set of arguments which could be advanced, rather a range of persuasive reasons to show how health in its various aspects affected important national and global interests. The addressees for these arguments were not only Governments but also multinational corporations, the public and NGOs who had considerable influence, and sometimes more credibility than Governments. Corporate social responsibility by multinationals in developing countries should be encouraged on the grounds of economic self interest. Community to community links were also powerful tools as had been shown by the fact that currently in 35 States in the USA, health and other partnerships had been established with communities in the former Soviet Union. In presenting the message, some argued that it would be counterproductive to rely too heavily on scare tactics linked to bioterrorism or cross border infectious diseases. While such arguments might be effective in the short term they could also have the disadvantage of not standing up to rigorous scrutiny and of diverting attention from the real underlying factors that create global health risks and from the appropriate policies for tackling them.

When it came to examining the ways in which health issues might be integrated with foreign and security policies, we were informed of a variety of existing practices. Health, together with science and technology had already been made departmental priorities in the US State Department. In addition joint task forces from State and Department of Health and Human Services had been established to look at emerging diseases. In the UK, funds had been voted for conflict prevention purposes and these were dispersed by agreement between the FCO, MoD and Development Ministry with some already allocated for health projects. In Canada 38% of development funds were earmarked for social development projects. In the Netherlands, health funds were only allocated to those countries which could demonstrate that they had effective systems for their use. Nevertheless we were warned by those who had experience of departmental budgets in foreign, defence and health ministries that if bids were to be made to redirect some of their funding to global health aims, detailed evidence based cases would be needed to show how the allocation of their resources for such projects would be likely to be more cost effective and appropriate than using the funds for the purposes for which they had originally been voted. Could we show that the deployment of health teams at the same time as combat troops in Afghanistan would lead to the earlier recall of the combat troops? Health professionals among us also acknowledged the need to use language which was readily comprehensible by the foreign and defence communities. It might be useful to exchange health, foreign and security experts between the bureaucracies so that greater mutual understanding could be built up. We were informed that health advisers were now sent to a number of US posts and that US Ambassadors were expected to be able to send informed reports on health issues. We thought that interdepartmental coordination on global health issues would not be easy, an unnatural act commented one former official. To be effective, strong and sustained interest would have to come from "the top" given the need for integration and the fact that global health was not the first priority for any of the principal agencies - Health, Foreign Affairs, Development or Defence. Integration in the field was also important with some good experience from IFOR and SFOR in Bosnia and Kosovo.

We thought that health impact assessments on the lines of environmental impact studies could play a useful role in identifying the linkages between a variety of policies, including importantly, the effect of some trade policies advanced by the WTO. Other assessments might be based on research into the impacts of foreign and defence policies on health in the sense either of their negative or positive impacts and how these might be measured. Such studies could also provide evidence of the need for specific health assistance to the countries concerned. Knowledge transfer was an essential element in such assistance since it allowed the recipient country to run its own programmes suited to its conditions. Recent advances in Information Technology were crucial enablers.

We concluded with a reminder from one participant that events of 11 September had revealed the depth of anger in parts of the world caused in part by the large imbalance of resources between the 20% of the world's population who were wealthy and the 80% who were not. It was not possible to deal with this anger by normal military means. The response of increasing defence budgets would prove ineffective. We needed to change our concept of foreign policy from a territorial struggle to the new realities. Global health policies could help considerably, particularly if they used all the channels open to us including NGOs and civil society. To this was added the warning that the time to act was now. The price would be high but it was affordable. In ten or so years time this might no longer be the case. We took note of over thirty specific recommendations for further action and study that the conference had produced which would now be evaluated by RAND and the Nuffield Trust. Our hope was that these further studies would convince senior decision makers of the urgent need to devote the political will and resources to tackling what we were convinced was one of the most important global challenges in the years ahead.

May I, in conclusion, express my thanks to the two chairmen who guided our discussions and also to RAND and the Nuffield Trust for their contributions to the success of this conference.

This report reflects the Director's personal impressions of the conference. No participant is in any way committed to its content or expression.



Sir Maurice Shock
Rector, Lincoln College, Oxford (1987-94) (Hon Fellow 1995); Member, General Medical Council (1989-94)

Dr David M Lawrence
Chairman and CEO, Kaiser Foundation Health Plan Inc

Mr Martin Méthot

Director, International Health Division, International Affairs Directorate, Health Policy and Communications Branch, Health Canada
Dr Carolyn Tuohy
University of Toronto: Professor of Political Science; Vice President Policy and Development and Associate Provost; author

Dr Els Borst-Eilers

Minister of Health, Welfare and Sport; Vice Prime Minister
Dr Geert van Etten
Director of International Affairs, Ministry of Health, Welfare and Sport

HE Rt Hon Donald McKinnon

Commonwealth Secretary General

The Rt Hon Virginia Bottomley JP MP

Member of Parliament (Conservative) Surrey SW (1984-); Partner, Odgers Ray & Berndtson (executive search) (2000-); Secretary of State for Health (1992-95); a Governor, The Ditchley Foundation
Dr Anne Coles
Social Development Adviser, Overseas Development Administration
Sir John Coles
Permanent Under Secretary of State, Foreign and Commonwealth office (FCO) (1994-1997); Chairman, Sight Savers International (2001-); a Governor, The Ditchley Foundation
Mr Nigel Crisp
Permanent Secretary, Department of Health
Professor Andy Haines
Dean, London School of Hygiene and Tropical Medicine
Dr Kelley Lee
Co-Director, Centre on Global Change and Health, London School of Hygiene and Tropical Medicine
Dr Graham Lister
Senior Associate, Nuffield Trust; Secretary, UK Partnership of Global Health
Professor Colin McInnes
Professor, Department of International Politics, University of Wales Aberystwyth
Professor Sir Keith O'Nions
Chief Scientific Adviser, Ministry of Defence
Mr Simon Stevens
Senior Policy Adviser on Health Issues, Prime Minister's Policy Unit (2001-); Policy Adviser to the Secretary of State for Health (1997-2001)
Mr Nicholas Timmins
Public Policy Editor, Financial Times
Mr Simon Webb CBE
Policy Director, Ministry of Defence
Mr John Wyn Owen
Secretary, The Nuffield Trust (1997-); Honorary Fellow, Faculty of Public Health Medicine

Dr C Ross Anthony

Director, Center for Military Health Policy Research, RAND
Dr Jo Ivey Boufford
Dean, Robert F Wagner Graduate School of Public Service, New York University (1997-); Principal Deputy Assistant Secretary for Health (1993-97); US representative on Executive Board of World Health Organization (1994-97)
Dr Robert Brook
Vice President RAND, Director RAND Health; Professor of Medicine and Health Services, UCLA Center for Health Sciences; Director, RWJ/UCLA Clinical Scholars Program
The Honorable David S C Chu
Under-Secretary of Defense (Personnel and Readiness); formerly Assistant Secretary and Director for Program Analysis and Evaluation, Department of Defense
The Honorable Paula J Dobriansky
Undersecretary of State for Global Affairs, US Department of State (2001-); Senior Vice President and director, Washington office of the Council on Foreign Relations (1997-2001)
Mr David C Gompert
President, RAND Europe; Vice President, RAND; formerly: Special Assistant to the President and Senior Director for European and Eurasian Affairs, National Security Council (1990-93)
The Honorable Robert E Hunter
Senior Advisor, RAND (1998-); US Permanent Representative to North Atlantic Council (1993 98)
Dr Nicole Lurie
Senior Natural Scientist and Paul O'Neill Alcoa Professor, RAND Corporation, former Deputy Assistant Secretary of Health
Dr Carol A Richards
Private investor; Co-Founder and spokesperson, Burma Forum of Los Angeles
Mr David K Richards
Private investor; formerly: Vice Chairman, Primecap Management, Pasadena (1985-91)
Dr William L Roper
Dean, School of Public Health, University of North Carolina; formerly: Director, US Centers for Disease Control and Prevention
Dr Kenneth I Shine
President, Institute of Medicine, National Academy of Sciences, Washington DC
Dr Eve Slater
Assistant Secretary of Health, Department of Health and Human Services
Mr James P Smith
Executive Director, American International Health Alliance
Dr James A Thomson
President and Chief Executive Officer, RAND Corporation (1989-)
Dr Harold Varmus
President and CEO, Memorial Sloan-Kettering Cancer Center (2000-); formerly: Director, National Institutes of Health (1993-99)

Dr Gro Harlem Brundtland

Director-General, World Health Organization
Dr David Nabarro CBE
Executive Director, World Health Organization
Dr Aviva Ron
Director, Health Sector Development, World Health Organization, Western Pacific Regional office, Manila