The World Health Organization (WHO) defines global health diplomacy as the ability to utilize disciplines of public health, international affairs, management, and law in negotiations as a means to shape and manage positive change. ¹ Historically, health diplomacy was born in the humanitarian community but has increasingly been used by governments to positively affect the behavior of others for the common good. These activities, frequently referred to as “soft power,” have also led to a more favorable opinion and credibility abroad.Reference Novotney and Kickbusch ² In the midst of chaos created by complex emergencies, health care providers have taken on additional roles to defend, negotiate, and cajole warring factions into sparing the health infrastructure from total annihilation. Health care providers have, out of necessity, evolved individual and collective strategies to leverage an acceptable and receptive political environment for conflict resolution. Negotiation and mediation with warring factions became essential to keep health programs viable in the face of continued threats or political violence. This concept is not new. Both Mary AndersonReference Anderson ³ and the Carnegie Commission on Preventing Deadly Conflict ⁴ have suggested that the “public health paradigm” of primary prevention might be useful in preventing conflict. With knowledge of the unprecedented destruction of public health infrastructure and protections in conflicts worldwide and its contribution to the indirect mortality and morbidity that follows, the public health persuasion offers a powerful argument for ending fighting and should be clearly identified and optimized in formal peace negotiations. These formal peace negotiations, however, will more likely than not initially emerge from soft power efforts at the local level.

There are many examples in which health diplomacy has been used to quell conflicts. Nongovernmental organizations (NGOs) have found that negotiations and mediation with warring factions are essential to keep health programs viable. In the 1990s, during numerous local wars in Africa, NGOs negotiated “days of tranquility,” brief periods of agreed-to cease-fires between competing combatant groups in support of critical public health interventions such as polio eradication campaigns. ⁵ These initiatives demonstrated that even in the absence of formally negotiated cease-fires, programs such as critical public health programming could be seamlessly and effectively conducted through the mediation of public health and health professionals. Similarly, the Carter Center’s Guinea Worm Eradication Program identified at-risk Sudanese villages that were inaccessible as a result of the ongoing war. Guinea worm cease-fires were effectively negotiated to guarantee vaccine coverage, leading to successful eradication of guinea worm in all vulnerable populations as well as being instrumental in ending the fighting.Reference Hopkins and Withers ⁶ Coordination meetings for the organization of polio and other vaccination campaigns remain viable today, many of which still rely on the use of “days of tranquility,” established cross-border activities, and cooperative military corridors to ensure access to vulnerable populations. Reed feels that cease-fires can break the “habit of fighting, and that the combatants may find that they like the pause more than returning to their war efforts.” ⁷ These programs bring the “shared interest in health” among the opposing factions within the territory under their mutual control.

Between 1993 and 1997, the NGO International Rescue Committee collaborated with Bosnian and Croatian hospitals to allow more than 3000 critically ill and war-injured Bosnian children to be evacuated to Croatian hospitals rather than being sent abroad. By enlisting and resourcing hospitals in wartime, NGOs were able to demonstrate the role they can play as mediators and “partners in an alliance.”Reference Richards ⁸ This project found that, through the NGO mediation, hospital directors became formidable “players” in the country’s wartime political arena. Hospital directors “attained positions of influence far surpassing their original mandates.”Reference Richards ⁸ The war taught them to think pragmatically and become more tolerant and accommodating toward refugees than senior government officials. A similar project existed in Lebanon for Palestinian refugees. ⁹

Health professionals from countries considered traditional “enemies” are working together to mitigate and manage emerging global pandemics such as SARS, avian influenza, and Ebola. Such examples illustrate the shared interest of health that brings together opposing factions, in contrast to “hard power,” the military and/or economic power tactics used to control or force changes in a governing regime’s position.Reference Nye ¹⁰

Humanitarian crises and the unique demands they provoke have changed every decade or two since the signing of the United Nation’s Charter in 1945.Reference Burkle, Martone and Greenough ¹¹ Global turmoil has heightened, especially in the Middle East, and with it, political, religious, and cultural differences have become major reasons to incite crises. The Haj annual pilgrimage, a demonstration of solidarity of the Muslim people and one of the 5 pillars of Islam, has become one of the world’s largest gatherings of people, second only to India’s Kumbh Mela, the mass Hindu pilgrimage of faith. Tragically, on 24 September 2015, a stampede caused the death of more than 2000 pilgrims during the annual Haj pilgrimage in Mina, Mecca.Reference Gambrell ¹² Among the casualties, Iran experienced the highest number of losses with 464 dead and 36 missing. ^{13 , 14} The catastrophe immediately added fuel to the already existing tensions between Iran and Saudi Arabia over Yemen. Iran faulted the Saudi government for its negligence and mismanagement in the implementation of the required safety measures, while the Saudi government saw Iran’s reaction as politicized. ¹⁵

As the number of Iranian victims rose, Iran made many efforts to provide assistance through diplomatic means but most failed. Amid the mounting tensions, the Iranian Minister of Health through his contact with his counterpart in Saudi Arabia paid a timely visit to Mecca to help mitigate the problems experienced by the Iranian Haj pilgrims. During several meetings held between the 2 health ministers, both sides cooperated effectively and settled some major problems including the transport of the bodies of the deceased Iranians to their homeland. As a result of these initiatives, the Saudi minister conveyed the condolences of his government to the Iranian government and the families of the dead, expressing the willingness of all Saudis to cooperate with the Iranian government. ¹⁶ The negotiations led to opening the diplomatic deadlock in a humanitarian crisis and brought peace of mind to many affected Iranians. The Iranian Deputy Foreign Minister for Arab and African Affairs stated, “Regarding to the type of political relations between Iran and Saudi Arabia, the health diplomacy and the direct contact that was established was very useful and increased the mutual confidence.” ¹⁷

This example again illustrates how health issues can be instruments of a “soft power” tool of foreign policy. Health workers often function as “referees” in conflict by promoting health as the common denominator in a society invested in the conflict resolution process. Although during recent years many efforts have been made to put the global health concerns on the agenda of foreign policy, the case of Mina proves that alternative foreign policy “soft power” options of mediation and negotiation may also use health issues to advance national goals in the interest of the people.Reference Gambrell ^{12 ,} Reference Feldbaum and Michaud ^{18 ,} Reference Kickbusch, Novotny and Drager ¹⁹ The case of Mina is one of the rare instances in current memory in which governments successfully ended a growing crisis with a focus on health and humanitarianism in a policy aimed in advancing the real interest of the people.

By making public health the only issue, politicos can find a reasonably level playing field and seek mutual gains. As suggested by some health professionals, the integration of health into foreign policy will promote solidarity in international relations which otherwise would only be focused on national interests.Reference Horton ²⁰ It is not uncommon in conflict resolution that the adversarial environment is alleviated by a desire on all sides to avoid the obvious negative consequences of collapsing public health. Ebersole suggests that “opposing sides have an interest in presenting a positive image of themselves both at home and abroad.”Reference Ebersole ²¹

Indeed, the insight of Margaret Chan, the WHO Director General, is timely: “It is clear that health and foreign policy are inextricably linked…WHO members are challenged to support this linkage.”Reference Chan, Store and Kouchner ²² As such, in situations where global health security is threatened, it is crucial that all health providers and their teams be trained in the skills of health diplomacy and as advocates for the use of “soft power” options. No longer are these programs limited to vaccination programs. It is important to increase the number of health providers who understand how conflict mediation in health can be used to mitigate conflict itself and to train them on the essential competencies through the growing number of humanitarian courses that focus on standards of care, research, and professionalization. NGOs, academic institutions, and research organizations have a role and responsibility to develop curricula in conflict resolution, health and human rights, and post-conflict transformation, rehabilitation, and recovery. Education must optimize training in mediation and negotiation skills throughout the entire health system from ministerial levels to health program directors and field workers. Regional specialization would help to address the nuances brought about by cultural, religious, and regional differences in health practices as well as the manner in which conflict is interpreted and resolved.Reference Burkle ²³

Knowing the importance of such focused training, WHO conducted a Global Health Diplomacy program for the first time in 2007 for 18 participants of 10 countries, recruited because of their previous backgrounds that involved “policy, international health negotiations, private sector, NGO and multinational organization work.” The goals of the instruction and debate centered on “health diplomacy as it relates to health issues that cross national boundaries and are global in nature” and addressed “the challenges facing health diplomacy and how they have been addressed by different groups and at different levels of governance.”Reference Kickbusch, Novotny and Drager ¹⁹ Since then, many public and global health schools have added special modules to their curricula to address training that brings health and foreign policy professionals together to collaborate with each other in the context of global health diplomacy. Such interdisciplinary training opportunities should be equally available to non-health policy makers and others skilled in negotiations as well as public health providers in conflict areas of developing countries who generally do not have relevant skills or the educational opportunities to acquire them.

We must recognize an equally critical connection and continuum between health, human rights, and peace building. There is strong evidence that the public health–peace building concept can serve as a basis for intervention, prevention diplomacy, conflict transformation, and sustainability.Reference Hess and Pfeiffer ²⁴ By enhancing the relationship between public health and societal and population-based interdisciplinary epidemiology, new peace opportunities that bridge health and peace building through a bevy of soft power options will be identified.