The 9/11 terrorist attack triggered important changes to how health fits into various countries’ foreign policies, and also to the dynamics and volume of developed countries’ foreign aid to low-income countries, in turn reflected in international cooperation.
Health has always been a foreign policy issue, but was not a high-profile item on the political agenda which was aimed more at controlling “external threats” (epidemics and diseases) which might undermine sovereign national power and elites’ material interests (trade and wealth). The past decade, however, has seen health grow in importance at the global level as never before and the concept of ‘health security’ has become important to development and global governance. That change did not happen by chance, but was actively fostered by the US and then followed by others.
In the 1990s, the concern with biological weapons and bioterrorism, on the one hand, and emerging and re-emerging infectious diseases (including the HIV/AIDS pandemic), on the other, drove vast intellectual endeavour in the public health field. However, these threats were not treated as national security issues.
The Bush government's new policy after 9/11 was a watershed because in 2002 public health preparedness for potential bioweapons use became a key theme in US national security policy. PEPFAR, Bush's 2003 Emergency Plan for AIDS Relief, strategically incorporated the HIV/AIDS threat among US national security and foreign policy objectives.1 It then used ‘health’ as a strategy to reiterate US hegemonic power.
This occurred in a context of increasing, and increasingly complex, official development aid and technical co-operation,2 both becoming more concessional, prioritising sectoral (particularly social) vertical programs. Agencies proliferated (especially in the health sector), managing significant earmarking of funds for specific purposes, while failing to support infrastructure and production. The outcome is that recipient countries face the high transaction costs of receiving aid and implementing programs, while labouring under enormous difficulties of fragmentation and coordination. Often, efforts to make external aid more effective function as clear constraints on recipient countries’ decision-making autonomy: either because of their dependency or the real threat of aid flows being severed if conditionalities are not met or if national political decisions displease prominent donors.
International – particularly South-South – co-operation, after decades of gradual reorientation faces new challenges in the early 21st century. The ‘politics of fear’ and ‘securitisation of health’ have fuelled, and ensured funding for, conservative ideas and practices globally, in opposition to more cooperative structural approaches to strengthen health systems as a health determinant.