It’s been a year since swine flu first surfaced in Mexico and the US, instantly spreading to other geographies, testing along the way, for the first time, the global framework for medical preparedness and equitable distribution of drugs and vaccines. Of all the lessons that were purportedly learnt, one that calls for abiding analysis is the need for global diplomacy in standing up to influential foreign interests to ensure that developing countries are equal stakeholders when it comes to public health security. After all, we saw how 90% of the vaccines were allocated for distribution in 12 wealthy nations.
If anything, the 2009 flu pandemic illustrated that healthcare is an integral part of foreign policy, an agenda that the Oslo Ministerial Declaration of 2007—the result of a seven-nation foreign ministers’ dialogue—laid down, and to which the United Nations and the World Health Organization (WHO) have since been adding heft.
The open source journal PLoS Medicine is currently publishing a Global Health Diplomacy series (concluding on 11 May) where experts debate if and how a nation’s foreign policy can make a difference to healthcare. And if public memory isn’t as short as it is metaphorically taken to be, the threats and the travel advisories arising out of SARS, avian influenza (H5N1), and pandemic influenza A (H1N1) outbreaks in recent years suggest that the role of foreign ministers just got wider. Along with the traditional goals of protecting national security and economic interests, foreign ministries will now have to resort to health interventions to achieve non-health goals.
In their paper “Health diplomacy and the enduring relevance of foreign policy interests”, Harley Feldbaum and Joshua Michaud argue that there is a growing perception that health can be “an effective soft power tool for foreign policy in contrast to the hard power of military force”. The use of hospital ships such as Mercy and Comfort by the US to provide short-term medical care to underserved citizens around the world is just one example. China is exerting such power through its growing aid relations with Africa.
Most experts writing in the series refer to Brazil’s use of soft power in international relations, which, they believe, is worth emulating by other emerging economies. Using its model national tobacco control programme, Brazil asserted its leadership which proved critical to the successful conclusion of the Framework Convention on Tobacco Control, a treaty that came into force in 2005 under the aegis of WHO.
Brazil’s another bold step—to provide free antiretrovirals (ARVs) to its HIV/AIDS patients before any other developing country despite a World Bank reproof that it’s not cost-effective—proved a success story. It later became a role model for the expansion of global support for HIV/AIDS.
It’s more than just coincidence that India’s role in some of these events, including the revision of International Health Regulations 2005, hasn’t been central. To be sure, many, including Feldbaum, would argue that not every country should focus on “global health diplomacy” and that India already works with the Global Fund to Fight AIDS, Tuberculosis and Malaria.
But given the size of the country, its daunting disease burdens, and the fact that India is critical to global health efforts, particularly in reaching the health-related Millennium Development Goals and eradicating polio, it should mainstream health with foreign affairs.
“The world needs India to develop economically but equally so politically into a true global citizen, (along with China of course),” says the London School of Hygiene’s Kelley Lee, who has examined Brazilian diplomacy in this series.
Since the Indian government, unlike the Brazilian, didn’t make a commitment to universal ARV access, it didn’t have the same internal “accountability” issues driving its global political engagement of “resistance”, says Lee.
This lack of “internal accountability” appears repeated in the 2009 H1N1 outbreak. Even though India has had at least 28,000 confirmed cases, which, experts say, according to the “infectious disease iceberg model” have a manifold impact, there’s no epidemiological analysis in the public domain. The risk factors for the Indian population too are not known, though it is public knowledge that the mortality rates are three times higher than the global average. The spread of swine flu like a wildfire in Pune is also an epidemiological blackbox. It was only in March (2010) that genomic sequences of the virus were published in PLoS ONE and made available in the public.
Such tardiness could prove tragically expensive should another variant of the virus strike. H1N1 wasn’t the last or the worst pandemic that the world has faced. India should realize that unless it boosts its domestic responses, it cannot strategically interact with the global health community.
The story isn’t very different in multi-drug resistant and extremely drug resistant (XDR) TB. In its new report in March, WHO expressed helplessness at the absence of epidemiological data on the incidence of XDR TB.
In global health diplomacy, “SARS was a watershed for China”, say experts, but India mustn’t wait for a pandemic to examine key elements of its foreign policy.
Seema Singh is a deputy chief of bureau at Mint.
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