PERSPECTIVES
Health and security in foreign policy
Rebecca KatzI; Daniel A SingerII
IDepartment of Health Policy, George Washington University, 2021 K Street, Suite 800, Washington, DC 20006, USA.Correspondence to Rebecca Katz (email: rlkatz@gwu.edu).
IIAvian Influenza Action Group, US Department of State, Washington, DC, USA
Introduction
Historically, health has occupied the lower echelons of national priorities. Over the past decade, however, national policy-makers have increasingly recognized the deleterious impacts that health crises may have on national interests. As a result, particular health issues occasionally have been elevated within national agendas, especially if they have implications for foreign policy and/or they are perceived as threats to national security.
Identifying a health issue as a foreign policy or security issue, or both, may lead to higher prioritization and more attention from top policy-makers, in turn, bringing greater political support and more funding.1 While health professionals may welcome the higher profile and greater resources given to their issues, characterizing a health issue as a national priority (and particularly as a security issue) may change the understanding of a health threat, put relatively greater emphasis on the views of those outside the health community and potentially alter the approach to solving the problem. Consequently, care should be taken in deciding which health issues should be given priority on par with national security issues and included explicitly in national foreign policy.
We support the assertion that "[w]hile it is clear that health issues often intersect with security issues, not all health challenges represent security concerns".2 Health issues that do not pose security threats should not be contextualized as such, since doing so may detract from overarching public health and foreign policy objectives. At the same time, however, we believe that efforts to address all types of health issues through foreign policy contribute to overall improvements in diplomatic relations, which may enhance the security of countries.
Health in foreign policy
Many health challenges, particularly infectious diseases, are widely recognized as global concerns that do not respect borders. As a result, countries often include in their foreign policies strategies on diseases that have the potential to threaten domestic interests. Public health challenges that are not concomitant security threats should be given consideration as foreign policy priorities on their own merits, without forcing them to be viewed through the prism of national security.
One example of a health issue that is addressed through foreign policy but is not a security issue is poliomyelitis. The eradication of polio requires sustained financial commitments and coordinated international efforts. Such coordination has resulted from countries negotiating high-level political commitments under the auspices of the Group of Eight (G8) and other organizations that are not typically seen as health institutions. Despite polio's role as a major cause of disability (and consequent loss of productivity), donor commitment to the Polio Eradication Initiative is not rooted in a concern for its economic or security impact, but in the belief that eradication would be a major victory for public health and would achieve a global good. The impetus for the international effort against polio is not national security concerns but an altruistic desire to ameliorate human morbidity and mortality. Thus, it can be argued that polio eradication is a foreign policy issue for countries, but not a national security issue.
Although characterizing a health issue as a foreign policy issue may provide greater visibility and greater funding, there is also a likelihood that programmes associated with such health priorities may be subject to enhanced political scrutiny. Additionally, identifying a particular health issue as a national (or international) priority inherently alters its importance relative to other public health issues. Since resources are generally limited and new funding is difficult to obtain, there is a great risk that the prioritized disease will draw resources away from other health programmes. Indeed, some research suggests that the Polio Eradication Initiative has provided secondary benefits to children's health, but competing studies suggest the contrary.3
Health as a national security concern
Promoting economic development and preventing political instability are core priorities for every government, and are generally the primary motivations underlying national security policy. Research has demonstrated that acute and chronic changes in health status have direct and indirect impacts on security, and that epidemics may lead to destabilization, political unrest, civil disorder or long-term deterioration of the economic viability of a country or region.4 Such health issues receive attention from senior policy-makers when they are possible threats to international, regional, national and individual security, or potentially may affect the economic welfare of a country or region.
The recent recognition that health issues have implications for national security has resulted in part from health officials' concerted efforts to educate policy-makers about the potential security impacts of certain disease-related events, whether naturally occurring (such as pandemic influenza) or in the form of intentionally released agents (such as acts of biological warfare or bioterrorism).5,6
In the United States of America, projections of the impact of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) on the workforces of many countries and data on the seroprevalence of HIV among military personnel in several global regions contributed to the determination that HIV/AIDS is a security issue.7 This led to that country's creation of the President's Emergency Plan for AIDS Relief, as well as motivating its support for global AIDS programmes. Likewise, the recognition of epidemiological similarities between H5N1 influenza and the 1918 influenza pandemic, combined with the economic impact of the relatively small outbreak of severe acute respiratory syndrome (SARS) and the potential impact of H5N1 influenza on economic and national security, led to increased interest among WHO and its Member States in preparing for the next pandemic.
Identifying a health issue as a security issue, as happened with HIV/AIDS and pandemic influenza, may bring more funding, political prominence and attention from senior policy-makers. This leads to more political support, increases in resources and higher prioritization. However, when the public health aspects of an issue outweigh its economic and security considerations, such as with polio, policy-makers and health professionals must resist the temptation to depict it as a security or economic threat, despite the increased political visibility and availability of resources that this might offer. Characterizing a health issue as a security threat often results in it being addressed through programmes and policies developed for law enforcement rather than public health. The result may be that a disproportionate emphasis is placed on assigning responsibility and levying sanctions to control the threat, as opposed to more traditional health models that identify and ameliorate risk factors and behaviours that contribute to the threat.
Additionally, characterizing a health issue as a security concern may assign a stigma to any assistance that is provided. Since good health is a common value shared among all people, international health programmes are naturally suited to being used as tools of diplomacy among countries that do not have a broad common agenda. Pegging health programmes to security programmes may undermine this opportunity for bridge building, to the detriment of both foreign policy and public health concerns.
Public health diplomacy and security
Cooperation and assistance targeted at public health challenges that are put in the context of foreign policy may broaden partnerships and build diplomatic relationships. In this way, the act of promoting global health enhances the security of countries. When countries work together to successfully address a global health challenge, be it a localized epidemic or a potential threat to international security, the world becomes a healthier and safer place. Maximizing the opportunity for such partnerships requires paying close attention to the nature of public health threats and carefully considering whether or not they are truly security threats. 
Competing interests: None declared.
References
1. Fidler D. Germs, norms and power: global health's political revolution, 2004. Available from: http://www2.warwick.ac.uk/fac/soc/law/elj/lgd/2004-1/fidler/
2. Ban J. Health as a global security challenge. Seton Hall Journal of Diplomacy and International Relations 2003;4:19-28.
3. Mogedal S, Stenson B. Disease eradication: friend or foe to the health system? Geneva: World Health Organization; 2000. (WHO/V&B/00.28.)
4. Price-Smith A. The health of nations: infectious disease, environmental change, and their effects on national security and development. Cambridge, MA: MIT Press; 2002.
5. Fidler DP. Health and foreign policy: a conceptual overview, 2005. Available from: http://www.nuffieldtrust.org.uk/ecomm/files/040205Fidler.pdf
6. McInnes C, Lee K. Health, security and foreign policy. Review of International Studies 2006;32:5-23.
7. National Intelligence Council, United States. The global infectious disease threat and its implications for the US, 2000. Available from: http://www.fas.org/irp/threat/nie99-17d.htm
(Submitted: 25 September 2006 - Final revised version received: 30 November 2006 - Accepted: 4 December 2006)