Opinion Pieces

What does global health have to do with foreign policy? Hillary Clinton: “everything”

On 16 August 2010, US Secretary of State Hillary Clinton took time out of her busy schedule to speak about the Obama administration’s Global Health Initiative (GHI) to faculty and students at the Johns Hopkins School of Advanced International Studies (SAIS). With so many crises in the world, what was a Secretary of State doing speaking about global health? “Some might accuse me of taking a little break from those crises to come to SAIS to talk about global health,” joked Clinton, “what exactly does maternal health, or immunizations, or the fight against HIV and AIDS have to do with foreign policy? Well, my answer is everything.”

Why the US invests in global health

Secretary Clinton spoke for just over an hour, introducing the audience to the central aspects of the new US policy on global health and why the US makes such large investments in this field. The US, Clinton explains, invests in global health to strengthen fragile and failing states, to promote social and economic progress, and to protect US security

“We have seen the devastating impact of AID on countries stripped of their farmers, teachers, soldiers, health workers, and other professionals, as well as millions of orphaned and vulnerable children left behind, whose needs far exceed what government agencies can provide”, recounts Clinton, “we have seen places where people who suffer from poor health struggle on many levels. Poverty is usually widespread. Infrastructure is usually incomplete. Food production and school enrolment is usually low.”

But global health is not only about the suffering of the world’s most marginalized populations. There is also “the threat posed by the spread of disease in our interconnected world in which thousands of people every day step on a plane in one continent and step off in another” Stressed Clinton. “We need a comprehensive, effective global system for tracking health data, monitoring threats, and coordinating responses”

US investments in global health are also about public diplomacy. “For millions of people worldwide, the prevention, treatment or care that the United States makes possible is their main experience of us as a country and a people. And it can be a very powerful one” says Clinton. This is exemplary of the US approach to what is known as soft or smart power. Referencing the CSIS Commission on Smart Global Health Policy, Secretary Clinton confirmed the belief that new strategies for global health will “help us build a safer, more secure world.”

And perhaps most importantly to the American tax payers who support US investments in global health, Clinton underlines that “we invest in global health as a clear and direct expression of our compassion. Millions dies every year simply because they lack access to very simple interventions, like bed nets, or vitamin-fortified food, or oral rehydration therapy. As a nation and a people, we cannot, we must not, accept those senseless deaths. It’s just not in our DNA.”

How the US will implement new strategies for global health

For these reasons the US government is investing US $ 63 billion in global health. “First, to sustain and strengthen existing programmes, and second, to build upon those programmes and take their work to the next level by collaborating with governments, organizations, civil society groups, and individuals to help broaden the improvements in public health that we can expect.

To drive her messages home, Secretary Clinton then recounted the life story of a woman living in a partner country where PEPFAR has made the diagnosis and treatment of her HIV possible. But her story also highlights the significant gaps that create obstacles for this woman to access other services, such as prenatal care. Or how while her home may have been sprayed for mosquitoes, it lacks clean water, so while her children may escape malaria only to die from diarrheal disease.

While treatment and prevention programmes will be expanded under the GHI, it will also strive to tackle some of the systemic problems, working with partner countries to uproot the most deep-seated obstacles that impede their own people’s health. The US is pursing this goal by focusing their GHI on a handful of key principles.

First, the US will work with countries to create and implement strategies for health that the countries take the lead in designing based on their distinct needs and existing strengths. The US will help them build their capacity to manage, oversee, coordinate, and operate health programs over the long term.

Second, the US is focusing on the needs and contributions of women and girls, “Because when a woman’s health suffers, her family suffers and then there is a ripple effect throughout a village as well. But when women are healthy, the benefits are similarly broad.”

Third, the US is “improving how we measure and evaluate our own impact. This includes shifting our focus from “inputs” to “outcomes and impacts”-that is, determining our success not simply by how many bed nets we distribute, but by how many people actually avoid malaria by using them correctly”.

Fourth, the US is “investing in innovation, with a focus on developing tools that will help diagnose, prevent, and cure disease in the communities where we work, which are often remote and poor in resources”.

Fifth, the US is “improving coordination and integration. And that begins with aligning all U.S. Government programs within a country by finding opportunities to bundle services-much like PEPFAR did in Kenya, by linking HIV and AIDS programs with maternal and child health, TB, and family planning.”

And finally, the US is “working with existing partners and seeking out new ones. We want to align our efforts with that of other donor countries and multilateral organizations, many of which do outstanding work to improve global health.”

The US approach to global health

The US investments in global health programming in underserved communities across the world is a driving force for the alleviation of suffering on the grandest scale the world has ever know. No criticism should detract from that fact. No other country or international organization comes close to the capital and human resources that the American people are putting behind this cause. Yet, some weaknesses in the new policy demand discussion. Despite the attention from the Secretary of State, the most senior diplomatic officer of the Obama administration, the US GHI is seriously lacking in its support for the build up of political capacity needed to achieve these goals

Global health is distinct from international health and it is also different from health development assistance. Global health is markedly political in nature, and the US recognises this with their emphasis on soft and smart power. However, the GHI views global health primarily as a wing of development cooperation. This perspective misses out on a variety of crucial global health activities that need to be approached politically, with diplomatic skill, such as the issue of virus sharing and intellectual property rights. The GHI does not include provisions to build US capacity for health diplomacy and for investments in institutions for the global governance of health. To fulfil its ambitious aims the US GHI must be supported with strong political infrastructure.

For more detailed recommendations, see Feldbaum (2010) Building U.S. Diplomatic Capacity for Global Health