Divided world, divided health outcomes
Historically and recently, health issues have been used as geopolitical fodder. As we approach new and pressing global challenges, we can risk this kind of harm no longer
Competition among states over power and ideology dominates world politics. The return and intensification of geopolitics have changed how countries make foreign policy and cooperate. Those changes have hurt collective action on global health.
With the balance of power on a knife’s edge, health cooperation lacks strategic purpose because it does not help policymakers mitigate the military, economic and ideological dangers that adversaries pose. Rival states, however, will weaponise health issues tactically in grasping for geopolitical advantage.
That geopolitical context marginalises – and those foreign policy choices manipulate – health diplomacy rather than build trust and resilience among countries. The hunt for ways to address health problems in a divided world often gravitates towards sovereignty, likeminded coalitions and regionalism rather than multilateralism. Those options are also vulnerable to geopolitics, but such approaches will shape whether and how trust and resilience in global health develop.
The ghost of geopolitics past
From the late 19th century through the Cold War, health cooperation happened in international systems marked by geopolitical competition. States concluded treaties, integrated scientific advances into policies, created international health organisations and expanded ambitions for health cooperation. Geopolitics did not eliminate all space for collective action on health.
However, across that period, health cooperation provided no traction in geopolitical competition and depended on a stable balance of power. Such dependence meant that foreign policymakers did not consider health a priority as they did military power, economic growth and ideological influence. President Jimmy Carter tried to elevate health in US foreign policy in the late 1970s, but Soviet aggression in Afghanistan and ambitions in the developing world forced the United States to double-down on countering Soviet military, economic and ideological threats.
Furthermore, the more unstable the balance of power, the more rival states turned health issues into geopolitical fodder. For example, tensions between the superpowers increased in the early 1980s. In those years, the US opposed the World Health Organization’s Health For All initiative on ideological grounds. The Soviets spread disinformation blaming the US for the spread of AIDS in Africa. Such weaponisation of health, however, had no effect on how the Cold War ended.
Global health without geopolitics
In contrast, health cooperation in the post–Cold War world’s early decades unfolded without geopolitical constraints. The US faced no rivals, and democracy was globally ascendant. The growing community of democracies elevated health in foreign policy. Global health received unprecedented political interest, diplomatic attention and financial resources that supported historic levels of traditional and innovative collective action through bilateral, coalition, regional, multilateral, public-private and non-governmental efforts.
That progress obscured the fact that a unipolar, ideologically homogenising international system was historically abnormal. That system created more political interest in and spaces for global health activities, but those activities depended on a particular distribution of power and ideas and would be at risk should that distribution change. And it changed.
Worse than the Cold War?
In the 2010s, geopolitics returned. China and Russia challenged US primacy and contributed to democracy’s global decline. Those states sought strategic gains through military, economic and ideological actions. Despite decades of global health leadership, the US and other democracies faced balance-of-power threats that such leadership neither prevented nor mitigated. American, Chinese and Russian responses to Covid-19 showed how geopolitical competition damages global health.
Geopolitics corrode trust and resilience in global health. The democratic ‘free world’ confronts the authoritarian ‘axis of resistance’, with both blocs courting ‘nonaligned’ countries in the Global South. Hostility, distrust and cynicism permeate foreign policy thinking, making it hard to develop the trust needed to build resilient health capabilities. Collective action still occurs, but agreements are more transactional than transformative and are vulnerable to shifting geopolitical machinations.
The current multipolar distribution of power also creates incentives for states to rethink global health against core national interests and to prefer bilateral, regional and coalition mechanisms over multilateralism. The Covid-19 disaster prompted countries at all income levels to focus on strengthening national health sovereignty, autonomy and security. The new US global health security strategy favours bilateralism. Countries with a history of regional cooperation are looking more to regional organisations to address health challenges. In a divided world, using likeminded coalitions of states to pursue health goals is also attractive.
Today’s landscape echoes aspects of health cooperation from the Cold War and post–Cold War periods. As in the Cold War, global health engagement provides no strategic leverage in geopolitical competition. Thus, health gets marginalised in foreign policy but weaponised when rival states perceive tactical opportunities to increase their influence. The options for collective action mirror the post–Cold War proliferation of channels for health diplomacy, offering diverse ways to address health problems in a fragmented world.
What is not clear is whether such disparate channels provide enough policy bandwidth to sustain collective action on pressing global health challenges. The severity of geopolitical threats and global health dangers, especially climate change, promise to grow over the next decade – a future in which tensions between realpolitik expediency and global health resiliency could get exponentially worse.
