Critically examine the UK government’s ‘Health is Global’ strategy document.

Due to permeable borders and an unrivalled frequency of travel and migration, health has become coupled with national security. Governments have recognized the detrimental impact that foreign health crises may have. According to its strategy document, the UK seeks to tackle health and security in five different areas. These are:

1. ‘Better health security
2. Stronger, fairer and safer systems to deliver health
3. More effective international health organizations.
4. Stronger, freer and fairer trade for better health, and
5. Strengthening the way we develop and use evidence to improve our policy and practice’ (HM Government, 2008).

Individually and collectively, these five interrelated areas present a range of complexities that arise when attempting to reconcile the interests of health with that of security, whether for national interest or altruistic intentions.

This essay will only focus on better health security. Better health security is chosen because it is from this that the other four sections stem and can be developed[1]. Within better health security, the UK strategy document identifies five goals including communicable diseases (HM Government, 2008)[2]. This is the most pressing in terms of immediate potential dangers because communicable diseases threaten national security (Feldbaum et al., 2006). This essay will examine the economic, ethical and political tensions that arise from the goal of reducing the threat of communicable diseases in an attempt to ensure optimal health security. Reference is made to the UK ‘Health is Global’ strategy document.

ECONOMIC TENSIONS

Economic tensions arise when health is coupled with security with regards to communicable diseases. The SARS outbreak in 2003 clearly demonstrated the world’s collective susceptibility to communicable diseases. As well as the tragic loss of more than 900 lives, lost work days cost approximately US$60 billion (Lee, 2003). The UK’s strategy document indicates that the UK aims to curtail HIV/AIDS, tuberculosis and malaria in developing countries in order to ‘reduce the threat from infectious diseases’ (HM Government, 2008).

Economic tensions can arise as a result of a developed country’s self-interested calculations by selectively choosing certain health issues it wishes to fund in developing countries. This can resemble the ‘tragedy of the commons’ whereby state-centric goals excessively exploit the global health commons (Fidler, 2007). With the UK’s proposed intention to reduce communicable disease threats and to fund these initiatives, the UK will have the means to force the developing country to tackle a particular communicable disease as a form of ‘horizontal germ governance’. This would reduce the UK’s own vulnerability to disease importation but would effectively siphon resources and manpower from the more long-term goal of improving primary health in the developing country (Fidler, 2004). While communicable diseases present as external threats to a state’s national interests that can only be alleviated through international cooperation, it must be acknowledged that such ‘cooperation’ through horizontal strategies is often not benevolent; these initiatives largely serve the interests of the strongest countries in the international system (Fidler, 2004).

Consequently, economic tension can arise when the UK imposes selected interventions to eradicate communicable diseases. The approaches for improved health become increasingly divided: more emphasis is placed on certain interventions and further partnerships which, consequently, reduce the chance for developing more long-term options such as building a thorough infrastructure (Ollila, 2005). Such inaccurate precedence can inevitably weaken broader health services and result in a burden for the developing country as a result of the uncoordinated aid from developed countries (Crisp, 2007).

Economic tensions can be exacerbated by selective interventions. Such action can result in a particular developing country being stigmatised, with the result that its trade and travel revenue are negatively affected. Drawing attention to a country on the basis of communicable disease in that country and the relevance of this to UK health security, can engender inequality. Another country with communicable diseases that are not significantly relevant to the UK’s health risk might escape stigma. Even though its economic revenue would not be as affected, the country’s health would continue to deteriorate and could increase global health inequality. By coupling health programmes to the more contentious matters of security, the opportunity to maintain strong diplomatic ties can be aggravated. This is not ideal for either health or security (Katz & Singer, 2007).

The UK strategy document barely mentions these issues[3] and does not offer explicit acknowledgement of economic tensions that could arise. It makes a token attempt by saying that the UK will use an ‘impact assessment’ to take into account the impact of global health and the equity of the UK’s foreign and domestic policies. It is not stated how regularly this assessment will be made and how the UK will attempt to rectify any inconsistencies that arise. While there is no doubt that there will be some tension, it is important to recognise that controlling communicable diseases does have significant benefits, both domestically and internationally. For example, malaria is restricting African economic growth by up to 1.3% a year, costing more than $12 billion annually (Donaldson & Banatvala, 2007). Reducing malaria in Africa will raise its gross domestic product by 20% over 15 years (Donaldson & Banatvala, 2007). The $300 million investment in smallpox eradication gave returns of more than $3 billion in economic benefits (Donaldson & Banatvala, 2007). Thus, the debate remains whether dealing with economic tension incurred by selectivity burdens on a developing country or travel and trade restrictions can outweigh the projected economic benefit that a higher income country could reap by protecting its own health.

It is important that the aforementioned economic tensions are addressed intentionally in order to keep in line with Article 2 of the International Health Regulation which states its purpose is ‘to prevent, protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international trade and traffic’ (Fidler and Gostin, 2006). Thus, reducing economic tension lies in reconciling trade interests with considerate development policies and upholding international health regulations.

ETHICAL TENSIONS

Ethical tensions can arise when health and security are considered simultaneously with regard to communicable diseases and in terms of dignity and human rights. For example, in an attempt to contain infectious diseases and have greater health security, according to Action 15 in the ‘Health is Global’ strategy document, the UK ‘wants to base our policies for infectious disease screening for migrants coming into the UK on best available evidence’ (HM Government, 2008). What this seems to imply is that the UK intends carrying out infectious disease screening on potential migrants. In February 2003, the UK contemplated enforcing compulsory HIV screening for potential migrants in response to public fears that HIV-positive foreigners were coming to the UK to seek treatment (Elbe, 2005). Indeed, there is no denying the financial benefits of vaccinating travellers. The eradication of smallpox has allowed $1 billion, previously allocated for travellers’ vaccinations, to be saved annually (Institute of Medicine, 2007).

Nevertheless, there are concerns about human rights and people’s dignity when it comes to communicable disease containment in developing countries as developed countries attempt to curb the spread of the disease. Attempts to quarantine people with HIV/AIDS, exacting violent treatment upon them and preventing them from working in state institutions are a few examples of how people with HIV/AIDS have been disrespected (Elbe, 2005). In Colombia, left-wing guerrillas of the Revolutionary Armed Forces of Colombia forced 30,000 occupants of Vista Hermosa to be tested for HIV/AIDS and removed those who were positive from their homes (Elbe, 2005). This is a particularly severe case; it is more typical that global HIV/AIDS policy has emphasised respect for human rights. SARS containment, on the other hand, required strict isolation and quarantining which raised concerns about infringements of dignity and human rights in order to facilitate domestic containment and mitigation of trans-boundary spread.

There is also the issue of the neglect of human rights. This occurs when developed countries want to research communicable diseases that could affect their domestic health security. In order to do this effectively, developed countries must conduct their research in the diseases’ region of origin which is typically a tropical country. Pharmaceutical companies site themselves in poorer regions and, due to lower standards, avoid more stringent health and safety regulations. Consequently, the locals are at risk for the dumping grounds for hazardous materials. The difference in occupational, food or drugs standards between developed and developing countries creates serious health risks for everyone (Institute of Medicine, 1997). Unfortunately, many potentially threatening diseases such as malaria and cholera must be studied abroad among populations and regions where the disease is most prevalent (Institute of Medicine, 1997). To further dissuade companies from being sited in developed countries, tests for new drugs and vaccines can done more cost-effectively in developing countries where disease rates are high (Institute of Medicine, 1997). It is not surprising, then, that there are ethical tensions. Human rights of people in the developing nation are compromised by reason of the developed nation’s intent and subsequent ability to initiate communicable disease control and containment. These practices reflect the unethical health treatment of citizens in less developed countries so that higher income countries can benefit from better health security.

The UK strategy document does state that the UK wants to ‘reduce the threat from infectious diseases’ as well as ‘improve the health of migrants’ but, again, fails to explicitly address possible ethical tensions (HM Government, 2008)[4]. Nevertheless firm phrases such as ‘our intentions are fulfilled’, ‘protect…the UK proactively’ and ‘in pursuit of our objectives’ make it very clear that while the UK is concerned about global health, the UK’s own health security takes precedence. Thus, achieving a balance between respecting the rights of the individual and protecting the nation is crucial. Calls for compulsory (as opposed to voluntary) vaccination and whether involuntary detention should be used to contain communicable diseases, are examples of some difficult ethical decisions (Donaldson & Banatvala, 2007). It is important to adhere to Articles 3.1 and 42 of the International Health Regulations which respectively state that

• ‘the implementation of these Regulations shall be with full respect for the dignity, human rights and fundamental freedoms of the person’ and
• ‘all health measures must be applied in a transparent and non-discriminatory way’ (Fidler and Gostin, 2004).

POLITICAL TENSIONS

Political tensions can arise between health and security with regards to communicable diseases. For example, political tension was caused by the securitization of HIV/AIDS with regards to USA and Nigeria. The 2002 National Intelligence Council report stated that HIV/AIDS contributed to the deterioration of Nigeria’s state capacity. The fact that Nigeria is important to US energy security and counter-terrorism strategies (PHM, 2008) forms part of the context for the massive increases in US aid to Nigeria. Indeed, in 2007 the President’s Emergency Plan for AIDS Relief (PEPFAR) allocated some US$578 million to Nigeria; significantly more than other donors. As part of this deal, PEPFAR is creating a complete HIV surveillance system for the Nigerian military, conducting prevention programmes, installing more reliable supply methods and arranging medical care for military troops and dependants living with HIV/AIDS (PHM, 2008). Concerns might be raised about whether directed HIV/AIDS relief risks privileging certain sectors of society such as the military or elites because of their strategic relevance to a developed country’s agenda (Elbe 2005 cited in PHM, 2008). This propagates the disparity: the affluent can access resources while the needs of the poor are ignored (Labonte & Schrecker, 2007). Thus while linking health and security might generate more attention and resources for health, it is evident that health is used as an instrument for ensuring stronger control over strategic resources of other countries (PHM, 2008). This is a form of bio-political racism that arises when a developed country portrays a communicable disease like HIV/AIDS in a developing country as being a security threat. It is interesting to note that data on the prevalence of HIV among peacekeepers who spread HIV/AIDS while on missions contributed to the determination of HIV/AIDS as a security issue in the first place (Feldbaum et al., 2006; Katz & Singer, 2007).

As set out in its strategy document, the UK aims to curtail HIV/AIDS, tuberculosis and malaria in developing countries in order to ‘reduce the threat from infectious diseases’ (HM Government, 2008). There are political tensions that can arise in terms of ‘security triage’, bio-political racism and loss of sovereignty for developing countries. A ‘security triage’ means that health issues that represent security threats are given automatic priority[5]. This is unwise because identifying a communicable disease as a security issue can lead to its prioritization and it will get more attention from top policy makers who in turn, can offer greater political support and more funding (Katz & Singer, 2007). While there is benefit to be gained from having a higher profile and increased resources, portraying a health issue as a security matter changes the context of health threats and conceivably revises the approach to solving the problem (Katz & Singer, 2007). There is a danger that inappropriate emphasis is given to designating blame and levying sanctions to control the threat, as opposed to more traditional health models that help identify and mitigate behaviours that instigate the health threat (Katz & Singer, 2007).

Bio-political racism can be identified in the case of Nigeria where the military benefited from HIV/AIDS treatment that was unavailable to the rest of the population. There is the concern that political elites will exploit the scaled-up AIDS relief to secure their positions (de Waal 2006, cited in PHM, 2008). A similar incident has occurred in Rwanda where high-ranking officials increasingly have access to anti-retrovirals but these are not available to the general population (Elbe, 2005). While this may save lives in the immediate future, targeted HIV/AIDS relief could retain a closed political loop that is detrimental to greater population security and fails to address the fundamental social determinants of health (PHM, 2008).

There is loss of sovereignty when developing countries have to follow foreign initiatives. As mentioned in the UK strategy document, the UK intends prioritizing certain programmes and increasing funding for these. Thus provision of aid is based on specific political concerns (Brower & Chalk, 2003). This has diverted scarce resources away from areas where they are needed and left many regions as ‘potential reservoirs of disease’ (Brower & Chalk, 2003). While strong developing countries like China, India and South Africa can negotiate with donors on equal terms, poorer developing countries are forced to comply with foreign initiatives (Crisp, 2007).

By coupling health with security in the light of communicable diseases, the UK has the potential to propagate bio-political racism and loss of sovereignty in its attempt to reduce its own domestic threat from communicable diseases. Crisp’s report elaborates that the UK’s approach of supporting ‘country-led’ plans, helping improve governance and reducing corruption, as well as offering long-term agreements on aid provides the right basis for the future (Crisp, 2007)[6]. Thus, this shows a degree of awareness for possible political tensions but nevertheless fails to address them explicitly. It is important for the UK to recognize that national priorities often differ from global priorities and can often differ from a developing country’s comprehensive health sector planning (Ollila, 2005).

DISCUSSION

The pincer model of the World Health Organization for member states reflects how an over-arching international organization has influence over member states to, for example, pursue the Millennium Development Goals. To achieve the Millennium Development Goals and also improve domestic health security, developed countries must realize the ‘survival advantage of caring about the other person’ as developed countries continually experience how communicable diseases present global threats (Guerrant, 1998). Developed countries such as the UK are aware that in their current policies they need to weave together epidemiology, national security interests and ethical practices. Inevitably, these criteria might not be weighted equally and might take the form of a hierarchy of importance, thus making choices between economic, ethical or political issues difficult (Musgrove, 1999). Consequently, high-income countries such as the UK are able to employ a pincer-like control over developing states. They can dictate what priorities their governments should have in order for the UK to contain communicable disease threats abroad before they affect vital domestic interests. With the power of funding as well as knowledge and technology, developed countries take sovereignty away from the developing countries in order to set their own national health agenda.

The UK is in a position of tug-of-war between ideals and practicality. Stanley Hoffmann captured the tension:

‘Whoever studies contemporary international relations cannot but hear behind the clash of interests and ideologies, a kind of permanent dialogue between Rosseau and Kant’ (Fidler, 2007).

Rosseau predicted there would be conflicts when countries interacted. Conversely, Kant believed that peace could be achieved through the transformation of national and international politics (Fidler, 2007). As Hoffmann further argued,

‘He ought not to give up the hope of a future world community but he cannot act as if it already existed’ (Fidler, 2007).

Thus, there will always be tensions but there needs to be a genuine focus on people’s health in the collective consciousness of national and international policy makers (Oslo Ministerial Declaration). The UK’s ‘Health is Global’ strategy document represents an awareness of the national responsibility to reduce communicable disease threats abroad before they affect domestic interests by altruistic means or otherwise. However, scepticism of government self-interest persists (Labonte & Schrecker, 2007). It seems that economic, ethical and political considerations will dictate the national health security policy agenda.

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[1] Better health security seeks to help achieve the Millennium Development Goals which in turn sets the stage for the ‘Health is Global’ second area of focus: stronger, fairer and safer systems to deliver health. By ensuring better health security, the UK can then be in a better position to influence the third area of focus – more effective international health organizations – by demonstrating coherent approaches that can support the European Union as well as demonstrate leadership or encourage reform within the United Nations system. Finally with respect to the fourth area of focus – stronger, freer and fairer trade for better health – better health security is required to initiate partnerships and establish the UK as a leader in ethical trade and robust systems of intellectual property rights. Thus, better health security is chosen.

[2] These goals are ‘combating global poverty and health inequalities; tackling climate change and environmental factors; tackling the effects of conflict on health and healthcare; reducing the threat from infectious diseases; and managing the health of migrants and tackling human trafficking’

[3] It acknowledges, among other points, that the UK will ‘set out to do no harm and, as far as feasible, evaluate the impact of our domestic and foreign policies on global health to ensure that our intention is fulfilled’; ‘use health as an agent for good in foreign policy, recognizing that improving the health of the world’ population can make a strong contribution towards promoting a low-carbon, high growth global economic’; ‘protect the health of the UK proactively, by tackling health challenges that being outside our borders’; and ‘work in partnership with other governments, multilateral agencies, civil society and business in pursuit of our objectives’ (HM Government, 2008).

[4] Again, there is only a brief acknowledgement that there are potential conflicts and that most relevant to ethical tensions. The UK will ‘set out to do no harm and, as far as feasible, evaluate the impact of our domestic and foreign policies on global health to ensure that our intention is fulfilled’; ‘protect the health of the UK proactively, by tackling health challenges that being outside our borders’; and ‘work in partnership with other governments, multilateral agencies, civil society and business in pursuit of our objectives’ (HM Government, 2008).

[5] Evidence of a ‘security triage’ can be seen in Action 8 of the ‘Health is Global’ strategy document which states “UK wants to encourage governments to include water and sanitation in national plans and budgets; increase UK funding for bilateral and multilateral water and sanitation programmes, including water resource management; ensure that there are clear links to climate change adaptation and conflict prevention; and encourage better coordination and prioritization of water security” (HM Government, 2008).

[6] Indeed, the UK document does state that the UK will ‘promote health equity within and between countries through our foreign and domestic policies’ and ‘ensure that the effects of foreign and domestic policies on global health are much more explicit and that we are transparent about where the objectives of different policies may conflict’ (HM Government).