key: cord-327592-8tqi958n
authors: Hunter, Anita; Wilson, Lynda; Stanhope, Marcia; Hatcher, Barbara; Hattar, Marianne; Hilfinger Messias, DeAnne K.; Powell, Dorothy
title: Global health diplomacy: An integrative review of the literature and implications for nursing
date: 2012-09-19
journal: Nurs Outlook
DOI: 10.1016/j.outlook.2012.07.013
sha: 
doc_id: 327592
cord_uid: 8tqi958n

The increasing interconnectedness of the world and the factors that affect health lay the foundation for the evolving practice of global health diplomacy. There has been limited discussion in the nursing literature about the concept of global health diplomacy or the role of nurses in such initiatives. A discussion of this concept is presented here by the members of a Task Force on Global Health Diplomacy of the American Academy of Nursing Expert Panel on Global Nursing and Health (AAN EPGNH). The purpose of this article is to present an integrative review of literature on the concept of global health diplomacy and to identify implications of this emerging field for nursing education, practice, and research. The steps proposed by Whittemore and Knafl (2005) were adapted and applied to the integrative review of theoretical and descriptive articles about the concept of global health diplomacy. This review included an analysis of the historical background, definition, and challenges of global health diplomacy and suggestions about the preparation of global health diplomats. The article concludes with a discussion of implications for nursing practice, education, and research. The Task Force endorses the definition of global health diplomacy proposed by Adams, Novotny, and Leslie (2008) but recommends that further dialogue and research is necessary to identify opportunities and educational requirements for nurses to contribute to the emerging field of global health diplomacy.

The increasing interconnectedness in the world that has resulted from globalization has significant implications for nursing and healthcare. The American Academy of Nursing Expert Panel on Global Nursing and Health (AAN EPGNH), whose members are active participants in the global arena, recognize that health problems transcend national borders and that all nurses must be prepared to address global health challenges. Since 2007, global health has become the top foreign policy issue of our times (Labonté & Gagnon, 2010) , encouraging the interaction of state and nonstate participants to position health issues more prominently in foreign policy decision-making. This process and the engagement of all key stakeholders are parts of a new approach to global health called "global health diplomacy" (Labonté & Gagnon, 2010) . Nurses who work in the global health arena need to be aware of this new emphasis and identify their responsibilities as global health diplomats.

Novotny and Adams (Novotny & Adams, 2007 ) defined global health diplomacy as "a political change activity that meets the dual goals of improving global health while maintaining and strengthening international relations abroad, particularly in conflict areas and resource-poor environments [and that] health diplomacy is not only the job of diplomats or health leaders in government structures, it is a professional practice that should inform any group or individual with responsibility to conduct research, service, programs, or direct international health assistance between donor and recipient institutions" (p. 1-2). To better inform nurses about the concept of global health diplomacy, this paper presents an integrative review of literature on the concept of global health diplomacy and identifies implications of this emerging field for nursing education, practice, and research. Whittemore and Knafl (2005) described an integrative review of the literature as the broadest type of research review, combining data from both empirical and theoretical literature to define concepts, review evidence, review theories, and analyze methodological issues. Those authors modified the original framework for literature reviews proposed by Cooper (1998) and suggested that an integrative review should include: (a) a clear statement identifying the problem or purpose of the review; (b) identification of the strategies used to search and identify relevant literature; (c) evaluation of the quality of the data; (d) analysis of the data; and (e) final synthesis and presentation of the data. Whittemore and Knafl (2005) acknowledged that many strategies can be used for each of these stages. The purpose of this review was to analyze the concept of global health diplomacy and identify implications of global health diplomacy for nursing practice, education, and research. The framework proposed by Whittemore and Knafl (2005) was used to organize the review. We did not find reports of empirical research other than descriptions of existing health-diplomacy programs, so our review focused on theoretical articles and empirical descriptions of global health initiatives. The articles included in this review were identified by searching the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PubMed databases using the search term "global health diplomacy," without specifying any date restrictions. Additional articles were identified by reviewing reference lists of the original papers, and by searching Google Scholar using the keywords "global health diplomacy." Empirical or theoretical articles were included in the review if they addressed the historical development of global health diplomacy, defined the components and challenges of health diplomacy, proposed future development of global health diplomacy, and/or discussed strategies for preparing global health diplomats.

To evaluate the quality of the articles that were included in the review, the authors adopted one of the strategies proposed by Whittemore and Knafl (2005) , which was to consider authenticity, informational value, representativeness of sources, and methodological quality of each document that was included in the review. To analyze and synthesize the data from these diverse sources, the authors reviewed all papers, wrote annotated summaries of each paper, and then developed a system for classifying the articles, displaying the data, comparing the themes that emerged from each paper, and drawing inferences and conclusions, using the methods proposed by Whittemore and Knafl (2005) . The review is organized according to the main themes that emerged from analysis of the papers: historical development of global health diplomacy, definition and components of global health diplomacy, challenges in global health diplomacy, and preparation of global health diplomats. The review concludes with the authors' recommendations and implications for nursing practice, education, and research.

The term global health refers to "an area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide. Global health emphasizes transnational health issues, determinants, and solutions; involves many disciplines within and beyond the health sciences and promotes interdisciplinary collaboration; and [it] is a synthesis of population based prevention with individual-level clinical care" (Koplan et al., 2009 (Koplan et al., , p. 1995 . Adams, Novotny, and Leslie (2008) defined global health diplomacy as "an emerging field that addresses the dual goals of improving global health and bettering international N u r s O u t l o o k 6 1 ( 2 0 1 3 ) 8 5 e 9 2 relations, particularly in conflict areas and in resourcepoor environments" (p. 316). Katz et al. (2011) proposed that the varying definitions of global health diplomacy fall into three different categories (1) core diplomacy or formal negotiations between and among nations; (2) multi-stakeholder diplomacy or negotiations that are not necessarily intended to lead to binding agreements; and (3) informal diplomacy or interactions between international public health actors and their counterparts in the field, including host country officials, nongovernmental organizations (NGOs), private-sector companies, and the public. Identifying these different categories of global health diplomacy may be important to clarify services/resources that may be offered, especially when governments argue for incorporating health issues into their foreign-policy debates (Kaufmann & Feldbaum, 2009) .

Global health diplomacy combines the art of diplomacy with the science of public health; it balances concrete national interest with the abstract collective concern of the larger international community's health; it reduces health inequities; it secures human rights; and it recognizes that effective international health interventions are ethical and sensitive to historical, political, social, economic, and cultural differences (Schrecker, Labonté , & De Vogli, 2008; World Health Organization, 2012) .

The plethora of definitions supports the basic premise that global health diplomacy encompasses a political change activity and requires both the art of diplomacy and the science of public health to promote formal negotiations between and among nations and international public health actors and their counterparts in the field to address security, development, global public goods, trade, human rights and ethical/ moral reasoning.

There is growing recognition of the importance of promoting global health. The United States (U.S.) Institute of Medicine (IOM) (2009a, 2009b) published two reports outlining recommendations to enhance the U.S. commitment to global health. A consortium of Universities for Global Health (CUGH) was developed in 2009 with a mission to define the field of global health, standardize curricula, expand research, and coordinate projects in low-resource countries (Consortium of Universisties for Global Health, 2009). The Center for Strategic and International Studies (CSIS) (2010) was also commissioned to identify recommendations for smart global health policy in the United States, and for the first time, the U.S. National Institutes of Health (2010) made global health one of its top five priorities.

The U.S. government document Healthy People 2020 (United States Department of Health and Human Services, 2011) included a new global health goal for the first time in the history of the Healthy People series: to improve public health and strengthen U.S. national security through global disease detection, response, prevention, and control strategies. The Healthy People 2020 document outlines the U.S. objectives for meeting this new global health goal to address continuing emerging disease threats: promote health abroad, prevent the international spread of disease, and protect the health of the U.S. population. Badeau (1970) described the historical evolution of the concept of "medical diplomacy," noting that centuries ago physician-priests sometimes accompanied Egyptian missions to neighboring countries and acted as ambassadors. He also noted that the nature of diplomacy changed following World War I and that diplomacy is no longer the purview of only a small elite corps of professional diplomats. Factors such as improved communication, educational levels, an end to colonial rule in many parts of the world, and increased public demand for civic participation has resulted in changes in the face of diplomacy. Fidler (2001) suggested that health diplomacy emerged because of global threats to public health in the 19 th century. The Marshall Plan, the end of the Cold War era, and the medical assistance provided by the U.S. military in Europe and Japan following World War II signaled increased emphasis on the importance of foreign aid and "persuasion" as a key component of foreign diplomatic initiatives in both the U.S. and in other countries (Adams, et al., 2008; Badeau, 1970) . Feldbaum, Lee, and Michaud (2010) noted that global health has historically been of importance in foreign policy as evidenced by the international sanitary conventions that began in 1851. These international sanitary conventions subsequently evolved into the International Health Regulations (IHR), focused on enforcing disease control with minimum interference with international trade (World Health Organization, 2005) . Feldbaum et al. (2010) suggested that although the World Health Organization (WHO) has had problems enforcing IHRs in the past, the 2003e2004 outbreak of the Severe Acute Respiratory Syndrome (SARS) resulted in revision of IHRs and granted the WHO authority to supersede interests of member states using surveillance data for purposes of infectious disease control. Those authors further described the historical link between international aid and foreign policy interests, which was a key factor in the 1961 establishment of the U.S. Agency for International Development (USAID).

Addressing health without addressing the causative factors for illnesses has contributed to the failure of many well-intentioned global health programs. Cahill (1974) called for "the diplomatic potential of medicine as a vehicle for international goodwill" (p. 190). Subsequently, Cahill (1997) introduced the term "preventive diplomacy," noting that diplomats and politicians frequently lack an understanding of the health and humanitarian issues that they address and challenged health professionals to become active in addressing global health and human rights issues to offer innovative approaches to health and human rights issues that may be more effective than the methods used in the past. Katz, Kornblet, Arnold, Lief, and Fischer (2011) noted that the concept of medical diplomacy was first introduced in the Carter administration in 1978, as a "vehicle by which channels of communication can be established between nations when international relations are strained or severed" (p. 121). Feldbaum et al. (2010) noted three recent trends in international aid to address health issues: (a) dramatic increase in funding for health; (b) increased number of organizations involved; and (c) a tendency to focus on HIV/AIDS as a single health problem. Others have also noted the increase in health-related aid and the increased international focus on HIV/AIDS (Ravishankar et al., 2009; Shiffman, Berlan, & Hafner, 2009) . Other factors that have contributed to the growing interest in global health diplomacy include the growth of NGOs participating in international health programs, the increasing globalization of science and of pharmaceutical research, and growing concerns about biosecurity (Adams, et al., 2008, p. 315) .

A major impetus to the development of global health diplomacy is the concern about threats to global health security. The 2007 WHO annual report focused on threats to global public health security, such as epidemic diseases, food-borne diseases, accidental or deliberate outbreaks (e.g., nuclear accidents, toxic spills), environmental disasters, and the identification of strategies to minimize and address those threats (World Health Organization, 2007a). Chan, Director General of the WHO, argued for "..inputs from policy analysis and research; .

[and] improved training opportunities for both diplomats and public health specialists in the interface between health and foreign policy" (Chan, Store, & Kouchner, 2008, p. 498 ).

Kickbusch and Buss (2011) described the use of health diplomacy to promote peace and to encourage the evolving global partnerships of countries across hemispheres to address global health issues. The authors cited several examples of global health leadership roles and emphasized the importance of the WHO in providing global coordination for the multiple initiatives in the often-overcrowded global health landscape. For example, in 2011 Brazil hosted the "Global Conference on Social Determinants of Health," and in May 1998, the World Health Assembly formally accepted the "Health as a Bridge for Peace" initiative as a feature of the "Health for All in the 21st Century" strategy (World Health Organization).

WHO launched the "Health as a Bridge for Peace Initiative," promoting cease-fires during times of conflict to permit health projects, such as vaccination campaigns, and promoting collaboration in training initiatives among countries that were previous enemies (Rodriguez-Garcia, Schlesser, & Bernstein, 2001). Further, the foreign ministers of Brazil, France, Indonesia, Norway, Senegal, South Africa, and Thailand issued the Oslo Declaration and Agenda for Action to increase the priority of global health issues in foreign policy (Amorim et al., 2007) . Barber, Cohen, and Rockswold (2011) noted that in the United States, the field of global health diplomacy has been bolstered by the $63 billion U.S. Global Health Initiative that was launched in 2005 to address HIV/AIDS, growing challenges posed by chronic diseases, and to strengthen health systems.

Labonte and Gagnon (2010) reviewed the literature published from 2000 to 2009 to identify arguments that governments have used to incorporate health issues into their foreign policy deliberations. The literature revealed six policy frames: security, development, global public goods, trade, human rights and ethical/ moral reasoning, noting that arguments within the different frames are sometimes contradictory. The most frequently mentioned argument was concern for national and economic security, followed by the use of health to stimulate development and promotion of the public good (by preventing pandemics, addressing problems related to climate change, or regulating health-damaging products such as tobacco).

In summary, the notion of incorporating medical or health care in foreign policy or international aid programs is not new; however, there has been limited discussion about this concept in the nursing literature. Badeau (1970) described a key challenge related to health diplomacy initiatives, noting that "the use of aid for political ends is always resented by those who receive it, but it is particularly resented when that aid deals with basic human needs such as food or health" (pp. 310-311). Other authors have also identified this challenge, particularly when aid that is tied to political ends addresses basic human needs such as food or health. In addition, focusing on health as a political instrument often limits the ability of global health initiatives to address priority health problems in a sustainable way (Feldbaum, et al., 2010; Institute of Medicine, 2009a; Kickbusch & Buss, 2011; Kickbusch, Silberschmidt, & Buss, 2007) . Ingram (2005) identified three potential problems with the use of health as a foreign policy tool: (a) decreasing the credibility of health workers who have previously been viewed as neutral and not involved with state politics; (b) giving priority to narrow state interests over the interests of alliances needed to address global health issues; and (c) focusing on health as a political instrument rather than a human rights issue.

To address the potential challenges associated with linking healthcare assistance to foreign policy goals, Badeau (1970) advocated separating U.S. foreign aid that addresses basic human needs for food, health, and education from other technical assistance programs and placing the responsibility for such programs with a private organization that receives U.S. governmental funding (similar to the model of the British Council in the United Kingdom). Labonté and Gagnon (2010) noted that some have recommended explicit ethical principles to guide policy decisions to prevent the "high politics" of foreign policy from consistently overriding the "low politics" of global health (p. 13). Lemery (2010) suggested that the U.S. State Department engage physicians in "white coat diplomacy" to address humanitarian needs and foster "good will," but noted the concern of academic skeptics who fear that linking healthcare services to diplomatic goals might invite "manipulation." Novotny (2006) noted the instances of interference by federal agencies into the scientific independence of global health programs, such as restrictions on travel, scientific input, and collaboration.

Other challenges for global health diplomacy relate to confusion and failure to develop a common definition of the concept of global health security, the conflict between the rights of individual nations versus the need for international health regulations (Aldis, 2008) , and the increasing number of stakeholders interested in global health issues and the potential problems resulting from failure to coordinate global health initiatives (Katz, et al., 2011) . An example of this conflict was Indonesia's refusal in 2006 to share influenza virus samples with the WHO Collaborating Centers on influenza that traditionally receive samples from around the world for analyses to be used in development of new vaccines. Indonesia's refusal was based on the perception that the vaccines would be used to benefit only wealthier nations and would not benefit Indonesia (Katz, et al., 2011) . Many writers have emphasized the importance of coordination of global health initiatives by groups such as the World Health Assembly (Chan, et al., 2008; Kickbusch & Buss, 2011; Novotny, 2006) .

It is important for nurses to be aware of the potential ethical issues that arise when healthcare that is provided as a foreign-policy tool decreases the credibility of health workers who have previously been viewed as neutral and have not been involved with state politics; when it gives priority to narrow state interests over the interests of alliances needed to address global health issues; and when it focuses on health as a political instrument rather than a human rights issue.

There is growing recognition of the need to develop educational programs to prepare global health diplomats. U.S. Secretary of State Hillary Rodham Clinton called for the creation of a corps of civilian health diplomats who could contribute to the joint goals of diplomacy and international development by addressing problems related to health, food insecurity, environmental challenges, and challenges related to global warming (Clinton, 2010) . Hotez (2011) suggested that the core of health diplomats proposed by Secretary Clinton could make significant contributions to addressing the global health challenges posed by neglected tropical diseases that affect nearly all of the world's "bottom billion" citizens who live on less than $1 per day. Kerry, Auld, and Farmer (2010) described a specific proposal for an International Health Service Corps (IHSC) to enhance local health capacity, similar to the health outreach programs that have been provided by Cuba.

Interdisciplinary programs to prepare future global health diplomats should involve experts in fields such as foreign policy, academia, global health, epidemiology, health policy, economics, law, environmental science, and bioethics (Kickbush, Novotny, Drager, Silberschmidt, & Alcazar, 2007; Lemery, 2010; Novotny, 2006) . Barber, Cohen, and Rockswold (2011) also recommended training U.S. military personnel in strategies for collaboration with humanitarian organizations and local governments, strategies to promote sustainability, cross-cultural and historical sensitivity, and disaster response. Adams, et al. (2008) summarized the goals of health diplomacy training programs, noting that "successful health development efforts have depended on functional and respectful relations among all the stakeholders, including donor and recipient governments, health care providers, local political leaders, and field-based NGOs. A capable health diplomat must have a sophisticated understanding of the structures, programs, approaches, and pitfalls surrounding these relationships to achieve success, whether working in the clinical setting or at the policymaking table" (p. 319).

Although no articles were identified specifically discussing global diplomacy content in nursing curricula, there are references related to addressing the general topic of global health in nursing curricula. Bradbury-Jones (2009) suggested that nurses have a global responsibility to address non-communicable diseases, as the leading cause of death worldwide, through work in health policy, research, education, and individual practice. Archambault (2010) recommended that undergraduate nursing programs address the key global health concepts of global citizenship, social justice, health equity, and the determinants of health, and suggested that content should include: introduction to global health, global health goals, determinants of health, healthcare systems policy and politics, primary health care, global nursing issues, culture and, healthcare, epidemics, communicable and non-communicable diseases, epidemiology and health outcomes, and humanitarian emergencies.

The Association of Faculties of Medicine of Canada (AFMC) Resource Group on Global Health and the Global Health Education Consortium (GHEC) proposed a set of global health competencies for medical students (Association of Faculties of Medicine of Canada Reference Group on Global Health and Global Health Education Consortium, 2009). Wilson et al. (2010 Wilson et al. ( , 2012 adapted these competencies for nurses, and surveyed nursing faculty in the U.S., Canada, and Latin America to identify their perceptions about whether the adapted competencies were appropriate for nurses. The competencies are divided into six broad categories: (a) global burden of disease; (b) health implications of travel, migration, and displacement; (c) social and environmental determinants of health; (d) globalization of health and healthcare; (e) healthcare in low resource settings; and (f) health as a human right and development resource. Survey responses were received from 561 nursing faculty members in the U.S. and Canada and from 56 nursing faculty in Latin America, indicating general agreement that the 30 competencies identified in these categories were important and appropriate for inclusion in nursing curricula. Although there is a need for further research to refine and validate these competencies, the survey results can be used to guide development of curricula to prepare nurses to contribute to addressing global health problems.

Finally, the Association for Prevention Teaching and Research convened a Healthy People Curriculum Task Force consisting of representatives from eight health professional educational associations in order to promote achievement of Healthy People 2010 objectives by integrating more content related to health promotion and disease prevention in curricula of the various health professions. The task force identified specific content related to global health that should be integrated into the curriculum (Association for Prevention Teaching and Research Healthy People Curriculum Task Force, 2009).

The literature reviewed provides important guidance that can be used to develop interdisciplinary curricula to prepare nurses and other healthcare providers to develop competencies in global health and global health diplomacy.

The estimated 35 million nurses and midwives in the world make up the greatest proportion of the global health workforce (World Health Organization, 2007a , 2007b , and thus nurses could play a critical role in global health diplomacy initiatives if they were properly educated and prepared to be global healthcare providers and diplomats. Since the time of Florence Nightingale, nurses have provided culturally appropriate healthcare in diverse global settings. They have been key participants in addressing global natural disasters such as the 2004 tsunami in Thailand or the 2009 earthquake in Haiti. Global health diplomacy is an interdisciplinary academic field. Global health diplomacy is guided by wisdom gained through experience and the ability to find mutually acceptable solutions to global health challenges. Preparing nurses to contribute to global health diplomacy initiatives begins with the preparation of nurses as global citizens who are morally and ethically bound to understand and help individuals and groups at local, national, and global levels.

In addition to building on initial efforts to identify global health competencies for nurses, research is needed to identify additional competencies necessary to prepare nurses as global health diplomats. There is a need for dialogue and discussion among leaders in diverse disciplines such as nursing, medicine, political sciences, social sciences, law, business, and economics to further define these competencies and develop curricula that will prepare future leaders both in global health and in global health diplomacy (Lemery, 2010) .

Before nursing can support the concept of global health diplomacy as a dimension of this profession's global work, it is important to have a critical dialogue about the ethical and moral conflicts inherent in this concept e providing healthcare as a humanitarian responsibility versus using healthcare as an instrument of political activity. To begin such dialogue and promote further research to evaluate and refine the concept of global health diplomacy as a nursing phenomenon, the members of the AAN EPGNH Task Force on Global Health Diplomacy in Nursing endorse the definition of global health diplomacy proposed by Adams, Novotny, and Leslie (2008) as "an emerging field that addresses the dual goals of improving global health and bettering international relations, particularly in conflict areas and in resource-poor environments" (p. 316). Further, the Task Force members believe that health diplomacy "is not only the job of diplomats or health leaders in government structures, it is a professional practice that should inform any group or individual with responsibility to conduct research, service, programs, or direct international health assistance between donor and recipient institutions" (Novotny & Adams, 2007, p. 2) .

If healthcare and healthcare providers truly wish to make a difference in the health of the people of the world, then identifying the causes of health problems, finding solutions, and implementing interventions are required steps. Global health diplomats must be prepared academically and experientially with astute negotiation skills; with collaboration skills to work with nations to protect health interests; with economic development acumen; epidemiological and research skills; and with diplomatic, economic, political, legal, medical, cultural, and conflict-resolution skills. There is need for further dialogue in the professional nursing community to identify nursing's role in global health diplomacy and identify competencies that should be

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