As the world has become more interconnected, the need for coordinated responses to shared global public health threats has increased. A small but growing cadre of diplomats known as health attachés is key among the practitioners of global health diplomacy (GHD) who employ the tools of diplomacy and statecraft to bridge governments’ public health and foreign policy objectives.
A health attaché is defined as a diplomat who collects, analyzes, and acts on information concerning health in a foreign country or countries and provides critical links between public health and foreign affairs stakeholders.1 The first mention in the literature of “health attachés” was in a 1948 issue of the Journal of the American Medical Association announcing the assignment of Morris B. Sanders to U.S. embassies in Brussels, Paris, and The Hague.2 Dr. Sanders was commissioned into the U.S. Public Health Service and detailed to the U.S. Department of State with a mission to collect information from these countries on health, medical research, and diseases of interest to the United States.3 Since then, a growing number of countries have assigned health attachés to work in embassies in countries of strategic importance. However, few papers specifically describe this special cadre of diplomats.
Understanding the role of health attachés, who work across disciplines and national boundaries, is important to improve the effectiveness of their work, enhance countries use of health attachés, and help shape training and professional development of future GHD practitioners. In this paper, we first describe the conceptual background of GHD in the twenty-first century and its impact on the development of the health attaché. Next, we introduce a Pyramid of Global Health Diplomacy, presenting myriad actors, definitions, and tools to update concepts used in this field, followed by a description of current practices and competencies of health attachés as a specific type of diplomat. Finally, we propose a tradecraft model for a modern health attaché to characterize the qualifications and training necessary for these professionals.
Global Health Diplomacy: Foundational Definitions and Concepts for the Twenty-First Century
A country's foreign policy can be understood as the strategy of a state to achieve its goals and to protect its national interests within the international community. Yet twenty years ago, few would have used the words “global health” and “diplomacy” in the same sentence, even though health is an integral component of global security.4 The term “global health diplomacy” is now firmly established in the global health lexicon, with relevance to both public health practice and foreign policy.5
In addition, many events over the last two decades have contributed to the development of the field of GHD, such as the increase in global funding to fight HIV/AIDS, the threat of emerging and re-emerging infectious diseases, the need for pandemic preparedness, the shifting of international health assistance to new multi-level collaborative partnerships, and the emerging focus on health system strengthening and universal health coverage. The field of GHD is supported by at least two peer-reviewed scientific journals,6 numerous training programs,7 at least four major public health institutions that maintain GHD content on their websites,8 and a dedicated Office for GHD in the U.S. Department of State.9
Twenty years ago, few would have used the words “global health” and “diplomacy” in the same sentence.
In 2008, Vincanne Adams, Thomas E. Novotny, and Hannah Leslie described GHD as a political activity that meets the dual goals of improving public health and strengthening relations among nation states.10 While this definition implies links between public health and foreign affairs, further refinements in the definition have followed. In 2009, U.S. Assistant Secretary of State for Oceans and International Environmental and Scientific Affairs Kerri-Ann Jones described GHD as a critical tool in foreign affairs. She encouraged diplomats in the Department of State to consider public health principles along with the traditional tools of commercial, military, and political diplomacy.11 Other stakeholders have also emphasized the use of health diplomacy as a “soft” or “smart” power tool in foreign policy,12 as well as in national security discourse.13 Ilona Kickbusch, a professor at the University of Geneva’s Graduate Institute of International and Development Studies Global Health Programme, has described the temporal continuum of global health and foreign policy14 with health becoming an increasingly important part of foreign policy discussions and negotiations in an integrated world. With health threats that impact national security, such as highly pathogenic avian influenza, challenges to the safety of the global drug supply,15 the continuing scourge of HIV/AIDS,16 and the spread of the Ebola virus declared a public health emergency of international concern,17 the need for diplomats who understand health issues while being able to negotiate effectively in the multinational foreign policy space is increasing.
In 2011, Katz et al. presented a taxonomy for GHD, defining “core,” “multi-stakeholder,” and “informal” forms of health diplomacy.18 We have employed Katz’s definitional terms to construct a diagram (Figure 1) to illustrate and emphasize aspects of GHD practice. As depicted, each category of GHD practice involves different tools and actors: (1) core health diplomacy uses bilateral and multilateral treaties and agreements among government and state actors; (2) multi-stakeholder diplomacy uses partnerships among government agencies and multilateral institutions; and (3) informal health diplomacy uses agreements with donor, academic, and humanitarian agencies.
This pyramidal structure does not imply that one category is more effective than another, but rather that the number of practitioners is fewer and the range of their activities is more focused at higher levels of the pyramid. Similarly, while neither actors nor tools are restricted to particular categories, actors and tools most frequently align within each respective category of GHD practice. To have a successful global health strategy that addresses public health and foreign policy goals, effective action at each level of the GHD pyramid is needed. As we propose below in our tradecraft model for a health attaché, GHD as practiced by health attachés requires identifying and engaging these tools and actors and coordinating action among multiple counterparts and stakeholders.
Health Attachés and Their Qualifications
A health attaché, typically assigned by a country’s ministry of health or foreign affairs, is accredited to the country of assignment—meaning that their name, diplomatic title, and mandate to represent the interests of their government—are presented by the sending government and accepted by the receiving government, according to the procedures set out in the Vienna Convention of Diplomatic Relations (VCDR) of 1961.19 Thus, a health attaché must be able to practice GHD and conduct related policy negotiations on behalf of his/her respective government. Negotiations may encompass other relevant sectors such as trade, security, and human rights, and thus the core competencies for a health attaché must include in-depth technical knowledge of public health issues as well as broad-based general knowledge, sound judgment, and strong interpersonal skills. The practice of GHD requires balancing these elements among multiple stakeholders to mutually address foreign policy and global health goals.
Specifically, a core practitioner of GHD, including a health attaché, must possess technical skills in understanding global health risks as well as skills in traditional diplomatic fields of political, economic, commercial, public affairs, and military diplomacy.20 Public health professionals generally value deep scientific knowledge and technical skills, but there is also a growing recognition of the need for a wider breadth of knowledge and skills in foreign affairs, international law, and public policy among public health stakeholders and counterparts in order to bring about change needed to mobilize global health action among nations. Hence, health attachés need to utilize a set of traits, knowledge, and competencies that encompass multidisciplinary areas of public health practice, global health governance, health security, and risk communication.
Today, a health attaché’s critical activities include facilitating links between domestic public health agencies and partners in their country or region of assignment, providing scientific and policy guidance on areas of public health practice, building and maintaining relationships in an international setting, and reporting on health matters in a foreign country.21 Other activities include facilitating and coordinating public health technical assistance; supporting research collaborations and information sharing; facilitating professional contacts; and negotiating bilateral and multilateral agreements.22 In addition, health attachés help coordinate public health policy across government agencies to help create a consistent foreign policy voice for their government on health issues. Health attachés also engage in promoting global health security and safety and facilitate global health governance.
Roles of U.S. Health Attachés
In the United States, health attaché positions are typically populated from agencies of the Department of Health and Human Services (HHS)—such as the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration, or the National Institutes of Health—or from the Office of Global Affairs (OGA) in the Office of the Secretary of HHS. OGA is an HHS staff office that provides formal support to the HHS secretary for global health matters, and supports HHS health attachés deployed in the field. In addition, the OGA coordinates with HHS agencies, the broader U.S. government interagency community, other countries, multinational organizations, and nongovernmental entities.
Currently, five posts have full-time, dedicated health attachés assigned by HHS (four other posts previously hosted attachés); four countries have part-time HHS country representatives who also serve as full-time CDC country directors but have a formal letter of appointment from OGA to represent HHS to a foreign government (Table 1). However, both health attachés and HHS country representatives represent the Secretary of HHS in-country and are the senior public health representative for the U.S. government that provides direct support and counsel to the U.S. ambassador. The Department of Defense (DOD) has two health affairs attachés, and there is one health attaché assigned by the U.S. Agency for International Development (USAID). While the DOD and USAID representatives respond to their own specific chain of command rather than HHS, they are senior active duty military or public health officers who maintain informal linkages to OGA and other HHS agencies and, as with all health attachés, provide support to the U.S. ambassador.
OGA receives more requests from U.S. embassies to furnish health attachés than there is capacity to support. To establish a new health attaché position, a confluence of support must exist among the U.S. government—including the Department of State, HHS, and the U.S. ambassador in a given country—in addition to identifying available funding. The priority for opening and closing positions is periodically reviewed with key stakeholders and U.S. government counterparts, and with host country governments. While much can be accomplished in the modern electronic communication and transportation age that enables offices to communicate with counterparts in other countries, there is increasing, not decreasing demand for the expertise of a resident health attaché, formally accredited to represent his/her government in foreign affairs.
Tradecraft Model of Health Attachés in the U.S. Government
U.S. health attachés interface with four key categories of stakeholders (Figure 2): (1) the U.S. government, (2) multinational organizations, (3) non-state actors (NGOs and large donor organizations), and (4) the host country government. Each may have different levels of focus on foreign policy or public health goals that must be thoroughly understood by the health attaché in order for him or her to succeed as a health diplomat. For example, within the U.S. government, HHS agencies are primarily concerned with domestic public health goals and have only a small focus on foreign affairs. Conversely, the U.S. Department of State has a primary responsibility for foreign policy goals with a lesser focus on public health. Knowing the nuances of each institution’s primary focus along the continuum of global health/foreign policy is necessary for the health attaché to align consultations and negotiations with appropriate interests, mechanisms, and partners.
As illustrated in Figure 2, partners are identified by either a counterpart relationship or a stakeholder relationship that must be further understood by the health attaché. Knowing which actors are in each category and which objectives they share will assist in framing discussions and defining expectations during negotiations.
A counterpart relationship is typically formalized in an official document or signed agreement, such as a memorandum of understanding or a health protocol between health agencies in the home government and the partner country. A counterpart relationship could also be established between multiple counterparts, such as through a science and technology agreement negotiated by the U.S. Department of State, which includes identifying health counterparts in the home and partner country. By comparison, a stakeholder relationship may or may not be codified in a formal agreement among partners. For example, the HHS health attaché in Geneva, Switzerland, functions primarily as a liaison officer between the U.S. mission and the World Health Organization (WHO), and thus has a central counterpart relationship. However, in any other country where a U.S. health attaché or HHS country representative is present, WHO would generally be considered a stakeholder and would not typically have a formal country-level agreement with U.S. health agencies. Stakeholder relationships also include those with the host country ministry of foreign affairs or other non-health agencies. Health attachés, in carrying out their responsibilities, must navigate discussions and negotiations with both counterparts and stakeholders.
Health attachés act as the central “node” or interface for a variety of counterparts and stakeholders (Figure 2). Tradecraft in this dynamic should include actively promoting domestic and shared global health interests in consultations and negotiations across the spectrum of national, host country, and global health stakeholders and counterparts through the formation and long-term cultivation of formal and informal relationships. More analysis and study of these dynamics, shared not only by today’s health attachés, but diplomats in the traditional fields of political, economic, commercial, public affairs, and military diplomacy, is needed to develop this tradecraft model further.
We note that our proposed tradecraft model has certain limitations. First, it provides only a preliminary description and a foundational approach to some of the core competencies, training, and roles of the health attaché. As there is little research assessing the functions and impact of health attachés, this tradecraft model will also likely evolve as this unique diplomatic role develops in twenty-first century diplomacy.
Non-U.S. GHD Practitioners in Washington, DC
To further understand the range of duties of GHD practitioners, we also examined the roles of official diplomatic representatives to the United States using the publicly available “Diplomatic List,” which is published quarterly by the Office of the Chief of Protocol of the U.S. Department of State. This list contains the name, title, and contact information for each government representative as required by signatory nations to the VCDR.23 Often, the diplomatic title listed suggests the specific area of focus for each diplomat on the list, such as defense attaché, or minister-counselor for commercial affairs. A review of the Diplomatic List for 2011 and 2012 reveals that seven nations name a diplomat accredited to the United States with some responsibility in the field of health (Table 2).
For the majority of countries with representation in Washington, DC, health matters are often included in the portfolios of diplomats who have other focus areas. Specifically, health may only be a component of economics, trade, or science portfolios. This may limit the attention paid or prioritization of health issues by the named representative. It is somewhat surprising that only seven of 130 countries represented (approximately 750 diplomats) in Washington, DC, have employed specifically named health representatives. Given substantial increases in the U.S. commitment and financing to global health initiatives in the past two decades through programs such as the President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis, and Malaria, one might expect that foreign representations would have required more specific health expertise to support their negotiations with relevant U.S. agencies. PEPFAR has involved more than seventy nations since 2003; and twenty-six nations have been involved in the U.S. Global Health Security Agenda since February 2014.24 This plethora of GHD activity suggests the need for more fully trained core practitioners of GHD, both for the United States and globally.
It is somewhat surprising that only seven of 130 countries represented (approximately 750 diplomats) in Washington, DC, have employed specifically named health representatives.
However, not every diplomat who practices GHD is a “health attaché,” nor is the role of a health attaché confined to only bilateral health negotiations. Government interaction with multinational organizations, such as WHO; nongovernmental organizations; private sector business enterprises; or even the general public also require GHD expertise in order to accomplish and negotiate governments’ health policy objectives. Recently, global health challenges and funding changes have stimulated many diplomatic missions to assign a specific health expert to their Geneva-based missions. Hence, the Diplomatic List, if replicated in Geneva, would contain many more diplomats with “health” in their titles though not all of these practitioners would necessarily be defined as a health attaché.
A critical factor differentiating health attachés from other diplomats is the health attaché’s role, regardless of the agency to which they belong, in providing a critical link between the health agencies and the foreign policy apparatus of both the sending and receiving country (Figure 2). As government priorities migrate along the continuum between foreign policy and global health, from health being an essential tool of foreign policy to a goal of foreign policy, the need for additional training in GHD, and, more specifically, the need, role, and influence of diplomats dedicated as health attachés, is evident.25
Building the Foundation for Future GHD Success
As the twenty-first century continues to emphasize the need for coordinated global health action among nations, the importance of GHD has become evident within foreign policy circles. We have described the duties of the health attaché in negotiating cross-cutting issues that intersect the fields of global public health and foreign affairs. In this paper, we have explored and defined an initial tradecraft model for health attachés in order to better describe his or her special brand of diplomatic practice. Further analysis of this model may assist both public health and foreign affairs practitioners and policy makers in developing more extensive pathways to address continuing global public health problems that impact the lives of millions. Hence, the success of the health attaché is of critical importance to addressing the core goals of GHD and to ensuring that health remains a priority in U.S. foreign policy and multinational engagement.
- Matthew Brown, Craig Shapiro, Alicia Livinksi, Thomas E. Novotny, and Jimmy Kolker, “Intersection of Diplomacy and Public Health: The Role of Health Attaches in the United States Government's Global Engagement.” Paper presented at the 141st Annual Meeting of the American Public Health Association, Boston, MA, November 2-6, 2013.
- Herbert G. Shepler, “First Public Health Attaché Appointed,” Journal Of The American Medical Association 10 (1948):761.
- Jeffrey P. Koplan et al., “Towards a common definition of global health,” The Lancet 373, no. 9679 (2009):1993-5, http://www.ianphi.org/documents/articlesArchives/2009Koplan%20Lancet.pdf.
- Jordan S. Kassalow, Why Health is Important to U.S. Foreign Policy (New York: Council on Foreign Relations, 2001), http://www.cfr.org/world/why-health-important-us-foreign-policy/p8315.
- Journal of Health Diplomacy and Global Health and Diplomacy. See Rachel Irwin and Mark Pearcey, “Editors’ Introduction,” Journal of Health Diplomacy 1, no. 2 (2013); and Joanne Manrique, “Letter from the Editor,” Global Health and Diplomacy 1, no. 1 (2012).
- Ilona Kickbusch and Christian Erk, Global Health Diplomacy: A Survey on Training Programmes & Courses (Geneva: The Graduate Institute, May 2008), http://graduateinstitute.ch/files/live/sites/iheid/files/sites/globalhealth/shared/1894/Health%20Diplomacy%20Education%20Survey%20-%20v9.pdf.
- For example, see
“Global Health Diplomacy,” World Health Organization, accessed August 14, 2014, http://www.who.int/trade/diplomacy/en/;
The Center for Global Health and Diplomacy, accessed August 14, 2014, http://globalhealthanddiplomacy.org/;
“Health Diplomacy,” Department of Health and Human Services, accessed August 14, 2014, http://www.globalhealth.gov/global-health-topics/health-diplomacy/; and
“Diplomacy at the GHP,” accessed August 14, 2014, http://graduateinstitute.ch/home/research/centresandprogrammes/globalhealth/about-us/diplomacy.html.
- Office of Global Health Diplomacy, U.S. Department of State, accessed August 14, 2014, http://www.state.gov/s/ghd.
- Vincanne Adams, Thomas E. Novotny, and Hannah Leslie, “Global Health Diplomacy,” Medical Anthropology 27, no. 4 (2008): 315-23, http://www.tandfonline.com/doi/abs/10.1080/01459740802427067#.VAoWGPmwLQA.
- Kerri-Ann Jones, “New Complexities and Approaches to Global Health Diplomacy: View from the U.S. Department of State,” PLOS Medicine (2010): e1000276, http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1000276.
- Joseph S. Nye, “Soft Power and American Foreign Policy,” Political Science Quarterly 119, no. 2 (2004): 255-70, http://onlinelibrary.wiley.com/doi/10.2307/20202345/abstract.
- Harry Feldbaum and Joshua Michaud, “Health Diplomacy and the Enduring Relevance of Foreign Policy Interests,” PLOS Medicine (2010): e1000226, http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1000226.
- Ilona Kickbusch, “Global health diplomacy: how foreign policy can influence health,” BMJ 342 (2011), http://www.bmj.com/content/342/bmj.d3154.
- Tim K. Mackey, “Global Health Diplomacy and the Governance of Counterfeit Medicines: A Mapping Exercise of Institutional Approaches,” Journal of Health Diplomacy 1, no. 1 (2013), http://www.ghd-net.org/sites/default/files/Global%20Health%20Diplomacy%20and%20the%20Governance%20of%20Counterfeit%20Medicines_0.pdf.
- Eduardo J. Gómez, “The Politics of Global Health Diplomacy: Conceptual, Theoretical, and Empirical Lessons from the United States, Southeast Asia, and Latin America," in Global HIV/AIDS Politics, Policy, and Activism: Persistent Challenges and Emerging Issues , (Santa Barbara: Praeger 2013), 73.
- Nigel Hawkes, “Ebola outbreak is a public health emergency of international concern, WHO warns,” BMJ 349 (2014):g5089, http://www.bmj.com/content/349/bmj.g5089.
- Rebecca Katz, Sarah Kornblet, Grace Arnold, Eric Lief, and Julie E. Fischer, “Defining Health Diplomacy: Changing Demands in the Era of Globalization,” The Milbank Quarterly 89, no. 3 (2011): 503-523, http://onlinelibrary.wiley.com/doi/10.1111/j.1468-0009.2011.00637.x/abstract.
- Grigory Tunkin, “Vienna Convention on Diplomatic Relations,” International Affairs 7 (1961):51-6.
- Rebecca Katz et al., “Defining Health Diplomacy: Changing Demands in the Era of Globalization.”
- Matthew Brown, Craig Shapiro, Alicia Livinksi, Thomas E. Novotny, and Jimmy Kolker, “Intersection of Diplomacy and Public Health.”
- Grigory Tunkin, “Vienna Convention on Diplomatic Relations.”
- Tom Frieden, “CDC: 5 ways diseases in other countries can kill you,” CNN, February 13, 2014, http://www.cnn.com/2014/02/13/health/frieden-global.
- Ilona Kickbusch and Mihály Kökény, “Global health diplomacy: five years on,” Bulletin of the World Health Organization 91 (2013):159, http://www.who.int/bulletin/volumes/91/3/13-118596/en.
Matthew Brown contributed to the overall planning and writing of the manuscript, the literature search, and the development of the figures, tables, and models. Tim Mackey, Craig Shapiro, Jimmy Kolker, and Thomas Novotny contributed to the writing and editing of the manuscript. The findings and conclusions are those of the authors and do not necessarily reflect the official positions of the U.S. Department of Health and Human Services.
We thank Holly Wong and Mitch Wolfe for editorial suggestions and Alicia Livinski for assisting with the literature review.