Medical Diplomacy A Brief Outline

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Thinking about Life Sciences http://blog.aesisgroup.com Saturday, September 08, 2007 Medical Diplomacy: A Brief Outline Definition of Medical Diplomacy In a Boston Globe Op-Ed piece - “The cure for tyranny” (10/24/2005) the former governor of Wisconsin governor Secretary of Health and Human Services Tommy Thompson described medical diplomacy as being: “the winning of hearts and minds of people … by exporting medical care, expertise, and personnel to help those who need it most.” While medical diplomacy has an intuitive meaning for most people, for the purposes of this discussion medical diplomacy can be defined as follows: Medical diplomacy is a form of international relations in which medical and healthcare assets and resources are used to encourage positive relations between nations and/or exchange specific benefits between nations. This should be contrasted with health diplomacy which refers to “diplomatic efforts to enact international health measures.” Health diplomacy overlaps with but is not necessarily the same as medical diplomacy. The World Health Organization (WHO) is an example of health diplomacy while specific U.S. support of the WHO may be regarded as an expression of U.S. medical diplomacy. It should be noted that very little has been published in the literature regarding medical diplomacy. For example, if one does a Google search on “medical diplomacy”, relevant results are found only on the first page and this blog ends up ranking 9th on the list. A Taxonomy of Medical Diplomacy At a high-level medical diplomacy can be considered to involve either short-term or longer term measures. 1. Short-term measures (often termed “medical outreach” ) a.

Disaster relief (e.g. Post-Tsunami relief)

b.

Non-disaster relief (e.g. Project Hope)

2. Long-term measures (often termed “medical sustainability” and often proverbially summarized by the phrase “teach a man to fish”) a.

Exporting personnel (e.g. Cuba’s efforts to export its physicians to other nations)

b.

Building facilities and providing other hard assets

c.

Providing medical training and education

Medical diplomacy can also be categorized in terms of its major goals, namely that of fostering positive public perception opinion and/or gaining specific trade benefits. There is also a third goal, overlapping with that of health diplomacy, which seeks to help ensure the health of U.S. citizens in the face of potential international health threats.

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1. Inspiring good-will a.

For the U.S. the most important outcome to be obtained from medical diplomacy and indeed this is what Gov. Thompson refers to by “winning the hearts and minds of people.”

2. Obtaining material benefits a.

Cuba export of physicians to Venezuela in exchange for oil and gas benefits is an example of leveraging medical diplomacy in this way

b.

While this may not be seem to play a significant role U.S. medical diplomacy, the reality is that with its preeminent pharmaceutical and medical technology industries, there is great opportunity for linking medical diplomacy with medical export.

c.

For example, because of what may be very high prices for such U.S. goods, medical diplomacy (as coordinated by the federal government through explicit programs, tax incentives, etc.) may play a role in facilitating a positive import-export environment between the U.S. and its trading partners. This was the essential point of the previous blog entry “An Unfolding Tragedy: Balancing Act between Innovation and Access” which pointed out how medical diplomacy may have been used to help resolve the intellectual property/drug pricing conflict that took place between Abbott Labs and the government of Thailand earlier this year.

d.

And, in a more indirect yet not insignificant fashion, healthy populations abroad make for stronger economies in those countries which are thus able to import U.S. goods. Medical diplomacy is often likened to the post World War II Marshall Plan in which massive aid (including medical aid) was provided to war ravaged Europe. The compassion involved in this remarkable project should not at all be discounted but the reality is that enabling Europeans to move beyond starvation and disease vastly accelerated the resumption of strong trade between the U.S. and Europe. Make no mistake, the Marshall Plan benefited both sides of the Atlantic.

3. Securing the health of U.S. citizens a.

Medical diplomacy efforts (such as international vaccination programs) may directly mitigate international health threats to the U.S. populations. To the extent that U.S. healthcare resources can benefit other nations which may not be able to address such problems on their own, U.S. citizens would also benefit.

Medical diplomacy can also be classified in terms of bilateral, multilateral and/or international efforts. 1. Bilateral a.

e.g. specific programs between the U.S. and other individual nations

2. Multilateral a.

e.g. U.S. support of regional health initiatives

3. International a.

e.g. U.S. support of the WHO

In developing a comprehensive medical diplomacy policy, it will be important to understand how the bilateral, multilateral and international approaches differ in terms of resource utilization and ultimate impact on the intended benefits of medical diplomacy. Resources used in medical diplomacy The U.S. has a predominantly private healthcare system although in reality when one sums up the government contributions with respect to Medicare, Medicaid, the VA system, DoD health systems and

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other government health services, the public provision of healthcare is much more substantial than commonly appreciated. Because of this, resources used in medical diplomacy by the U.S. can involve: 1.

Government a.

Military

b.

Non-Military i. HHS ii. DoS iii. Other agencies

2.

3.

Non-Government Organizations (NGO non-profits) a.

Predominantly disaster relief organizations (e.g. Red Cross, International Medical Corps, Doctors without Borders, etc.)

b.

Non-disaster relief organizations (e.g. medical missions, groups supporting reconstructive and ophthalmic surgery missions, etc.)

c.

Sustainability organizations (e.g. public health oriented groups, Gates Foundation, etc.)

Private companies (which include non-profit or for-profit) a.

Healthcare Services i. Hospitals and health systems (e.g. Johns Hopkins International, etc.) ii. Telemedicine and teleradiology services

b.

Medical Technology i. Pharmaceutical ii. Medical device firms iii. Other technology providers (imaging, hospital supply, etc.

c.

Healthcare consulting and other professional services firms

The contributions of each of these groups to medical diplomacy can individually be very significant. Public-private partnerships - collaborations between government and private groups - are very relevant but such partnerships in medical diplomacy are almost non-existent. In addition, there are significant impediments to leverage our substantial healthcare resources for the purposes of medical diplomacy. These include direct barriers such as trade and regulatory barriers or indirect ones such as insufficient financing. Finally, it is important to think “outside the box” of this framework in considering innovative cross-sector organizations. One could imagine a Fannie Mae or Sallie Mae like public/private financing group for medical diplomacy purposes. Measuring medical diplomacy Like anything, it is important to measure the effectiveness of medical diplomacy in terms of its main goals of inspiring good will, obtaining trade benefits and securing U.S. citizen’s health. To the extent that other forms of “soft power” (such as cultural and educational exchange programs) measure their outcomes such precedent may be useful in developing assessments for medical diplomacy efforts. Measurement of outcomes is very important and the example of the World Health Organization’s successful small pox vaccination program is very relevant in this regard. In retrospect, the decision to gauge the effectiveness of this program by measuring the actual incidence of small pox (rather than by other surrogate measures such as number of clinics opened or number of people vaccinated) was essential to the program’s ultimate success. If the WHO small pox program, for example, had used these other

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outcomes measures, one can imagine situations in which these benchmarks can be manipulated or misinterpreted even in the absence of an overt malicious intent. It is also crucially important to assess any unintended consequences arising from medical diplomacy. For example, local health providers may resent outside intervention, however helpful it may be. Strategies to avoid or mitigate such unintended consequences should be considered. We need to know more to do more As mentioned there has been virtually no detailed study or policy research around medical diplomacy. Important goals of such work would be: 1. To gain an overall perspective on the value of medical diplomacy and where most of the resources and effort may be most optimally aligned. 2. Develop policy recommendations to the U.S. Government (and constituent agencies as appropriate) regarding medical diplomacy. 3. Develop policy recommendations to NGOs and private companies who are involved in medical diplomacy or in aspects of international trade in which medical diplomacy may play a role. 4. Of particular importance will be policy recommendations that relate to public-private partnerships that may further optimize medical diplomacy efforts. Part II of this blog on medical diplomacy will discuss these ideas in the context of the recent New York Times report on Sen. Bill Frist’s work with Save The Children. Hopefully we can convincingly answer the question why – with all the medical suffering with have in our own country and a healthcare system which more than a few (a là Michael Moore) say is on the verge of collapse – we must do more to save the children around the world. Ogan Gurel, MD MPhil [email protected] http://blog.aesisgroup.com/

Medical Diplomacy Disaster relief Tommy Thompson Gates Foundation Marshall Plan Project Hope Health diplomacy Abbott Laboratories Medical outreach soft power world health organization Aesis Research Group Ogan Gurel medical diplomacy medical diplomacy

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