The magnitude and nature of today’s global health challenges are formidable and arguably unprecedented due to shifts in the world landscape. From physical and mental trauma of populations fleeing unparalleled large-scale armed conflicts and increasing natural disasters to spread of infectious diseases fueled by a rise in global interconnectivity to the rapid increase of non-communicable diseases related to present-day aging populations and modern sedentary lifestyles–global health issues have become increasingly large and complex. Effective responses, more than ever, require coordinated efforts by diverse stakeholders across countries and communities. Constructive relationships between countries and strategic partnerships within a country are critical. Implementation of global health initiatives needs to acknowledge local perspectives and contexts, as well as long-term consequences.

Being the largest funder and implementer of health programs around the globe,¹ the U.S. is uniquely positioned to use diplomacy to drive advancement in global health, but only if a comprehensive and holistic approach is adopted, whereby diplomacy is coupled with other societal responses. Racism, distrust in government, and other systemic issues have time and again thwarted progress toward improved health outcomes for all. They must be addressed. Predictably, these issues have made a robust domestic national response to the coronavirus disease 2019 (COVID-19) pandemic much more difficult. If the U.S. intends to play a significant role in shaping the future of global health, it must strategically integrate diplomacy into various dimensions of global health initiatives to achieve broad-ranging impact.

Private Sector Collaboration for Public Health Solutions: Building effective partnerships

Global health diplomacy goes beyond interactions among nation-states to achieve public health goals. It can be leveraged to facilitate identification of shared interests and enhance collaboration across many sectors, for instance in public-private partnerships. Public-private partnerships can involve an array of partners from academia, non-governmental organizations, non-profit organizations, industry, and government and intergovernmental agencies. Partnerships capable of pooling resources and assets such as capital, logistics infrastructure, communications platforms, and international collaborations are essential for meeting future global health challenges. Combining the reach and scale of the public sector with the strengths of the private sector enables the rapid development and deployment of novel treatments and therapies for infectious diseases and non-communicable diseases (NCDs).

As one example, the World Health Organization’s (WHO) Drugs for Neglected Diseases Initiative established partnerships to leverage donations of essential drugs from private pharmaceutical companies to help meet targets for controlling and eliminating neglected tropical diseases; the targets themselves are set in cooperation by member states via World Health Assembly resolutions. Additionally, the Bill and Melinda Gates Foundation (BMGF) uses its significant monetary resources and name recognition to tackle public health challenges around the world, often in collaboration with national or international governing bodies. Most notably, BMGF provided the seed funding to launch Gavi, the Vaccine Alliance, an international organization that brings together the public and private sectors to facilitate access to vaccines in low- and middle-income countries.² However, there are widespread concerns that wealthy countries and private foundations can hold significant power in public domains and can result in potentially inequitable partnerships. For instance, significant concerns have been raised that BMGF’s massive donations to the WHO give the foundation outsized influence over WHO’s agenda, and that private foundations more broadly may operate without the same accountability that governments have.^3,4

Furthermore, while both the public and private sectors advance the public good by pursuing health solutions, they are not always aligned in their interests. In particular, participation of for-profit private organizations requires the promise of a net profit, direct or otherwise. This inherent profit motive can drive private companies to behave contrary to public health objectives, including when in public-private partnerships. For instance, the COVID-19 drug remdesivir was developed via a research collaboration between the pharmaceutical company, Gilead Sciences, the Centers for Disease Control and Prevention (CDC), and the U.S. Army Medical Research Institute of Infectious Diseases.⁵ Gilead sought and received orphan drug status for remdesivir at the outset of the COVID-19 pandemic; these efforts were widely criticized as an abuse of the Orphan Drug Act (Gilead later withdrew the request amid fierce public backlash).⁶

Carefully designed, innovative, and loophole-free policies are needed to ensure that public-private partnerships meet emerging global health challenges by motivating constructive participation and leveraging unique strengths. Communications with potential private sector collaborators about incentivizing policies that may be of interest can be used to spur private sector involvement and establish effective partnerships. Additionally, clear expectations and negotiation of terms at the outset of a partnership can avoid unwanted downstream actions and promote intended public health goals. Given the strength of the U.S. private sector and historic leadership in the G7, the U.S. can play a significant role in this arena and lead by example.

“Local” Health Diplomacy: Building trust and engaging with communities

To be effective, public health and health diplomacy must center on people and the communities where they reside. Communities must have meaningful input and agency to make decisions to develop, adopt, and implement health initiatives. Approaches for achieving local engagement include tailoring communications to specific populations and working collaboratively with local leaders. Effective health diplomacy creates venues for health researchers and practitioners and local leaders to exchange information and design and implement locally-appropriate programs and interventions. As researchers noted in a 2015 report of the Pan-African Medical Journal, “traditional and religious leaders command more respect and authority in their communities than unfamiliar trained health personnel” in achieving public health goals. Failure to engage local leaders who understood the importance of traditional burial practices inhibited the response to an Ebola outbreak in six West African nations, despite the availability of necessary medical expertise and resources.⁷ When practiced without meaningful engagement with local community leaders and an understanding of cultural customs and practices, well-intentioned health programs may not only fail to achieve important health goals, but even exacerbate public health issues and jeopardize diplomatic relationships.

Health campaigns rooted in good science, earned community trust, and an ability to deliver measurable improvements in health, coupled with a long-term sustainability plan, can be powerful agents of diplomacy. For example, approval ratings for the U.S. are much higher among countries participating in the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) than the global average (see below).⁸ Key to developing diplomatic ties is a sense of solidarity and equitable partnership dynamics. Cuba has long built political goodwill by exporting its substantial health care workforce, including being the first country to send health workers to West Africa in response to the Ebola epidemic.⁹ A critical aspect of this program’s success is that Cuba not only embeds its medical professionals within communities, with routine house calls, but also provides free training for medical personnel in partner countries (though Cuba’s health diplomacy programs have come under scrutiny amid allegations that the civil liberties and human rights of Cuban doctors are violated during postings abroad).^10,11 Indeed, when practiced with a commitment to ensuring health equity for all, health diplomacy can be used “as a tool for peace.”¹² Vaccinations have even been used to negotiate temporary ceasefires in conflict zones. Most recently, the United Nations Security Council unanimously adopted a resolution in February 2021 calling for a ceasefire to allow for COVID-19 vaccinations.

As the U.S. seeks to renew and restore American leadership in health diplomacy and build capacity in other countries, it would be best served by utilizing the core principles of community engagement, which facilitate the conditions of trust, autonomy, and mutual respect that are the cornerstone of effective health diplomacy. This is particularly important when advancing diplomatic efforts concerning areas of health associated with significant cultural importance (e.g. nutrition, elder care) or potentially high levels of stigma (e.g. sexual and reproductive health, gender-based violence, mental health).

PEPFAR: An effective global health response

HIV/AIDS presented one of the most devastating global health crises of the 20th century. The worldwide impact of HIV/AIDS prompted the UN Security Council to adopt the first resolution focused solely on an infectious disease, resolution 1308. In 2001, the UN General Assembly held a Special Session exclusively to combat HIV/AIDS. The Declaration of Commitment on HIV/AIDS was developed and unanimously adopted by the 189 Member States. In 2003, the U.S. launched PEPFAR, the largest global health initiative focused on a single disease. PEPFAR programming is complex and multifaceted, reflecting both the magnitude of the disease and the fifty-three countries involved as partners. PEPFAR has been successful in reducing the impact of HIV/AIDS: approximately 5,000 people were dying from AIDS each day when the initiative began; that number has been reduced by almost half to date.¹³ In order to end the AIDS epidemic, the program must continue to reach the nearly thirty-eight million people currently living with HIV, fifteen million of whom are not on treatment.¹⁴

Several key factors have contributed to PEPFAR’s success. First, there has been a strong commitment from the U.S. and global partners to fund PEPFAR over many years. For example, the U.S. has invested more than $70 billion to support the program, and it continues to receive strong bipartisan support from Congress. Additionally, steadfast leadership within partner countries, especially in terms of adopting laws and policies that eliminate programmatic barriers and support implementation, have been critical for PEPFAR’s progress. Strategic partnerships with the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria (Global Fund), the Joint United Nations Programme on HIV/AIDS (UNAIDS), and World Health Organization (WHO) have been vital. Key to maintaining diplomatic relationships, PEPFAR’s leader is appointed by the U.S. President and holds the rank of Ambassador within the U.S. Department of State, Office of the Global AIDS Coordinator and U.S. Special Representative for Global Health Diplomacy. Further, a data-driven approach that enables real-time programmatic adjustments has been vital to PEPFAR’s success. Analyses of highly detailed, immediately actionable data facilitate country-specific strategies for reaching targets and goals. Importantly, PEPFAR data is publicly accessible via the internet, enabling public analysis and adding a layer of accountability and transparency.¹⁵

PEPFAR is gradually transitioning toward direct, country ownership of implementation. As responsibility shifts to local capacity, a key indicator of success will ultimately be each country’s ability to achieve and sustain epidemic control.  As PEPFAR has matured, substantial steps have been taken to more explicitly include health systems strengthening in PEPFAR programming. Local health systems that have been strengthened by PEPFAR are better suited to not only address HIV/AIDS, but other diseases as well. The trust established within PEPFAR-supported countries, enhanced service delivery, management of comorbidities, and detection and treatment of infectious and NCDs demonstrate the significant impact of leveraging PEPFAR.

In many ways, the U.S. can utilize PEPFAR as a template for future multilateral health programs. However, from a funding perspective, PEPFAR is not likely to be sustainable or duplicated. The U.S. may consider exploring innovative approaches toward a more balanced, shared fiscal responsibility to diversify partnerships and advance health goals.

Where Do We Go From Here?

As global health practitioners and advocates address emerging challenges, lessons from the past must continue to inform existing and new frameworks. We must not fail to address long-standing and urgent systemic issues that delay or prevent progress in health diplomacy, including racism and discrimination, infrastructure, and the interplay between science and diplomacy.

Diplomacy can operate levers meant to advance human rights and equity for all. For instance, the U.S. has repeatedly linked foreign aid allocations with provisions meant to protect and advance the rights of the LGBTQ community worldwide, most recently with a Presidential memorandum issued in February 2021.^16,17,18 Conversely, the U.S. Mexico City Policy prohibits NGOs receiving U.S. family planning funds from providing or promoting abortion services, even with non-U.S. funds; under the Trump Administration, this policy was expanded to most U.S. global health funds, including PEPFAR, despite the recognition by the UN Human Rights Committee and other bodies of access to safe and legal abortion as a human right.^19,20 However, the future of such diplomacy is threatened by systemic issues within countries.  For example, domestic actions can hinder the effectiveness of diplomatic efforts–the way in which countries treat their own citizens influences how these countries are perceived and suggests how they may act globally. In the U.S., this will require addressing and eliminating systemic racism and discrimination. During the first U.S.-China talks under the Biden Administration, China’s top diplomats criticized the U.S. for human rights abuses, citing police brutality against Black citizens. While the U.S. Secretary of State took issue with China’s human rights record regarding Hong Kong and minority Uyghurs in western China, China’s view underscores an American credibility gap that undermines U.S. efforts in health diplomacy, including defeating the COVID-19 pandemic.²¹

Operation Warp Speed, the U.S. effort to rapidly develop vaccines for COVID-19, led to the fastest vaccine authorizations in history. Such a feat was possible only because of decades of international scientific investments that built the infrastructure and knowledge (e.g., genetic sequencing databases, prior work on vaccines) needed to rapidly respond to the COVID-19 pandemic. Similarly, there is a critical need to develop the infrastructure and tools required for successful global health diplomacy, such as international data protocols and mechanisms for providing affordable treatments globally. Readily available and shareable data can greatly benefit global health initiatives. The WHO’s R&D Blueprint, developed via a collaborative and consultative process with several stakeholders, is meant to help foster the development of norms and standards for data and sample collection, management, and application during epidemics. However, as the COVID-19 pandemic has shown, significant issues remain with collecting, sharing, and using data given the current lack of standards regarding data stewardship, storage, and format,²² which diplomatic efforts can help to address in the future, given sufficient political will.

PEPFAR would have not been successful without affordable generic drugs to fight HIV.²³ Initially, HIV antiretrovirals (ARV) were generally available exclusively in proprietary form for use in high-income countries such as the United States. PEPFAR adopted a tentative drug approval process and worked closely with WHO to enable the development of quality generic drugs. The affordability of generic drugs dramatically improved global access to ARV. There remains a need for affordable and accessible therapeutics for many other health issues, including COVID-19. Access to affordable vaccines is a major forum for diplomacy amidst the COVID-19 pandemic. So-called “vaccine diplomacy” is being pursued by India, China, and Russia, in which access to doses is used as a form of soft power to expand political influence. In particular, China has pledged to make its vaccines a “global public good” and has committed to fulfilling orders for nearly 600 million doses of its vaccine.²⁴

The U.S. has also begun to engage in vaccine diplomacy amid the pandemic, though not without first pursuing a policy of vaccine nationalism. Under the Trump Administration, the U.S. chose not to participate in the COVID-19 Vaccines Global Access (COVAX) initiative co-led by WHO and others, meant to provide billions of COVID-19 vaccine doses to low- and middle-income countries.²⁵ In December 2020, the U.S. Congress reversed this position by approving billions for Gavi, a decision reaffirmed by the Biden Administration when it announced it would join COVAX in February 2021.²⁶ This announcement came alongside a call from President Biden for G7 partners to prioritize sustainable health security financing so all countries can develop the needed capacity to respond to and prevent pandemics.²⁷ Further, the Biden Administration recently announced that it would loan four million doses of the U.S. stockpile of AstraZeneca’s COVID-19 vaccine, not currently authorized for use in the U.S., to Canada and Mexico, where the vaccine is authorized; the move comes amid pressure from allies to share vaccine doses in an effort to more rapidly curb the pandemic.²⁸

Failures at the science-policy interface also have exacerbated public health issues time and again.²⁹ The COVID-19 pandemic has demonstrated the disastrous consequences when there is distrust in government, an absence of leadership, and when public health is politicized. A number of evidence-based actions that would have reduced transmission and helped to control the spread of COVID-19 were not taken, largely for political reasons. In the U.S., leadership not only disengaged from WHO but also actively silenced the voice of the CDC, dramatically weakening the role of public health experts in fighting the disease. All of these failures are precisely what health diplomacy, when used effectively, can be leveraged to address.

Health diplomacy creates avenues in which relevant expertise from a wide range of stakeholders can be brought to bear. The importance of such enabling reveals this truth–good science alone will not solve global health problems. The future of global health hinges upon technical expertise and strong leadership in diplomacy, as well as the ability to bridge the two arenas. In remarks made at a 2018 global health diplomacy symposium, Ambassador Jimmy Kolker noted that scientists and health researchers publish in journals that diplomats do not read. Echoing the call for more scientists in the diplomatic corps, there is a pressing need for including more public health experts in diplomatic efforts.³⁰ Health attachés, a cadre of diplomats who operate at the intersection of public health and foreign affairs, serve as central practitioners in advancing global health diplomacy.³¹ These individuals can help foster communication between practitioners and the public, along with open and contemporaneous sharing of information and the use of trusted messengers. As the world continues to face global health threats, we must ensure that we not only train and develop the next generation of health diplomats but also help them earn the community trust and authority needed to be effective. However, sending delegations of experts to attend global health summits and key health negotiations requires resources which some countries cannot afford, limiting their representation in diplomatic efforts. Indeed, even the U.S. acknowledges that demand for health attachés exceeds current capacity to support these individuals.³² Additionally, countries without an embassy at key locations or limited human and financial resources at existing embassies may need to form regional alliances with other countries to ensure representation, introducing an imbalance of power in health diplomacy.

From Sick and Tired to Healthy and Invigorated

While we have learned valuable lessons from previous global health initiatives, COVID-19 has yet again exposed a number of systemic issues-racism, distrust in government and health care systems, failure to effectively engage communities–that have long plagued us. Failing to remedy these systemic issues  not only risks rendering future planning for naught but also hinders our ability to advance global health diplomacy goals for everyone. In order to achieve successful health diplomacy in the future, the U.S. must be willing to take bold actions today to solve these issues. The time for health and restoration is now.

Acknowledgements

We thank A. Hooper for his substantial feedback and input on earlier versions of this article. We also thank the presenters, organizers, and attendees of the 2018 Global Health Diplomacy Symposium, organized by the AAAS Science & Technology Policy Fellows Science Diplomacy Affinity Group and co-sponsored by the AAAS Center for Science Diplomacy. The discussion at that event led to earlier versions of this paper.

Disclaimer

This publication was prepared by the authors in their personal capacity. The opinions expressed in this article are solely the authors’ own and do not reflect the views of or endorsement by the National Institute on Aging, the National Institutes of Health, the Department of Health and Human Services, the United States Department of Agriculture, the United States government, or the authors’ employers.

Endnotes

1. Kaiser Family Foundation, “The U.S. Government and Global Health,”  https://www.kff.org/global-health-policy/fact-sheet/the-u-s-government-and-global-health/.
2. Gavi, “The Bill & Melinda Gates Foundation,” https://www.gavi.org/operating-model/gavis-partnership-model/bill-melinda-gates-foundation
3. Julia Belluz, “The Media Loves the Gates Foundation. These Experts are More Skeptical,” Vox, June 10, 2015, https://www.vox.com/2015/6/10/8760199/gates-foundation-criticism
4. Natalie Huet and Carmen Paun, “Meet the World’s Most Powerful Doctor: Bill Gates,” Politico, May 4, 2017, https://www.politico.eu/article/bill-gates-who-most-powerful-doctor/
5. Richard T. Eastman, Jacob S. Roth, Kyle R. Brimacombe, Anton Simeonov, Min Shen, Samarjit Patnaik, and Matthew D. Hall, “Remdesivir: A Review of Its Discovery and Development Leading to Emergency Use Authorization for Treatment of COVID-19.” ACS Central Science 6, no. 5 (2020): 672-683.
6. Kao-Ping Chua and Rena M. Conti, “Policy Implications of the Orphan Drug Designation for Remdesivir to Treat COVID-19,” JAMA Internal Medicine 180, no.10 (2020): 1273-1274.
7. Arthur Manguvo and Benford Mafuvadze, “The Impact of Traditional and Religious Practices on the Spread of Ebola in West Africa: Time for a Strategic Shift,” The Pan African Medical Journal 22, supplement 1 (2015): 9.
8. Tom Daschle and Bill Frist,  The Case for Strategic Health Diplomacy: A Study of PEPFAR, (Washington, DC: Bipartisan Policy Center, 2015), https://bipartisanpolicy.org/wp-content/uploads/2019/03/BPC_Strategic-Health-November-2015.pdf
9. Stephen G. Waller, Jane B. Ward, and Miguel A. Montalvo, “Cuba's 50-Year Health Diplomacy Program: Lessons Learned for Global Health Engagement,” Military Medicine 182, no. 1-2 (2017): 1451-1452.
10. Julie M. Feinsilver, “Cuban Medical Diplomacy: When the Left Has Got It Right,” Foreign Affairs en Español 6, no. 4 (2006): 81-94.
11. Octavio Gómez Dantés, “The Dark Side of Cuba's Health System: Free Speech, Rights of Patients and Labor Rights of Physicians,” Health Systems & Reform 4, no. 3 (2018): 175-182, doi: 10.1080/23288604.2018.1446275.
12. Vijay Kumar Chattu and W. Andy Knight, “Global Health Diplomacy as a Tool of Peace,” Peace Review 31, no. 2 (2019): 148-157.
13. John McMannis, “15 Years of PEPFAR: Past Success and Future Progress.” Friends of the Global Fight Against AIDS, Tuberculosis and Malaria,https://www.theglobalfight.org/15-years-pepfar/.
14. Kaiser Family Foundation, “The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR),” https://www.kff.org/global-health-policy/fact-sheet/the-u-s-presidents-emergency-plan-for-aids-relief-pepfar/
15. Daschle and Frist, The Case for Strategic Health Diplomacy.”
16. Eyder Peralta, “U.S. Says It Will Use Foreign Aid to Promote Gay Rights,” NPR, December 6, 2011, https://www.npr.org/sections/thetwo-way/2011/12/06/143221630/u-s-says-it-will-use-foreign-aid-to-promote-gay-rights.
17. Sebastian Malo, “Advocates Laud U.S. decision to Ban LGBT Discrimination in Foreign Aid,” Reuters, October 27, 2016, https://www.reuters.com/article/usa-aid-lgbt/advocates-laud-u-s-decision-to-ban-lgbt-discrimination-in-foreign-aid-idUSL1N1CX007
18. The White House, “Memorandum on Advancing the Human Rights of Lesbian, Gay, Bisexual, Transgender, Queer, and Intersex Persons Around the World,” https://www.whitehouse.gov/briefing-room/presidential-actions/2021/02/04/memorandum-advancing-the-human-rights-of-lesbian-gay-bisexual-transgender-queer-and-intersex-persons-around-the-world/
19. Kaiser Family Foundation, “The Mexico City Policy: An Explainer,” https://www.kff.org/global-health-policy/fact-sheet/mexico-city-policy-explainer/
20. United Nations Human Rights Office of the High Commissioner, “Information Series on Sexual and Reproductive Health and Rights: Abortion,” https://www.ohchr.org/Documents/Issues/Women/WRGS/SexualHealth/INFO_Abortion_WEB.pdf
21. Lara Jakes and Steven Lee Myers, “Tense Talks with China Left U.S. ‘Cleareyed’ About Beijing’s Intentions, Officials Say,” New York Times, March 19, 2021, https://www.nytimes.com/2021/03/19/world/asia/china-us-alaska.html
22. Jonathan LoTempio, D’Andre Spencer, Rebecca Yarvitz, Arthur Delot Vilain, Eric Vilain, and Emmanuele Delot, “We Can Do Better: Lessons Learned on Data Sharing in COVID-19 Pandemic Can Inform Future Outbreak Preparedness and Response,” Science & Diplomacy 9, no. 2 (2020),https://www.sciencediplomacy.org/article/2020/we-can-do-better-lessons-learned-data-sharing-in-covid-19-pandemic-can-inform-future
23. Jimmy Kolker, “A Diplomat’s Perspective on Use of Science and Evidence in Implementing PEPFAR,” Science & Diplomacy 7, no. 1 (2018), https://www.sciencediplomacy.org/article/2018/kolker-pepfar
24. Yanzhong Huang, “Vaccine Diplomacy Is Paying Off for China,” Foreign Affairs, March 11, 2021, https://www.foreignaffairs.com/articles/china/2021-03-11/vaccine-diplomacy-paying-china
25. Anna Rouw, Jennifer Kates, Jose Michaud, and Adam Wexler, “COVAX and the United States,” https://www.kff.org/coronavirus-covid-19/issue-brief/covax-and-the-united-states/
26. The White House, “Fact Sheet: President Biden to Take Action on Global Health through Support of COVAX and Calling for Health Security Financing,” https://www.whitehouse.gov/briefing-room/statements-releases/2021/02/18/fact-sheet-president-biden-to-take-action-on-global-health-through-support-of-covax-and-calling-for-health-security-financing/
27. Ibid.
28. Jeff Mason, “U.S. to Share 4 million doses of AstraZeneca COVID-19 vaccine with Mexico, Canada,” Reuters, March 18, 2021, https://www.reuters.com/article/us-health-coronavirus-usa-mexico/u-s-to-share-4-million-doses-of-astrazeneca-covid-19-vaccine-with-mexico-canada-idUSKBN2BA22S
29. E. William Colglazier, “Response to the COVID-19 Pandemic: Catastrophic Failures of the Science-Policy Interface,” Science & Diplomacy 9, no. 1 (2020), https://www.sciencediplomacy.org/editorial/2020/response-covid-19-pandemic-catastrophic-failures-science-policy-interface
30. Nick Pyenson and Alex Dehgan, “We Need More Scientists in the U.S. Diplomatic Corps,” Scientific American, November 16, 2020, https://www.scientificamerican.com/article/we-need-more-scientists-in-the-u-s-diplomatic-corps/
31. Matthew D. Brown, Tim K. Mackey, Craig N. Shapiro, Jimmy Kolker, and Thomas E. Novotny, “Bridging Public Health and Foreign Affairs: The Tradecraft of Global Health Diplomacy and the Role of Health Attachés,” Science & Diplomacy 3, no. 3 (2011), https://www.sciencediplomacy.org/article/2014/bridging-public-health-and-foreign-affairs
32. Department of Health and Human Services, “Health Attachés,” https://www.hhs.gov/about/agencies/oga/global-health-diplomacy/health-attaches/index.html