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Daniel M. Fox, PhD and Jordan S. Kassalow, OD, MPH

Daniel M. Fox is with the Milbank Memorial Fund, New York, NY. Jordan S. Kassalow is with the Council on Foreign Relations, New York, NY.

Correspondence: Requests for reprints should be sent to Daniel M. Fox, PhD, Milbank Memorial Fund, 645 Madison Ave, 15th Floor, New York, NY 10022-1095 (e-mail: dmfox{at}milbank.org).

	INTRODUCTION

TOP INTRODUCTION DEFENDING THE UNITED STATES THE ENLIGHTENED SELF-INTEREST OF... THE UNITED STATES AS... THE PAST AND THE... References

 
Professionals in health and foreign policy have recently begun to coalesce to devise strategies to persuade the president, the secretary of state, and congressional leaders that it is prudent and practical to raise the priority accorded to health on the United States' foreign policy agenda. Members of the coalition advocating higher priority are arraying evidence and argument that the health problems of people in other countries affect vital American interests.

This advocacy rests on 3 principles: (1) Americans face growing danger from recognized and emerging diseases. (2) Global health risks undermine US economic and security interests. (3) The United States has a unique opportunity to lead in arraying incentives to create a healthier world population. These principles are grounded in a long history of activism in international health by American public health pioneers and their allies in business, foundations, and government. The articles in this issue offer considerable evidence that supports these principles.

The initial statement of the new case for raising the priority of health in foreign policy is a report, Why Health Is Important to US Foreign Policy, published earlier this year by the Council on Foreign Relations and the Milbank Memorial Fund. This report summarizes evidence presented at meetings of public- and private-sector leaders in foreign and international health policy convened by the 2 organizations beginning in 1999. The 3 principles listed above underlie the detailed recommendations for policy included in the report. The incentives for political action derived from the principles are national defense, enlightened self-interest, and the mission of a democratic superpower.

	DEFENDING THE UNITED STATES

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The direct threat to Americans' health from abroad is increasing. Recognized infectious diseases, especially tuberculosis, malaria, and cholera, are resurgent in developing countries. Thirty new diseases have emerged in these countries in recent years, among them HIV/AIDS, Ebola, and hepatitis C. An increasing number of diseases that are more prevalent in countries other than the United States are becoming more difficult and expensive to treat because of increasing microbial resistance to drugs. The porous borders of a globalized economy facilitate the spread of disease through trade, travel, population movements, and a shared food supply. Last year alone, 477 million people, 127 million automobiles, 11.5 million trucks, and 5.8 million maritime containers entered US territory. America's food imports doubled in the years 1995 through 1999.^1(pp18–20)

	THE ENLIGHTENED SELF-INTEREST OF THE UNITED STATES

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Improvements in health status abroad—especially improvements in health in developing countries, which receive just over 40% of America's exports of goods and services—promote this country's economic and security interests. Economic growth is linked to population health status in every country. This link is particularly important in countries that have fragile economies and political institutions as well as inadequate systems of health care and public health. There is substantial evidence, for instance, that increased longevity and increased female participation in the paid workforce, which usually accompany economic growth, create incentives that stimulate even more growth. These incentives yield smaller families, greater personal investment in education, and savings for retirement, all of which contribute to improvements in health status.

Poor health, in contrast, diminishes economic productivity, makes governance and peacekeeping less effective, and contributes to the erosion of social cohesion. Poor health reduces productivity because it discourages foreign investment; creates labor shortages; reduces worker attendance, productivity, and exports; redirects public spending from education and infrastructure to health services; drains individual savings to pay health care costs; and discourages tourism. Perhaps most important, countries whose population is in declining health also experience reduced foreign investment.

Poor health compromises governance because it erodes leadership and removes individuals' incentives to participate in civil society. The AIDS/HIV epidemic in sub-Saharan Africa, for example, has disproportionately affected urban centers and the best educated, most mobile, and most influential individuals. Although poor health is not a direct cause of random violence and insurrection, it reduces the number of people who are able and eager to resist such disruptions.

Increased transmission of disease, particularly HIV/AIDS, is an unexpected consequence of United Nations peacekeeping missions. In June 2000, Richard Holbrooke, then US ambassador to the United Nations, said, "One of the ugliest truths that everyone knows about AIDS is its spread by United Nations peacekeepers." According to Holbrooke, "almost none of the troop-contributing countries will agree to have their troops tested."²

Health is essential for maintaining as well as creating social cohesion. Poor health in Russia, for example, contributes to distrust of local government, higher rates of crime, and disruption in the workplace. Eroding social cohesion contributes to vicious cycles of worsened health status, for instance, by diminishing the capacity of families and the state to care for children. (For additional evidence about poor health in Russia, see Zabina et al.³)

In this issue of the Journal, Galavotti et al. describe a promising method of preventing HIV infection that combines changes in individuals' behavior with action to change social norms.⁴ Preventive methods that involve changes in norms and institutions have a place in policy for national and international security as well as for health.

	THE UNITED STATES AS A GOOD LEADER

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This country's humanitarian commitment to reduce human suffering justifies action to integrate health and foreign policy. Moreover, leadership by the United States in improving health in other countries would deflect some of the increasing criticism abroad that this country prefers a unilateral approach to world affairs.

The United States could exert leadership in several ways. Increased spending for research that addresses poor health in other countries could deliver significant international public benefits, for example, by allocating more resources to devise and test orphan drugs and vaccines. This country could also increase the attention accorded to health on the human rights agenda. The United States could, moreover, offer debt relief to poor countries contingent on their allocating new resources to projects that promise to achieve measurable improvement in health status, for example, by increasing access to primary health care and providing water that is safe to drink. (Several articles in this issue offer evidence in point.^5–7) The United States could implement many of these policies through partnerships for improving health that involve multilateral institutions, the private sector, and nongovernmental organizations.

	THE PAST AND THE FUTURE

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US foreign policy has historically been most effective when it has combined humanitarian ideals with protecting and promoting national interests. Examples include the eradication of yellow fever in Cuba and Panama early in the 20th century and the Marshall Plan after the Second World War. A foreign policy that accords higher priority and hence more resources to improving global health would be an illustrious achievement in the political, economic, and ethical history of our country.

Accepted for publication July 2, 2001.

	References

TOP INTRODUCTION DEFENDING THE UNITED STATES THE ENLIGHTENED SELF-INTEREST OF... THE UNITED STATES AS... THE PAST AND THE... References

 
1. Kassalow JS. Why Health Is Important to US Foreign Policy. New York, NY: Council on Foreign Relations and Milbank Memorial Fund. Also available at: http://www.cfr.org/public/pubs/Kassalow_Health_Paper.html. Accessed July 25, 2001.

2. Statement by Richard Holbrooke at an on-the-record meeting (AIDS: A New Priority for International Security) at the Council on Foreign Relations; June 5, 2000; New York, NY.

3. Zabina H, Schmid TL, Glasunov I. Monitoring behavioral risk factors for cardiovascular diseases in Russia. Am J Public Health.2001;91:1613–1614.[Free Full Text]

4. Galavotti C, Pappas-DeLuca KA, Lansky A. Modeling and reinforcement to combat HIV: the MARCH approach to behavior change. Am J Public Health.2001;91:1602–1607.[Abstract/Free Full Text]

5. Dunston C, McAfee D, Kaiser R, et al. Collaboration, cholera, and cyclones: a project to improve point-of-use water quality in Madagascar. Am J Public Health.2001;91:1574–1576.[Abstract/Free Full Text]

6. Makutsa P, Nzaku K, Ogutu P, et al. Challenges in implementing a point-of-use water quality intervention in rural Kenya. Am J Public Health.2001;91:1571–1573.[Abstract/Free Full Text]

7. Schmid T, Kanenda O, Ahluwalia I, Kouletio M. Transportation for maternal emergencies in Tanzania: empowering communities through participatory problem solving. Am J Public Health.2001;91:1589–1590.[Abstract/Free Full Text]

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