Charity
The second perspective is perhaps the most common. This perspective is motivated by ‘charity’. Charity engenders a foreign policy that motivates voluntary, periodic engagement with events where an imminent threat to the health of the “other” is present. This ethical perspective is easily observed in the foreign policy of states following natural disasters or catastrophic events. Recent examples include the devastating earthquakes in Haiti, Pakistan, Japan, and New Zealand.
The support that results from this type of foreign policy is often not coordinated with other states, is temporary and reactive. For example, Merchant and colleagues recently described the complex coordination, or rather primarily uncoordinated efforts, that were involved in the post-disaster response to the 2010 earthquake in Haiti [
10]. The response to the earthquake in Haiti provides a pointed and common example of a charity-based response to a natural disaster. This response is characterized by hundreds of non-governmental organizations (NGOs) such as Doctors without Borders, Partners in Health and the Red Cross working alongside, not necessarily in collaboration or coordination with, governments and intergovernmental organizations. Michaelle Jean, the former Governor General of Canada and a native to Haiti commented that the much of the efforts in Haiti have not delivered sustainable programming and have been carried out independent of the wishes of the Haitian government. The following statement reaches to the heart of the challenge of a charity-based ethical frame:
“Right now, the government of Haiti is completely decapitalized. Even after the earthquake, of all the money and the financial commitments of the international community to support the reconstruction of Haiti, only one per cent went to the government of Haiti.
Now the government cannot compete with the NGOs on the ground, which can pay a lot more for very skilled workers. That creates a total contradiction. The donor countries have validated the Haitian strategic plan for reconstruction but are not supporting the government in its capacity to implement those policies. It doesn’t make sense [
11]”.
Although many circumstances call for this type of response from governments and other actors, the above example demonstrates the limitations of this approach to provide sustainable measures.
Pressing global issues such as the rise in non-communicable diseases (NCDs) are often neglected by a charity perspective simply because of the orientation to short-term relief efforts that are often not coordinated with the host government. To address NCDs on a global scale, a commitment to the development of long-term governance mechanisms that address complex, systemic determinants such as the international trade of health-harming products is required [
12]. A charity-based foreign policy can support preparation for disaster preparedness but it tends to create reactive forms of engagement rather than the development of ongoing system strengthening [
13]. The premise of this ethical perspective, at least for governments, is that “we take care of the health of our nation on a sustained basis, but if others need help in the occurrence of an emergency then we will help until the emergency is resolved”. This type of engagement tends to be voluntary and rendered as much by NGOs as by states.
Security
The third ethical perspective reflects a country’s decision to act for the protection and promotion of the health of “the other” for the sake of their own citizens. This type of engagement has taken over from the charity perspective as the dominant ethical frame in the foreign policy for health discourse [
14]. National security has historically been at the top of the foreign policy hierarchy [
15]. It is in light of this history that it is not surprising that legislators and health advocates have attempted to frame health issues in security terms. The security rhetoric is found in such high level programs as the US Global Health Initiative. At the launch of this initiative on May 5th, 2009, then Secretary of State Hillary Clinton noted that the initiative would be “a crucial component of American foreign policy and a signature element of smart power” [
16]. Deputy Secretary of State Jack Lew further expounded on the security rhetoric a few days after the launch of the initiative by stating: “we have the opportunity to cost-effectively contribute to political stability in a way that enhances our national security, while advancing our core humanitarian values” [
17]. More pointedly, national-interest finds itself embedded in two of three of the United States’ Department of Health and Human Services global health strategy goals related in late 2011 [
18]. Goal 1 is to protect and promote the health and well being of Americans through global health action. Goal 3 is to advance the United States’ interests in international diplomacy, development and security through global health action. These examples reflect the dominant inward emphasis taken by decision-makers. This inward focus on “us” is reasonable given the order of sovereign states and the pressures imposed within states to rationalize “global” spending. It is true that states face numerous fiscal and political realities that draw them into the protection and promotion of domestic interests. However, this paper argues that the narrow emphasis on security (as well as charity and non-engagement) may be antithetical to global health objectives.
Despite the recent dominance of the security perspective scholars have begun to highlight the over-securitization of health issues in the development of foreign policy [
19]. Katz and Singer note, “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” (p. 233) [
20]. For example, the commitment made by the United States to the global HIV/AIDS pandemic through the President’s Emergency Plan for AIDS Relief (PEPFAR) was deeply rooted in national security interests [
15]. For example, the National Intelligence Council (NIC) produced a report titled The Global Infectious Disease Threat and Its Implications for the United States wherein it is stated that “These diseases (including HIV/AIDS) will endanger US citizens at home and abroad, threaten US armed forces deployed overseas, and exacerbate social and political instability in key countries and regions in which the United States has significant interests” [
21]. Although it is tempting to assert that the emergence of PEPFAR indicates that a security frame can indeed bring about substantial commitment to global health issues, it is important to note that the way HIV/AIDS was framed had and continues to have (often negative) implications for the sustainability and success of the program. It is important to note that HIV/AIDS was and continues to be a critical global health issue, but framing it as a security issue was limiting.
d Feldbaum notes that framing HIV/AIDS as a security threat was challenged over time where the questioned credibility of the security threat of the disease created barriers to the actual program that was developed to address the disease [
21]. What needs to be asked is whether security is the most appropriate frame to improve global health and perhaps more importantly, is national security ethically justified when working towards global health in an interconnected world?
Philosophically, the security perspective contends, whether implicitly or explicitly, even more than the charity frame, that the strongest identity is that of nation-state. Subsequently, this state-based identity is considered the locus of responsibility. In other words, the national polity is responsible to further the good of the demos or the nation in this case. The lines of responsibility are demarcated according to formal citizenship. This logic has provided fodder for a strongly asserted opposition to a cosmopolitan ethic of
global justice. This opposition draws on the fact that there is currently a lack of a global demos or citizenship tied to the lack of a global (supranational) authority [
22]. Some suggest that without a global polity or a global rule of law for which to bind citizens and the reciprocal responsibility of citizen-state relationships that they engender, there is no basis for a transnational global ethic [
23]. As was mentioned at the outset of this paper, this argument represents what Beitz calls the “morality of states” [
4]. This outlook sees states as the “principle bearers of rights and duties rather than persons” and that these states are then “obligated to follow a system of norms analogous to those that apply to individuals in the state of nature” [
4]. Ruger notes that within the state-centric ethical frames the “global health inequalities have no moral standing: justice, an associative obligation, is owed only to a government’s own citizens” (p. 428) [
24].
Although the security frame shares the charity frames’ emphasis on responsibility to a national citizenship, it is distinguished by the tendency to motivate long-term action. The security frame follows the logic that sustained support for resource-poor regions or for collaborative forums will ensure sustained national security through enhanced diplomatic relations, good will fostered among the citizens of those regions (e.g. strategic war on terror) and the establishment of dependence and control [
9]. For example, Brennan and Waldman describe the response to the earthquake that struck northern Pakistan and India in 2005, and note that “when natural disasters occur in countries in which the United States believes it has a national-security interest, a strong case can be made for long-term involvement” [
25]. This statement is meant to demonstrate that security interests can actually provide long-term support for health issues in “foreign” countries, making it a good thing when compared to the reliance on short-term relief provided through “altruism” (characteristic of the charity frame) [
25]. However, despite the good it produces, one must again ask, who is being left out because they do not engender security-based concerns? For example, the Global Health Security Initiative that was initiated by the United States provides a forum for countries to communicate and work to protect themselves from “key risks to global health security” including “chemical, biological, radiological and nuclear threats and the spread of pandemic influenza” [
26]. Although this initiative is an important forum to address the key identified risks, the structure represents a common tendency towards strategic rather than global partnerships. The initiative, although linked to the World Health Organization, includes only the European Commission and eight other countries (only Mexico is represented from the Global South).
Despite the tendency to engender long-term health measures, the security frame is not consistent in this regard. Rubenstein provides the most nuanced critique of the security frame to date by articulating its underlying assumptions and analyzing whether these assumptions are in fact correct [
27]. Rubenstein provides examples of how the following three desired assumptions, “health interventions contribute substantially to achieving objectives like (1) increasing security, (2) securing the allegiance of the population, or (3) stabilizing a region”, often do not result from “instrumental” uses of health interventions [
27]. He refers to two studies that demonstrate that health interventions carried out by the United States military in the destabilized countries of Kenya and Afghanistan were seen as counterterrorism efforts rather than acts of concern for the local populations and thus did not have the desired effect of garnering allegiance or even achieving health benefits. Rubenstein discusses a recent case in which the CIA conducted a vaccination program in Pakistan in order to acquire blood samples and confirm the location of Osama Bin Laden, probably the most dramatic example of a health “ruse” to achieve national security objectives. This example represents the extreme end of “health instrumentalism” by highlighting that health was not even a desired outcome, demonstrated by the fact that follow-up vaccinations were not provided once the raid on Bin Laden’s compound was complete.
Frist affirms that the charity discourse has been replaced by that of “self-protection” despite the faith he places in health as a tool for international peace [
14]. He notes that “health is a source of the most potent of forces in each human: the fear of death and the desire to preserve our own lives and the lives of those we love. Because health is so fundamental to all humans – of all nations, religions, races and situations – healthcare communicates a remarkable message of understanding and human connection across all boundaries and thus provides a unique, heretofore under-applied, tool of diplomacy” (p. 219) [
14]. The aspirations that Frist puts forward are indeed noble and his thesis provocative, however, the examples provided above provide reason for concern. The limitation of the security frame, as demonstrated by the previous examples, is that trust, solidarity, and diplomacy are built on a foundation of altruism and mutual caring. With respect to the security frame, governments may not build trust but rather engage in superficial cooperation for their own self-interest [
19]. The security frame may produce temporary and periodic global health benefits, but the examples provided in this section demonstrate that the ceiling of cooperation, global solidarity and system development is low.
Cosmopolitanism
The final perspective is cosmopolitanism. Cosmopolitanism is founded on the following core principle.
“Cosmopolitanism takes the individual to be the ultimate unit of moral worth and to be entitled to equal consideration regardless of her culture, nationality or citizenship, besides other morally arbitrary facts about her (p. 431) [
28].”
The cosmopolitan perspective contrasts the three perspectives described above, and particularly the security frame, by treating the individual as the ultimate unit of concern, a concern that takes primacy ahead of other units of identity such as nation and community. Thomas Pogge argues that “rich nations” have a negative duty to global citizens, those situated outside of one’s own borders, because of their role in creating and perpetuating a global order that often creates the conditions that are detrimental to the needs of those citizens [
29]. This negative duty requires these nations not to cause harm to global persons through global economic and political practices. Pogge explicitly situates his argument for harm avoidance against beneficence or charity which do not acknowledge the systemic contributions to injustice and inequality. Gilabert critiques Pogge’s cosmopolitan project by articulating a positive duty to provide “reasonable assistance securing the conditions of autonomous agency” [
30]. Gilabert argues that this positive duty promotes a solidarity that actually engages with a global citizenship to help create the conditions for human flourishing. In sum, the cosmopolitan account is supported by principles of harm avoidance and active assistance (positive solidarity) toward individuals at the global level over and above national allegiances characteristic of the above three forms of engagement.
The principles of individual moral worth and the duty not to harm and contribute to the betterment of the lives of individuals is then applied to the political sphere to ensure that justice “ought to apply among individuals
across national boundaries, and not be limited within or constrained by these boundaries” (p. 431) [
28]. The cosmopolitan ethical frame is inherently transnational in scope. The following section will review arguments that suggest that this ethical frame is the right one for a health-based foreign policy, that it engenders various goods that are not possible within a charity or security frame, and that a cosmopolitan frame is indeed possible.