James Bond and Global Health Diplomacy

In the 21st Century, distinctions and boundaries between global health, international politics, and the broader interests of the global community are harder to define and enforce than ever before. As a result, global health workers, leaders, and institutions face pressing questions around the nature and extent of their involvement with non-health endeavors, including international conflict resolution, counter-terrorism, and peace-keeping, under the global health diplomacy (GHD) paradigm.

alone intelligence operatives -and should not be exposed, voluntarily or involuntarily, to risks which may affect their colleagues as much as themselves. 8However, those doctors, nurses, project managers, field staff, epidemiologists, and other specialists within the global health community traveling to countries such as Afghanistan, Sudan, South Sudan, and Iraq do so with the knowledge that they are placing themselves in potentially perilous situations -and that, directly or indirectly, their endeavours are inexorably tied to concerns of conflict resolution, "smart power, " diplomacy, foreign policy, and international relations. 9Implicitly, if not explicitly, it is not uncommon for global health professionals -particularly those politically appointed, or representative of national governments -to undertake duties far beyond their brief related to foreign policy, and international relations, 5 even if these pursuits are not always directly related to the advancement of health goals, but instead operate in parallel with them.Similarly, bilateral aid programs have consistently combined political goals with healthcare agendas in an implicit manner 10 ; GHD approaches merely make these implicit mechanisms explicit, and therefore both clearer, and better optimized, by both donors and recipients.The historical parallel of global health workers doubling as missionaries, or vice versa, is a compelling representation of the medical community's capacity to pursue broader, "downstream" goals.In parallel, at the personal level, anecdotal evidence suggests that global health work often demands an inherent courage and awareness of environmental and situational risks -dangers which may not necessarily increase in direct proportion to the addition of diplomatic duties and responsibilities. 11

The Wrong Way
The assassination of community health workers in Pakistan 12 as an indirect result of associations with clandestine activities in the search for Osama Bin Laden, though possibly a oneoff catastrophic event, may have damaged the credibility of immunization programs throughout the developing world for years to come. 13Such tragedies have, in recent years, raised serious questions around the acceptability of implicitly combining global health with foreign policy initiatives. 14his was not an isolated event: Germany's foreign spy agency "routinely camouflages its agents as development aid workers, even in war zones, " 15 while other countries have allegedly made use of aid personnel for intelligence purposes in locations such as Cuba. 16Further examples abound: In March 2009, Sudan expelled several major foreign aid agencies, including Oxfam and Save the Children, from the Darfur region in response to accusations by President al-Bashir of foreign aid workers being "spies" and "thieves." 17 Global health personnel, due to their location and activities, may therefore face ethical and moral dilemmas around their implicit role and function, including situations such as vaccination or family planning programs being used as plots for "western control, " 18 or the training of health workers manifesting as a threat to the military-government apparatus.Even more critically, many personnel also remain hopelessly naïve about how both donor governance and recipients of aid interpret their work in political terms. 19The unplanned, unstructured, and ad-hoc combination of global health and foreign policy initiatives will, therefore, inevitably lead to further tragedies and failures of the kind described above -with correspondingly greater threats to global health workers' safety and security -while the discrediting of associated agencies threatens both diplomatic and broader international relations between donors and recipients.

Opportunity Points
Within the global health architecture, opportunity points for the involvement of global health in foreign policy can only be identified through an understanding of the actors, contexts and challenges of both fields.Medicine and health are, to a far greater extent than other forms of international development, involved in situations of conflict, terrorism, warfare, and humanitarian emergency and catastrophe, making the integration of diplomacy into related projects and interventions of critical importance. 20The advancement of foreign policy goals by national governments through health and development programs is, thus, a natural evolution of this association.Actors such as the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM), the President's Emergency Plan for AIDS Relief (PEPFAR), and the United Nations Development Program (UNDP) frequently (though on an ad-hoc basis) advance both health and non-health agendas in unison, such as the secession of South Sudan from the Republic of Sudan, 21 challenging extremism in Afghanistan, 22 or contributing to conflict resolution in Iraq. 23Even players such as Medicins sans Frontieres (MSF) and the World Health Organization (WHO), despite their exclusively apolitical manifestoes, cannot hope to avoid some form of non-health influence, partisanship, or even (in the case of MSF) potentially offensive elitism. 24At the individual level, even non-political global health representatives are frequently presented with opportunities to design and deliver recommendations and programmatic adaptations that address or report on both health and non-health (eg, political, social or economic) goals in concert with each other. 25Even more fundamentally, such personnel are implicitly responsible for North-South relations in their comportment, behaviours and personal diplomacy when operating overseas. 5To date, however, no standards, trainings, operating procedures, evaluation tools or guidelines, though now available, 26 have been routinely employed this regard. 27e Right Way? Rather than advocating for greater delineation on this basis, fields such as GHD, under certain interpretations, 28 attempt to resolve these tensions by encouraging, leveraging and making explicit such overlaps from the "smart power" perspective, employing altruistic operations to pursue broader non-health goals including international security. 24GHD can therefore be leveraged to pursue global "goods" unrelated to health programs -a benign force, as long as it is not manipulated into pursuing global "bads" via rapacious foreign policiesand, even then, remains a better route than violent conflict.Is there, then, a "right" way for global health to interact with international politics, intelligence and diplomacy?Or, conversely, can non-health professions such as the clandestine services also help to advance global health?In spite of the threats, dangers, and blanket opposition to such proposals from the medical community, 13 if appropriately structured, delivered and monitored, there may yet be a place for diplomatic, security, and political activities embedded within the global health milieu.Those shocked and appalled by the scale and scope of civilian casualties in recent conflicts 29 have called for alternatives to engagements such as the Iraq War through the implementation of global health programs working in collaboration with intelligence services and operating under "military umbrellas." 30 Such approaches seek to exploit synergies between health and non-health organizations such as the advancement of humanitarian causes, conflict resolution, and international cooperation, as well as via operational overlaps: both groups are embedded, often for long periods, in remote and potentially hostile cultures; both operate under the aegis of international agencies; and both play a (conscious or unconscious) part in broader international strategic initiatives which may be unrelated to their primary programmatic responsibilities. 20Examples such as the highly political nature of the polio immunization boycott in Northern Nigeria and related diplomatic efforts to overcome challenges to uptake, are representative of potential future successes of disciplinary integration based on GHD approaches. 31However, successful collaborations are equally dependent on adherence to a set of standards and operating principles that recognize and respect both mutual and distinct goals, operating procedures, and standards of conduct between health and non-health organizations. 32

Building Mutually Acceptable and Appropriate Collaborations
Such approaches represent the antithesis of contemporary thought in this regard, and will inevitably provoke controversy.Innovative and interdisciplinary combinations, most frequently designed to involve health in broader global agendas but also, conversely, to integrate and pursue foreign policy concerns via international development, if ever to occur successfully, must be carefully and meticulously plannednot least to protect the health, safety, prestige and operational independence of the global health community.If this is possible, on the basis, perhaps, of adherence to and application of appropriate criteria for the "diplomatic" and "foreign policy" sensitization of global health interventions, 11 opportunities for mutually acceptable associations may exist.These might include, for example: (1) Leveraging the location and presence of international health programs in unstable regions for international security and conflict resolution purposes; (2) enhancing and engaging with information gathered through monitoring and evaluation systems to better understand local communities, cultures, and preferences; (3) exploiting the extensive collaborations that global health efforts develop with community, district, regional, and international bodies; and (4) eraming such associations as an explicit quid pro quo with recipient countries, whereby vital intelligence efforts related to national and international security are, formally or informally, exchanged for, or combined with, the provision of altruistic development programs.

Uneasy Allies
As health and politics become increasingly and inexorably intertwined, the risk of "cross-contamination" across previously-distinct professional and disciplinary challenges increases exponentially; associations between clandestine organizations such as the Central Intelligence Agency (CIA), world politics, and global health initiatives have never before been so much in the public eye. 33Similarly, the invovement of military organizations as potential actors in in global health operations -such as under Operation United Assistance in response to the Ebola outbreak 33 -are the subject of intense contemporary media interest, scrutiny, and even alarm.Such reflection is both welcome and necessary, and has both the safely of global health workers and the advancement of international cooperation and diplomacy as it's goal.Nonetheless, with the decreased stature, cost-effectiveness, international social and cultural acceptability, and even relevance of "hard power" operations in the 21st Century, opportunities for such collaborations in the interests, not just of global health, but also of broader international security, are both of increasing importance and increasingly unavoidable.In the context of contemporary crises such as Syria and the Islamic State, both strategic and altruistic initiatives have either failed, or faced unacceptable security challenges -at both the individual and organizational levels -when operating independently of each other.Structured liaisons and collaborations may be the only alternative left.Success, in turn, relies on intelligence, military, global health, and development organizations working together in unprecedented ways, as characterized by the recent creation of the United States' Office of Global Health Diplomacy (OGHD) embedded within increasingly political divisions of the State Department. 34The involvement, in such cases, of essentially political and foreign policy departments into the very mechanics of global health program design and delivery should be welcomed and endorsed by the global health community -not just for the added global health funding this dual agenda may generate, but because of the essential and urgent need to integrate diplomatic principles and practices into a profession that has, for too long, been dominated by the narrow (and often culturally, politically and diplomatically insensitive) nature of interventions designed exclusively by the medical and economic professions. 35Those involved will likely resent and resist such encroachments of their purview -but both shaking and stirring such boundaries will, in the 21st Century, continue to be an essential part of global health's evolution.