Nationalist leaders can close borders to migration and trade, but how does the 'America First' model fare against pandemic disease? Not well.

In January this year, Richard Haass defined the principle of ‘sovereign obligation’, in Foreign Affairs, as the responsibility that nations share with one another and to people outside their borders. In an increasingly interconnected world, global health security will not be achieved without transnational cooperation and investment focused on health system strengthening, as opposed to the narrow, often disease-specific (vertical) interventions that have gained favor in recent years.

Between 2000 and 2016, total spending on development assistance for health rose dramatically from $10.5 billion to $37.6 billion, an indication of a growing sense of sovereign obligation in this sphere. Simultaneously, the language surrounding investments in health has undergone ‘securitization’ – relying on the threat of infectious and pandemic diseases to advocate for the prioritization of health investment.

Two problems now emerge. First, the rise of nationalist sentiments threatens the strengthening of transnational health systems, and also the broader thinking that champions the principles of sovereign obligation. Second, and perhaps more damningly, achieving authentic health security remains impossible through merely the narrow lens of pandemic preparedness. While the danger posed by infectious diseases remains very real – today, a pathogen can move around the world in as little as 36 hours – eradicating this threat depends upon tackling the broader nexus of poverty and disease.

Health, Wealth, Welfare and Peace are Linked

Improved population health is often viewed as a derivative of economic growth. In reality, the two are reciprocally linked. In the United Kingdom, 30 percent of GDP growth between 1870 and 1979 can be attributed to improved health and nutrition, and in the US, increases in life expectancy between 1970 and 2000 added $3.2 trillion to the economy. The association holds true for poorer states. In these countries, investments in health have shown returns as high as 9:1, and 25 percent of economic growth in low and middle-income countries (LMICs) from 2000 to 2011 came from improved health. Adding a single year of life-expectancy boosts GDP per capita by 4 percent.

Expanding access to healthcare also has significant implications for employment. Jobs in two large sectors of the global economy – industry and agriculture – continue to wane. Healthcare jobs, meanwhile, are far less automatable, and by 2030, total global demand for healthcare workers will top 80 million, with a projected shortfall of 15 million. In addition, the growth of healthcare markets often results in increased female participation in the labor market, and the corresponding empowerment of women has been shown to offer broad societal benefits, including lower fertility rates and increased school enrollment and achievement.

In turn, these economic benefits have implications for security. Both high GDP and high rates of growth reduce the likelihood of countries falling into a ‘coup trap’, and the poorest nations are 21 times more likely than other states to experience coups d’état. The same is true in the inverse, as even minor political instability has been shown to depress growth through a variety of means, including productivity decline, human and physical capital reduction, and limited flow in foreign direct investment.

In terms of human health, an analysis of conflicts from 1980 to 2005 showed that in the five years prior to the outbreak of violence, states that entered conflicts had child malnutrition rates 50 percent higher, child mortality rate 102 percent higher, and GDP per capita 48 percent lower than states not entering conflict. Conflicts often spill over to neighboring states, destabilizing entire regions. The war in Syria, for instance, has led to the reemergence of polio after a 15-year absence, and driven the spread of tuberculosis, disfiguring leishmaniosis and measles in Lebanon, Jordan, Turkey and Iraq.

Sovereign Autonomy and Health

The monolithic nation-state is an increasingly inappropriate way of conceptualizing health – a fact emphasized by Hans Rosling towards the end of his career. Disease moves without regard for national borders or citizenship, and health and wealth disparity are better understood at local and regional levels.

Before 2014, the countries of West Africa, unlike other extraordinarily poor countries like North Korea or Yemen, were considered unlikely to destabilize states outside their immediate vicinity. The Ebola outbreak of 2014 fundamentally upended this calculus. The outbreak impacted ten countries, four of them high-income states, and the cost of the global response surpassed $4 billion – $2.4 billion of this borne by the United States. It is clear that poverty and failed health systems anywhere threaten states and peoples everywhere.

There are several reasons why the current system is failing to deliver the required health, economic and security benefits. First, despite development assistance programs from high income states, health systems in low and middle-income countries remain grossly underfunded.

Second, foreign assistance for health systems remains exceedingly fractured in nature, and domestic political pressure within donor-states often demands that such programs create fast and demonstrable impact. Instead of focusing on long-term partnerships to strengthen entire health systems – so-called horizontal efforts – these agencies predominantly focus on efforts expected to have immediate, measurable impact before the close of funding cycles. Spending on system strengthening contracted from 2010 to 2016, a period in which overall spending rose by 7.2 percent.

Third, and perhaps most importantly, foreign health assistance continues to be undertaken as charitable work rather than as essential partnership, with donor states often setting priorities unilaterally and, at times, leveraging assistance as a foreign policy tool.

Global Health Security 2.0

A modern conceptualization of health security recognizes that improving access to healthcare is both a moral and a strategic imperative. A modern conceptualization of health security also prioritizes local and district level capacity building, and values the importance of data driven, measurable work over years to decades, rather than days to weeks. Moreover, national level data is not enough – subnational and regional/transnational data that focuses on geographic health deserts is desperately needed.

Recently, two new collaborations have emerged in global health, each bringing with them important attributes of a new paradigm. The first – the Global Health Security Agenda (GHSA) launched in 2014 – is a consortium of 50 countries and nongovernmental organizations. The GHSA is focused on preventing, monitoring and responding to pandemic disease. The second – the World Bank Global Financing Facility (GFF) – seeks to coordinate the work of disparate actors in maternal, child and adolescent health in the poorest countries.

Although not nearly horizontal enough, these two programs are a positive start. Fortunately, a new paradigm for global health security has begun to emerge in each. And while it must be noted that many of the ideas underpinning each program – improved collaboration and increased local leadership – are not new, the coupling of these ideas within models of long-term partnership and health system strengthening, represent important innovations moving towards authentic health security.

Today, many states remain incapable of providing care for those within their borders. The resulting health deserts imperil their own citizens, neighboring states and the broader international community. The historic approach to this problem – channeling funds from high-income to low-income states through implementation agencies, focused on narrow, disease-specific interventions – has failed to deliver authentic health security. The emerging linkages between health security and pandemic preparedness will similarly fail to make the world safe. The vast majority of disease, pandemic included, is born from the confluence of poverty, health inequity and poor health delivery systems.

Health, welfare and peace are intimately linked, and attention to health equity must form the foundation of any strategy for stability in the 21st century. The future of global health security involves a reciprocal obligation amongst all nations – some providing more capital than others to be sure, but the nature of the commitment, collaboration and benefit are reciprocal. Authentic and durable global health security will only be realized through horizontal health system strengthening and capacity building that brings us closer to achieving health equity.

Dr. John Meara is the Kletjian Professor of Global Surgery and Director of the Program in Global Surgery and Social Change at Harvard Medical School and Plastic Surgeon-in-Chief at Boston Children's Hospital. Follow him on Twitter at @JohnMeara. Brian Till is a Research Associate at the Program in Global Surgery and Social Change at Harvard Medical School. He was previously a Research Fellow at the New America Foundation. Follow him on Twitter at @brianmtill.