For Gates, global health should drive foreign policy

With the end of the Cold War, the number, intensity, and lethality of wars were believed to be in decline [PDF]. However, new research from the Institute for Health Metrics and Evaluation (IHME) at the University of Washington challenges the idea that war deaths are falling. The IHME paper claims war deaths are three times higher than previously thought and not decreasing. Beneath the surface, the debate shows an increasingly prominent and well-funded global health community flexing its muscle in the foreign policy arena.

The IHME was founded a little more than a year ago with a 10-year, $105 million grant from the Bill & Melinda Gates Foundation. The institute is tasked with evaluating a multitude of health programs worldwide as well as developing an overall report card on global health by 2010. IHME represents the Gates Foundation's hard-nosed drive for evidence-based policies and accountability, sussing out what works, identifying the causes of death — and what or who is to blame.

Lead author of the IHME study, Ziad Obermeyer, told Crosscut that previous estimates of war deaths "fit with an increasingly common view in the academic and political communities that technological innovations (â'ꂬ˜smart' bombs, precision warfare, etc.) and strategic priorities in recent years have dramatically reduced the number of civilian war deaths ... " Obermeyer noted: "If civilian deaths can essentially be ignored in the political calculus, war becomes a less difficult and more defensible option."

The common view has been that battle deaths were in decline. War deaths, by definition, exceed battle deaths because wars also kill by disease or starvation, for example. Data on all war-related deaths have been scant. IHME's estimates are hotly disputed because the number and trend of deaths are highly sensitive to assumptions in their model. Changing the treatment of data from Georgia, for instance, dramatically swings the estimate of war deaths and also whether the trend has been up or down over the last half century.

Oddly, the debate over war deaths is not between hawks and doves. The view that Obermeyer and colleagues seek to revise largely derives from the aptly-named Peace Research Institute, Oslo, Norway. The deeper question is: Whose voice should be authoritative on foreign policy? From a global health perspective, the present keepers of the world order have made a hash of it: Just count all the dead and dying. The Gates Foundation believes a more intelligent approach is possible — and necessary.

Early in their foundation's work, the Gateses discovered a "failure of collective action" among developed nations and international bodies leading to, for example, underfunded vaccination programs and vaccine research. More recently, in a speech to the Council on Foreign Relations in June, Melinda Gates elaborated: "Bill and I have come to recognize that poor people cannot get adequate food, and education, and health care because they cannot express their needs in ways that matter to markets or that motivate governments." In words dense with ramification, she concluded: "Only the non-profit sector has the primary mission of serving the people who've been left out."

Global health advocates emphasize a borderless world and policies focused on health orchestrated by non-profits, as against the prevailing system centered on nations and national security. The people, policies, and basic paradigms all differ, at times starkly. However, because these problems are so complex, the Gateses once wrote, "government has to be involved in solving them." In turn, "that means we need to get these issues on the political agenda."

Recently, it's been more clear how they propose to change the international agenda. In 2003, the Gates Foundation funded a new Global Health and Foreign Policy Fellow at the Council on Foreign Relations. Publisher of Foreign Affairs, the Council arguably wields more influence on foreign policy than any other private body. The first Gates fellow, Pulitzer prize-winning journalist Laurie Garrett, authored "HIV and National Security: Where Are the Links?" [PDF] in 2005, arguing that AIDS epidemics — eventually — jeopardized security in nations suffering from them while other countries faced a possible threat of terrorists arising from the resulting, destabilized regimes. in such a way, global health policy and foreign and defense policies are tied together.

In the most recent example of this juncture, Garrett came out strongly against calls for abandoning AIDS vaccine research in favor of an exclusive focus on prevention. "The wrong way to fight AIDS" appeared July 30 in the International Herald Tribune, just ahead of the International AIDS Conference assembling in Mexico City.

In 2006, the Gates Foundation established the Global Health and Foreign Policy Initiative at Johns Hopkins University. The initiative probes the structure of the international order with a view to erecting a new order centered on health. Researchers there observed that "the national security perspective dominates the conduct of international relations" and that global health risked being "reduced to a bit player on the grand stage of power politics." Scholars examined different modes (PDF) of engaging and changing this world, ranging from "supplicant," "Trojan horse," and "partnership" to "independent actor." Given daily, mass-scale deaths, they point out that there is "no time for a long game."

Bill Gates, in 1992, well before there was a Gates Foundation, marvelled at Napoléon's rewriting of the laws of Europe, remarking "even today the Code Napoléon is a big thing." The new civil code replaced the old feudal order overthrown by the French Revolution. Gates represents a vastly improved torch-bearer of the Enlightenment, and the era of continent-sweeping war is over or in abeyance. Conquering energies are now aimed at disease, with war itself under attack by epidemiological methods.

So what will a foreign policy built on eradicating the plague of infectious disease look like? It could require a fluid transnational order based on health and human security. Rather than a frontal assault, it would rely on different modes — Trojan horse and the rest — of engaging the existing order. The Gates approach also stands apart from particular institutions. His major pronouncements come from the World Economic Forum in Davos, Switzerland, rather than UN headquarters in New York or the World Health Organization in Geneva.

As global health issues transform and infuse foreign policy and national security, we have one more dramatic example of the way Bill Gates is riding and fomenting the wave of globalization. Large expanses of the globe will bear his imprimatur. As Dr. William Foege, an adviser to Gates put it: "I don't think very many people appreciate just how significant this is, in both concept and scope."