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Global health diplomacy: a new era of health in U.S. foreign policy

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Global health diplomacy: a new era of health in U.S. foreign policy

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GLOBAL HEALTH DIPLOMACY: A NEW ERA OF HEALTH IN U.S. FOREIGN POLICY

by

Coral Teresa Andrews

A Dissertation Presented to the
FACULTY OF THE SOL PRICE SCHOOL OF PUBLIC POLICY
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF POLICY, PLANNING, AND DEVELOPMENT

August 2021

Copyright 2021 Coral Teresa Andrews

ii
EPIGRAPH
You always have choice. You simply need courage.
Coral T. Andrews

iii
DEDICATION
This dissertation research is dedicated to my husband, David, and our sons, Nicholas and
Daniel; to my parents, Donald and Carolyn; and to my siblings, Richard, Julia, David, and
Jeffrey.
May the value of knowledge remain treasured.

iv
ACKNOWLEDGEMENTS
I am deeply grateful to the members of my dissertation committee, Dr. Peter Robertson
(Chair), Dr. Mellissa Withers, and Dr. Philip Zelikow, for their scholarly guidance and steadfast
support.
I wish to thank Dr. Deborah Natoli, director of the DPPD program, for her vision,
dedication, and resourcefulness. To the dean and the DPPD faculty of the Sol Price School of
Public Policy, thank you for your commitment to this degree program and for your belief in the
value that policy entrepreneurs bring to the field of public administration.
To the research participants who so generously devoted their time in support of this
research, thank you. To all who have worked tirelessly to advance the statecraft of diplomacy,
lead the strategic inclusion of health in U.S. foreign policy, and advocate for those affected by
global health challenges, I strived to give voice to your experiences. Your personal stories inspire
me beyond measure.

v
TABLE OF CONTENTS
Epigraph .................................................................................................................................... ii
Dedication ................................................................................................................................. iii
Acknowledgements ................................................................................................................... iv
List of Tables .......................................................................................................................... viii
List of Figures ........................................................................................................................... ix
Abstract ......................................................................................................................................x
Chapter 1: Introduction ...............................................................................................................1
Statement of the Problem and Research Imperative ...............................................................1
U.S. Foreign Policy Powers: The Policy-Making Process ......................................................4
The Role of GHD as a Soft Power in U.S. Foreign Policy......................................................7
Research Question .................................................................................................................8
Outline of the Research Project ........................................................................................... 10
Value of the Study ............................................................................................................... 12
Project Significance and Contribution to Literature ............................................................. 15
Health as a High Politic Issue in U.S. Foreign Policy ..................................................... 15
Devising a Conceptual Framework: Explaining Transnational Global Health Policy
Events ........................................................................................................................... 16
Advancing the Practice of GHD .......................................................................................... 17
Chapter 2. U.S. Foreign Policy and GHD .................................................................................. 20
Concepts and Heuristics ...................................................................................................... 21
International Relations Theories and Analysis ............................................................... 24
Rosenau’s Pre-Theory of Foreign Policy........................................................................ 26
Role Theory ................................................................................................................... 27
Rational Choice Theory ................................................................................................. 30
Garbage Can Model ....................................................................................................... 31
Almond’s Input-Output Framework Analysis ................................................................ 31
Middle Powers: Political and Diplomatic Issues............................................................. 32
The Evolution of GHD ........................................................................................................ 33
GHD Definitions ........................................................................................................... 35
Current Trends............................................................................................................... 38
Current Drivers .............................................................................................................. 43
Assessment and Synthesis.............................................................................................. 54
Chapter 3. Theoretical Foundations ........................................................................................... 59
The Foreign Policy Agenda-Setting Process ........................................................................ 59
Participants .................................................................................................................... 61
Theoretical Underpinnings ............................................................................................. 67
Analytical Frameworks ....................................................................................................... 74
Kingdon’s Multiple Streams Framework ....................................................................... 74
vi
Zelikow-Allison’s Conceptual Models ........................................................................... 78
Research Focus ................................................................................................................... 82
Key Takeaways ............................................................................................................. 84
Linking Global Health Diplomats to U.S. Foreign Policy ............................................... 84
Research Questions ....................................................................................................... 85
Chapter 4: Methodology ............................................................................................................ 87
Review of Public Documents............................................................................................... 88
Goldwater-Nichols Act of 1986 ..................................................................................... 89
U.S. National Security Strategy (NSS) ........................................................................... 91
Aspen Strategy Group (ASG) Papers ............................................................................. 92
U.S. Global Health Security Strategy (GHSS)................................................................ 95
U.S. Global Health Security Agenda (GHSA) ................................................................ 96
International Health Regulations (IHR) .......................................................................... 97
USAID Policy Framework ............................................................................................. 98
Congressional Research and Bills .................................................................................. 98
Interviews ......................................................................................................................... 100
Participants .................................................................................................................. 101
Interview Process ........................................................................................................ 102
Data Coding and Analysis ........................................................................................... 103
Overview of Two Historical Cases .................................................................................... 105
The Global Fund to Fight AIDS, Tuberculosis, and Malaria ........................................ 107
The President’s Emergency Plan for AIDS Relief (PEPFAR) ...................................... 111
Chapter 5: Findings ................................................................................................................. 114
Themes and Subthemes ..................................................................................................... 117
The Rise of Health on the Global Policy Agenda ......................................................... 117
Global Governance and Aligned Incentives ................................................................. 122
Agenda Setting, Politics, and Negotiations................................................................... 127
Moral Imperatives and the Global Public Good............................................................ 131
Champions and Leaders ............................................................................................... 132
Wicked Problems and Design Thinking ....................................................................... 135
Pivotal and Seminal Changes ....................................................................................... 138
Cycles of Complacency in Public Health Events .......................................................... 143
Public Perceptions Shape Transnational Cooperation ................................................... 149
Modernize U.S. Foreign Policy and Strategy ............................................................... 151
Conclusions to Research Questions ................................................................................... 157
Chapter 6. Continued Development of Health Policy ............................................................... 168
Telling the Story of the Global Fund and PEPFAR ............................................................ 168
How the Global Fund Originated ................................................................................. 171
How the PEPFAR Policy Development Unfolded ........................................................ 178
How the PEPFAR Policy Decision was Made .............................................................. 181
A Conceptual Framework ............................................................................................ 186
Conclusions ....................................................................................................................... 190
Implications for Policy ................................................................................................ 191
Recommendations for Policymakers ............................................................................ 201
vii
Appendix A. Study Memorandum ........................................................................................... 206
Appendix B. Research Participants .......................................................................................... 207
Appendix C. Interview Guide .................................................................................................. 218
References .............................................................................................................................. 220
Vita Auctoris ........................................................................................................................... 241

viii
LIST OF TABLES
Table 1. U.S. Foreign Policy Powers: Congress and the President ............................................. 24
Table 2. International Relations Theories in GHD Literature ..................................................... 25
Table 3. GHD Definitions ......................................................................................................... 35
Table 4. Health and Foreign Policy’s Four Functions ................................................................ 46
Table 5. “Globalization and Health,” Labonté & Gagnon (2010) ............................................... 48
Table 7. Features of Traditional vs. Human Security ............................................................... 145

ix
LIST OF FIGURES
Figure 1. Pyramid of Global Health Diplomacy: Myriad Actors, Definitions, and Tools ..............8
Figure 2. Evolution of the System of Diplomacy ....................................................................... 23
Figure 3. Levels of Analysis in International Relations .............................................................. 40
Figure 4. U.S. Global Health Funding, FY 2006–FY 2021 Request ........................................... 53
Figure 5. Organization of U.S. Global Health Efforts ................................................................ 63
Figure 6. U.S. Health Attachés’ Relationships ........................................................................... 65
Figure 7. Pyramid of Global Health Diplomacy: Myriad Actors, Definitions and Tools ............. 67
Figure 8. A Multiple Streams Model of Policymaking (Tomlin et al., 2008) .............................. 76
Figure 9. The Policy Analysis Circle ......................................................................................... 83
Figure 10. A Conceptual Framework for the Prioritization of Health in U.S. Foreign Policy: A
Dynamic Transnational Lifecycle ............................................................................................ 187
Figure 11. The ENISA Four-Phase Recommendation for Lifecycle of National Cybersecurity
Strategy ................................................................................................................................... 190

x
ABSTRACT
Global health diplomacy (GHD) is an emerging practice that stands to achieve
unparalleled influence on 21
st
century global health initiatives and shape a new grand strategy for
the United States on the heels of a pandemic. GHD is described as the “practices by which
governments and non-state actors attempt to coordinate and orchestrate global policy solutions to
improve global health” (Ruckert et al., 2016, p. 1). The entrance to the global health field by a
multiplicity of jurisdictional actors has introduced conflicting goals and metrics. This diversity
and complexity in the global health ecosystem has led to a fracturing in how GHD is applied
(Cooper & Farooq, 2015). “Each country must be resolute/firm in addressing health concerns in
its foreign policy as they are with their domestic policy” (Chattu & Chami, 2020). The strategies
that lead to the prioritization of a health policy agenda in U.S. foreign policy decision making are
unknown.
Security, development, and human rights are the driving forces that are moving health
from a “low politic to a high politic” issue (Fidler, 2005). Yet, there is “elasticity for health in
development, economic, and national security policies” (Fidler, 2011, p. 5). The literature on
GHD is fragmented and lacks rigorous theorizing (Ruckert et al., 2016). Utilizing a qualitative
constructivist worldview, the purpose of this phenomenological study is to investigate GHD,
summarize the current state of literature, and to analyze the complex nature of U.S. foreign
policy to determine under what conditions the health policy agenda enters decision making and
for what purpose or value. Kingdon’s (2011) Multiple streams framework (MSF) and Zelikow-
Allison’s (1999) conceptual models will be utilized to examine the research questions. The
conceptual models, a set of three, will be used to explain government decision-making and to
xi
“inform a fundamental rethinking of national security strategy, foreign policy, and the role of the
United States” (Zelikow & Allison, 1999, p. 9).
My research focuses on advancing the health policy agenda as a strategic and
multilateral/bilateral utility alongside security and economics in U.S. foreign policy. Utilizing a
phenomenological approach, I will collect data through an elite interview methodology and a
document review. Research implications include developing a conceptual framework that
describes the conditions under which the health policy agenda is prioritized within the U.S.
national security strategy and foreign policy decision making (FPDM), enhancing the strategic
collaboration between health and foreign policy scholars, and advancing GHD as an applied
practice.
1
CHAPTER 1: INTRODUCTION
“Grand strategy,” according to van Hooft (2017, p. 1), is “the highest level of national
statecraft that establishes how states, or other political units, prioritize and mobilize which
military, diplomatic, political, economic, and other sources of power to ensure what they
perceive as their interests.” In U.S. foreign policy, this presents an opportunity to examine the
role of non-military tools, such as health, to promote international cooperation and diplomacy.
According to RAND Corporation (2020), a non-partisan, non-profit research institution, the U.S.
grand strategy is described across several policy doctrines. The National Security Strategy
(NSS), developed by the Executive Branch (www.whitehouse.gov) and statutorily required by
Congress, is a cornerstone document in U.S. foreign policy and serves as a framing document for
this Global Health Diplomacy (GHD) research.
Statement of the Problem and Research Imperative
This research aims to provide a comprehensive and critical overview and assessment of
the current state of scholarship on global health diplomacy (GHD) with the goal of identifying
the core assumptions and themes driving the conditions under which the health policy agenda
gets incorporated into U.S. foreign policy decision making (FPDM) and for what purpose or
value. A thorough literature review and summary reveals a panoply of theoretical and analytical
frameworks stemming from the synthesis of inter-disciplinary lenses (International Relations,
Diplomacy, Foreign Policy). My research problem statement is ‘the strategies that lead to the
prioritization of health in U.S. foreign policy decision making are unknown’. This study focuses
on a research gap: to identify the conditions under which the health policy agenda enters U.S.
foreign policy decision making and for what purpose or value. Consistency in a policy-making
approach creates a potential for better outcomes.
2
GHD is an emerging practice that stands to achieve unparalleled advances in 21
st
century
global health initiatives. However, scholarly research by Ruckert, Labonté, Lencucha, Runnels,
and Gagnon (2016, p. 1) found that “GHD lacks rigorous theorizing. The literature is fragmented
and not clearly structured around key issues and their theoretical explanations. The lack of a
theoretical framework to guide the multi-stakeholder environment impedes the ability to
effectively measure GHD outcomes.” GHD is defined as the “policy-shaping processes by which
States, intergovernmental organizations and non-state actors negotiate responses to health
challenges and utilize health concepts or mechanisms in the policy-shaping and negotiation
strategies to achieve other political, economic, or social objectives” (Smith, Fidler, & Lee, 2010,
p. 7).
Global health issues are at the forefront of everyday life. Coronavirus (COVID-19) is a
pertinent example of this as the world engages collectively to combat the spread of this novel
disease which is wreaking havoc around the globe, causing illness and death, leading to
worldwide quarantine strategies, and potentially destabilizing one of the world’s largest
economies (Centers for Disease Control and Prevention [CDC, n.d.). Globalization has
intensified the complexity of these issues which has led to a convergence of the global health
agenda with foreign policy.
Foreign Policy Decision Making (FPDM) falls within the field of foreign policy analysis
(FPA). FPA is a “subfield of International Relations (IR)” (Hudson & Day, 2020, p. 6). The field
of FPA is a useful tool in analyzing human decision making (Hudson & Day, 2020). The factors
that influence FPDM are innumerable. Examples include distinctions of foreign policy problems
that arise as a crisis or of a more routine nature (Hudson & Day, 2020). The risks associated with
decision-making in a crisis can pose a higher risk. This research will focus on explaining FPDM
3
during the AIDS epidemic during the bounded timeframe of 2001-2003. U.S. FPDM on this
crisis was shaped by concerns over terrorism. Anthrax scares and national strategies about
terrorism that emerged following September 11, 2001 (also referred to as 9/11) are described in
Chapter 5, Findings.
A key feature of FPA is that its theory is “profoundly actor specific” when examining the
individuals involved in the decision-making process (Hudson & Day, 2020, p. 6). This means
that to understand FPDM, it is necessary to gather “specific and concrete information about the
decision makers … would be necessary to explain that crisis” (Hudson & Day, 2020, p. 7). They
specifically referred to the three countries (the US, the Soviet Union, and Cuba) involved in the
Cuban Missile Crisis which was analyzed and led to the formulation of the Zelikow-Allison’s
models which are described in Chapter 3 of this dissertation research. “The source of all
international politics and all change in international politics is specific human beings using their
agency and acting individually or in groups” (Hudson & Day, 2020, p. 7). In Chapter 5,
Findings, the role of champions and leaders is highlighted.
This research seeks to bridge the policy domain gaps between global health diplomacy
(GHD), international relations (IR), and foreign policy. GHD practitioners are the policy
entrepreneurs who implement diplomacy as a soft power. During these uncertain times, GHD is
essential to fostering the international cooperation necessary to advance foreign policy. Our
shared human experiences during this pandemic ‘new normal’ highlight the nation-to-nation
interdependencies associated with health and economics.
The pandemic underway is threatening the health and prosperity of humankind.
Coronavirus (COVID-19), according to the World Health Organization (WHO) emerged in
Wuhan, China with the earliest cases traced to November 2019. The pandemic has led to
4
worldwide social distancing and isolation, community quarantines and disruptions in global
business continuity. The U.S. financial market is strained, and unemployment is widespread. The
number of U.S. cases reported by the CDC (2021) on April 12, 2021 are 31,015,033 and the
number of deaths is 559,172.
The pandemic has also revealed the interdependencies across the globe and highlighted
the levels of cooperation necessary to achieve enough capacity to respond effectively. Will this
shared global threat present a policy “window of opportunity” that leads to a change in U.S.
foreign policy and a renewed prioritization of health? (Kingdon, 2011). Will the widespread
impact to business sectors (economics) act as drivers in moving health to a new level of political
and strategic importance alongside economics and security?
IR and FPA disciplines utilize individual, decisional, and national levels of analysis to
examine foreign policy creation. However, despite this approach recommended by system-level
theorists, there is value in “understanding the processes by which decision makers choose certain
options over others” (Most & Starr, 1984, p. 406). A conceptual framework would help to clarify
the processes that are necessary to advance the health policy agenda into U.S. FPDM.
U.S. Foreign Policy Powers: The Policy-Making Process
The United States, post-World War II (WWII), developed a “hegemonic order”, or
“preponderant power” model that was oriented around its military and economic power (Neack,
2014, p. 153). This world order led to the development of the international system whereby
organizations such as the “United Nations, the International Monetary Fund, the World Bank, the
General Agreement on Tariffs and Trade (GATT), and the World Trade Organization, and
NATO are chief components of the American hegemonic order” (Neack, 2014, p. 157). At the
same time, globalization drove the establishment of the World Health Organization (WHO). The
5
increase in global health threats drove the need for greater engagement by foreign policy makers
(Smith, Fidler, & Lee, 2010). Global health law emerged and with it came a lens toward health
equity (Ruger, 2008).
Key framing documents that shape U.S. foreign policy powers and responsibilities
include the U.S. Constitution and the Goldwater-Nichols Defense Reauthorization Act of 1986.
The U.S. Constitution, according to the Council on Foreign Relations (Masters, 2017, pp. 1),
“parcels out foreign relations powers to both the executive and legislative branches. It grants
some powers, like command of the military, exclusively to the President. Regulation of foreign
commerce is delegated to Congress. Other powers are divided or not assigned.” In policy areas
where the powers are not explicitly assigned, there is opportunity for conflict. The use of
executive privilege in recent years has, “according to foreign policy experts, led to an
accumulation of power by Presidents at the expense of the Congress” (Masters, 2017, p. 2).
The Goldwater-Nicholas Defense Reauthorization Act of 1986 compels the
Administration to develop a National Security Strategy (NSS) annually for review by Congress.
The NSS, as the grand strategy, serves as the umbrella document for my research and document
review. According to the historical office in the Office of the Secretary of Defense, the “NSS has
been transmitted annually since 1987, but frequently reports come in late or not at all. The NSS
is to be sent from the President to Congress in order to communicate the executive branch’s
national security vision to the legislative branch. The NSS provides discussion on proposed uses
of all facets of U.S. power needed to achieve the nation’s security goals. The report is obligated
to include a discussion of the United States’ international interests, commitments, objectives, and
policies, along with defense capabilities necessary to deter threats and implement U.S. security
plans” (Office of the Secretary of Defense, n.d.). The NSS provides the whole picture of the
6
US’s global goals and strategic priorities and develops a framework whereby all other
subordinate policies within the government are created (Kugler, 2006). The health policy agenda
that drives the application of GHD in U.S. foreign policy should originate from this overarching
framework.
Beyond foreign policy formulation on the domestic front, the International Health
Regulations (IHR) represent an international agreement that is “binding” and whose purpose is to
“ensure maximum security against the international spread of disease with a minimum
interference with world traffic” (Ruger, 2008, pp 434-435). Gaps in the effectiveness of the IHR
were highlighted following the Ebola outbreak in West Africa in 2014. This led to reforms by the
World Health Organization (WHO) which included internal reviews and an effort to harmonize
the IHR with other governing documents, such as the Global Health Security Agenda (GHSA).
According to Halabi, S. F., Gostin, L. O., & Crowley, J. S. (2016), the “pandemic potential of
HIV/AIDS” brought attention to changes needed in the IHR to sufficiently respond to new
infectious diseases (p. 103). The World Health Assembly (WHA), decision-making body of the
WHO, revised the IHR (Halabi et al., 2016). The United States notified the WHO of its plans to
withdraw from WHO effective July 6, 2021 (Nichols, 2020). The actions to withdraw from the
WHO were subsequently reversed at the change of Presidential Administration in January 2021
(The White House, 2021a); however, the issues relating to the enforcement of the IHR in this
circumstance remain unclear at the time of this writing.
The U.S. foreign policy-making process is complex. It originates from the U.S.
Constitution and flows through the Executive and Legislative branches. My research examines
the system processes that shape the inclusion of the health policy agenda in U.S. FPDM.
7
The Role of GHD as a Soft Power in U.S. Foreign Policy
The opportunity to progress in tackling wicked problems associated with global health
and foreign policy have led to increasing attention being placed on the value of GHD. Former
WHO Director-General Margaret Chan declared “GHD as heralding a ‘new era’, while Alcazar
writes of a ‘Copernican shift’ or ‘radical mind shift’ in how we think about health. Others have
defined GHD as a ‘new educational field’” (Lee & Smith, 2011, p. 1).
To better understand GHD, “International Relations (IR) scholars distinguish between
foreign policy and diplomacy. Diplomacy is the art or practice of conducting international
relations through negotiating alliances, treaties and other agreements” (Lee & Smith, 2011, p. 2).
The applied practice of diplomacy involves stakeholder dialogue with the goal of identifying
areas of common agreement and areas where parties disagree. In contrast, “foreign policy is the
activity whereby state actors act, react and interact at the boundary between the internal
(domestic) and external (foreign) environment” (Lee & Smith, 2011, p. 2). Diplomacy can be
described as an instrument of foreign policy (Lee & Smith, 2011).
As a soft power, GHD is complex and involves a range of state and non-state actors. The
tools used in GHD, as described in Figure 1, include agreements and partnerships as contrasted
to hard power which often relates to the use of force/military strategies (Brown et al., 2016, p. 4).
Diplomatic engagement is shaped by foreign policy priorities and is utilized as a tool to
advance relationships and country goals. The term “‘new diplomacy’ describes shifts in foreign
policy that challenge how diplomatic practice is carried out” (Lee & Smith, 2011, p. 2). The two
shifts in the post-Cold War period that contribute to this new term include the “end of
superpower rivalry (the rise of Brazil, Russia, India, and China) which has led to a geopolitical
reconfiguration of the international states system” and “globalization” (Lee & Smith, 2011, p. 3).
8
These shifts have resulted in diverse stakeholder groups engaging more fully in global health
issues and that has “elevated the soft power in foreign policy” and challenged the norms of
diplomacy (Lee & Smith, 2011, p. 3).
Figure 1. Pyramid of Global Health Diplomacy: Myriad Actors, Definitions, and Tools
Source: Brown et al., 2016, p. 4.
Research Question
The predominant literature resource that I utilized to logically distill my research
questions resides in “Global health diplomacy: A critical review of the literature” (Ruckert et al.,
2016). The critical research review comprehensively searched three English-language scholarly
databases which yielded 606 articles, 135 of which were retained for importing into NVivo10
and coding. A gap that Ruckert et al. (2016) identified was a “lack of clarity in what drives the
presence of health in the foreign policy agenda” (p. 1). Thus, my research question is:
9
• Under what conditions does the health policy agenda enter U.S. foreign policy decision
making (FPDM) and for what value or purpose?
My research sub-questions are:
• What do the Zelikow-Allison’s models contribute to our understanding of foreign policy
decision making (FPDM)?
• What policy windows of opportunity (Kingdon, 2011) exist in which to advance health as
a strategic priority within U.S. foreign policy?
• How has the prioritization of health as a high politic issue in U.S. foreign policy impacted
GHD?
International Relations (IR) literature also informed my research inquiry by fostering an
appreciation of its theoretical and analytical perspective. Collaboration with International
Relations (IR) scholars is recommended because the field of IR is rich with theoretical
knowledge and analytical concepts about foreign policy (Ruckert et al., 2016).
The goals of my research are:
1. To investigate the knowledge and policy decision-making practices utilized in the
establishment of the President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global
Fund to Fight AIDS, Tuberculosis, and Malaria.
Objective: By understanding the decision-making used to formulate the PEPFAR and
Global Fund cases, I am able explain how a rudimentary agenda develops into global health
strategy and U.S. foreign policy.
2. To develop a conceptual framework that models the conditions under which a
rudimentary health policy agenda gets incorporated into U.S. foreign policy decision making
(FPDM) (Hudson & Day, 2020). By examining the cases of PEPFAR and the Global Fund, the
10
framework can explain the conditions that led to these health policy agendas, clarify the
transnational activity that shaped the resultant U.S. FPDM, and link the decision makers and
actors to this complex global health policy ecosystem.
Objective: By applying Kingdon’s Multiple Streams Framework (Kingdon, 2011) in
conjunction with Zelikow-Allison’s Conceptual Models (Zelikow & Allison, 1999), this research
advances an understanding of U.S. foreign policy decision-making (FPDM) during global health
policy events. In so doing, I am better positioned to communicate an applied approach to future
U.S. GHD practices.
Outline of the Research Project
This qualitative research is conducted as a phenomenological study. Creswell (2014)
states that “phenomenological research uses the analysis of significant statements, the generation
of meaning units, and the development of what Moustakas (1994) called an essence description”
(p. 196). I am interested in examining GHD to determine under what conditions the health policy
agenda enters into U.S. foreign policy decision making (FPDM) and for what purpose or value. I
utilize elite interview data collection and document review of federal records as the research
methods. Former authors of the U.S. National Security Strategy (NSS) are interviewed to gain
insight into the decisions that inform the prioritization of U.S. foreign policy considerations. To
gain saturation in the data collection, I examine the NSS across four (4) Administrations. U.S.
Congressional senior staff were also interviewed. Access to Congressional members was limited
due to COVID-19 committee priorities, remote working conditions during the pandemic, and the
timing of a Presidential election cycle. Individuals from other affiliated federal government
agencies (e.g., the U.S. Department of State) may be interviewed, as needed, to clarify the
diplomatic operationalization of health in U.S. foreign policy.
11
The elite interviews are conducted through technology-supported face-to-face encounters,
as in-person face-to-face interviews are not possible during this 2020 pandemic environment of
social distancing. The teleconferencing platform, Zoom, can support the remote interviews. It
offers a protected platform (i.e., HIPAA mode), a recording feature, and the ability to share
interview documents with the interview participants. Note-taking and recordings of the interview
are utilized to ensure accuracy.
The disadvantages of virtual interviews need to be acknowledged. They include: “no
direct observation of emotion or visual clues, risk to security of data, the potential that some
participants may be more preferential to face-to-face interviews” (Braun & Clarke, 2013). Elite
interviews are utilized by social scientists to gain perspectives on the behaviors of leaders.
Interviews are guided by an elite interview tool comprised of open- and closed-ended questions.
Thematic coding and analysis are utilized in qualitative research to develop a concepts or
patterns from the data that is collected during participant interviews (Braun & Clarke, 2013). The
codes that are created and analyzed aid in telling the story of how these two cases, PEPFAR and
the Global Fund, emerged from a rudimentary agenda. Inductive and deductive reasoning also
contribute to this analysis (Creswell, 2014). Findings are summarized and presented utilizing a
descriptive and narrative approach. Identified conditions are captured in the coding that ties back
to Zelikow-Allison’s Conceptual Models (Zelikow and Allison, 1999) and Kingdon’s Multiple
Streams Framework (MSF) (Kingdon, 2011). These conditions are useful in explaining the
research question.
The validity of the research is supported by utilizing triangulation to ensure that themes
can be justified. This includes a review of recorded interview data, hand-written notes, and any
other documents that emerge as meta data in the interview process. The current environment
12
caused by COVID-19 limits the use of any in-person validity tools. Efforts to ensure the
reliability of the research include a thorough review of consistency in coding the data to ensure
that the themes come together to form a picture with “dominant patterns in the data that
addresses” the research question. (Braun & Clarke, 2013, p. 249).
Value of the Study
The global political agenda has intensified around health because of COVID-19. The
policy complexity facing the United States necessitates a thorough examination of health and
U.S. foreign policy priorities. There are strategic opportunities to leverage GHD in those policy-
shaping processes, in nation-to-nation negotiations necessary to align U.S. diplomatic goals with
public health priorities, and as a national leader in shaping the future of global governance.
However, GHD lacks a governance framework, a grounded theory, and a unifying
definition to guide the practice. The accelerated pace of globalization is dissolving the distinction
between domestic and foreign policy issues. The 2020 COVID-19 pandemic has amplified our
interconnectedness as a global society. The political environment, emerging during the
pandemic, has led to a destabilization of the global health governance center within the World
Health Organization (WHO). U.S. leadership as a world power is being challenged by China and
Russia. The imperative to “reform global institutions and infrastructure so we are better
positioned to deal with the next pandemic and international challenges as a whole” is upon us.
Through my research, I have the possibility of explaining gaps and opportunities to advance the
U.S. health policy agenda and shape the applied practice of GHD. A conceptual framework that
explains FPDM during the AIDS epidemic may inform U.S. FPDM in future events and
contribute to a normative strategy.
13
Paradigm shifts, or changes in the way ideas have been conceptualized in the past, create
the catalyst for the individual and collective movement of conscious evolution. The new
paradigm emphasizes the interconnectedness of all beings. This shift draws together scientists
and practitioners into a system of thinking. Our actions as human beings impact our sustainable
life system. Hubbard (1998) reminds us to strive for a rethinking of our global mindsets and to
develop the new worldview called conscious evolution (p. 9). A response to a crisis can bring
about this shift in thinking (Hubbard, 1998, p. 11).
Rebalancing toward a moderated political center during this highly partisan era will be
challenging. Political differences of opinion have wreaked havoc and led to the absence of
consistent and unifying policies. An era of capitalism prioritized over collective value as a
human society have led to an imbalance that focuses on wealth creation for shareholders versus
investments that benefit society (McIntosh, 2017). This may be a driving factor behind
economics being prioritized as a ‘high politic’ issue in U.S. foreign policy decision making
(FPDM).
In the US, we lack a consensus among our President, Congress, and members of the
public regarding the prioritization of health in foreign policy. Utilizing insights from complex
adaptive systems (CAS), I learned that by identifying connections to a system “many of the
governance challenges of the global environment can be posed as commons problems, with
emphasis on commons institutions. As these challenges are in the context of rapid change,
system dynamics become crucially important, requiring adaptive governance with feedback
learning” (Berkes, 2017, p. 2). My goal in developing a conceptual framework for use by U.S.
institutions is to more fully integrate the health policy agenda into U.S. foreign policy.
14
Clearly defining the complex adaptive system (CAS), the simplistic and disordered parts that
come together to form a more cohesive policy, is necessary to deconstruct how FPDM occurs
(Berkes, 2017). I utilize Zelikow-Allison’s Conceptual Models to make sense of the complex
global health policy milieu (Zelikow & Allison, 1999). Understanding the associated governance
challenges that may be limiting the prioritization of health alongside security and economics as
high priority issues, can aid in clarifying areas of opportunity for strategically advancing the
health policy agenda. Elite interviews with participants in the PEPFAR and Global Fund policy
initiatives can aid in clarifying the governance challenges (Zuckerman, 1972).
In my research, I apply Kingdon’s Multiple Streams Framework (MSF) to foreign policy
research, as contrasted to its dominant use in domestic policy research. To advance GHD as an
applied practice (Brown et al., 2018), I present a foreign policy decision making (FPDM)
element to my research that can aid policymakers in determining where the health policy agenda
“window of opportunity” (Kingdon, 2011) is and how to shape it into a foreign policy frame.
Insights are also gained from an historical examination of the U.S. global health policy
experiences from the PEPFAR and Global Fund initiatives (Orza, 2007). When a national
problem becomes known, as in the case of the COVID-19 pandemic, it provides an opportunity
for policy issues (e.g., health) to get “elevated on the governmental agenda because they can be
seen as solutions to a pressing problem or because politicians find their sponsorship expedient”
(Kingdon, 2011, p. 172). Lessons from the case studies may clarify ways to advance the health
policy agenda during the COVID-19 pandemic.
Beyond the formulation of U.S. FPDM on health, GHD can also play a critical role in
advancing nation-to-nation connections as global governance (e.g., the WHO) is called into
15
question over its role in the pandemic outreporting and as U.S. foreign policymaking takes shape
in a post-pandemic world.
Project Significance and Contribution to Literature
The key contribution to literature that my research will fulfill is that it will advance GHD
and U.S. FPDM at a time when global health issues have emerged as a leading U.S. foreign
policy and transnational challenge. My research is unique because it incorporates a
transnational view of policy, not just a domestic lens which most literature I’ve found
chooses one or the other (domestic or global). I will also be able to contribute empirical
research content to the literature on comparative elite studies and global health diplomacy.
Health as a High Politic Issue in U.S. Foreign Policy
GHD scholars have built upon the assumption of health rising to a higher level of
importance along a continuum of high politic to low politic (Fidler, 2005). Building upon
Fidler’s (2005) work, Youde (2016) tackles the policy debate of whether global health is a ‘high
politics’ or ‘low politics’ in international relations. He defines “high politics” as “those issues
that are integral to the existential nature of the state itself” (p. 157). This definition places global
health in the same category as national security and defense. “Low politics” is defined as
“anything that is not related to national security” (p. 158). Youde (2016) concluded that the
“high politics framework does not work well for global health” because its depiction as a
“securitized issue has not succeeded in substantive policy changes by the UN Security Council”
(p. 168). Rather, Youde (2016) states that “the international community has increasingly come to
recognize the importance and merit of global health as a leading political issue” (p. 168).
The significance of this research is that it provides a new framework for conceptualizing
health in U.S. foreign policy. The framework moves away from a continuum and moves toward a
16
lifecycle approach. Additionally, the framework integrates the domestic and international
ecosystems into a transnational policy view. The timing of this research is additionally beneficial
as a contribution to literature as it can be used to transform U.S. foreign policy, strategy,
assumptions, and design on the heels of the COVID-19 pandemic. The global ecosystem is also
in flux as countries reflect on gaps in the cooperative agreements that contributed to delayed
reporting of the COVID-19 outbreak. Note: For the purpose of this research, how global health is
categorized (high or low politic) or labeled did not affect my analysis
Devising a Conceptual Framework: Explaining Transnational Global Health Policy Events
The world is amid a pandemic. Global interdependencies have been exposed, such as global
supply chain disruptions, and span the ‘high politic’ areas of economics (trade) and security
(Fidler, 2005). My research focusing on the health policy agenda framed in the NSS and its value
in U.S. foreign policy is representative of tackling a critical policy question. My goal is to create
a conceptual framework that can guide policymakers as they advance the role of global health in
U.S. foreign policy.
Teasing out the causal factors that contribute to the positioning of health within U.S. foreign
policy will help to illuminate new thinking about where health sits within transnational policy
debates. Zelikow and Allison (1999) acknowledge that the causal factors illuminated by each of
their analytic models “should inform a fundamental rethinking of national security strategy,
foreign policy, and the role of the United States (and other nations) in the post-Cold War
environment” (p. 9). Causal factors, such as unitary or collective decisions, policy choices, and
actions that reflect the dominant models-at-play, are teased out through elite interviews and
document review (Zelikow & Allison, 1999). The pandemic has catapulted the US, and the
world, into a new “era of confusion” (Zelikow & Allison, 1999, p. 9). RAND Corporation (2020)
17
established a Center for Analysis of U.S. Grand Strategy to “advance the debate on American
foreign policy by tackling key unresolved theoretical, empirical and policy questions” (para. 1).
This provides an example of the increasing interest in the U.S. grand strategy and foreign policy.
The conceptual framework produced in this research will contribute to the rethinking of how the
United States approaches the global health agenda within the NSS and overarching foreign
policy issues.
Advancing the Practice of GHD
The early 21
st
century brought global health to the forefront and is described as having
unprecedented convergence of global health and foreign policy. In 2007, global health was
identified in the Oslo Declaration as “a pressing foreign policy issue of our time” (Labonté and
Gagnon, 2010, p. 1). The 2020 COVID-19 pandemic is now an unfolding case study that depicts
the essential role that GHD plays in bilateral and multilateral nation-to-nation cooperation. This
pandemic has accelerated the interconnectedness of nation states and is intensifying the need for
clear governance, timely policy decisions, and a political lens focused on collective action.
Research by Brown et al. (2018) on health diplomats, those who practice at the intersection of
global health and foreign affairs, highlights the challenges faced in aligning U.S. diplomatic
goals with public health goals. Advancing applied GHD requires “skills in diplomacy and
negotiation, applied science, and cross-cultural competency” (Brown et al., 2018, p. 10). It
requires interdisciplinary collaboration.
Globalization, technology, and the introduction of non-state actors are driving the
increasing complexity of GHD. While GHD lacks a grounded theory, in qualitative research,
theories and models can be utilized to facilitate analysis and to further support answering the
research question or sub-questions (Creswell, 2014). I will be utilizing two frameworks in this
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research. They are Kingdon’s Multiple Streams Framework (MSF) (Kingdon, 2011) and
Zelikow-Allison’s Conceptual Models (Zelikow & Allison,1999). Kingdon’s Multiple Streams
Framework (Kingdon, 2011), coupled with Zelikow-Allison’s Models (Zelikow & Allison,
1999), are utilized to explain where health enters U.S. foreign policy and for what purpose or
value.
Kingdon’s Multiple Streams Framework (MSF) is found to have powerful theoretical and
analytical value in trying to understand how GHD themes get articulated and incorporated into a
policy window of opportunity (Kingdon, 2011). Three streams, or what Kingdon (2001)
describes as “families of processes in federal government agenda setting include “problems,
policies, and politics” (pp. 86-87). An imperative for this research is driven by the literature’s
affirmation of health moving from a “low politic to a high politic issue alongside security and
economics” (Fidler, 2005) and the timing of its relevance which have been showcased because of
the cataclysmic events unfolding due to the pandemic. Like GHD, there are a multiplicity of
actors engaged in the foreign policy formulation process. Kingdon’s (2011) works account for
the movement of actors across the three streams and builds upon the “garbage can model of
Cohen-March-Olsen” (p. 86). Kingdon’s MSF (2011) is not a predictive model. Rather, it is
useful in clarifying the circumstances that propel policy change. Gormley (2007) states that
“according to Kingdon, an agenda change depends on the emergence and ability of a ‘policy
entrepreneur’ who takes advantage of the ‘window of opportunity’ that permits reform when
these streams converge” (pp. 301-302). The political stream, according to Kingdon (2011), is a
key stream in “promoting or inhibiting a high agenda status” (p. 163). The grand strategy, the
NSS, is the highest point of statecraft and frames the foreign policy agenda for the United States.
The role that politics plays in GHD emerges in the findings in Chapter 5.
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Zelikow-Allison’s Conceptual Models, recognized for their use in analyzing the USG
foreign policy actions associated with the October 1962 Cuban Missile Crisis, serve as a
framework for understanding U.S. foreign policy decision-making and can support the data
analysis that examines my research questions (Zelikow & Allison, 1999). The models include:
Model I – The Rational Actor; Model II - Organizational Behavior; and Model III -
Governmental Politics. (Zelikow & Allison, 1999). Each model focuses on unique constituent
groups and the agenda setting and negotiations at play within each group as a foreign policy case
unfolds.
The next chapter will expand on the concepts and heuristics that have influenced modern-
day FPDM and give insight into the complexity of GHD.
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CHAPTER 2. U.S. FOREIGN POLICY AND GHD
Global health diplomacy (GHD) is an emerging practice that stands to achieve
unparalleled advances in 21
st
century global health initiatives. This systematic review of
literature will provide a baseline understanding of GHD, the trends and drivers influencing the
practice, an overview of U.S. foreign policy, and areas of opportunity for future research. The
predominant literature resource that I utilized to logically distill my research questions is “Global
Health Diplomacy: A Critical Review of Literature” (Ruckert et al., 2016). This critical and
systematic research comprehensively searched “three English-language scholarly databases
which yielded 606 articles. They retained 135 articles” (p. 27). Some of the key findings from
their research included:
• A “lack of clarity in what drives the presence of health in the foreign policy agenda” (p.
3).
• “Little academic work that has comprehensively examined and synthesized the
theorization of GHD, nor looked at why specific health concerns enter into foreign policy
discussion and agendas” (p. 61).
• “GHD lacks rigorous theorizing. GHD literature is fragmented and not clearly structured
around key issues and their theoretical explanations. The lack of a theoretical framework
to guide the multi-stakeholder environment impedes the ability to effectively measure
GHD outcomes” (p. 1).
• Collaboration with International Relations (IR) scholars is recommended because the
field of IR is rich with theoretical knowledge and analytical concepts about foreign
policy (Ruckert et al., 2016).
21
My research seeks to build upon the work of Ruckert et al. (2016) and to contribute to the
field of policy scholarship in the practice of GHD. In my own literature review, I found that
GHD continues to take shape as global events drive international cooperation, that the role it
plays in advancing the health policy agenda in U.S. foreign policy differs by political party
prioritization of diplomacy, and that its value to policymakers who reside outside of the public
health field requires translation or meaning making for it to be prioritized alongside security and
economics as a strategic resource.
In addition to the systematic review by Ruckert et al. (2016), I reviewed 206 books,
reports, articles, and other resources for this dissertation research. My review included articles
published after 2016. The key themes that I found that intersect with those by Ruckert et al.
(2016) include the role that power plays in shaping the global health agenda, the growing
complexity and number of state and non-state actors engaging in advocacy and negotiations
around global health policy, the interdependencies that globalization (as a driver) has created
across world economies, the imperative for global governance to foster nation-to-nation
collaboration, and the importance of GHD in fostering these connections. These drivers have
contributed to the complexity and evolving nature of GHD.
This chapter will cover core concepts and heuristics associated with foreign policy, such
as where it resides in literature, how it is formulated with the USG, and the role of diplomacy in
advancing foreign policy objectives. It includes an overview of IR literature since the
phenomenon of GHD draws its theoretical foundation most prominently from this genre.
Concepts and Heuristics
Neack (2014) describes the study of foreign policy as a “subdiscipline of international
relations” that at times “jumps over the fence into the subdiscipline of comparative politics” (p.
22
19). The field of foreign policy analysis (FPA) emerged in the mid-1960s (Neack, 2014, p. 19).
Foreign policy serves as a “bridge between international relations and comparative politics”
(Neack, 2014, p. 19). Feldbaum & Michaud (2010) pragmatically highlight the coupled nature of
health and foreign policy. GHD is a practice that bridges, or cuts across, international relations,
foreign policy, and comparative politics.
GHD is evolving to keep pace with the 21
st
century post-modern era. The 21
st
century is
drawing in concerns for the global public good (e.g., climate health) and foreign policy design
will need to factor this in when striving to achieve diplomatic cooperation. (Novotny et al.,
2013). Figure 2, developed by Kickbusch (2012), highlights this evolution toward polylateral
diplomacy which is described by Wiseman (2005) as “diplomacy which links the bilateral, the
multilateral, and the non-state actors in negotiations that may help reach binding goals through
better forms of global health governance (GHG)” (Novotny et al. 2013, p. 67).
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Figure 2. Evolution of the System of Diplomacy
Source: Evolution of the System of Diplomacy, Graduate Institute Geneva, 2012. PowerPoint Presentation: Global
Health Diplomacy: A New Relationship Between Health and Foreign Policy, Kickbusch (Slide 5).
Three levels of analysis emerged from an examination of foreign policy and contrast to
the IR levels of analysis. They include:
• “Individual level of analysis: a focus on individual decision-makers, how they make
decisions, their perceptions, and how they interact in groups (for example, as elite
decision-makers)” (Neack, 2014, p. 10).
• “State level of analysis: an examination of societal (ex: historical, cultural, etc.) and
governmental (type of government, division of powers) factors” (Neack, 2014, p. 10).
• “System level of analysis: an exploration of bilateral (state-to-state) relations, regional
issues and interactions, and global issues and multilateral interactions between states”
(Neack, 2014, p. 11).
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To gain an understanding of how foreign policy is operationalized in the US, it is
important to understand the foreign policy powers that are divided among the U.S. government
and who bears responsibility for it. U.S. foreign policy making powers are separated between the
Executive branch and Congress (Masters, 2017). A recent trend of “accumulated Executive
power at the expense of Congress” has been seen in recent years. “National emergencies and
times of war” were highlighted as situational examples where this trend emerged (Masters, 2017,
p. 2). The respective foreign policy making powers of the U.S. president and the U.S. Congress
are summarized in Table 1.
Table 1. U.S. Foreign Policy Powers: Congress and the President
Powers of the President Powers of Congress
Detailed in Article II of the Constitution Detailed in Article I of the Constitution
The power to make treaties and appoint
Ambassadors (advice and consent of the Senate
required)
Regulation of foreign commerce
Command of the military, use of force, and
collection of foreign intelligence
Declare war
Implicit power to acknowledge foreign
governments and engage in diplomacy
Oversight of diplomatic budgets and programs
Conduct investigations on issues relating to
foreign policy or national security
Create, eliminate, or restructure Executive Branch
Agencies
Source: Masters, 2017, pp. 1-12.
The rest of this section provides an overview of various theoretical perspectives that are
pertinent to understanding foreign policy.
International Relations Theories and Analysis
Theoretical grounding of GHD is supported by examining international relations
literature (IR). The field of IR, according to Ruckert et al. (2016), “contains a vast literature
about diplomatic processes and holds significant theoretical knowledge and analytical concepts
to better understand the emergence and formulation of foreign policy” (p. 62). Ruckert et al.
25
(2016) completed a critical review of literature and summarized the IR theories utilized to
explain GHD (p. 35). Seeking to build on IR theory while integrating public health input for
application to the field of GHD, they identified a “theoretical taxonomy to explain GHD
outcomes based on a popular categorization in IR, identifying three levels of analysis (individual,
domestic/national, and global/ international) and the driving forces for the integration of health
into foreign policy at each level” (Ruckert et al., 2016, p. 3). This taxonomy is summarized in
Table 2. Ruckert et al. (2016) labelled the table as “International Relations Theories in GHD
Literature” and utilize the format to draw distinctions between the levels of analysis from IR
theory that cut across GHD. The levels of analysis aid in explaining the goals of state action in
GHD.
Table 2. International Relations Theories in GHD Literature
Realism Constructivism Liberalism Kingdon ’s policy theory
Core beliefs of
theory
Self-interested states
compete for power in
an anarchical
international order
International politics is
shaped by collective
and individual norms
and ideas
Democracy, global
economic ties, and
international
organizations lead to
global cooperation
Foreign policy choices
reflect a convergence
between problem, policy,
and politics stream
Goal of state
action
Maximize security
and ensure state
survival
Align state actions with
collective norms and
values
Maximize
cooperation and
ensure peace
Achieve desired policy
outcomes
Level of analysis Global/International Global/International,
Domestic/National, and
Individual
Domestic/National
and
Global/International
Individual,
Domestic/National and
Global/International
Main unit of
analysis
(ontology)
States States, IOs, INGOs, and
individuals
States and IOs Individuals and domestic
policy processes
Dominant
framing of health
Security Security, development,
and human rights
Trade and
development
N/A
Driving forces of
GHD activity
State security
interests; desire for
international
influence; improve
national image
Collective norms and
values; epistemic
communities and
advocacy networks;
national reputation;
interest groups
International
organizations as
agenda-setters;
domestic interest
groups
Policy entrepreneurs that
exploit a window of
opportunity
Source: Ruckert et al., 2016, p. 35.
Neack (2014) clarifies that IR is a “subdiscipline of political science” and foreign policy
is enveloped in IR. Brief definitions of the IR theories included in Table 2 are:
26
Realism: realists assume that states are sovereign within an international system and
pursue the self-interests of individuals and nation states (Neack, 2014). A primary focus of a
realist is to maintain autonomy (Neack, 2014).
Constructivism: “a view that proposes that our understanding of world politics is a social
creation (construction)” (Neack, 2014, p. 228).
Liberalism: contrasts to realism in its assumptions (Neack, 2014). A liberalist sees the
value of collective action and networks in advancing the “rights of individual, self-determining
states and serve the collective good” (Neack, 2014, pp. 14-15).
Rosenau ’s Pre-Theory of Foreign Policy
In 1964, Rosenau identified that foreign policy analysis lacked a “general theory”
(Hudson & Day, 2020, p. 15). In his pre-theory, he sought to identify a half-step that could be
taken to identify general principles that could explain the international system at-large and the
individual activity by leaders. This required explanations that brought together various social
science sectors and an integration of knowledge that was both “multilevel and multicausal”
(Hudson & Day, 2020, p. 15). Like GHD, analysis of foreign policy requires an integration of
theories across disciplines to gain a systematic understanding of the complexities.
Rosenau sought to better understand what factors (internal and external) “intermixed” in
shaping foreign policy and to clarify “the conditions under which one predominates over the
other” (Hudson & Day, 2020, p. 194). His goal was to inform the analysis of foreign policy and
to move from the “ad-hoc cross-level integration of foreign policy explanations” (Hudson &
Day, 2020, pp. 195-196). Rosenau used a genotyping model (borrowed from the science of
genetics) to categorize variables and to determine how the modeled variables would predictably
behave or react (given a series of patterns) (Hudson and Day, 2020). Examples of the variables
27
included individual characteristics, such as personalities of leaders, and country characteristics,
such as large or small, developed or underdeveloped (Hudson and Day, 2020). Unfortunately,
this approach of integrating influencing variables into a genotype scientific model adaptation
does not result in a uniform model for application across all situations. Rather, Rosenau indicates
that “specific issue areas” can contribute to differences in how the variables integrate within his
pre-theory model (Hudson & Day, 2020, p. 195). Rosenau’s efforts to code individual behavior,
such as personalities of leaders, were directed by a desire to better understand foreign policy
decision making. The research was deemed beneficial but was viewed by some scholars as
providing insufficient understanding of how variables can shape foreign policy decisions
(Hudson & Day, 2020).
Role Theory
Campbell (2018) examined role theory and describes it as “mainly concerned with
patterns of human conduct and consists of a particular viewpoint regarding factors presumed to
be influential in governing human behavior” (p. 43). The formulation of foreign policy involves
a range of participants, coalitions, and stakeholders which are described later in this chapter. An
explanation of foreign policy decisions can consider a “US President’s belief systems, as an
independent variable, as potentially mediated by the intervening variable of the senior advisory
process” (Campbell, 2018, p. 46). This interaction between the U.S. president and his/her
advisors can shape political and policy beliefs (Campbell, 2018).
Role theory may offer an opportunity to bridge IR and foreign policy analysis (FPA)
theories (Hudson and Day, 2020) as the convergence of domestic and international policy
agendas contribute to “the emergence of shared roles” (p. 214). Role theory can be used to
examine the role of diplomatic elites who make choices on behalf of a nation state and for the
28
purpose of influencing foreign policy decision (Hudson and Day, 2020). The range of state and
non-state actors involved in regional foreign policy activities is varied such that the individual
role of diplomatic elites is not exactly replicable. This is beneficial in the study of GHD because
GHD is grounded in IR theory but operationalized within the framework of U.S. foreign policy.
Hudson and Day (2020) suggest that progress may be made through “cross-level theoretical
integration through the study of role theory and FPDM” (p. 214).
Role theory literature reflects a lack of consensus on the defining terms such as the
meaning of “role” or “role conflict” (Campbell, 2018, p. 52). With the increase in transnational
policy issues, Campbell (2018) suggests that there is additional room for scholarly research on
senior advisory roles and role conflicts that can emerge between senior advisors (e.g., National
Security Agency (NSA) and the Secretary of State). Each of these advisors has importance in the
cases analyzed in this dissertation.
Lasswell ’s Decision-Making Theory
Harold Lasswell’s work on decision-making (1956) has been applied to the practice areas
of transnational and international policy (Balla et al., 2015). An important feature of Lasswell’s
work focused on the role that politics played in determining “who gets what, when, how” (Balla
et al., 2015, p. 56). Time is a critical element in Lasswell’s model that I have not found in other
models. He acknowledges that time can contribute positively to strengthening the level of trust
and cooperation among actors as they get to know one another, “adjust their behavior and build
relevant alliances founded in common interests (Balla et al., 2015, pp. 59-60). Trusted
relationships established over time played a critical role in the interactions between Champions
and Leaders in Chapter 5, Findings.
29
Lasswell identified seven stages in the decision-making process. As summarized by Balla
et al. (2015, pp. 57-58), these include:
• Intelligence: a collection of information and data.
• Promotion: policy alternatives are identified and offered by individuals involved in the
decision-making or policy promotion process.
• Prescription: a set of rules that govern the process of reconciling conflicting points of
view are adopted to assist in formulating recommendations.
• Invocation: the expected and desired behavior of participants in the decision-making
process is a type of regulation applied to promote behavioral compliance.
• Application: all actors involved in the process (the ones governing the process and those
participating in the process) comply with rules of decision-making (a suggestion that
those overseeing processes could informally act to influence decision-making).
• Appraisal: an assessment of the successes and failures is undertaken to determine if
decisions led to the expected outcomes.
• Termination: allows for strategies in decision-making to be modified or replaced and may
also provide an opportunity to revisit the beginning of a decision-making and policy
cycle.
Lasswell’s model has been applied to foreign policy decision-making because of its focus
across disciplinary boundaries, even though it has received criticism for utilizing an approach
that assumes linear policymaking versus the more complex, random unfolding that occurs (Walt,
2008). With the expanding influence of globalization, his work has been cited when examining
global governance, rules influencing the behaviors of state and non-state actors in international
policy issues, and the role that law and power play in policy making. Most importantly, his work
30
identified the role that time plays in influencing decision-making events. He sought to use his
work to “influence and promote human dignity” (Balla et al., 2015, p. 64). Looking back at
Lasswell’s historical work provides an opportunity to use history, another period in time, as an
informant in foreign policy decision making (FPDM).
Rational Choice Theory
Rational Choice Theory is useful in situations where there is desire to make sense of a
complex puzzle, such as a nation state’s contemplation of foreign policy issues, and to identify
the causal mechanisms that contribute to the outcome (Keohane, 2002). “A rational choice
theory tells us what we ought to do in order to achieve our aims as well as possible. It does not,
in the standard version, tell us what our aims ought to be. A rational choice theory can be viewed
as a theory of advice that informs individuals or, potentially, collectivities of individuals, about
how best to achieve objectives whatever these may be. In this normative role, a theory must treat
all individuals as attempting to be rational” (Ostrum, 1991, p. 238). GHD involves a series of
complex interactions with a multiplicity of actors, domestic and international and rational choice
theory may be useful in explaining the narrative that contributes to understanding “why” or
“how” a particular or action was chosen over another. (Keohane, 2002, p. S311).
Keohane (2002) states that “rational choice theory is valuable in at least five ways: (1) as
a basis for skeptical interpretations of talk and action; (2) as a menu of causal mechanisms; (3) as
an explanatory device for helping to resolve specific puzzles; (4) as part—but only part—of an
explanation of legal and political phenomena; and (5) as the basis for generating further puzzles
for research. It can contribute to a better understanding of social behavior of actors engaging in
complex foreign policy initiatives” (p. S310).
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Garbage Can Model
The Garbage Can Model (GCM) emerged from the interdisciplinary work of James
March, Michael Cohen, and Johan Olsen. The focus of their collaboration centered on social
institutions and an examination of organizational theories (Jann, 2015). The output of their work
resulted in the development of “a model for describing decision making within organized
anarchies, and the impact of some aspects of organizational structure on the process of choice
within such a model” (Cohen et al., 1972, p. 2). Organizational decision-making is
“characterized by three main properties: problematic preferences, unclear technologies, and fluid
participation” (Balla et al., 2015, p. 302). Decisions emerge after organizations have examined
their range of options, measured against desired goals, and arriving at the decision that the
decision-makers feel is the best choice (Balla et al., 2015). The decision becomes the output from
the garbage can model resulting from inputs that were generated from four independent streams
(Cohen et al., 1972). The four streams include: “problems (issues of importance to the people
inside or outside of the organization); solutions (the answer to a problem); participants (those
who enter and exit the streams deposit choices); and choice opportunities (the moments when
organizations have occasions to make decisions)” (Balla et al., 2015, p. 302). This model laid the
foundation for Kingdon’s Multiple Streams Framework (MSF).
Almond ’s Input-Output Framework Analysis
Almond (1965) is identified as one of the first researchers to propose an input-output
framework as a tool for analyzing foreign policy (Brecher et al., 1969). Almond explores the
political environment as a system of activities. “Legitimate force is the thread that runs through
the inputs and outputs of the political system, giving it its special quality and salience and its
coherence as a system. The inputs into the political system are all in some way related to claims
32
for the employment of legitimate physical compulsion, whether these are demands for war or for
recreational facilities. The outputs of the political system are also all in some way related to
legitimate physical compulsion, however remote the relationship may be” (Almond, 1965, p.
192). Inputs and outputs are defined as “interactions which affect the use or threat of use of
physical coercions” (Almond, 1965, p. 192). The elites in the political system have influence
over choices within the system, along with all other actors who are engaging and working to
influence the political system (Almond, 1965). He clarifies that the term “physical coercions”
does not refer to means of force as it could also mean peace, diplomacy, or whatever is of
interest to the political elite (Almond, 1965, p. 191-192). The political system is likened to the
engine of a car. When something new is added to the system, it needs to be “broken in”
(Almond, 1965, p. 190). He specifically listed “diplomats” in this category. The ability for this
new input to be able to produce outputs relies on socialization within the system, time, and
politics (Almond, 1965, p. 190).
Middle Powers: Political and Diplomatic Issues
The role of middle power countries is relevant to the discussion of GHD and the
changing global landscape of the powers of nation states. Jordaan (2003) defines middle powers
in two distinct categories: “traditional middle powers are stable social democracies, whereas
democracy in emerging middle powers is often far from consolidated, and in many cases only
recently established, with undemocratic practices still abounding (ex: human rights violations)”
(p. 171). The period of the Cold War saw traditional middle powers rise to prominence, whereas
the class of emerging middle powers became more prominent within the global arena after the
Cold War (Jordaan, 2003). The significance of this evolution in the middle powers as global
influencers is that it represented a shift toward the importance of economic issues and away from
33
a “military and strategic concern in foreign policy” evident in the Cold War era (Jordaan, 2003,
p. 171).
Democratic principles may not be uniform across all middle power democracies. This can
present challenges in both the political and diplomatic areas of practice. When negotiating
foreign policy, the middle power democracies (stable or less well-defined) have risen in
prominence and will play a role in the ongoing discussions about global health.
The Evolution of GHD
The evolution of GHD is best summarized in an historical accounting by Dr. Ilona
Kickbusch, in the chapter “21
st
Century Health Diplomacy: A New Relationship Between
Foreign Policy and Health” (Novotny, Kickbusch, & Told (Eds.). (2013). Reflecting on a 2009
UN General Assembly Resolution (63/33), entitled “Global Health and Foreign Policy”,
Kickbusch describes that “it is only within the past decade that the technical areas of global
health have been explicitly linked to the sphere of diplomacy” (p. 2). UN General Assembly
Resolution (63/33) was adopted on November 26, 2008 and (in its declarations) formally
acknowledged the linkages between global health and foreign policy. Collective action to
address pressing global health issues was emphasized by highlighting the development of the
Millennium Development Goals (MDGs) which have now been replaced by Sustainable
Development Goals (SDGs) (United Nations General Assembly, 2009). The world has become
more interconnected since the origins of health diplomacy dating back to the 19
th
century
(Novotny et al., 2013).
In the 21
st
Century, Kickbusch describes “three parallel power shifts” (Novotny et al.,
2013, pp. 26-32) that characterize this period of rapid change and are contributing to the changes
34
in diplomacy, global health, and the associated “rules, norms, and expectations” (Novotny et al.,
2013, p. 26). They include:
• Shifting power between nations. “As more and more countries learn to take advantage of
the decision-making and political power of international platforms, multilateral
organizations gain new strength” (Novotny et al., 2013, p. 27).
• Shifts of power beyond nations. “The increased importance of global health has captured
the growing interest among philanthropic foundations, advocacy networks, think tanks,
and academic institutions” (Novotny et al., 2013, p. 29). This enables power outside of
the nation state that can influence changes in global health (Novotny et al., 2013).
• Shifting power within nations. The transnational nature of global health will require
politicians to balance foreign policy decision-making between issues abroad with issues
“at home” (Novotny et al., 2013, p. 31). We are seeing this play out during the pandemic
of 2020 as this global health incident disrupts supply chains, wreaks havoc on economic
markets, and forges new allies and shifts in global power centers.
International Relations (IR) literature provides a wealth of information about diplomacy and
its processes, theoretical insights, and analytical concepts. However, GHD lacks a consistent
analytical framework to measure its effectiveness, and the complexity of the global ecosystem
will add to this challenge. An interdisciplinary lens offers opportunities to gain insight into the
theoretical underpinnings of GHD, but gaps remain.
Additional research is needed to understand the influence that health diplomacy is having
on foreign policy development (Ruckert et al., 2016). Kickbusch suggests that the stance taken
by the United Nations emphasizes a “relationship between health and foreign policy in the 21
st

Century and the dynamic role of diplomacy in supporting health” (Novotny et al., 2013, p. 33).
35
This “new stage of institutionalism of global health” (Novotny et al., 2013, p. 33) should move in
the direction of “health becoming an integral part of foreign policy” (Novotny et al., 2013, p.
33). In the sections that follow, I will build upon these themes and examine opportunities to
advance the health policy agenda within U.S. foreign policy.
GHD Definitions
GHD does not reside in any one domain of practice. To conduct a thorough literature
review, it was necessary to search a range of terms beyond GHD. These included: health
diplomacy, global health, and applied diplomacy. The definitions of GHD, and associated
research, appear to be shaped by the professional domain from which the researcher resides
(security/economic, public health, health policy) (Ruckert et al., 2016). This leads to
inconsistencies when tracing across literatures. An examination of definitions of GHD provides a
glimpse into the diversity of language used to describe what GHD is. The complexity of GHD
necessitates that definitions also include a mention of the participants who are engaged in the
process. Prominent definitions from GHD literature include those in Table 3.
Table 3. GHD Definitions
Author(s) GHD Definition
Kickbusch et al.
(2007)
“Diplomacy is referred to as the art and practice of conducting
negotiations. GHD aims to capture these multi-level, multi-actor
negotiation processes that shape and manage the global policy
environment for health” (p. 230).
Smith, Fidler &
Lee (2010)
“Policy-shaping processes through which States, intergovernmental
organizations, and non-State actors negotiate health responses to health
challenges or utilize health concepts or mechanisms in policy-shaping
and negotiation strategies to achieve other political, economic, or social
objectives” (p. 7).
Michaud &
Kates (2013)
“International diplomatic activities that (directly or indirectly) address
issues of global health importance and are concerned with how and why
global health issues play out in a foreign policy context” (p. 24).
Labonté &
Gagnon (2010)
“The processes by which state and non-state actors engage to position
health issues more prominently in foreign policy decision-making” (p. 1).
36
Ruckert et al.
(2016)
“GHD describes the practices by which governments and non-state actors
attempt to coordinate and orchestrate global policy solutions to improve
global health” (p. 1).
Over time, the definitions have become progressively defined, to include the addition of
state and non-state actors engaged in global health. The inclusion of these actors adds to the
complexity in the practice of GHD as it reflects the expanding variables which require
consideration in the practice of negotiation. While policy outcomes benefit from a unifying
definition and a well-defined framework to shape the practice, Michaud and Kates (2013) point
out there is “little agreement on how to define global health diplomacy. Global health and
foreign policy practitioners would benefit from working more closely together” (p. 24). The
value of this collaboration may enhance how health is interpreted as a national security priority.
Interdisciplinary coordination around how health is used as a soft power in GHD may strengthen
GHD practitioner’s insights in navigating a more complex and dynamic global health ecosystem.
This research gap contributed to my research focus on GHD and U.S. foreign policy decision
making (FPDM). Observations regarding the above definitions are provided below.
Kickbusch et al. (2007) conceptualize GHD within a global health arena by defining it as
an art and a science. Within the global ecosystem, there are a range of stakeholders who engage
in negotiations relating to health and other topics of international interest. These “multi-level and
multi-actor negotiation processes” contribute to how global health is shaped and managed within
international agreements (Kickbusch et al., 2007, p. 230).
The Smith, Fidler and Lee (2010) definition of GHD reflects the negotiating that is
necessary to create policy in an executive policy-making body such as the U.S. Congress. As an
advantage, I believe that they have presented a modern view of GHD and incorporated the
competing policy priorities that Congressional members weigh and balance in agenda setting and
negotiations. Each participant potentially brings their own unique priorities to the discussion and
37
different agendas relating to politics, economics, or broader social objectives. The political,
social, and economic elements must be considered in the policy-making process. These elements
also reflect the expanding complexity of GHD that is confirmed in literature.
Smith, Fidler and Lee (2010), in choosing this definition, identified three important
characteristics of GHD. They include:
• “Global refers not only to geographical meaning, but the range of actors involved” (p. 7).
• “Health draws attention to problems that involve the protection or promotion of
population health, arising either as: (i) a direct threat to human health; (ii) an indirect
threat to health; or (iii) unrelated to health but stimulating a health-related response” (p.
7).
• “Diplomacy refers to processes in which all actors interact articulating, advocating for,
and defending their interests. Diplomacy is not an end; it is a means to an end” (p. 7).
Labonté and Gagnon (2010) provide a broad definition of GHD which is adaptable to any
nuances that may arise in trying to define GHD more narrowly (e.g., by trying to list all of the
participants of state or non-state actors). One advantage is its specificity to foreign policy which,
in today’s world, may accommodate a transnational (domestic and international policy) lens.
Michaud and Kates (2013) encourage collaboration between health and foreign policy
practitioners when engaging in international diplomacy. They identify a driving force behind this
recommendation which stems from an increase in interdisciplinary linkages between “health and
other areas such as international trade and intellectual property rights, agriculture, education, and
the environment” (p. 25). The increasing complexity of the global ecosystem, comprised of state
and non-state actors, necessitates interdisciplinary collaboration to gain a full grasp of the
38
nuanced issues and to devise meaningful policy solutions (e.g., climate health and its impact on
humans, the environment, etc.).
The Ruckert et al. (2016) definition of GHD showcases the active voice that is necessary
in diplomatic engagement. GHD requires adaptable practices that are shaped appropriately to the
policy priority. This varies in each circumstance as the state and non-state actors, drivers and
incentives, etc. are unique to each policy event. Ruckert et al. (2016) provide a specific example
of an opportunity for collaboration on GHD projects where the research relies upon “an
enhanced transdisciplinary and trans-theoretical research design in GHD” (p. 17). Scholarly
collaboration should focus on advancing change in the process of GHD.
The diversity in definitions associated with GHD highlights a complex phenomenon.
Although it isn’t defined uniformly, it can be described through varying disciplinary lenses
depending upon the nature and complexity of its use in foreign policy.
Current Trends
GHD can be constructed theoretically utilizing the international relations (IR) levels of
analysis. There are three levels of analysis, including the international/global level, the
national/domestic level, and the individual level. Each level is explained in further detail as
follows.
International/global and multilateral level: In foreign policy, this is the “dominant level”
(Ruckert et al., 2016). According to Ruckert et al. (2016), this level of analysis aids in a deeper
understanding of what influences “health and outcomes from GHD negotiations” (p. 6). This
level of analysis helps to explain the framing of health as a security threat. An example of this
was the HIV/AIDS pandemic that was viewed as both a global health and a security threat
(Ruckert et al., 2016).
39
National/domestic level: This level of analysis is the second most prevalent (Ruckert et
al., 2016). The composition of interested parties in this level includes interest groups,
associations, think-tanks, and non-governmental organizations. According to Ruckert et al.
(2016), the “policy focus is becoming increasingly ‘intermestic’ – international and domestic” (p.
11); in other words, transnational.
A think tank focused on global health issues, for example, the Nuffield Trust, United
Kingdom (UK), as an interested party, played a role in influencing a nation state on its policy
position on health. Policymakers in the UK engaged around the issue of globalization and health
where the Nuffield Trust exerted its influence on government through consultation and lobbying
(Ruckert et al., 2016, p. 8). This level of analysis is not reflected in the fact that a non-
governmental organization was involved, but in the fact that the dynamics of the engagement
took place at the national level.
Individual level: This is the least referenced level, as little scholarly research has been
devoted to it. The emergence of celebrities as advocates for policy positions on global health
issues are giving rise to its prominence (Ruckert et al., 2016). The list of those who have engaged
around health causes include political leaders, actors, singers, and other recognizable
personalities. Bill and Melinda Gates established the Gates Foundation and have prioritized
global health issues and poverty eradication (Ruckert et al., 2016, p. 3). The list of causes they
have supported can be located at www.gatesfoundation.org. Another visible figure on the global
stage is the singer, Bono. His public engagement in disaster relief was highlighted in the
documentary, Poverty, Inc.
Figure 3 pictorializes the relationship between, and interconnectedness among, the three
levels of analysis in international relations.
40
Figure 3. Levels of Analysis in International Relations
Source: Mingst, 2008.
Kickbusch et al. (2007) describe “global health diplomacy as a field in the making” (p.
3). As the levels of analysis expanded to include national/domestic and individual, the role of
NGOs, non-state actors, and organizations (lobbying, private interests) emerged. The role of
power, politics, and international cooperation have contributed to the complexity and types of
driving forces impacting GHD (Ruckert et al., 2016, p. 30-34).
As an emerging field of practice, global health diplomacy addresses the dual goals of
improving global health and bettering international relations (Adams, Novotny & Leslie, 2008).
The demand in practice is being driven by global health financing, which has increased
dramatically in recent years (Labonté & Gagnon, 2010). This trend in increased financing also
41
reflects the growing engagement and influence of non-state actors. As actors, agencies, and
stakeholders expand, the complexity in GHD grows.
Global health issues garner attention by the nation state when they are accompanied by a
security element. According to Labonté and Gagnon (2010), “health has risen as a foreign policy
issue that needs to be addressed through traditional approaches. It does not transform thinking, is
not an overriding norm, and has risen as a foreign policy issue only because it threatens high
politics of national security and material interest” (p. 15). When health and security are partnered
as an issue of strategic importance, this can elevate health to a higher level of political
importance.
Health is a foreign policy issue, but it is not uniformly elevated alongside security and
economics because it arises to a policy level in different ways. Fidler is cited by Labonté and
Gagnon (2010) for his three “conceptualizations to clarify global health’s recent rise in foreign
policy prominence: revolution, remediation, and regression.
• Revolution argues that health’s increasing role in foreign policy is transformative of the
health-foreign policy nexus.
• Remediation asserts that health’s rise as a foreign policy issue reflects the continued
reality of the traditional hierarchy of foreign policy functions.
• Regression views health’s integration into foreign policy as an indicator that health
problems are getting worse” (p. 15).
They argue that “increased attention paid to health across the functions of foreign policy
signifies a failure of public health efforts and a short-term need for some improvement to simply
‘stay the course’” (Labonté & Gagnon, 2010, p. 15). Health problems hit a global scale with the
42
2020 COVID-19 pandemic which suggests, utilizing the conceptualizations above, that there is a
forthcoming rise in the importance of foreign policy decision-making relating to global health.
GHD is “increasingly establishing itself as a key component of mainstream foreign
affairs, with its own institutions, researchers, and policies. GHD is now widely used and is
described in different categories as core diplomacy, multi-stakeholder diplomacy, and informal
diplomacy. Its relevance to soft power, security, policy, trade agreements, environmental and
development policy are driving foreign minister engagement” (Matlin & Kickbusch, 2017:
p. 3-4). Interdisciplinary literature on GHD also includes global health law, and global health
financing. Global health law is identified as a relatively new field in academia that is
“developing an international structure based on the world as a community, not just a collection of
nation-states” (Ruger, 2008, p. 424). The rule of law is essential to effective policymaking.
As globalization drives the need for communities to cooperate, principles of social justice
are needed to guide the complexity of nation-to-nation negotiations. Principles can serve as a
baseline. Complexity refers to the interplay of the differing legal frameworks that govern
individual and collective nation states. Health equity, for example, may not be uniformly defined
nor displayed in individual government’s policies. Principles, developed through international
cooperation, can aid in developing such a framework.
The importance of equitable and ethical policies in global health are evident as the United
States grapples with how to distribute the COVID-19 vaccine in 2020. These policy
conversations focus on how to achieve moral good while overcoming political, strategic, and
financial barriers. Ruger (2008, p. 35) introduces a moral and ethical theory of global health that
includes “provincial globalism (PG) and shared health governance (SHG)” to examine reasoning
associated with “health inequalities, externalities, and cross border issues that are morally
43
troubling.” These are issues that have also emerged in U.S. politics relating to immigration and
our bordering countries. No policy resolution has been achieved.
Global health emerges as a transnational, diplomatic cooperation tool. Ruckert et al.
(2016) concur with this finding and recommend including IR scholars in GHD research to
“generate enhanced trans-disciplinary and trans-theoretical research design in GHD” (p. 66). The
value of interdisciplinary research in GHD scholarly works has been that it captures a wide
frame of progress that is being made to advance GHD as a practice. This is a result of non-
governmental stakeholders infusing financing into the global ecosystem to eradicate disease and
improve the health and well-being of those most at-risk or vulnerable. The pandemic of 2020 has
accelerated a focus on global health, and I anticipate that we will see evidence of this with a
growing body of literature relating to global health and international relations.
Current Drivers
There are four drivers of GHD that emerged in the literature. They include globalization,
health coupled with foreign policy, security, and economics. I’ve focused on these four due to
their relevance to the post-Cold War contemplations in the U.S. NSS and because of the
inclusion of security and economics in the global health high-politic/low-politic continuum
debate (Youde, 2016). Each driver is explained in more detail in the sections that follow.
Globalization
Globalization is drawing the US, as a superpower, further into the global ecosystem and
onto the world stage (Kugler, 2006). Beeson and Higgott (2005) define globalization as a
“process of enhanced global economic integration via the progressive liberalisation of trade, the
deregulation of finance, the privatisation of assets, and the hollowing out of state activities” (p.
1176). The U.S. hegemonic state post World War II, as a world superpower, shaped how the
44
United States engaged globally. Its ability to unilaterally apply its power also gave it leverage in
shaping foreign policy in areas of economics and securitization of trade (Beeson & Higgott,
2005). The United States was able to engage in the international environment “indirectly,
ideationally, institutionally and at a distance” (Beeson & Higgott, 2005, p. 1176). The events of
September 11, 2001, also referred to as 9/11, changed U.S. strategy on how it engaged globally.
“It is in this context that the unilateral application of US power and the re-securitisation of US
economic foreign policy is to be understood” (Beeson & Higgott, 2005, p. 1176).
The events following 9/11, under the leadership of President George W. Bush, put the
United States at the center of the global stage and drove change in how the United States
strategically approached foreign policy issues. It led to a “unilateral application of US power, a
self-conscious linking of formerly discrete strategic and economic issues, and the general
securitisation of foreign policy. Because foreign economic policy under Bush has come to be
articulated in the language of security, the distinction between high politics and low politics is
disappearing” (Beeson & Higgott, 2005, p. 1180). Expanding globalization necessitates that the
United States also design a relevant transnational grand strategy. Defeating communism used to
be a key driver in the grand strategy during the Cold War era. Post-Cold War, the United States
more broadly focuses on three functions: “First, it acts as a leader of the democratic community
and its system of alliances. Second, it acts as an architect of global and regional security affairs
for the purpose of containing new-era dangers and threats in unstable regions. Third, it acts as a
global developer, seeking to enlarge the world economy, reduce poverty in poor regions, and
promote democratization. leading democracy and a system of alliances” (p. 87). The events of
9/11 acted as a catalyst toward shaping U.S. foreign policy which, in turn, frames how global
health diplomacy is leveraged in the 21
st
century.
45
Globalization and technology are accelerating the connections across stakeholders. In a
globalized world, policymaking becomes more complex, global capital spreads across a world
economy, and “foreign policies become subject to growing domestic pressures” (UN Secretariat,
6 April 2000, p. 1-2). As the roles of NGOs, non-state actors, and organizations (lobbying,
private interests) expand, the role of power and politics will contribute to greater complexity in
the influencing factors on GHD (Ruckert et al., 2016). These networks, formal and informal,
contribute to advocacy, information sharing, and influence. Maor (2020) examines how products
of one “policy bubble”, or the origin of an issue in one policy domain, can be spread to other
policy domains (p. 14) The active shaping of policy results from the role of policy entrepreneurs
across multiple domains. Globalization has facilitated this connectivity.
Globalization is also driving the interface between competing national priorities and
driving U.S. strategic considerations about how to engage globally. It has presented “practical
challenges and ethical dilemmas” (Patrick, 2003, p. 37). Tools of diplomacy feature different
approaches to implementing policy and can be used to position policy outcomes. The tools
include hard power diplomacy and soft power diplomacy. Hard power is generally associated
with tangible, material resources, i.e., “coercion and payment” (Nye, 2009, p. 160). “Soft power”
relates to intangible resources, such as “culture, values, and perceived legitimacy of policies”
(Nye, 2009, p. 161). Each option Nye (2009) concludes by suggesting the greater value in the
USs use of power is to focus on “smart power” which leverages a “combination of hard and soft
power” to achieve policy objectives (p. 162).
Fidler acknowledges that “experts in foreign policy and international relations have
frequently discussed the existence of a hierarchy of objectives for foreign policy, often described
as the categories of ‘high politics’ and ‘low politics’’ (p. 3). Table 4 identifies the hierarchical
46
functions in foreign policy with the purpose of showing how countries establish priorities within
foreign policy (Fidler, 2005).
Table 4. Health and Foreign Policy’s Four Functions
Material interests National security High politics
Economic interests
Development
Normative values Human dignity Low politics
Source: Fidler, 2005, p. 3.
Resources that contribute to security and economic interests are depicted as those that
raise the attention on global health in foreign policy to a ‘high politics’ level (Fidler, 2005).
‘High politics’ is distinguished by Ruckert et al. (2016) as “security, economic growth, etc.”
whereas ‘low politics’ is described as “the environment, health, etc.” (p. 66). ‘High politics’
connotes higher priority than ‘low politics’. Youde (2016) states that “‘high politics’ is a poor
framework for understanding the international community’s responses to the challenges posed by
transnational health issues like HIV/AIDS, tuberculosis, malaria, and Ebola” (p. 168). This
presents a gap in research where a new conceptual framework for health in U.S. foreign policy
can be of value. I have developed a framework to build upon past works in this area.
For this dissertation research, health is assumed to be a ‘high politic’ priority alongside
security and economics within the realm of U.S. foreign policy discussions. The pandemic of
2020 has catapulted it to that level. Using a time horizon, it will take work by policymakers to
sustain it as a policy priority.
Health and Foreign Policy
Health in foreign policy has traditionally been viewed as a ‘low politic’ issue, and in the
IR literature, research has debated whether GHD should be framed as ‘low’ or ‘high’ politic
47
(Labonté & Gagnon, 2010). Labonté and Gagnon (2010) explain that GHD has risen as a foreign
policy issue and contributes to economic growth. Rising to a level of ‘high politic’ within the
context of foreign policy is often coupled with a “securitization of health” (Labonté & Gagnon,
2010, p. 17). This means that an accompanying security concern acts as a companion in raising
the interest in health as a national priority. This can lead to a country’s national security strategy
weighing and measuring a health policy issue alongside other traditionally ‘high politic’ issues
(economic interests and national security) (Labonté & Gagnon, 2010). Most GHD research
focuses on its use in advancing foreign policy (Lee & Smith, 2011). However, the principles,
ideology, grounded theory, and framework for why we engage with health as a U.S. foreign
policy priority are not well-defined. Strategically positioning health as a higher priority presents
a window of policy opportunity.
Labonté and Gagnon (2010) found that in a “summary of key arguments for including
health in foreign policy, six (6) categories emerged. The six categories are security, global public
goods, development, trade, human rights, and moral/ethical reasoning” (p. 15). A summary of
these arguments is provided in Table 5. While the table provides for a categorization, or topical
themes of situations where global health can be employed, it does not provide a synthesized
framework for the statecraft of GHD such that it informs the practitioner how to apply health
uniformly in U.S. foreign policy (Novotny et al., 2013). As Ruckert et al. (2016) concluded in
their critical review of literature, the policy-shaping process is driven by the different rationales
depending on the desired goal (political, economic, or social objectives). The six policy frames
in Table 5 offer differing viewpoints of policy depending upon which lens is being used. These
differences contribute to how “foreign policy is being conceptualized” and which “arguments
48
prevail in actual state decision-making” (Labonté & Gagnon, 2010, p. 1). Opportunities exist to
establish a framework to explain why health enters foreign policy.
Table 5. “Globalization and Health,” Labonté & Gagnon (2010)
Security gives global health interventions greater
traction across a range of political classes than a
rights-based argument alone. To the extent that
this strengthens a base of public health expansion,
securitization of health may be a prerequisite to its
eventual de-securitization. But vigilance is needed
to avoid national security from trumping human
security.
Trade can improve health through global market
integration, economic growth and positive health
externalities. However, present trade rules skew
benefits towards more economically and
politically powerful countries; and evidence of
negative health externalities demands careful a
priori assessments of trade treaties for their
health, development and human rights
implications.
‘Global public goods ’ provides a language by
which economists of one market persuasion, or a
public good that can be traded for value, can
convince economists of another that there is a
sound rationale for a system of shared global
financing and regulation.
Human rights, though weak in global
enforcement, has advocacy traction and legal
potential within national boundaries. Such rights
do not resolve embedded tensions between the
individual and the collective, an issue to which
human rights experts are now attending.
Development remains the invitation to global
governance debates. It provides a seat at the table.
Risks inherent in its ‘investing in health’
instrumentalism can be tempered by continuously
reminding decision makers to distinguish which
one is the objective (human development) and
which one the tool (economic growth).
Moral/ethical reasoning is suggested as a
necessary addendum to the legalistic nature of
human rights treaties. This need, in turn, has
created scholarly momentum to articulate more
rigorous argument for a global health ethic based
on moral reasoning. Competitors for such an ethic
range from a liberal theory of assistive duties
based on ‘burdened societies’ in need, to
cosmopolitan arguments that emphasize minimum
capabilities needed for people to lead valued lives,
to more recent arguments for a new ethic of
relational justice based on cosmopolitan and
human rights theories. “
Brown et al. (2018), in their research on GHD, surveyed health attaches located at U.S.
embassies. The findings from the research revealed that for “GHD to continue growing in the
future, GHD practitioners must be able to balance public health and foreign affairs goals and
objectives and find strategic areas of overlap and convergence” (Brown et al., 2018, p. 9).
Practitioners in public health and foreign affairs prepare for their fields of practice through
different paths and with different competencies (Brown, Bergmann, Mackey, Eichbaum,
McDougal, Novotny, 2016). Yet, the practice of GHD necessitates intersecting paths between
49
these two domains. These differences have led to “tension between the fields of public health and
foreign affairs” (Brown et al., 2018, p. 9). The differing views of health as a foreign policy
priority between the disciplines contributes to the cycles of complacency described in Chapter 5
in this research.
Advancing the U.S. health policy agenda relies upon the role of diplomats and health
attaches at U.S. embassies abroad. Brown et al. (2016) developed a competency model that can
be utilized to strengthen the interoperative relationship between public health and foreign policy
and advance the effectiveness of GHD. Novotny et al. (2013) clarify the evolving role of
diplomats in the 21
st
Century and have suggested that a “new mindset” is needed that “accepts
the diplomatic corps’ double responsibility: that for one’s own country and that for the global
community” (p. 33). This has implications for how health and foreign policy are conceptualized
and organized within the U.S. government into the future.
Security
When health is presented as a security risk, it can compel a nation state to incorporate
health as a strategic priority. The “securitization of health” (Labonté & Gagnon, 2010, p. 3) was
a predominant theme in document reviews in this study leading to the observation that it is a
trend in “21
st
century public health governance” (Labonté & Gagnon, 2010, p. 3). However,
Youde (2016) suggests that securitizing health has led to inconsistencies in the ‘high politic’
movement of health along a continuum. The inconsistencies result from the dependency on
actors who present the health issue and the accompanying narrative that is used to support or
detract from the rationale that led to its positioning as a high politic issue. (Youde, 2016). The
pandemic of 2020 has reinforced that politicians and policymakers are influenced by narratives
that accompany global health events in transnational policymaking. Youde (2016) amplifies this
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point by clarifying that the framing of a policy issue (e.g., high or low politics) can impact how it
is acted upon by politicians and policymakers. (Youde, 2016). More information about the
securitization of health is described in Chapter 5.
Three rationales for linking health and security were offered by Labonté and Gagnon
(2010). They include:
• “conflict prevention” which focuses on “health as a bridge for peace”.
• “international humanitarian law” which offers a framework within which the rule of law
governs combatants; and
• “fear of disease pandemics” which has historically led to opportunities for chaos and
security risks.
Youde (2016) addresses this issue from a different perspective. He states that “successful
securitization requires three elements: (1) a securitizing actor who attempts to make (2) a referent
object into a security issue and convinces (3) an audience to accept that the referent object does
indeed constitute an existential concern to the state” (p. 161). In these contrasting examples of
the securitization of health, these elements can inform the work of a GHD practitioner or
Diplomat in advancing a health policy agenda and constructing a compelling case for action.
We are living through a pandemic during this time. It has disrupted the daily practices of
civil society, destabilized world economies, and threatened political power in the U.S. and
abroad. Labonté and Gagnon (2010) reflected upon the “HIV/AIDS” epidemic in Africa and the
associated “evidence linking conflict and disease” (p. 3). They offer three key rationales are
listed for foreign policy intervention when epidemics arise in foreign states (Labonté & Gagnon,
2010, p. 3). They are:
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• National conflicts that are associated with epidemics can turn into regional conflicts;
containment is key.
• Poverty associated with the epidemic can result in an opportunistic ecosystem for terrorist
activity.
• U.S. citizens serving in the military or working abroad can become threatened resulting
in additional costs to ensure protection, continue to carry out peacekeeping missions, and
may impact economic stability.
Global health risks can rise to the level of the U.S. National Security Strategy (NSS)
(Labonté & Gagnon, 2010). According to McInnes and Roemer-Maeler (2017), “global health
issues, and especially risks from disease outbreaks, have risen ever higher on the international
political agenda in the last two decades. The harbinger for this change was the emergence in the
1980s of HIV/AIDS, a novel communicable disease which at its height led to the deaths of more
than 2 million people a year and threatened the stability of states and the security of regions” (p.
1316). “Attention to health as a national security concern increased after the terrorist attacks of
11 September 2001 and the subsequent discovery of anthrax spores in letters to U.S. politicians
and media” (McInnes, 2009, p. 44). Youde (2016) discusses the role that the public plays in
accepting policy efforts to frame a health issue as a security threat. Congressional members
balance decision-making and voting based on political risk. Political risk can be described as a
risk that is measured based on the potential to align or misalign to the views of their constituents
(Kingdon, 1989). The role of constituents (the general public-at-large) represents the growing list
of interested stakeholders that Congress must consider on issues pertaining to global health. As
we’ve witnessed during the 2020 pandemic, health is not just a foreign policy issue but a
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domestic policy issue which bears a more visible risk to Congressional members as constituents
focus on how votes will affect their lives directly.
Economics
Global health threats can disrupt economies, destabilize regions, and contribute to
vulnerabilities in global security. The 2020 pandemic caused by COVID-19 showcased
global and regional resource allocation challenges that emerge during global health threat
events. Supply chains were disrupted as consumers scrambled to acquire the basic supplies.
Unemployment skyrocketed as communities sheltered in place. The worldwide economy
came to a screeching halt. Trade and travel disruptions drove global economic risk. There
was a surplus of oil without sufficient storage capacity. Economies that relied on oil as their
wealth-producing capital saw gas prices plummet. Global economic interdependencies were
magnified.
Figure 4 represents the U.S. global health funding from FY 2006-FY 2021. In
general, U.S. global health funding continues to trend upward. These figures do not
represent the additional funding provided by Congress in 2020 COVID pandemic relief bills
(also known as the Coronavirus Aid, Relief, and Economic Security Act, or CARES Act, of
2020). Global health investments, as we are seeing in the dissemination of the newly created
vaccines against COVID-19, can drive international engagement in vaccine diplomacy.
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Figure 4. U.S. Global Health Funding, FY 2006–FY 2021 Request
Source: Kaiser Family Foundation (2020b).
Global power centers are shaped by current events. An example of this is Brazil.
Brazil has been viewed as a “rising global power” (Khazatzadeh-Mahani et al., 2018, p. 6).
The pandemic of 2020 has revealed fragility in their health delivery systems amidst a
backdrop of political discourse in Brazil. A recent Congressional Research Service report
indicates that Brazil has a strong reliance on China as a partner in trade (Congressional
Research Service, July 2020). Foreign investments can influence foreign policy choices and
national security resources. Changes in country leadership, as Brazil recently experienced,
can also affect transnational relationships in global health and shift the centers of power in
international cooperation.
Recent examples of transnational partnerships where diplomatic efforts potentially
jeopardized health in foreign policy included the Trans-Pacific-Partnership (TPP)
agreement, the Trans-Atlantic Trade and Investment Partnership (TTIP) and the
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Comprehensive Economic and Trade Agreement (CETA) between Canada and the EU
(Khazatzadeh-Mahani, 2018). These were cited as failures that prioritized “trade
negotiations over health concerns” (Khazatzadeh-Mahani et al., 2018, p. 5). Power and
politics played a role in deal negotiation and led to a “UN high-level panel on Access to
Medicines to establish a framework for balancing trade and industry interests with human
rights” (Khazatzadeh-Mahani et al., 2018, p. 5). Member states of the UN collaborated on a
plan entitled “2030 Agenda for Sustainable Development” It includes 17 Sustainable
Development Goals (SDGs) that incorporate human rights and the balance between
economic prosperity and sustainability of our natural resources (United Nations, n.d.).
When examining U.S. foreign policy-making prioritization going forward, it is
essential that a strategic and model framework provide for an equitable approach to high
politic drivers, such as economics and trade. Health, as an investment, must be conceived of
within an equitable framework that offers balanced outcomes between health, economics,
and security in U.S. foreign policy. Important factors in negotiating foreign policy in GHD
include consensus building, the identification of dominant coalitions, and mapping
networked governance structures (Provan & Kenis, 2007). Financial incentives, such as
development assistance, have also been used by some countries as opportunities for agenda
setting, power influencing, and shaping the overall objectives of the receiving countries
(Khazatzadeh-Mahani et al., 2018, p. 6).
Assessment and Synthesis
The assessment of literature has provided an overview of GHD as an interdisciplinary
and applied practice. A review of IR and Foreign Policy literature clarified where GHD sits
across the domains of practice. There are opportunities to build upon the works of previous
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scholars to advance the health policy agenda in U.S. foreign policy. To do so will require a
greater effort to synthesize and balance the tradeoffs between health, security, and economics.
Current gaps in GHD research will also need to be considered when constructing the global
health agenda in U.S. foreign policy. Gaps are described in the next section followed by the
explanatory value in bringing these concepts together into an applied GHD research.
Gaps
The current gaps in GHD research include:
• There is little academic work comprehensively examining and synthesizing the
theoretical underpinnings of GHD (Ruckert, Labonté, et al., 2016).
• There is a “need to include nongovernmental actors, philanthropy and the private sector
in this new field of study. The landscape of global health and foreign relations has
changed, and thus a new lens through which to view this landscape is needed”
(Kickbusch, Novotny, Drager, Silberschmidt, & Alcazar, 2007, p. 3). More research is
needed to understand the influence that health diplomacy is having on foreign policy
development (Ruckert, 2016).
• There is a “challenging task of evaluating global health programs from a diplomatic,
international relations, and foreign policy standpoints” (Novotny & Kevany, 2013, p.
314).
• GHD research needs to be socialized more broadly to shape “national decision making
and public opinion” on the critical role that it plays in supporting global health
investments (Novotny & Kevany, 2013, p. 315).
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• Most importantly, leaders in foreign policy and global health (and government “agencies
responsible for those sectors”) need more information to guide them in understanding the
value of GHD (Novotny & Kevany, 2013, p. 319).
The drivers of GHD continue to shape its complexity. The 2020 pandemic is no
exception. Okma and Marmor (2013) emphasized the need for a systematic approach to
developing health policy, particularly in a cross-national environment. They admonished past
processes to develop policy swiftly and without the due diligence necessary to explore and
engage with cross-national representatives. Doing so requires a comprehensive understanding of
GHD’s role in foreign policy and how its outcomes shape national strategic decision making.
GHD research is critically needed to guide U.S. foreign policy decision making and to advance
the health policy agenda.
Applied GHD Research
The 2020 pandemic has disrupted economies and is driving unemployment and poverty.
The attention on global health will accelerate the role of GHD as a central practice and tool in the
international policy arena. The areas that have been previously cited in literature as future areas
of research may be altered in the wake of our current global crisis. What is clear is that the past
trajectory of global health policy has now been given a sharp turn.
This research presents an opportunity to make an applied contribution to the practice of
GHD. Policy practitioners will be out front in the post-pandemic phase working to make the
nation-to-nation connections and diplomatic engagements around vaccine distribution,
resumption of trade and travel, and reexamining global governance relationships following the
U.S. presidential transition in 2021.
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This pandemic has amplified the U.S. focus on global health and foreign policy – a space
this research occupies. My goal as a professional researcher is to challenge the normative way of
thinking (what ought to be) to expand the application and value of how GHD is leveraged in
advancing the health policy agenda in U.S. foreign policy decision making.
GHD research findings often align with the area of practice of the researcher (e.g., public
health, foreign affairs, etc.). My area of practice includes a combination of health policy, health
system delivery, defense, international relations, and diplomacy. Personal experiences gained
from the 2005 multinational humanitarian assistance-disaster response (HA/DR) to the South
Asian tsunami affirmed the value of GHD to me in U.S. foreign policy decision making.
Engaging in human-to-human collaboration at the international/global scale allowed for a
synergistic response to mass devastation and loss of life. It also allowed for a strategically paced
navigation of associated security, economic, humanitarian, etc. issues which intersect in foreign
policy decision making. This research seeks to harness a more effective way to frame the impact
and outcomes of GHD.
My research on GHD combines two angles, foreign policy decision making and
diplomacy. I examine U.S. foreign policy from the perspective of international institutionalism.
International institutionalism refers to a nation states’ position within a global economic order
(Beeson and Hibbott, 2005). The current pandemic appears to be driving a change in the existing
global governance model with challenges to the WHO accompanied with the populist shift in
elected leaders who are driving change in nation states’ positions within the global economic
order. An example of this is the US’ unilateral withdrawal from the World Health Organization
(WHO) signaled by the U.S. president in 2020. Note: this was reversed in January 2021
following a change of Administration.
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The relationship between foreign policy and domestic policy considerations is drawing
closer together as the public engages more fully around the impact that foreign policy decisions
have on the domestic agenda (e.g., immigration and human rights, and domestic immigration
onto U.S. shores). The way GHD is applied is influenced by bilateral and multi-lateral
negotiations country-to-country. It is important for the GHD practitioner to be aware that
country-to-country nuances make it challenging to measure the effectiveness of GHD. There
may be metric variations when seeking to evaluate GHD effectiveness (Ruckert et al., 2016).
This presents a new opportunity for practitioners to evaluate outcomes of their bilateral or
multilateral diplomatic engagements.
The next chapter will describe the theoretical foundations used in this research. An
overview of the U.S. foreign policy decision making process will be described and two analytical
frameworks will be presented.
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CHAPTER 3. THEORETICAL FOUNDATIONS
This chapter will cover how agenda setting influences policy priorities and the role that
state and non-state actors play in shaping the agenda. The theoretical underpinnings of the
agenda setting process will be explored. Two analytical frameworks are highlighted in this
research. They include Kingdon’s Multiple Stream Framework (Kingdon, 2011) and Zelikow-
Allison’s Conceptual Models (Zelikow and Allison, 1999). These models will be utilized to
analyze two key U.S. policy initiatives, which will be detailed in the next chapter: the U.S.
president’s Emergency Plan for AIDS Relief (PEPFAR), an example of bilateral health
diplomacy; and the Global Fund to Fight AIDS, Tuberculosis, and Malaria, an example of
multilateral health diplomacy. This chapter concludes with an explanation of the focus of this
research.
The Foreign Policy Agenda-Setting Process
This section will explore the role of politics and agenda setting in executive decision-
making. Beland (2005), in his critical analysis of Kingdon’s earlier works on the process of
agenda setting, clarified the definitions of agendas and alternatives. They “are the product of the
interaction between three autonomous streams through which social and political actors mobilize
in order to promote specific issues or policy options” (p. 6). The three autonomous streams are
problem, policy, and political streams (Kingdon, 2011). Kingdon (2011) refers to agenda as “the
list of subjects or problems to which governmental officials, and people outside of government
closely associated with those officials, are paying some serious attention at any given time” (p.
3). The distinction between these two definitions is Kingdon’s (2011) reference to government or
non-government actors. Whereas Beland (2005) focuses on a broader reference to actors. Each
definition highlights the active process of agenda setting that includes a component of advocacy.
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The relevance of agenda setting in public policy decision making is also present in
Lasswell’s work during the mid-1950’s. Walt, Shiffman, Schneider, Murray, Brugha, & Gilson
(2008) discuss Lasswell’s (1956) stages heuristic public policy framework which includes:
“agenda setting, formulation, implementation, and evaluation” (p. 310). “Agenda setting is the
issue sorting stage during which a small number of the many problems societies face rise to the
attention of decision-makers” (Walt et al., 2008, p. 310). The key criticism of Lasswell’s
heuristic public policy framework was that its design suggested that the policy process occurs in
a linear fashion (Walt et al., 2008). However, the process, with its complexity and increasing
number of participants lends itself to an iterative process more than linear. As part of Kingdon’s
problem stream, agenda setting is the stage where issues (problems) get sorted into a smaller
number of problems with the goal of leading to decision making (Walt et al., 2008). The role of
agenda setting is important because it helps to explain why some issues, such as the health policy
agenda in U.S. foreign policy decision making, rise or fail to rise to levels of importance
alongside other issues.
The numbers of state and non-state actors, and the underlying motivations of each, will
ebb and flow particularly as the effects of the 2020 pandemic continue to have far-reaching
economic implications. The global supply chain has been challenged in meeting basic supply
needs for personal protective equipment (PPE) for health service workers around the globe and
access to vaccines are rising to the forefront of diplomatic discussions. The theoretical
underpinnings that help to explain the narratives and discourse on these types of issues is
discussed later in this chapter.
Global health diplomacy (GHD) is a dynamic practice and its complexity within the
foreign policy making process continues to expand as the dynamic international arena evolves.
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The practice of GHD would benefit from better understanding the conditions under which the
health policy agenda is advanced in U.S. foreign policy decision making (FPDM). These insights
can be useful to the participants who are engaged in shaping FPDM.
Participants
Global health diplomacy (GHD) is a process whereby “multi-level and multi-actor
negotiations can shape the global policy environment for health” (Khazatzadeh-Mahani et
al., 2018, p. 3). The World Health Organization (WHO) and the United Nations (UN) are
the primary international organizations engaged in global health governance. In the 21
st

century, the participants involved in global health collaboration and negotiation have
expanded to include “the World Trade Organization (WTO), summit meetings for the G7/8
and G20 meetings, large nongovernmental organizations (ex: The Global Fund) that present
themselves as partnership organizations who bring financing to disease eradication
campaigns” (Khazatzadeh-Mahani et al., 2018, p. 4). According to Ruckert et al. (2016), a
global regime model could be supported by a “broad collaboration between private, non-
state actors and governments across cooperating institutions, e.g., Global Fund” (p. 10).
Regime models also have a role in international investments, of which health is one of them.
Salacuse (2010) discusses the growth in international investment treaties since World War
II (WWII) that can be bilateral or multilateral. Participants, also known as actors, who
engage with one another within an agreed upon system of international governance
(“international regime”) are governed by a series of “principles, norms, rules, and decision-
making procedures (Salacuse, 2010, p. 431). At the heart of why participants engage in
global regimes focused on investment may be explained by a desire to utilize treaties or
agreements to advance nation state power or to advance cooperation (Salacuse, 2010). The
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pandemic of 2020 will foster another phase of global investment regimes as state and non-
state participants/actors work to influence global governance and cooperative treaties.
Within the USG, the foreign policy agenda is set by the President. The President
subsequently shares it with Congress but remains a powerful force in the agenda setting
process (Kingdon, 2011). The President uses three resources to maintain his/her position in
shaping the agenda. They include: “institutional resources, such as the veto and prerogative
to hire and fire; organizational resources, through unitary decision-making and the ability to
command the executive branch; and the command of public attention, which can be
converted into pressure on other governmental officials to adopt the President’s agenda”
(Kingdon, 2011, pp. 24-25). The role of coalitions and stakeholders in shaping global health
on the U.S. foreign policy agenda is described in more detail in Chapter 5, Findings.
In contrast to how the President drives his/her policy agenda, Kingdon (2007)
examined factors that contributed to Congressional decision-making. Congress is the
primary policy-making branch of the U.S. government, and as the legislative body, has an
important role in “determining and shaping the Government’s global health policy and
programs” (Moss & Kates, 2019). There are seven forces that can affect a Congressman’s
vote (Kingdon, 2007, p. 326): his/her own specific attitude on the issue; his/her
constituency; fellow congressmembers to whom s/he pays attention; his/her staff; interest
groups; his/her party leadership; and the Administration. Figure 5 depicts the U.S.
government organizational structure responsible for global health efforts. The collective
efforts of overseeing and administering global health programs is intergovernmental and
cross-departmental and draws in actors (state and non-state) who are elected, appointed, and
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tenured bureaucrats. The President and the Congress engage with the public and interest
groups in advancing their policy agendas.
Figure 5. Organization of U.S. Global Health Efforts
Source: Kaiser Family Foundation (2019).
With globalization, involvement by non-state actors in global health diplomacy has
grown. Cooper and Farooq (2015) argue that health diplomacy is becoming fractured
because of the entrance of non-state actors into the debate on global issues, who introduce a
problem-solving bias that is shaping 21
st
century health diplomacy. What this means is that
the increase in and range of non-state actors is positioning them to set “and implement the
policy agendas” which has the “potential to break with traditional methods and practices of
diplomacy” (Cooper & Farooq, 2015, p. 314). The implications of this, depending upon the
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complexity of global issues, can result in a “divergent set of global responses” (Cooper &
Farooq, 2015, p. 315).
The growing presence of non-state actors in the global health arena is also
contributing to increased overall financing on global health initiatives outside of the United
States. This is “multiplying the number of actors involved in foreign policymaking and
agenda setting as well as the emergent number of nontraditional security challenges”
(Khazatzadeh-Mahani et al., 2018, p. 113). This intensification of engagement and focus on
global health, and its associated impact, have “elevated it to the status of a national (or
international) security concern” (Khazatzadeh-Mahani et al., 2018, p. 10). This statement in
2018 preceded the 2020 pandemic which will likely amplify the U.S. foreign policy debates
on the securitization of health. The increased financing by non-state actors to global
investments on health puts pressure on nation states to maintain or increase levels of global
health financing to ensure that they have sufficient power and leverage to exercise in
shaping global health policy within the global governance hierarchy.
The addition of non-state actors in global health diplomacy (GHD) has also led to
expanded “advocacy networks” that have “shared values, norms and understandings to
influence the agenda setting process of GHD” (Khazatzadeh-Mahani et al., 2018, p. 10).
These networks have a role in shaping GHD policy making based on the interests of the
various state and non-state actors. There has also been a proliferation of comprehensive
regional trade agreements which may have a role in health outcomes that can increase or
decrease regional stability (Khazatzadeh-Mahani et al., 2018).
Figure 6 depicts the complex stakeholder network including state and non-state
entities who engage bilaterally and multilaterally around health policy issues. Health
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attaches, who reside at the center of the network, are defined as “representatives of core
GHD practitioners that collect, analyze, and act on information concerning health in a
foreign country or countries and cultivate relationships establishing critical links between
public health and foreign affairs stakeholders and institutions. They represent the views of
their governments and forge partnerships with other governments, multilateral institutions,
private sector companies, non-governmental organizations, academia, and the public”
(Brown et al., 2018, p. 2).
Figure 6. U.S. Health Attachés’ Relationships
Source: Brown, Mackey, Shapiro, Kolker, & Novotny, 2014, p. 7.
The pace at which state and non-state actors are engaging around global issues of
concern has intensified following globalization. Policymaking isn’t always afforded the
“run-up” time to create a detailed and well-crafted policy. The diversity of participants who
exert influence on U.S. Congressional members and the range of agendas under
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consideration add to the complexity of the negotiation necessary to achieve consensus in
policymaking.
The array of actors has presented one of the greatest challenges in 21
st
century
negotiations relating to health and foreign policy. The challenges have been amplified
because the actors are not specialists in health (e.g., trade and foreign policy specialists)
(Khazatzadeh-Mahani et al., 2018). Diverse ideas and interests, patterns of thinking, and
technical language barriers further exacerbate the challenges in global health negotiations
(Khazatzadeh-Mahani et al., 2018). This creates a gap opportunity for global health
diplomats to contribute policy expertise to global health negotiations.
Figure 7 highlights the participants who are engaged in the process of GHD. Health
attaches and Diplomats, at the top of the pyramid, are the lead participants that the U.S.
government currently relies upon to engage in GHD. Identifying the advocacy groups that have
shaped or will shape how health enters into U.S. foreign policy is a key step in my research, to be
discussed in the next chapter. This research will focus on all tiers of the pyramid which
incorporate U.S. transnational policymaking.
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Figure 7. Pyramid of Global Health Diplomacy: Myriad Actors, Definitions and Tools
Source: Brown, Mackey, Shapiro, Kolker, & Novotny (2014), p. 4.
Different laws and governance bodies come into play in directing how and when
stakeholders on this pyramid engage. National and international laws have jurisdiction over
nation states and individuals representing nation states. International treaties and agreements
must also be considered as they represent country commitments to one another and
cooperative agreements as a coalition. The next section will explore the theoretical
underpinnings of foreign policy decision making and power games employed by
participants as a way of shaping foreign policy outcomes.
Theoretical Underpinnings
This section provides an historical perspective of the theoretical underpinnings of foreign
policy decision making and foreign policy analysis that bridge from a Cold War to a post-Cold
War era. The foundational work by Snyder, Bruck and Sapin (1954) sets a framework for foreign
policy decision making by “inspiring researchers to look below the nation-state level of analysis
to the players involved” in the decision-making (Hudson & Day, 2020, p. 14). The emphasis in
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analysis pivoted from “foreign policy outcomes to foreign policy decision-making (FPDM)”
(Hudson & Day, 2020, p. 15). This baseline set by Snyder in the 1950s acted as a catalyst for
other theories to be formulated in the field of foreign policy decision making and analysis. An
overview of theories that have contributed to the study of foreign policy were described in
Chapter 2.
Discourse Analysis and Counternarratives
As the global ecosystem grows increasingly complex, Kaki (2004) cites Roe (2001) in
recommending that the policy world should look for new “techniques that frame uncertainty and
complexity in ways we can do something about them, without at the same time supposing that
uncertainty and complexity can be dismissed, avoided, or otherwise dispelled” (Kaki, 2004, p.
33). Narrative analysis can identify the narratives and counter-narratives that emerge as part of
policy goal and agenda setting. According to Kaki (2004, p. 35), “more often researchers
interested in narratives have regarded narrative as a field in which multiple disciplines converge,
each with its own focus.” GHD as an interdisciplinary field, can use narratives and
counternarratives to promote a common understanding of its science, political and diplomatic
value, and contribute to the discourse on global health policy and security issues.
Global health equity is a mainstream conversation as countries proceed to distribute
vaccines in response to the pandemic of 2020. This process brings together nation states, large
corporations (e.g., pharma), wealthy and less wealthy populations, and regions where the
prevalence of non-communicable diseases (NCDs), also known as chronic diseases, are a focus
of attention by the World Health Organization. Discourse analysis and the use of narrative
analysis may guide policymakers in advancing policy agendas through the development of
counternarratives to profit over value, consumerism over social justice, and health for some vs.
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health in all things. The pre-pandemic narrative on global health policy has been abruptly
assaulted by the events of this unfolding pandemic. As new narratives emerge post-pandemic,
counternarratives will be equally useful in shaping USG decision-making on how health enters
into foreign policy and for what value (Kaki, 2004).
The Role of Power in Foreign Policy Decision Making
Global health diplomacy (GHD) can function as a soft power tool, which means a
tool of power that is not a warfighting or defense machinery tool (Khazatzadeh-Mahani et
al., 2018). When practiced, diplomacy can exercise “‘hard power’ which includes economic
sanctions and military operations, ‘soft power’ which includes co-option and cooperation, or
a combination of hard and soft power which is known as ‘smart power’ (Khazatzadeh-
Mahani et al., 2018, p. 3). The term ‘smart power’ was “first used by the U.S. academic
Joseph S. Nye in the early 1990’s to describe a power as ‘the ability to influence behavior of
others to get the outcomes one wants’” (Khazatzadeh-Mahani et al., 2018, p. 8). In the case
of global health diplomacy (GHD), it is largely based on the exercise of soft power. With an
increased focus on “health and global political negotiations, there is a growing importance
of soft power in foreign policy” (Khazatzadeh-Mahani et al., 2018, p. 8).
Hahn (1987) discusses the role that power can play in shaping policies. Power has the
“capacity to shape or maintain a value system that discourages people from perceiving situations
as problems deserving of public attention” (p. 230). This use of power can shape what issues rise
to the level of a policy agenda, how issues are shaped to favor one or another group, and the
potential to control the lives of others. Hahn (1987) identified commonly used models in
research on the policy making process with a goal of summarizing developments in research and
theory. This is useful in guiding policymakers in shaping strategies to ensure that the role of
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power is balanced by the development of equitable and sustainable policies. These models
include:
• “Institutionalism: the focus on structures, organization, duties and functions of
governmental institutions” (p. 222). This can be useful in defining which organizations
within government are responsible for what. Utilizing the USG organizational structure
presented in this chapter, a policymaker can assess which entities have the power to
influence policy outcomes.
• “Systems theory: a theoretical emphasis on the environment of political systems, inputs
and outputs, and feedback” (p. 222). This offers value in determining the links and
relationships between the centers of power on specific policy issues.
• “Pluralism: the most common form of group theory that is used to explain national
political behavior, interprets policy making as a result of influence by groups” (p. 222).
This theory is useful in examining the role that groups or coalitions have in exerting
power on issues.
• “Elitism: a model that recognizes most people are uninvolved and uninfluential. Policy
making on most issues is heavily influenced by elites” (p. 223). The power of elites is not
necessarily visible to those outside of the elite group. The power that elites bear in
influencing policy outcomes may reveal inequalities (unequal levels of influence)
compared to those outside of the elite group.
• “Process models: models that attempt to generalize about the sequence of steps or actions
that occur as policy issues are raised, debated and resolved” (p. 223). Process models aid
in identifying the points in the policy process where outcomes can be affected.
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• “Rationalism: a model of decision making rather than policy making. This model
attempts to describe the process of efficient decision making. Hahn (1987) cites
Anderson (1979) as characterizing “decision making as a narrower focus than policy
making, as an intellectual process and not a political one” (p. 223). Power can be
influenced based on the construction of alternatives and aligning decisions to goal
optimization (Hahn, 1987).
• “Incrementalism: formulated in reaction to rationalism. It offered a prescriptive model as
well as a better description of reality. It states that decision makers are more likely to
move away from problems than toward goals; only a limited number of alternatives are
considered; only direct, short-range consequences are considered for each alternative;
only enough analysis is done to find a solution that policy-makers can agree on” (p. 223).
Power is maintained when risk is avoided. Constructing alternatives to mitigate risk is
useful in Congressional decision making because it provides a means to limit situations
where lawmakers must vote counter to their constituents’ preferences. (Kingdon, 2007).
Two-Level Games
Two-level games refer to the politics of international negotiations and can be found in the
comparative study of foreign policy (Putnam, 1988). It’s a metaphor for the conceptualization of
negotiations taking place on a game board with the game pieces reflecting the various
participants (domestic and international) in this negotiation process. Two-level games serve to
depict the “entanglement of domestic politics and international relations” (Putnam, 1988, p. 428).
They are relevant to foreign policy when examining the intersecting relationship between a
nation’s domestic politics/policies and its international politics/policies (Putnam, 1988). “At the
national level, domestic groups pursue their interests in pressuring the government to adopt
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favorable policies” (Putnam, 1988, p. 434). Politicians engage with the domestic groups or
coalitions because they are motivated by power. (Putnam, 1988). “At the international level,
national governments seek to maximize their own ability to satisfy domestic pressures” (Putnam,
1988, p. 434). The risk they must balance in the game is potential outcomes that result in
“adverse consequences of foreign developments” (Putnam, 1988, p. 434). Participants in this
game can include the national leader who is flanked by diplomats and international advisors who
interact with their foreign counterparts (Putnam, 1988). The participants in this interaction are
depictive of game pieces on the game board (Putnam, 1988). Negotiations ensue and the game
begins. Every player in the game can influence decision-making, influence alignments in
coalitions, and risk losing power in the game if other players within the international
composition make moves to accumulate power (Putnam, 1988). Single players in the two-level
game can exhibit “rational decisions on one board and be impolitic on the other board” (Putnam,
1988, p. 434). This means that players can move between domestic and international games
(negotiations) and can also use disruption as a way of driving realignments between players in
each game. The purpose of this is to set-up preferable outcomes that were “otherwise
unattainable objectives” (Putnam, 1988, p. 434) in the status quo. Putnam (1988) describes the
complex nature of two-level games as “staggering” (p. 434). The complex nature of international
negotiations plays out in the cases analyzed for this dissertation research.
Putnam (1988) identifies three factors that influence who achieves the ‘win’ in the two-level
game:
• “The size of the win-set depends on the distribution of power, preferences, and possible
coalitions among Level II (institutions) constituents” (p. 442). Putnam emphasizes that
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testing the two-level game theory in negotiations in the international arena must include
“theories of domestic politics and theories of power” (Putnam, 1988, p. 442).
Note: Putnam distinguishes win from win-set. “A win-set for a given Level II
constituency as the set of all possible Level I agreements that would “win”-that is, gain
the necessary majority among the constituents-when simply voted up or down” (Putnam,
1988, p. 437).
• “The size of the win-set depends on the Level II political institutions” (p. 448). This
means that the structure of the U.S. government, a separation of powers between the
branches of government, includes an opportunity for policy initiatives to be vetoed.
Within the international arena, nations engaging with or contemplating engagement with
the United States in a cooperative way may be guided in their decision-making by the
risk of international initiatives being thwarted by its political institutions (Putnam, 1988).
• “The size of the win-set depends on the strategies of the Level I negotiators” (p. 450).
The Level I negotiators rely upon a tactical strategy that balances advancement of a
nation’s desire to achieve international cooperation with the support and rallying efforts
of its constituents (Putnam, 1988). The balance is necessary because the Level I
negotiator must seek and appear to be cooperative in international negotiations while also
ensuring the interests of the nation state are included in the win-set. The risk in the
pursuit of the ‘win’ if too aggressive or rushed is the potential to lose negotiating
leverage and an overall loss of the international agreement (Putnam, 1988). Strategies to
engage constituents in rallying support (e.g., using polls from constituents) of the Level I
negotiator’s actions can serve to accelerate negotiations and give cover to the Level I
negotiator’s actions. Utilizing constituent sway as a negotiation tactic, can provide a
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public rationale for the Level I negotiator to defer to during difficult international
negotiations.
GHD, as a process, requires that diplomats are well-positioned with a quiver of
diplomatic and negotiation tools and well-versed in the factors that drive the artful construction
of international agreements.
Analytical Frameworks
Kingdon’s MSF (Kingdon, 2011) will be coupled with Zelikow-Allison’s conceptual
models (1999) in adding explanatory value to the two case initiatives in my research (see
Chapter 5). I selected Kingdon’s MSF because it aligns with the research question in clarifying
how the policy making activity, occurring independently in three streams, comes together to
provide for a policy window of opportunity. Case examples where policy windows of
opportunity have emerged can be instructive to future situations where health needs to be
positioned prominently on the foreign policy agenda. Zelikow-Allison’s (1999) work has shown
value in the field of IR and foreign policy (Balla et al., 2015). The models provide value in
bridging interdisciplinary work such as exists with the phenomena of GHD (Balla et al., 2015).
The models, described in further detail below, provide a framework for understanding how
decisions are contemplated by participant groups within and outside of the USG. Politics and
bureaucracies are important components of transnational diplomacy. More opportunities exist to
advance research in the field of “intra-national” policymaking (Balla et al., 2015, p. 283). The
analytical frameworks are explained in more detail below.
Kingdon ’s Multiple Streams Framework
Kingdon built upon the work of Cohen, March, and Olsen (1972) to explain the agenda-
setting process in the making of public policy (Mucciaroni, 1992). Kingdon’s Multiple Streams
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Framework (MSF) reflects a convergence between problem, policy and politics streams that
align to a window of opportunity (Kingdon, 2011). It is depicted in more detail in Figure 8 on the
next page. Alignment of the streams toward a window of opportunity means that the parties who
are engaged in the problem, policy and politics of an issue have harmonized (or brought into one
confluent stream) their ideological policy agreement. Given its explanatory value, I use
Kingdon’s MSF to analyze the policy process and the role that agenda setting plays in this
process. For this research, I will incorporate a constructivist perspective using Kingdon’s
theoretical framework.
As policy entrepreneurs, GHD scholars have a role to play in shaping the policy,
problem, and political streams of activity. Within government, they engage in interagency policy
issues across key departments (Health and Human Services, Department of State, USAID, CDC,
etc.). Within the U.S. embassies abroad, they are afforded broad diplomatic insight and are well-
positioned to serve as health experts to national security country teams within the USG.
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Figure 8. A Multiple Streams Model of Policymaking (Tomlin et al., 2008)
Windows of opportunity to advance the health policy agenda are varied and each
opportunity is comprised of unique circumstances, timing, and actors. As such, it is difficult to
measure GHD effectiveness because of the complexity and variability of each policy
circumstance.
Within Chapter 2, I identified several theories that lend tangential value to the two
analytical frameworks that I am using to answer my research questions. Role theory is instructive
in explaining the President’s foreign policy choices in the two cases in this research. Belief
systems, such as moral reasoning, can influence foreign policy decision making. (Campbell,
2018). Rosenau’s (1964) work was groundbreaking to the field of foreign policy as he worked to
harness the variables at play within the complex international ecosystem utilizing a scientific
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methodology. However, foreign policy decision making is not expressly predictable as each
moment-in-time is unique to the circumstances of real-world events, who the participants are and
how their beliefs shape decision making, and what the strategic imperatives for the nation state
are at the time of the decision. Lasswell’s work on heuristics (1956) is relevant because it
considers the timing of decisions and the nature of the situation presented to the decision-maker
(Balla et al., 2015). Variables, such as who the leaders are at the time of a decision and the depth
and breadth of their networked relationships, can greatly influence situational decision making
and that will be highlighted in Chapter 5. Rational choice theory draws in the role that power
plays in international relations and foreign policy decision making (Hart, 1976). When
approaching the design of bilateral and multilateral negotiations, the use of power may aid the
decision maker in achieving what has been deemed as the rational choice (among alternatives).
The United States used leverage in positioning its preference for the Global Fund’s governance
to be established outside of the UN. As one of the leading contributors to the Global Fund, the
United States demonstrated the role that power can play in positioning what it viewed as the
rational choice of alternatives. The Garbage Can Model (GCM) (Cohen et al., 1972) dovetails
into the subsequent works of Kingdon (2011) and Zelikow-Allison (1999), Model II. Cohen et al.
(1972) utilized the concept of streams to explain how decisions emerge. Decisions are described
as outputs. In Model II (Zelikow-Allison, 1999), described in more detail in the next section,
organizational bureaucracies are faced with decisions that are often influenced by the routines of
the bureaucracy. In this model, the decisions are described as outputs. Almond’s Input-Output
framework analysis offers explanation of policy elites and their influence within a political
system. This has relevance to the participant population in this research who are elites.
Diplomats were listed as an elite (Almond, 1965) and they are the global connectors who are key
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to advancing U.S. foreign policy strategies abroad. Middle powers is useful because it addresses
the changing landscape of powers of nation states in a post-Cold War environment. The
collective power of middle states must be considered in diplomatic and political areas of practice
(Jordaan, 2003).
The information in this section has been covered to provide insight into a theory that
offers explanatory value to policy formulation and the factors that contribute to policy adoption.
It is often described as an ad-hoc process versus a well-organized linear event. The implications
to be drawn from this information are that it takes a great deal of synergistic effort and timing for
policies to be realized. As strategists, GHD practitioners will benefit from understanding the
theoretical concepts associated with foreign policy and GHD.
Zelikow-Allison ’s Conceptual Models
The conceptual models of decision making specified by Zelikow and Allison (1999) are
widely known for their use in examining USG decision-making associated with the Cuban
Missile Crisis of 1962. The Cuban Missile Crisis refers to a thirteen-day period in October 1962
where the United States and the Soviet Union were on the “precipice” (p. 1) of nuclear war over
the Soviet Union’s movement of a nuclear arsenal to Cuba. This represented the grave prospect
of at least “100 million Americans and more than 100 million Russians” (p. 1) potentially losing
their lives if nuclear war erupted. The decision-making that unfolded over the thirteen days is
examined in this revision of Allison’s original works (Allison, 1971; Zelikow & Allison, 1999),
with the new version analyzing three updated conceptual models.
I selected the Zelikow-Allison’s conceptual models as the most useful framework for
analyzing U.S. foreign policy decision-making because of its explanatory value in executive
decision-making and its “important implications for the current foreign policy agenda” (p. 9).
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My research examines two cases of foreign policy decision making, the President’s Emergency
Fund for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis, and Malaria.
These initiatives will be examined to gain insight into the key policy entrepreneurs involved in
their crafting, their lived experiences during this period (2001-2003), and how their domestic
policy actions linked to the international/foreign policy actions. In Chapter 5, examples will be
provided from the cases to depict how each of the models explains the actions of a participant or
group of participants during the formulation of these initiatives. Each of the three conceptual
models is described in more detail in the sections that follow.
Rational Actor Model
This model identifies the “national government” as an actor (Zelikow & Allison, 1999, p.
15). It has applicability to foreign affairs. The unit of analysis is the government action as a
choice (Zelikow & Allison, 1999). This model offers explanatory value of the nation state’s
actions as the unitary decision maker and it is used to examine the circumstances that contributed
to the national government’s choice with an assumption that the goal is to achieve a rational
decision (Zelikow & Allison, 1999). It is achieved by examining the conditions faced by the
state. In the rational actor model, the “unitary states are the key actors in international affairs and
the states act rationally, calculating costs and benefits of alternative courses of action and
chooses the action that maximizes their utility” (Zelikow & Allison, 1999, p. 27). The role of the
USG is critical in shaping how health is incorporated into U.S. foreign policy and subsequently
operationalized abroad.
When reflecting upon examples of the securitization of health as a strategy for advancing
the political importance of the health policy agenda, this model clarifies the nation state’s
rationale for linking health to security. When faced with options in foreign policy decision-
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making, securitizing health may have been the most rational choice. “In an uncertain world, the
decision analyst maximizes expected utility” (Zelikow & Allison, 1999, p. 17). The rational
actor, given a range of choices balanced against the potential threats or opportunities, will decide
based on what is strategically most beneficial (Zelikow & Allison, 1999).
As Zelikow and Allison (1999) journeyed through an overview of the theoretical
underpinnings of decision-making, they quoted Henry Kissinger, “a former national security
advisor and secretary of state who spoke to the complexities of policy formation. States’ actions
portray unitary actors pursuing national objectives. He praises statecraft that can ‘bridge the gap
between people’s experience and the statesman’s vision’ unfettered by the morass of
governmental politics” (Zelikow & Allison, 1999, p. 29). This is the space wherein diplomacy
wields its value.
Organizational Behavior Model
In contrast to the rational actor model, which can be used to focus on the executive
decision-making of the President of the United States (POTUS), the organizational behavior
model can be applied to organizations that are separate entities but that work together through
loose association. Formal organizations are defined by Zelikow and Allison (1999, p. 145) as
“groups of individual human members assembled in regular ways, and established structures and
procedures dividing and specializing labor, to perform a mission or achieve an objective.” The
process of decision-making in organizations and what guides those decisions differs from the
first model. Each distinct government organization has inputs and outputs that vary. While the
leaders of the organizations ultimately report to the POTUS, the individual actions of
departmental leaders are not controlled and are loosely coordinated. Departments have
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responsibilities for programs. Routines and past ways of doing things inform how organizations
approach new situations or decision-making (Zelikow & Allison, 1999).
The key differences between the two models are reflected in their different “logics of
action” (March & Simon, date) or ways of explaining why actors made the decisions that they
made (Zelikow & Allison, 1999, p. 146). There are two different logics of action:
• “Logic of consequences: actions are chosen by evaluating their probable consequences
for the preferences of the actor. It operates principally through selective, heuristic search
among alternatives, evaluating them for their satisfactoriness” (Zelikow & Allison, 1999,
p. 146).
• “Logic of appropriateness: actions are taken based on a matching of rules to situations.
Actions are chosen by recognizing a situation as being of a familiar, frequently
encountered, type, and matching a recognized situation to a set of rules. It is linked to
conceptions of experiences, roles, intuition, and expert knowledge” (Zelikow & Allison,
1999, p. 146).
A barrier or constraint in decision-making that this model presents is that organizations may be
“confined to the past” when they are faced with making decisions that are new or previously
unencountered (Zelikow & Allison, 1999, p. 149).
Governmental Politics Model
This model addresses the role of bureaucratic politics in decision-making. It contrasts to
the rational actor model as it goes beyond a unitary actor to “many actors as players” (Zelikow &
Allison, 1999, p. 255). It incorporates non-state actors in interaction with state actors whereupon
bargaining and negotiating occurs to shape decision-making outcomes (Zelikow-Allison, 1999).
The entrance of a multiplicity of actors means that there are differing priorities and competition
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for resources that must be weighed and balanced in the decision-making process (Zelikow &
Allison, 1999).
A discussion of the role of power is introduced in this model. Within foreign policy
decision-making, the power of networks and coalitions can be shaped by politics. Alternatives
are advanced as options and choices and then negotiated. The role of relationships becomes
essential when bargaining and negotiating in an international arena (Zelikow & Allison, 1999).
The governmental politics model is particularly useful in gaining an understanding of
actions and decisions of international and transnational events making it more useful that Models
I and II when analyzing the increasingly complex multilateral, global ecosystem. As actors
change, so too will the agendas and patterns of decision-making.
Research Focus
The focus of this research is to analyze the complex nature of foreign policy to determine
under what conditions the decision-making process advances the health policy agenda. Utilizing
two case examples, the President’s Emergency Fund for AIDS Relief (PEPFAR) and the Global
Fund to Fight AIDS, Tuberculosis, and Malaria, I will explore the lived experiences from key
policy entrepreneurs who were involved in shaping these initiatives from 2001-2003. Utilizing
the National Security Strategy (NSS), I will gain insight into the President’s foreign policy
strategy and how this shaped the decision making associated with the AIDS epidemic. I will
utilize two models in this dissertation research to frame GHD in U.S. foreign policy decision-
making: Kingdon’s MSF and Zelikow-Allison’s Conceptual Models. An analytical framework
clarifies how elements work together to shape the policy-making process. The fragmentation in
GHD literature results in fragmented analytical framing.
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The process of negotiating policy in GHD is a consensus building process. With social
networks engaged in global health, the policy analysis circle, Figure 9 provides value in thinking
about the various policies that feed the policy stream in Kingdon’s Multiple Stream Framework
(MSF) (Gagnon & Labonté, 2013). For example, when considering the three streams, the policy
analysis circle tees up questions that an analyst can apply to trends along each stream to explore
the movement toward alignment. It may add clarity to why a policy was conceived and who the
actors involved in the advocacy are. It’s an easy-to-use and rudimentary/quick approach to policy
analysis.
Figure 9. The Policy Analysis Circle
Source: Gagnon & Labonté, 2013, adapted from Walt and Gibson’s policy analysis triangle.
By winding around the circle, the researcher responds to questions that attempt to distill
the policy under consideration down to an acceptable threshold or narrow framework such that it
can operationalized. In a dynamic global ecosystem, the complexity of unwinding the policy
process becomes more challenging. This research will lead to the development of a conceptual
framework that will help to explain the complexity of transnational global health policy events.
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Key Takeaways
GHD lacks a theoretical framework. The multi-stakeholder environment in global health
continues to grow and the pandemic of 2020 will drive the diversity and complexity even further.
The sharing of resources that countries rely upon are facilitated through international
cooperation. Diplomats represent the USG interests in international negotiations and health
attachés provide the health policy insights that contribute to those negotiations. Therefore,
having a well-defined health policy agenda for operationalizing U.S. foreign policy aids in
positioning Diplomats and Health Attaché’s for success in their roles abroad. The statist view of
international relations is being shaped by the entrance of non-state actors. The impact of the
pandemic on the global health ecosystem is an unfolding scenario, which as a case study, will
further contribute to the insights gained from this dissertation.
Linking Global Health Diplomats to U.S. Foreign Policy
Diplomats serve on the front lines of U.S. foreign policy engagement. Assigned to U.S.
embassies abroad, they interact with foreign nations and non-state actors within the global
ecosystem on global problems. They provide essential foreign policy advice to executive leaders
in Washington, DC. They act as a bridge between domestic and international issues –
transnational. In their role as global connectors, they are essential links to advancing health in
U.S. foreign policy. The cases in this research highlight their role as leaders in this process.
Through bilateral and multilateral agreements, the USG has fostered global cooperation
and formalized its negotiated interests. Patrick (2003) brings attention to the post-Cold War
debate about “the appropriate balance between unilateralism and multilateralism in American
global engagement” (p. 37). Global health diplomats play a critical role in fostering cooperation
abroad on issues where health is at the forefront. The 2020 pandemic has highlighted how health
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can rise in prominence on the foreign policy agenda and drive new avenues for international
cooperation and conflict.
The statecraft of diplomacy requires that diplomats be highly skilled in unilateral and
multilateral strategies to effectively balance the advancement of the nation state’s interests with
the policy criteria of equity, human rights, and actions focused toward achieving global public
good (Patrick, 2003). Diplomats provide the pathway to pursue soft power solutions to global
challenges.
Research Questions
The predominant literature resource that I have utilized to logically distill my research
questions is “Global health diplomacy: A critical review of the literature” (Ruckert et al., 2016).
A gap that Ruckert et al. (2016) identified was a “lack of clarity in what drives the presence of
health in the foreign policy agenda”. My research will fill this gap. My overall research inquiry is
“how from an inchoate agenda do a few things emerge?
A. My research question is:
• Under what conditions does U.S. foreign policy decision making advance the health
policy agenda and for what value or purpose?
B. My research sub-questions are:
• What do Zelikow-Allison’s models contribute to our understanding of foreign policy
decision making?
• What policy windows-of-opportunity exist in which to advance health as a strategic
priority within U.S. foreign policy?
• Has the prioritization of health in U.S. foreign policy impacted global health diplomacy?
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In the next chapter, an explanation of the methodology used to investigate these questions
is provided.
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CHAPTER 4: METHODOLOGY
Global health issues are at the forefront of everyday life. Globalization has intensified the
complexity of responding successfully to human disasters. Beyond the drivers that have
intensified a focus on global health, the factors shaping the need for this research include the
ongoing pandemic of 2020, the growth in the multi-stakeholder environment in global health, the
lack of a theoretical framework in GHD, and a statist view of international relations. The statist
view is amplified in the definition of high politics offered by Youde (2016, p. 157): “those issues
that are integral to the existential nature of the state itself.” This complexity has led to a
convergence of global health, foreign policy decision-making, and international cooperation.
The pandemic underway has caused illness and death, led to worldwide and regional
quarantine strategies, and disrupted the world economy (CDC, n.d.). The global health and high
politics/low politics debate discussed by Youde (2016) presents an opportunity for new ways of
thinking in foreign policy.
My research problem statement is the strategies that lead to the prioritization of health in
U.S. foreign policy decision making are unknown. The purpose of this research is to analyze the
complex nature of foreign policy development to address the following research question: under
what conditions does U.S. foreign policy decision-making advance the health policy agenda and
for what value or purpose. The Multiple Stream Framework (MSF) by Kingdon (2011) and the
conceptual decision-making models outlined by Zelikow and Allison (1999) will be used to
guide my research inquiry. The research aims to develop an integrative conceptual framework
that will explain the complexity of the transnational global health policy process.
In this chapter, I will describe the methodology for my research on global health and U.S.
foreign policy. First, I summarize the public documents I reviewed, since they gave me a better
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understanding of the context and the foundations of the policy process. I then explain my
interview methods that were used to gain insights regarding the specific processes involved in
the development of policy, and I conclude with a summary of the two cases that I focused on in
my interviews and subsequent analysis.
Review of Public Documents
This section summarizes several USG executive-level governing documents that can be
traced to parts of the health policy agenda in U.S. foreign policy. The documents included in this
section are relevant to the two cases in this research as they provide background information on
events and actions that led to the authorizing statute for the Global Fund to Fight AIDS,
Tuberculosis and Malaria and for PEPFAR. These documents will be considered during the
triangulation process of data analysis and used as a form of validating the findings.
The research questions also led to my inclusion of historical and recently produced USG
documents in this section. They include the U.S. Global Health Security Strategy (GHSS), the
U.S. Global Health Security Agenda (GHSA) and the USAID Policy Framework. While the
recently produced documents will not be utilized to triangulate to the data in this research since
they were produced long after the bounded timeframe for the cases, I felt that it was important to
include them in this section to provide the reader with an update on the progressive expansion of
global health framing documents generated within the USG since the time of the two case
studies. This information will be woven into the final chapter to position the reader with an
understanding of how these documents bear an important relationship to the current debates
about global health governance following the pandemic.
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Goldwater-Nichols Act of 1986
This Act is included in the research because it is the enabling statute that imposes the
requirement for the President to “transmit to Congress each year a comprehensive report on the
National Security Strategy (NSS). (Public Law 99-433, Sec. 104 (a)(1)). The NSS serves as a
strategic framework for this study since it is the document that defines U.S. foreign policy
priorities.
Public law 99-433, the Goldwater-Nichols Act, was published on October 1, 1986. With
a focus on defense, it emerged as a solution for resolving U.S. military interservice rivalries and
sought to establish collaboration. “Addressing unnecessary duplication between service
secretariats and military headquarters staffs, Goldwater-Nichols consolidated seven functions in
the secretariats” (Locher, 2001, p. 14). Congress took steps to drive greater political and policy
coordination and transparency, by seeking to “strike the balance between joint and service
interests” (Locher, 2001, p. 11). Nine key objectives were specified (Locher, 2001, pp. 11-12):
• “strengthen civilian authority
• improve military advice to the president (in his constitutionally specified capacity as
commander in chief of the armed forces), secretary of defense, and National Security
Council
• place clear responsibilities on the unified commanders in chief for mission
accomplishment
• ensure that a unified commander’s authority is commensurate with his responsibilities
• increase attention to strategy formulation and contingency planning
• provide for the more efficient use of resources
• improve joint officer management
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• enhance the effectiveness of military operations
• improve Defense Department management and administration.”
For this research, two objectives have critical relevance to the formulation of health
policy within the foreign policy agenda: the prioritization of issues that emerge from the National
Security Council (NSC) to the President and the formulation of strategy to insure efficient use of
resources.
The Congressional Research Service (CRS) completed a report entitled “Goldwater-
Nichols at 30: Defense Reform and Issues for Congress” (McInnis, 2016). Evaluations of the
legislation identified outdated assumptions that have relevance to this research topic. They
include:
• “the act introduced changes that were necessary, but not sufficient, to meet the challenges
of the post-Cold War environment, and that further reform of the national security
architecture is needed” (pp. 9-10);
• “thirty years later, the strategic environment has shifted significantly” (p. 10);
• under the heading of “Emerging Threats,” “the international security environment has
become increasingly more complex and unpredictable in recent years” (p. 10);
• “the Ebola outbreak of 2014” (p. 11) which is presented as a securitization of health
concern
• under the heading of “Interagency Reform” (p. 28), “signal a whole-of-government
approach; expanding the number of State Department foreign policy advisors (or Political
Advisors) at Combatant Commands; better aligning how the Department of State and the
Department of Defense divide up geographic regions of the world” (p. 28); the goal
appears to focus on strengthening interagency cooperation.
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• “designing a Goldwater-Nichols Act for the interagency” (p. 28), as contrasted to the
current focus on the Department of Defense. The idea behind this recommendation is to
strengthen interagency institutions;
• under the heading of “Actions Recommended” (p. 29) and the sub-heading of “Strategy
Development”, “improved capabilities should be focused on trans-regional, multi-domain
and multi-functional threats, and multiple threats with overlapping timeframes” (p. 29).
For the period following September 11, 2001 (also referred to as 9/11), a key theme that
the CRS report (McInnis, 2016) identified from a 2006 Defense Quadrennial Review Report was
the “need for greater collaboration with other agencies in the national security interagency
system to manage a variety of challenges, from counterinsurgency and stability operations to
humanitarian assistance and disaster response” (p. 57). The Executive Summary of the CRS
report (McInnis, 2016) states that “some observers maintain that a reform of the broader
interagency system on national security matters is needed” (p. i).
U.S. National Security Strategy (NSS)
The NSS is utilized to convey a President’s grand strategy regarding foreign policy. The
grand strategy can be diffused across U.S. government agencies to achieve consistency in
supporting U.S. foreign policy priorities. However, “the Goldwater-Nichols Act of 1986 fails to
address the domestic agenda. When the law was published in 1986, this was appropriate for the
national security community as globalization of the economy had not reached the level of
integration that it has today. Today’s level of global integration of the world economy, and the
international structures that the United States has put into place, dictates that the domestic
agenda of the United States is now inextricably linked to the national security objectives of the
country” (Barton et al., 2018, pp. 4-5).
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The pandemic of 2020 has highlighted these interlinkages in global health. Barton et al.
(2018) makes the case that the NSS is inconsistently utilized by each Administration as its policy
roadmap once published. He suggests that “as directed by the Goldwater-Nichols Act, the NSS
will never be a complete expression of American grand strategy: administrations need to change
their NSSs to reflect a more complete American grand strategy” (p. 5). There is a gap in the
traceability from the NSS, as the grand strategy for U.S. foreign policy decision making, to a
cohesive foreign policy agenda on health. To apply the NSS effectively and consistently in
support of the President’s foreign policy priorities on global health, it would be beneficial to
include an integrated policy path for how those priorities make their way into and out of the
NSS.
Aspen Strategy Group (ASG) Papers
The Aspen Institute, according to its website, serves as an educational and policy studies
organization based in Washington, DC. Its mission is to “is to convene decision makers in
resolutely non-partisan public and private forums to address key foreign policy challenges facing
the United States” (Aspen Institute, n.d., para. 1). During a critical period domestically and
globally, it served as a convener to senior executive and distinguished leaders for four days in
August 2002. It’s guests from the public and private sectors “examined the nexus of biological
security and global public health” (Campbell & Zelikow, 2003, p. 3). The anthrax attacks of
2001 spawned the need for a discussion on “global preparedness to address extreme biologic
dangers” (Campbell & Zelikow, 2003, p. 3). The gathering identified a set of nonpartisan
recommendations that were developed into Presidential Policy Memos where the target recipient
of the policy analysis and recommendations would be respective policymakers in the White
House.
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Three concepts linking public health and biosecurity were presented in the Executive
Summary of the Final Report to aid in clarifying how policymakers view public health and
bioterror threats. The three concepts are:
1. “They are connected to research” (Campbell and Zelikow, 2003, p. 3). An emphasis
was placed on the need to conduct research with a “national and international perspective”
(Campbell and Zelikow, 2003, p. 4).
2. They are linked by surveillance and detection activities. A second emphasis was placed
on the need to “focus surveillance and detection activities nationally and internationally”
(Campbell and Zelikow, 2003, p. 4).
3. There are transnational dimensions to first response and consequence management
which requires strategies to plan for this “overlap between national and international
dimensions” (Campbell and Zelikow, 2003, p. 3) To strengthen the response to these overlapping
dimensions, the “national level should have three dimensions: an integrated system with the aim
of uniting federal, state, regional, and local action” (Campbell and Zelikow, 2003, p. 4). An
emphasis was placed on dimension one which includes leveraging a “local interagency
organization to coordinate the implementation of a national strategy” (Campbell and Zelikow,
2003, p. 5). Dimension two includes conformity to “national guidelines or templates that would
become specific only as they are developed and applied in state, regional, and local strategies”
(Campbell and Zelikow, 2003, p. 5). The final dimension is an evaluative step that uses
“systematic testing and evaluation” (Campbell and Zelikow, 2003, p. 5) to mine for lessons
learned. Lessons can emerge from “exercises or evaluative research” (Campbell and Zelikow,
2003, p. 5).
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The model of the Global Fund was highlighted as setting “an important precedent, with a
mixed government and non-governmental approach to designing a purposeful international
institution” (Campbell and Zelikow, 2003, p. 5). This represented a new business model in the
international domain that could be leveraged to “distribute the aid and manage service delivery
infrastructure” (Campbell and Zelikow, 2003, p. 5). Each of these capabilities are essential
during a global bioterror event and/or for global preparedness. A public-private partnership
model delivers value with “research, drug production and stockpiling, liability issues, and the
role of private hospitals” (Campbell and Zelikow, 2003, p. 5).
Public messaging is essential during global health disasters. Its importance has been
highlighted during the 2020 COVID-19 pandemic. Four objectives to communication are:
“establishing a knowledge base, strengthening programs of public education (national and
international), creating a contingency plan to designate lead crisis communicators within the U.S.
government, and educating the media about their responsibilities as first responders” (Campbell
and Zelikow, 2003, p. 5). Much of this still rings true during the current pandemic. The inclusion
of modern technology platforms has influenced the pace at which information moves through the
public. Getting the right messages out early and often is essential to minimizing risk to the
public.
The key organizations, domestically and globally, that were identified as essential to
carrying out responsibilities in response to a health security event included HHS, DHS, and DoD
within the USG and the G-8 internationally. Of critical note, the Aspen Strategy Group
collectively agreed that “the most powerful national and international policy initiatives should
have overlapping rationales. Americans want to protect themselves. They also want to help
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humanity. On the political front, America needs to stand for something in the world” (Campbell
and Zelikow, 2003, p. 4).
U.S. Global Health Security Strategy (GHSS)
This document was written after the 2001-2003 bounded timeframe for this research.
However, it is important for me to discuss a few documents that emerged following that
timeframe that attempt to incorporate global health with an overall objective of further distilling
what constitutes global health security, global health strategy, and a global health security
agenda (to be discussed below).
The Global Health Security Strategy (GHSS) was released by the White House in May
2019 as a new U.S. strategy document to “outline the USG approach to strengthen global health
security” (The White House, 2019, p. 5). In conjunction with the NSS, a new National
Biodefense Strategy (p. 5), and an “executive order on ‘Advancing the Global Health Agenda to
Achieve a World Safe and Secure from Infectious Disease Threats’, the GHSS is intended to
“guide the Federal Government in protecting the US and its partners abroad from infectious
disease threats by working with other nations, international organizations, and nongovernmental
stakeholders” (p. 5).
The GHSS affirms the value of a “coordinated, multisectoral approach” “between human,
animal, and environmental health” (p. 5) in thwarting disease threats.” The Global Health
Security Agenda (GHSA), described next, is the collaborative agreement with international
partners that creates the vehicle for multilateralism and to uphold the provisions of the
International Health Regulations (IHR), also described below.
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U.S. Global Health Security Agenda (GHSA)
The GHSA which was launched in 2014 and was developed by “nearly 30 countries and
international organizations” (www.ghsagenda.org, p. 2). It is now “comprised of a group of 65
countries, international organizations and non-government organizations, and private sector
companies that have come together to achieve the vision of a world safe and secure from global
health threats posed by infectious diseases” (p. 2). It is a “collaborative, multi-sectoral initiative”
that serves as a catalyst for progress toward global health security (p. 2). A 2024 framework
outlines goals and objectives for multi-sectoral and multi-lateral cooperation to collectively pool
resources to fight common threats. Strategic objective #3 aligns well with the focus of this
research, indicating that participants should “strengthen and support multi-sectoral engagement
and commitment to health security” (www.ghsagenda.org, p. 5). Global health security goals are
garnering political support and the White House has offered a multi-year commitment as a
country partner (Gronvall et al., 2014). A workshop entitled “One Health Security,” convened by
the Department of Homeland Security (DHS) and held in January 2014, included security
professionals alongside health and veterinary health professionals. Outputs from that forum
included an acknowledgement that the integration of health and security professionals is
necessary to achieve a “One Health Security” objective (Gronvall et al., 2014, p. 221). Execution
of this strategy across “security, agriculture, and health sectors is needed in the GHSA. It will
remain complicated to integrate these diverse disciplines. Nonetheless, the objectives of the
GHSA depend on the integration of One Health concerns as well as security and law
enforcement to adequately prevent, detect, and respond to emerging natural and deliberate
biological threats” (Gronvall et al., 2014, p. 223).
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International Health Regulations (IHR)
The HIV/AIDS epidemic is an example of an event that served as a catalyst to changes in
the IHR. The recognition that new disease threats were emerging and that “globalization
facilitated the rapid spread of these diseases” led to a resolution at the 1995 World Health
Assembly (WHA) to revise the International Health Regulations. (Katz et al., 2010, p. 2). The
resolution focused on a better way to address contemporary realities and aid in global
governance of disease reporting and responses (Katz et al., 2010). “The existing regulations
contained no answer, either in disease surveillance or response, to the growing international
HIV/AIDS crisis. The tools available to govern the international response to cross-border
outbreaks had clearly become inadequate” (Katz et al., 2010, p. 2).
The International Health Regulations (IHR) were passed by the World Health Assembly,
a “decision-making body” of the World Health Organization (n.d.), in 2005. The purpose of the
IHR is to “prevent, protect against, control and provide a public health response to the
international spread of disease in ways that are commensurate with and restricted to public health
risks, and which avoid unnecessary interference with international traffic and trade” (Katz et al.,
2010, p. 2). The IHR has undergone many revisions since the 1990s as global health threats
emerge.
The inadequacies identified in the IHR which led to subsequent changes is a narrative
that continues to this day as the WHA grapples with country reporting expectations in the wake
of the pandemic of 2020. The strength and value of the IHR is optimized when all countries who
agree to participate fulfill the obligations inherent to the document.
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USAID Policy Framework
The U.S. Agency for International Development (USAID) was created by executive order
in 1961 by President John F. Kennedy and its purpose is to “lead the US government’s
international development and humanitarian efforts” (USAID, 2019, para. 2).
According to the most recent version (April 10, 2019), the USAID Policy Framework is
aligned to the NSS goals and the USAID Joint Strategic Plan (JSP) (p. 6). The framework is
intended to inform USAID personnel and programs, and country teams serving abroad, about
budget priorities in development assistance and humanitarian responses. It serves as an
overarching policy document for activities under the jurisdiction of USAID.
The USAID Policy Framework was developed with an intentional focus on incorporating
elements of the grand strategy, the NSS, into the international development assistance policy
priorities and agenda. “U.S. foreign assistance complements America’s defense and diplomacy.
Our work to foster self-reliance is an essential tool to safeguard U.S. national security. These
programs curb threats at their source, bolster our economic opportunities and commercial ties,
advance liberty and democracy, extend U.S. influence, and ensure we stand with those in need
when disaster strikes” (p. 8). Real world events will always emerge that cannot be fully
accounted for in a static document. However, the framework demonstrates an intentional focus
on linking the health policy agenda to U.S. foreign policy. USAID is a key stakeholder in the
GHD arena working alongside defense and diplomatic resources of the United States.
Congressional Research and Bills
The authorizing legislation for U.S. participation in the multilateral Global Fund to Fight
AIDS, Tuberculosis, and Malaria and the bilateral participation through NGOs (including faith-
based and community organizations) and international organizations to combat HIV/AIDS,
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tuberculosis, and malaria is the United States Leadership Against HIV/AIDS, Tuberculosis, and
Malaria Act of 2003. It became public law on May 27, 2003. Authorization for the President to
establish programs to meet the objectives and to operationalize the appropriations for each were
also specified in this authorizing statute.
To complement the GHSA themes of health, security, and integration of disciplines
focused on global health security threats, the U.S. Congress currently has two bills proposed in
the 116
th
Congress. The Global Health Security and Diplomacy Act of 2020, was introduced on
May 21, 2020, by Senator James E. Risch (R-ID). The purpose of this bill is “to advance the
global health security and diplomacy objectives of the United States, improve coordination
among the relevant Federal departments and agencies implementing United States foreign
assistance for global health security, and more effectively enable partner countries to strengthen
and sustain resilient health systems and supply chains with the resources, capacity, and personnel
required to prevent, detect, mitigate, and respond to infectious disease threats before they
become pandemics, and for other purposes” (para. 1). The key highlights of the bill include
recommendations to establish a “Coordinator of United States Government Activities within the
Department of State to Advance Global Health Security and Diplomacy overseas, who shall be
appointed by the President” and that “the President should consider appointing an individual
serving on the National Security Council, at the senior director level or higher and with
significant background and expertise in public health, health security, or emergency biological
response management, to convene and coordinate the interagency process of the Federal
departments and agencies” (Global Health Security and Diplomacy Act of 2020). While the bill
has not advanced beyond a single hearing, the content of the bill reflects ongoing efforts within
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the USG to explore the organizational structures in support of global health security and
diplomacy.
Finally, insights about the Congressional agenda and policy formation for the two cases has
been harvested from Congressional Research Services (CRS) reports. A comprehensive
summary of the policymaking activity associated with PEPFAR can be found at the Kaiser
Family Foundation’s website (Kaiser Family Foundation, 2020a, 2021).
A comprehensive database of annual reports for the Global Fund to Fight AIDS,
Tuberculosis, and Malaria can be found at the Global Fund’s website (www.theglobalfund.org).
Interviews
My primary data collection method was elite interviews, which Rodríguez-Teruel and
Daloz (2018) identify as a preferred method for empirical research on elite activities. Elite
research participants are defined as “individuals and small, relatively cohesive, and stable groups
with disproportionate power to affect national and supranational political outcomes on a
continuing basis” (Rodríguez-Teruel, 2018, p. 3). According to Harvey (2011), social scientists
are “increasingly interested in understanding the perspectives and behaviours of leaders in
business, politics, and society as a whole” (p. 3), and interviews are frequently used to acquire
this information. It is an economical way to collect data for elite studies and puts a “high degree
of control of the process of inquiry in the researcher’s hands” (Rodríguez-Teruel & Daloz, 2018,
p. 95). The goal was to learn from the lived experiences of the elite research participants to gain
greater insight into how the health policy agenda is formulated into U.S. foreign policy and for
what value. Through interactions with interviewees, I gained insight into the key drivers moving
health from a low politic issue (human dignity and development) to a high politic issue
(alongside security and economics) (Fidler, 2005) in U.S. foreign policy. I was also able to
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uncover how domestic policy actions linked to the international/foreign policy actions which led
to transnational policy insights.
Participants
I conducted interviews with a diverse group of elite participants to help identify the key
policy entrepreneurs who led to the development of The Global Fund and PEPFAR initiatives
during the period of 2001-2003. Prospective research participants were initially identified
through a combination of purposive selection based on contributions in the literature on this
research topic and/or facilitated introductions by research faculty familiar with my topic.
Following the first introductory call with a prospective participant, a “snowballing” process
contributed to the identification of additional research participants, who were then contacted via
email. If referred by another party, I received permission by that person to include his/her name
in the “Subject line” of the introductory email. The introductory email included two attachments:
my resume as the Principal Investigator and an introductory memorandum summarizing my
research topic and focus (see Appendix A).
Three individuals who were sent outreach emails and/or follow-up phone calls never
successfully established contact with me and/or failed to respond at all. One individual with
whom I established contact via email was not able to participate due to contractual agreements in
place. Ultimately, 14 people agreed to participate in the study, and I held an introductory
telephone call with all but three of them, who had scheduling constraints. As none of those I
spoke with during these calls declined to be interviewed, a recorded Zoom session was
subsequently scheduled. For the three participants who did not participate in an introductory call,
it was more efficient just to schedule the Zoom interview. Also, one person who did participate
in an introductory call was then not available for an interview within the allowable timeframe for
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this research. In summary, then, out of the 14 participants, 11 of them took part in both the
introductory call and the interview. One invitation to participate in this research was turned down
due to a professional conflict. Five participant invitations did not yield responses. One additional
semi-structured interview invitation was accepted but couldn’t get scheduled due to professional
time constraints.
The interviewees were individuals who have held senior or appointed roles in global health,
national security, and/or U.S. foreign policy decision making (see Appendix B). The participant
population is this research includes past USG senior policy entrepreneurs who crafted or were
associated with the period (2001-2003) of crafting the PEPFAR and Global Fund Initiatives.
Participants may also be associated agency staff from U.S. Congress, U.S. Health and Human
Services (HHS) and or other State Department staff. Some participants have retired and are now
working in the private sector. Private sector executives who were engaged in policymaking for
these initiatives also participated. Only U.S.-based participants were included in this research.
A richly diverse group of participants is included in this research. Male and female
participants are represented. The range of disciplines and programs included in this research
include public, private, and plural sector representatives; professional expertise in GHD; national
security; foreign policy; foreign service and diplomacy; Congressional policymaking; policy
analysis and diffusion; global health policy; medicine and science; academia; advocacy
coalitions; and law.
Interview Process
An introductory conversation (usually 20-30 minutes in length) was utilized to share an
overview of the research project, dialogue with prospective participants to gain a general
understanding of their public or private sector role in relation to the cases, and to invite their
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participation in a recorded interview session using the Zoom video platforms. Notes taken during
these calls are included as synthesized meta data in this research. This means that interpretations
I made from notes taken during the initial calls are incorporated with the primary data collected
during the subsequent interviews to add context or meaning. The goal of meta-synthesis is
“interpretive not aggregative” (Jensen & Allen, 1996, p. 554).
Semi-structured interviews were administered utilizing an interview guide (see Appendix
C). The interviews were recorded utilizing the Zoom meeting platform and a back-up hand-held
electronic recording device. The Zoom session included a review of an information sheet
provided to participants ahead of time, and verbal consent to record was obtained from each
participant. Two participants requested prior approval of any of their anonymized quotes to be
included in the summary of findings. Whereas Kingdon (2007) did not take notes during his
interviews for his research on Congressional voting decisions (an elite interview population),
which he explains was to foster trust and to enable forthcoming responses, I did take notes
during each interview. Audio files of the recorded interviews were subsequently transcribed to
create a textual database. The interviews were conducted in compliance with the USC IRB-
approved format, and the audio files, Zoom video files, and written transcription records will be
maintained in accordance with USC IRB protocol.
Data Coding and Analysis
Transcripts, produced from recorded Zoom interviews, and field notes from introductory
calls were utilized to code data. Utilizing thematic analysis (TA), which Braun and Clarke (2013)
describe as the process of analyzing qualitative data to look for themes and patterns, I went
through each transcript and field note and made notations of key points made by participants.
This process of reviewing transcripts and field notes was replicated over and over until I began to
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see patterns across the participant population and no new themes emerging. Braun and Clarke
(2013) describe this as “saturation: the point when additional data fails to generate new
information” (p. 55). I created a code book to summarize the themes and this process required an
eventual winnowing to a reasonable number of overarching codes. Data was hand coded. I did
not utilize qualitative data analysis (QDA) software for this project due to access and training
constraints associated with the COVID pandemic.
To compile the codebook, I used a numbering system aligned to a theme and began
annotating those numbers alongside of each instance in a transcript or field note. Once I had
coded all the data with the numbering system associated to each theme, I analyzed the data
further to tease out the patterns of subthemes. I isolated 10 themes in total.
I utilized subthemes that reflected the essence of the participants’ meaning. Upon the
completion of the coding of themes and identification of subthemes, I developed a spreadsheet
that summarized the instances of coded themes for each participant. The summaries were broken
into two groups: recorded sessions with the interview guide and field notes (meta data). A final
summary of all the instances was tallied on the spreadsheet as well. A brief description of the
coded categories will be provided in Chapter 5.
The elite interview research method will be supported by a document review.
Triangulation is defined by Braun and Clarke (2013) as the process by which “two or more
methods of data collection or sources of data are used to examine the same phenomenon” (p.
285). An effort will be made to triangulate the data from the participant interviews with public
documents associated with the two cases in this research and documents made known to me
through the course of the individual participant interviews.
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Overview of Two Historical Cases
This research focuses on the analysis of two historical cases of global health policy: The
Global Fund to Fight AIDS, Tuberculosis, and Malaria, and the President’s Emergency Fund for
AIDS Relief (PEPFAR) (Orza et al., 2007). The origins of the Global Fund are well-documented
in a Congressional Research Service Report by Copson and Salaam (November 6, 2003). It was
established as a financing vehicle to distribute resources to developing countries who were
challenged in their efforts to fight infectious diseases (Copson and Salaam, 2003). It contrasts to
USAID as its focus is not on development, whereas, USAID is. The origins of the Global Fund
are traceable to several key events leading up to the establishment of it being headquartered in
Geneva, Switzerland.
The conceptualization of the Global Fund arose in April 2001 when UN Secretary
General Kofi Annan “urged the creation of an independent funding vehicle” to aid African
countries in their fight against HIV/AIDS (Copson and Salaam, 2003). The United States
pledged $200M in a “founding contribution” to the Fund (Copson and Salaam, 2003, p. CRS-2).
In July 2001, at a G-8 summit meeting (comprised of “industrialized countries plus Russia) in
Genoa, Italy, the Global Fund was endorsed by the UN General Assembly with a focus on
establishing it as a public-private partnership with sufficient funds to operate by the end of 2001
(Copson and Salaam, p. CRS-2). The Global Fund is an example of a multilateral agreement
where many partnering nations are engaged in a cooperative international agreement to support
the mission to finance strategies to thwart infectious diseases in developing countries.
PEPFAR, in contrast, is an example of a bilateral initiative. It emerged in a January 2003
State of the Union Address by President Bush (Copson, 2005). The background of PEPFAR is
also well-document in a Congressional Research Service Report by Copson (November 3, 2005).
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The implementation of PEPFAR, “which was authorized in May 2003, brought together the
Clinton Administration’s 1999 LIFE (Leadership and Investment in Fighting an Epidemic
initiative and the CDC under HHS into one effort” focused on the prevention and treatment of
HIV/AIDS (Copson, 2005).
I will examine the historical and developmental period of these initiatives, from 2001-
2003, based on an analysis of primary data collected through semi-structured interviews with
elite research participants as well as secondary data available in a set of public documents. This
bounded timeframe ensures that the research focus doesn’t become too broad and instead focuses
on a period when there were accompanying events associated with terrorism that shaped the U.S.
foreign policy strategy during this time.
My role as a researcher is to make sense of the complexity of U.S. foreign policy-making
decision-making by identifying patterns or themes that help to clarify how the health policy
agenda was advanced in these two cases. These two cases are relevant to my research questions
because they provide examples of how, from an inchoate agenda, big policies can emerge; they
highlight the complexity involved in global health issues as a policy agenda; they draw in the
strategic discussions framed around the formulation of the NSS and where health fits in its
relationship to security and economics (in USG executive decision making); and they offer an
opportunity for reflection on health in U.S. foreign policy as we begin to emerge from a
pandemic. Domestic and international leaders are once again faced with a global crisis. The
personal narratives gained through semi-structured interviews shed light on the innerworkings of
the establishment of these model initiatives.
Case research is used to “illuminate a decision or set of decisions” to gain an
understanding about “why they were taken, how they were implemented, and with what result”
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(Yin, 2018, p. 14,). The interlinkages of health, security, and economics have been illuminated
during this pandemic in 2020/2021. Similar themes emerged across during the implementation of
these two case initiatives in response to the HIV/AIDS epidemic.
In the paragraphs that follow, I provide an overview of key events that led to the
implementation of the Global Fund to Fight AIDS, Tuberculosis, and Malaria followed by The
President’s Emergency Plan for AIDS Relief (PEPFAR). The chronology of their
implementation periods is overlapping; however, they tell different stories.
The Global Fund to Fight AIDS, Tuberculosis, and Malaria
According to Ruckert et al. (2016), the Global Fund, which was created in response to the
HIV/AIDS pandemic, could serve as “an effective model for a global regime; not through a
single governmental agency, but a broad collaboration between private, non-state actors and
governments across cooperating institutions” (p. 10). It is an example of multilateralism as
defined in the authorizing statute, the Global AIDS and Tuberculosis Relief Act of 2000.
According to a Congressional Research Service (CRS) report, the Global Fund was
“established in Geneva, Switzerland, in January 2002” (Copson et al., 2005, p. CRS-1). It is a
grant-making organization that distributes funds to developing countries for the purpose of
impacting the incidence of HIV, tuberculosis, and malaria (Copson et al., 2005). The fund is
governed by a board of directors consisting of “representatives from seven donor countries and
seven developing countries” (Copson et al., 2005, p. CRS-1). In addition to the representatives
above, the board “also includes one representative from a developed country NGO, a developing
country NGO, the private sector, a contributing private foundation, and the community of people
living with HIV/AIDS, tuberculosis, and malaria” (Copson et al., 2005, p. CRS-1). The Global
Fund is not attached to the United Nations. Rather, it operates as an “independent foundation”
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(Copson et al., 2005, p. CRS-1). As an independent organization, it collaborates with agencies of
the UN, aid organizations, and NGOs who share a desire to eradicate and/or treat HIV,
tuberculosis, and malaria (Copson et al., 2005). At the time of the 2005 CRS Report, the Fund
projected that “over five years, the 313 grants it has approved in 127 countries will result in 1.6
million patients receiving antiretroviral (ARV) therapy for the treatment of AIDS, as well as
treatment of 3.5 million additional cases of TB” (Copson et al., 2005, p. CRS-1).
The origin of the Global Fund’s independence is traceable to a speech on April 26, 2001
by the UN Secretary General, Kofi Annan to “African leaders gathered at a summit on
HIV/AIDS and other infectious disease in Abuja, Nigeria” (Copson et al., 2005, p. CRS-2). On
May 11, 2001, President George W. Bush made a “founding pledge of $200 million to the
Global Fund” (Copson et al., 2005, p. CRS-2). It was important to the United States that the
Global Fund be established as an independent “public-private partnership drawing upon
contributions of private corporations, foundations, faith-based organizations, and NGOs”
(Copson et al., 2005, p. CRS-3). The United States did not want the Global Fund to be set up
within the United Nations. In June 2001, the UN General Assembly Special Session on
HIV/AIDS (UNGASS) endorsed the establishment of the Global Fund. In July 2001, the “Group
of Eight (G-8)” met at a summit “of industrialized countries plus Russia” in Genoa, Italy to
“affirm that the Global Fund would be a public-private partnership” and to “make the fund
operational by the end of the year” (Copson et al., 2005, p. CRS-3).
At the time of the 2005 Congressional Research Service (CRS) report the United States
had representation on the Global Fund Board when Secretary of Health and Human Services
Tommy Thompson served as its Chairman. The Executive Director of the Global Fund at its
inception was Dr. Richard Feachem, a British physician (Copson et al., 2005, p. CRS-1).
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The mission of the Global Fund is to serve as a “financing instrument complementing
existing programs with an intent to attract, manage, and disburse additional resources, rather than
re-channel existing resources” (Copson et al., 2005, p. CRS-2). It distinguishes itself from an
organization such as USAID (housed in the Department of State). Rather, it is a “fiduciary agent
designed to direct new resources to programs in countries in need, rather than an agency that
implements projects” (Copson et al., 2005, p. CRS-2). The Fund is supported by the World Bank
as the fiduciary agent where contributed funds from donors can be received and disbursed
(Copson et al., 2005).
In July 2000, the United Nations Security Council adopted Resolution 1308 in response
to growing concerns about the impact of the HIV/AIDS crisis on economic stability and regional
security. A key concern was the exposure to the disease on UN peacekeeping troops in the
affected regions. So, it arose as a security concern for uniformed personnel, their movement and
training in-country, and the prospects for destabilization and violence depending upon the impact
on uniformed personnel continuing to perform in their current roles.
In June 2001, a Special Session of the United Nations General Assembly was convened
in New York to address the epidemic of HIV/AIDS and to discuss the need for resource
mobilization to the affected areas. The epidemic had an impact globally which necessitated the
coming together of state and non-state actors in a collaborative forum to brainstorm and marshal
resources to develop a strategy to fight the disease, to deter economic destabilization, and to
move as quickly as possible in this unfolding, global emergency. The output of the General
Assembly was its Declaration of Commitment on HIV/AIDS, signed on June 27, 2001. This is a
non-binding commitment.
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The Declaration of Commitment (2001) stated that “by the end of 2000, 36.1 million
people worldwide were living with HIV/AIDS, 90 per cent in developing countries and 75 per
cent in sub-Saharan Africa.” According to Salomoni (2006, p. 1), the World Health Report 2001
indicated that “HIV/AIDS had become the 4
th
leading cause of death and 3
rd
leading cause of
disability-adjusted life years (DALYs) globally.” This epidemic signaled a global emergency.
Global health events can wreak havoc on world economies, as we are seeing in this 2020
pandemic, and raise concern for societies around the world. In response, the Declaration of
Commitment included, as one of its provisions, “the establishment of a Global HIV/AIDS Health
Fund to finance an urgent and expanded response to the epidemic based on an integrated
approach to prevention, care, support and treatment.”
The 15-page Declaration included a call-to-action, made a commitment to hold summits
for ongoing planning and discussion, and highlighted actions at the global, national, and regional
levels. It also discussed the human rights impact of HIV/AIDS, including attention to the
children orphaned and made vulnerable by HIV/AIDS”. The impact of the HIV/AIDS epidemic
on women and children played a role in shaping the U.S. political and policy narratives about
those affected by HIV/AIDS and acted as a catalyst to the creation of PEPFAR. It was no longer
seen as a disease solely associated with homosexual behavior, but also affected families,
heterosexual couples, and society-at-large.
The World Trade Organization (WTO) convened a conference of Ministers of Trade in
Doha, Qatar. An outcome of that meeting was the Doha Declaration that was issued in December
2001 (McInnes et al., 2020). “The Doha Declaration was a watershed moment that cleared the
way for large-scale purchase of generic medicines by governments and donors” (McInnes et al.,
2020, p. 615). The WTO website provides more detail about the legal and statutory relationship
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between the Doha Declaration within the Trade-Related Aspects of Intellectual Property (TRIPS)
agreement. “The TRIPS Agreement, negotiated during the 1986-94 Uruguay Round, introduced
intellectual property (IP) rules into the multilateral trading system for the first time. It establishes
minimum standards for the protection and enforcement of IP that each Member has to accord to
the nationals of fellow WTO Members” (World Trade Organization, 2021). Following the Doha
Declaration, generic antiretrovirals could begin being imported by participating countries and
“the Global Fund became the largest purchaser of generic HIV medicines” (McInnes et al., 2020,
p. 615).
The President ’s Emergency Plan for AIDS Relief (PEPFAR)
PEPFAR, the U.S. President’s Emergency Plan for AIDS Relief, was established in 2003
and resulted from a bipartisan effort by the U.S. Congress (www.pepfar.gov). At the time of its
inception, HIV/AIDS “threatened the very foundation of society by creating orphans, destroying
families as a stable unit, halting economic development, and leaving countries in a poverty
spiral” (Bipartisan Policy Center, 2015, p. 10).
According to the Kaiser Family Foundation (2020a), “PEPFAR is the largest
commitment by any nation to address a single disease in the world; to date, its funding has
totaled more than $90 billion, including funding for the Global Fund to Fight AIDS,
Tuberculosis and Malaria (Global Fund), to which the U.S. government is the largest donor”
(para. 2). Announced in a State of the Union (SOTU) address by President George W. Bush in
2003, it is described “then, and remains today, by far the largest investment ever by any
government to address a single disease” (Daulaire, 2012, p. 1573).
PEPFAR is an example of bilateral policy development. “The Congress declares that the
principal purpose of United States bilateral development assistance is to help the poor majority
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of people in developing countries to participate in a process of equitable growth through
productive work and to influence decisions that shape their lives, with the goal of increasing their
incomes and their access to public services which will enable them to satisfy their basic needs
and lead lives of decency, dignity, and hope” (Foreign Assistance Act of 1961). The bilateral
efforts to combat HIV/AIDS are described in the United States Leadership Against HIV/AIDS,
Tuberculosis, and Malaria Act of 2003. This public law is the enabling statute for PEPFAR,
effective May 27, 2003. This section of the statute was used to update the Foreign Services Act
of 1961 where assistance to combat HIV/AIDS is inserted. It also brought the “bilateral
international AIDS projects through the US Agency for International Development (USAID)
since the mid-1980s, the Clinton Administration’s 1999 LIFE (Leadership and Investment in
Fighting an Epidemic) initiative, CDC and prevention efforts by HHS into a single program” led
by a “Global AIDS Coordinator” headed by Ambassador Randall Tobias (Copson, 2005, CRS-
3). A detailed timeline of events leading up to the implementation of PEPFAR can be found in
the Presidential Oral History project and interview of Mark R. Dybul on December 6, 2016
(Miller Center, 2016).
The PEPFAR program, while housed in the U.S. State Department, operates under
interagency cooperation within the U.S. government. Furthermore, collective action across the
public and private sectors led to policy success, and the role of diplomats in this effort was
instrumental in bridging the sectors. PEPFAR can and should serve as a model program when
seeking to develop other global public health development programs post-pandemic 2021.
The cooperation between PEPFAR and the Global Fund has resulted in “20 million
people accessing life-sustaining anti-retroviral treatments” minimizing the effects of HIV/AIDS
on affected individuals and communities (Summers, 2017, p. 1). Sustaining these programs will
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require data to demonstrate their ongoing effectiveness and accountability shown by recipient
countries, bipartisan Congressional support to fund appropriations, and a commitment to
continuing to support these initiatives as a global leader. Next steps for each program were
identified by the Center for Strategic and International Studies in 2017 and they included
recommendations to leverage diplomacy to “apply pressure to secure greater engagement by
affected countries and to translate sustainability assessments being conducted by PEPFAR and
the Global Fund into action plans” (Summers, 2017, p. 6). Sustainability of these programs in
their fight against infectious diseases, in particular, HIV/AIDS should remain a strategic priority
of the United States.
In the next chapter, findings from the data collection process will be summarized.
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CHAPTER 5: FINDINGS
This chapter provides a summary of the findings from document review and elite
interviews. This research focused on the historical cases of the Global Fund and PEPFAR, and
respondents could comment on one or both cases based upon their knowledge, roles, or lived
experiences associated with the establishment of these two initiatives. In the interviews,
participants moved between reflection and explanation based on their experiences with global
health policy issues and threat events. The narratives offered by the interviewees add rich,
behind-the-scenes knowledge about the implementation of these initiatives.
It is not the intent of this research to provide a detailed examination of these cases, the
Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund) and the President’s
Emergency Plan for AIDS Relief (PEPFAR). Rather, these cases were chosen for this GHD
research because they provide a sampling of U.S. bilateral and multilateral health initiatives that
can be utilized to apply the analytical frameworks of Kingdon’s Multiple Stream Framework
(MSF) (2011) and Zelikow-Allison’s (1999) Conceptual Models.
Many resources are available in the public domain that have tackled this effort. Some
examples include the comprehensive research and policy analysis conducted by the Kaiser
Family Foundation (n.d.); the Health Affairs article by John Donnelly (2012), the book on
Heroic Conservatism by Michael Gerson (2008), the Oral History Project by the Miller Center at
the University of Virginia (Miller Center, 2016), a study of 15 years of PEPFAR (Bipartisan
Policy Center, 2018), and a “A Diplomat’s Perspective on Use of Science and Evidence in
Implementing PEPFAR” (Kolker, 2018). Several others are noted in the reference list.
I started this research conceptualizing executive policy making prominently from the lens
of power, politics, and agenda setting. From information gained about the two cases (PEPFAR
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and the Global Fund), and accompanying personal stories obtained from semi-structured
interviews, I ended up discovering moral courage. This rose above power, politics, policy, and
agenda setting. It takes leaders and champions at the top to drive policy windows of opportunity.
The global health policy process is not linear. It seems to be a “bottom-up diplomacy”
where it percolates, driven by advocates, up to a foreign policy agenda (if not naturally arriving
there as part of biosecurity/bioterrorism at the level of the National Security Council or
Department of Homeland Security (DHS)). Security and economics, in contrast, get incorporated
more readily into foreign policy from the top down. How health gets conceived as a policy issue
determines how it is framed.
Analyzing these public and global health policy cases was also not a linear process.
Fafard (2021) states that “public health and health policy researchers often rely, if only
implicitly, on a linear model of policy making where, if good data are provided, good policy
decisions will follow. In this model, a policy decision is seen as an exercise in applied problem
solving. A problem is defined, and evidence is gathered or generated, that offers a solution to the
problem; this evidence is transferred to a decision maker who acts based on the best available
evidence. This dominant model has been modified to encourage what some call “integrated
knowledge translation”: collaboration between researchers and decision makers on how the
problem is defined” (p. 909).
Utilizing thematic analysis, data were sorted into coded themes and associated
subthemes. Ten overall themes, along with several sub-themes, emerged from the interviews.
The ten themes are:
1. The rise of health on the global policy agenda
2. Global governance and aligned incentives
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3. Agenda setting, politics, and negotiations
4. Moral imperatives and the global public good
5. Champions and leaders
6. Wicked problems and design thinking
7. Pivotal/seminal changes
8. Cycles of complacency in public health
9. Public perceptions shape transnational cooperation
10. Modernize U.S. foreign policy and strategy
These themes highlight ten categories of participant observations related to the decision-
making that led to the establishment of the two initiatives and the challenges that remain in
advancing global health priorities in U.S. foreign policy. The observations addressed by the
themes include the role of unitary actors in championing broad policy initiatives, the
contemplative actions by the United States in its post-Cold War transition from hard power to
soft power ideology, the challenges associated with addressing transnational health policy issues,
and advancing the interest of the public in global health policy events. Together, they highlight
drivers behind executive, legislative, and USG organizational decision-making.
These themes and related sub-themes, described in detail below, are relevant to the
research questions in three ways. First, the themes string together to form the skeletal structure of
two historical initiatives. As if following a plot in a novel, the themes clarify how a rudimentary
agenda becomes a policy initiative. Second, they highlight the roles of various actors involved in
establishing the two case initiatives. This is important in sorting out how Zelikow-Allison’s
models inform the foreign policy agenda. Third, they display the barriers and opportunities
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associated with advancing health in U.S. foreign policy and the key role of policy entrepreneurs
in preparing the window of opportunity.
Themes and Subthemes
The ten categories of themes presented in the forthcoming pages were derived from
participant responses and reflect an integration of information from both cases collectively. The
interview guide was framed utilizing Kingdon’s Multiple Stream Framework (MSF). Utilizing
the cases within a bounded timeframe, and the National Security Strategy (NSS) as a mental
framework, participants could comment on their individual experiences and observations during
the time of the implementation both cases. Their responses were shaped by where they sat or
stood, what position they held, or what part of the puzzle piece they held as PEPFAR and the
Global Fund were operationalized.
The Rise of Health on the Global Policy Agenda
Health has continued to gain prominence on the global policy agenda following SARS,
Avian Influenza, Ebola, and now the COVID-19 pandemic. It has also risen within the context of
other associated global problems: poverty, climate change, and immigration. Bioterror, such as
the anthrax attacks in the United States (coinciding with 9/11), the sarin gas attack in Tokyo
(1995), and other weaponized uses of biologics rose to the level of health as a security issue. The
collective drum beat of these bioterror instances and associated complex policy issues have
contributed to the rise of health on the global policy agenda. Despite its rise on the global policy
agenda, participants did not feel that it was being treated as a high politic issue. Participant 7
stated that “for the most part, the people who decide foreign policy are people who come from
the military and the economic and security realms. They saw global health as something nice you
do for poor people. It’s an act of charity and it shows what a nice country America is. But it’s
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not fundamentally contributory to a real sense of national security or well-being for the US”.
This is an example of a barrier to health’s prominence on the U.S. foreign policy agenda.
Barriers to health’s prominence on the global policy agenda can be accounted for simply
by its lack of a unifying definition. Participants described that it depended upon who you were
talking to about it and what domain of practice they reside within- much like GHD, there is no
unifying definition. Health gets contextualized within biosecurity, development, health care
delivery systems, and human security. Sorting each of this into categories of health or health
threats into a quadrant or matrix decision-making tool suggests that there are absolutes that make
that sorting and the lines between each distinct. However, as has been evident in the pandemic,
there is a blurring of the lines between traditional and human security. The security matrix does
not provide a dynamic decision-making tool for sorting through these nuanced categories of
health and health related events. More work is needed to develop a robust interdisciplinary
decision-making tool to more consistently advance health as a global policy agenda priority.
The Confluence of Domestic and International Agendas
Global issues, such as poverty, climate change, and disease threats have intensified policy
priorities which make it difficult to isolate where the domestic agenda and international agendas
begin-and-end. According to Jacobson (2020), there was a significant increase in the incidences
that HIV/AIDS was mentioned as a global concern during the period of 2001-2003. “94 per cent
of mentions from W. Bush in this period were coded as global, as his administration prepared for
the enactment of PEPFAR” (p. 153). This is highlighted because it contrasts to how it had been
previously mentioned primarily as a domestic concern. Participant 4 stated that “there is an
absolute connection between domestic and international health activities”.
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Contrasted to the prior periods during the “Reagan, H. W. Bush and Clinton years, the presidents
spoke primarily of HIV/AIDS in a domestic context, where the majority (65%) of mentions from
1981 to 2001 were coded as domestic” (Jacobson, 2020, p. 153). There is a trend that more aptly
reflects that agendas have moved transnationally. This necessitates that policy makers devise
strategies with a consideration of how international issues, threats and opportunities, impact
domestic policymaking.
Health as an Investment
The Global Fund, as a multilateral organization, is representative of the international
interest in global health as an investment. Cooperative investments in health benefit from
alignment in foreign policy views.
Participant 11 stated that “health is wealth and wealth is health. Investments in health
are investments in economic growth and in the well-being of a country and a region.”
The U.S. Congress, as the policymaking body of the USG, debated the governance
structure of the Global Fund and was reticent of its affiliation with the United Nations. Health as
an investment is not devoid of political constraints. During this period, Congress described the
Global Fund and its independent governance as “the acceptable face of multilateralism”
(Participant 11).
At the outset of the Global Fund, relationships were strained between the United States
and France over the foreign policy views of the events leading up to the post 9/11 Iraq War, with
each taking different positions. Despite these differing views on one foreign policy issue, global
health presented an opportunity to collaborate as U.S. and European partners contributed to the
Global Fund. This transatlantic partnership, and associated complexities, is playing out again in
the global health arena as the United States resumes its affiliation with the WHO in 2021. The
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United States has been a leading contributor to PEPFAR and the Global Fund. Its interest in
maintaining a partnership with the UN and affiliated WHO aligns with a strategic objective to
continue to invest in global health.
Burden Sharing and Resource Harmonization
The pandemic has highlighted that a timely and effective response to global health events
cannot be achieved by any one country alone (no matter how powerful) and that global
cooperation is required. This becomes complex as it relies upon existing relationships and the
ability to do so within a supportive international, legal, and regulatory framework. A stable
world, conceptually, allows for “global prosperity, global security, and the alleviation of
extreme poverty” (Participant 11). Sharpening this narrative is an area where GHD can play a
role in bringing state and non-state actors together to support burden sharing and resource
harmonization. More information can be found on this topic through the robust research and
modeling by the University of Washington’s website (Institute for Health Metrics and
Evaluation, 2015).
A study, supported by the Global Burden of Disease Health Financing Collaborator
Network, examined global health financing from 1995-2014. It looked at development assistance
recipients, the organizations responsible for disbursement, and relational contributions by
country income. The study found that “health spending remains disparate, with low-income and
lower-middle-income countries increasing spending in absolute terms the least, and relying
heavily on out-of-pocket (OOP) spending and development assistance” (Dieleman et al., 2017, p.
1981). “If you look at the WHO budget, the large percentage of it is provided by voluntary
contributions from governments, as well as organizations such as the Bill and Melinda Gates
Foundation, and only a minor percentage of its budget is through assessed contributions”
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(Participant 2). The growth of non-state actors, and the proportional share of their voluntary
contributions to the WHO, is poised to drive a policy discussion within the governing body of
the WHO as voluntary contributions grow disproportionately to assessed contributions. Pharma
will be a key player in 2021, similarly as they were during the antiretroviral pricing was during
the HIV/AIDS epidemic. Discussions of vaccine diplomacy continue to grow on the heels of the
pandemic. The public and private sector have demonstrated an interest in health as an
investment. The profound effects that global health events have had on economies will contribute
to further interest in this area.
Coalitions and Social Networks
Technology has provided opportunities for coalitions and networks to organize quickly.
While the Bush Administration was able to secretly plan for the rollout of PEPFAR (Gerson,
2008), similarly as President Kennedy was able to keep a tight hold on his decisions relating to
the Cuban Missile Crisis (Zelikow & Allison, 1999), the availability of social platforms to spread
information rapidly and to hold governments accountable to its citizens has intensified.
Coalitions and networks were instrumental in raising awareness of the AIDS crisis. The
disease was characterized as a homosexual disease domestically. When women and children
were identified as victims of the disease, new participants joined in the effort to compel the USG
to act in response to “10 million AIDS victims and the orphans they leave behind” (Gerson,
2008, p. 1). Despite the Global Burden of Disease Index in 2002 (Mathers et al., 2004, p. 56)
reflecting that other disease states (and associated non-communicable diseases-NCDs) had a
higher incidence than HIV/AIDS at the time of PEPFARs rollout, the catalyst that led to
HIV/AIDS being elevated above other NCDs was “public advocacy-it’s what turned the tide”
(Participant 4).
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Private partners also provided the capability of scaling up services in Africa that would
have been more limited if utilizing strictly the public health approach with CDC as the lead in
antiviral treatment. Participant 5 stated that “getting the private sector as a partner inside the
tent and having a multiplicity of partners outside of people who had a public health purpose was
a valuable policy objective”.
The political relationship among advocacy groups with Congressional members can also
influence appointments to key USG positions responsible for global health. While political
appointments are discretionary, and may lean more progressively or more conservatively, it can
have detrimental effects in advancing the global health policy agenda if appointees come into
their roles without the appropriate qualifications. The statecraft of diplomacy is built upon a
foundation of trust. An accumulation of wisdom that informs foreign policy decisions is also
something that takes time, and which should serve to temper decision-making about government
appointments to key health policy positions. Continuity in foreign policy strengthens U.S.
relationships abroad. The United States is in a trust rebuilding phase amid a pandemic and as it
contemplates its relationships across global governing bodies. The rise of health on the global
policy agenda necessitates that policymakers appointed to key leadership positions be well-
versed in global health transnationally.
Global Governance and Aligned Incentives
While this research does not focus on the COVID-19 pandemic underway, there were
concerns expressed by some respondents regarding the U.S. withdrawal from the WHO that was
anticipated in 2021. There is a recognition that there needs to be a revisiting of the role of the UN
and associated WHO in global health threats. The International Health Regulations (IHR) of
2005 do not achieve universal compliance. For global health monitoring and reporting to be
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effective, the country incentives (e.g., limited disruption to trade) need to be better aligned so
that they support compliance in disease reporting/disease threats as a measure of compliance.
One key determinant in the effectiveness in global governance and the effectiveness of
the IHR relates to individual country willingness to be transparent. The incentives to do so will
need to be better aligned to improve the effectiveness and intent of the IHR from 2021 and going
forward. The role of human rights, international legal structures, and ethics are expected to be
drivers in shaping governance in the global health ecosystem for years to come. (Kennedy et al.,
2002). A key challenge for the twenty-first century will be to advance global cooperation in a
highly globalized economy (Kennedy et al., 2002). One key document that will establish a
framework for these engagements will be the revised IHR discussed in Chapter 4.
GHD will play a critical role in advancing nation-to-nation connections at a time when
global governance has been called into question by the United States. On July 6, 2020, during the
emerging months of the COVID-19 pandemic, U.S. President Donald J. Trump communicated
plans of U.S. withdrawal from the World Health Organization (WHO) and a desire to “redirect
funds to US global health priorities” (Gostin et al., 2020, p. 293). On January 20, 2021, U.S.
President Joseph R. Biden rescinded that plan (The White House, 2021b).
As U.S. foreign policymaking takes shape in a post-pandemic world, diplomacy will be
essential to navigating and strengthening transnational alliances.
The World Health Organization budget and how it is funded were discussed in January
2021 at the 148
th
Session of the Executive Board meeting in Geneva, Switzerland (World Health
Organization, 2021). The 2022-2023 budget, status of member payments, and those who are in
“arrears” was discussed (p. 5). The 74
th
Session of the World Health Assembly (WHA), the
decision-making body of the World Health Organization (WHO) is set to meet in Geneva,
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Switzerland from May 24-June 1, 2021. “The USA is also a state party to two WHO treaties: the
WHO Constitution, establishing it as the “directing and coordinating authority on international
health”; and the International Health Regulations (IHR 2005), the governing framework for
epidemic preparedness and response” (Gostin et al., 2020, p. 294). Global governance was
identified by some of the participants as an area of foreign policy interest. Epidemics, as was
experienced during the HIV/AIDS crisis and subsequently the COVID-19 pandemic, have
highlighted the need to update the 2005 International Health Regulations (IHR) and improve
upon the incentives for WHO member countries to comply with timely reporting of disease
threats.
The term ‘assertive multilateralism’ arose during a participant interview. Assertive
multilateralism is a term associated with former U.S. Ambassador to the United Nations
Madeleine Albright. “Her concept was that if the United States no longer had the political will
nor the resources to act as a global policeman, it was in America’s interests to form coalitions to
do so. It meant, that when America acted with others, [America] should lead in establishing goals
and ensuring success” (Boys, 2012, p. 2). Its mention is an example of the rise of multilateralism
in foreign policy thinking beginning in the 1990’s. Ambassador Albright had a national security
background from her role on the National Security Council during President Jimmy Carter’s
Administration (Boys, 2012).
The term ‘assertive multilateralism’ is important because it linked, in a broadened
definition, security and national interests: The transition from the Cold War Era to the Post-Cold
War Era, coupled with the September 11, 2001 (9/11) attacks on the US, has led to an emergence
of “five essential redefinitions of what national security means for the US in the 21
st
Century”
(Zelikow, 2003, p. 17). One of the redefinitions is the need to “redefine multilateralism”
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(Zelikow, 2003, p. 19). The four other topics include: “redefining the geography of national
security; redefining the nexus between principles and power; redefining the structure of
international security; and redefining national security threats in the dimension of time”
(Zelikow, 2003, p. 19). As the pandemic rages and the United States examines its strategic
position in the world, it will need to revisit its approach to multilateralism.
Coming on the heels of the bounded timeline of 2001-2003 utilized in these cases, the
ideology of U.S. multilateralism provides a general framework for strategic thinking about
foreign policy in and around the periods when these initiatives were implemented. Zelikow
(2003) provides an explanation of the “five contrasting ways of conceiving and operationalizing
multilateral action” (pp. 24-25) which were used by the Bush Administration. They include: “an
inductive method for drawing ideas from many sources to adapt them to specific conditions; a
preference for international institutions that judge performance and stress accountability;
multilateral strategies that rely on sovereign accountability of states; international law that
emphasizes democratic accountability (linking the authority of international officials to
constitutional sources of political authority); and functional institutions that produce concrete
results instead of symbolic measures that might rally more support for an ideal” (Zelikow, 2003,
pg. 25). Multilateralism and this framework for U.S. executive thinking and national security
strategy is evident in the governance structure of the Global Fund to Fight AIDS, Tuberculosis,
and Malaria. It operates out of Geneva and is not attached to the United Nations. Each
participating country receives an equal vote. Grants extended to countries-in-need include
performance measures to promote accountability. A new theme, transformational diplomacy,
emerged from Department of State that shaped bilateral and multilateral engagement on the heels
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of 9/11. The Global Fund is an example of a multilateral financing mechanism that focused on
collectively impacting, or transforming, the HIV/AIDS epidemic.
In contrast to the Cold War era strategic priorities stated by Secretary Albright, Secretary
Condoleezza Rice pivoted to transformational diplomacy in her speeches (2005-2006) as the new
U.S. foreign policy direction (Vaisse, 2007). The “concept involves transforming the instruments
and structures of American diplomacy so as to make it more capable of transforming the world”
(Vaisse, 2007, p. 5). Transformation should also “include concern for failed states, concern to
promote democracy, human rights, etc.” (Participant 8).
The US, within this philosophical construct, is demonstrating a pivot away from
promoting government’s transition to democracy and now focused on ways to strengthen the
international system by working to advance the network of a community of individual nations
who supported democratic values (Vaisse, 2007).
For USG organizations, like USAID, transformational diplomacy presented a concern
that development would be subordinated to diplomacy abroad. Recalling that USAID resides in
the Department of State where the core diplomatic roles in U.S. foreign policy reside. The impact
of 9/11 and the transition to post-Cold War have “impacted the purpose and goals of foreign
assistance and the methods and approaches to accomplishing international development goals”
(Herisse, 2007, p. 2). For development assistance to respond to humanitarian needs abroad, the
environmental threats (global disease, terrorism, and other regional destabilizing influencers)
needed U.S. foreign policy strategies to cooperatively align to development and foreign
assistance goals (Herisse, 2007). The pandemic will once again require a reexamination of the
strategic balance between economic and human threats abroad.
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Transformational diplomacy was a catalyst to a paradigm shift within USAID, located
within the U.S. State Department. This shift led to an effort to grow economic partnerships as a
way of strengthening individual country’s abilities to self-sustain and moved away from a
development model that fostered long-term reliance on U.S. development dollars (Herisse,
2007). This new strategy of engagement abroad was focused on community level interaction and
was accompanied by added accountability for dollars spent.
The expansion and contraction of what constitutes a global health security threat varies
by Administration, NSS, and is shaped by human interpretation. These variables contribute to an
inconsistent definition of global health security threats. Bioterror is an exception to this as it is
uniformly, across security and health policymakers, accepted as global health security threat. As
the prioritization of global health security threats cycle (Administration to Administration), there
is a resultant impact on and correlation to the complacency cycle of global health.
Transformational diplomacy was a diplomatic strategy that conceptually framed how the U.S.
would allocate resources (Defense, State Department, National Security) in response to broad
global health threats and for what purpose or value.
Agenda Setting, Politics, and Negotiations
Real-world events continue to shape the content of the NSS year-to-year. Kingdon (2011)
explains how certain items get on an agenda. The role of the President and his/her executive
powers can influence the policy agenda. The explanation for the President’s influence over
agenda setting and policy prioritization includes control of “a set of institutional resources (veto
power and the ability to hire and fire); “organizational-being a more unitary decision-making
entity”, and “command of public attention” (pp. 24-25). The NSS is an example of a document
that is shaped by Presidential strategy and priorities.
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The cases used in this research, and accompanying research participant narratives,
highlight the complexities of GHD as a soft power tool According to Gallarotti (2011), it is more
difficult to evaluate the direct and indirect benefits of soft power. As some of the participants
conveyed, the value of the human relationships (built upon trust) enabled a more effective
distribution of antiretroviral drugs throughout affected communities. Establishing relationships
and trust takes time. This is one of the complexities of soft power. It also makes it more difficult
to measure. Soft power strategies, in contrast to hard power strategies, need to be thoroughly
examined to truly understand the breadth at which they have been effectively utilized as a
foreign policy resource (Gallarotti, 201). Despite these nuanced complexities, the value of soft
power diplomacy shone through in these cases.
HIV/AIDS rose in prominence politically in 2000 when Vice President Al Gore spoke at
the UN Security Council Meeting and in the President George W. Bush Administration with the
establishment of the Global Fund and PEPFAR. Key individuals who had existing and trusted
relationships played an important role in navigating policy agendas, politics, and contentious
negotiations. Global politics also influence how health is prioritized. Like the US, if the health
issue rises to the level of the country President, then it can drive prioritization, funding, and
resources. This mirrors the champion/leader structure described later. Global politics become
dimensional meaning that it’s filled with numerous stakeholders with each having a different set
of agendas, politics, and incentives for negotiation. Advancing a political or policy agenda
benefits from a similar politic or policy prioritization by nation states or global partners.
Political Ideology as a Precursor to U.S. Foreign Policy
Politics frame how health gets incorporated into U.S. foreign policy from the origins of a
political campaign. When a new Administration takes office in the US, the political agenda that
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was part of the campaign carries over into policy formulation. This includes the rhetoric that is
used to shape the drafts of the National Security Strategy (NSS). While the development of the
NSS is an iterative process that includes an integration of U.S. government department input, the
political ideology has a role in shaping U.S. foreign policy ahead before the new Administration
assumes office.
Varying Narratives
Not unlike the varying narratives that are circulating by politicians, public health
officials, and the media during the COVID-19 pandemic of 2020, the HIV/AIDS crisis and
response was similarly immersed in varying narratives. Response to the HIV/AIDS crisis in
Africa varied by country leader and narratives contrasted based on politics, beliefs, and
relationships. For example, South African President Thabo Mbeki was criticized for his
response. Sheckels (2004), provided a recounting of the varying narratives on the HIV/AIDS
crisis from 1998-2000. The article showcases how President Mbeki uses politics and his
formative educational beliefs to draw distinctions between the West (homosexuals and drug
addicts) and Africa (heterosexuals with risky sexual behavior) (Sheckels, 2004). The internet
became a resource that he recommended to colleagues as a place of truth to find independent
information (Sheckels, 2004). ‘‘Through this education, Mbeki learned how oppressive
governments would use claims of ‘‘truth’’ to regulate the masses. He furthermore recommended
to his fellow government officials that they use the internet to gather their own independent
information on the matter” (p. 72).
In contrast, the United States provided antiretroviral treatments to individuals infected
with HIV in Uganda (Kolker, 2018). “The HIV treatment model for PEPFAR was developed
with Uganda in mind” (Kolker, 2018, p. 4). Several of the champions listed under theme 5 (Drs.
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Fauci and Dybul) had relationships with Dr. Peter Mugyenyi at the Joint Clinical Research
Center (JCRC) in Kampala (Kolker, 2018). The role of trusted relationships is critical in
facilitating an effective response to a global health event and highlighted the different scenarios
in how the HIV/AIDS epidemic played out between Uganda and South Africa (Kolker, 2018).
Domestically, the narrative about HIV/AIDS within the Evangelical Christian community
was not always reflective of compassion. It was a disease of gay men and homosexuality was
viewed as a sin (Igoe, 2018). As a prominent evangelical couple, Shepherd Smith, and his wife
Anita, utilized media channels to change the messaging to faith-based groups after immersing
themselves in organizations such as the Ryan White HIV/AIDS Program and following a trip to
Africa (Igoe, 2018). Narratives influence policy outcomes, political alignment to issues, and
individual decision-making on global health issues. Changing narratives within the Evangelical
Christian community acted as a catalyst in the conservative political beliefs within the US, and
according to Dr. Fauci, the role of faith-based groups was “quite helpful in getting Congressional
and other support for PEPFAR” (Igoe, 2018, p. 9). Narratives enable or disable public trust.
Cultural Ideology as a Barrier to Knowledge Sharing
The importance of providing culturally appropriate and science informed public
information is essential. Participant 5 stated that “we always have to have permanent interests
not permanent friends, but at the same time, we need to know what about that other society is
going to make a difference for us and how we can work together to advance what are their
agendas and how do we get them to own our agenda and make it part of theirs. That’s
fundamental to diplomacy.” Prevention and treatment of HIV/AIDS necessitated that public
health discussions were sensitive to and shaped to work with in-country leaders and providers on
behalf of their communities. Cultural ideology can be a barrier to knowledge sharing. If, for
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example, male circumcision is identified as means of deterring transmission of HIV in
heterosexual relationships, then the development of education programs for the public must be
tailored around the beliefs and values of a culture. There needs to be a balance between
advancing public health interventions and adaptability to cultural nuances. As trust is established,
the process can accelerate.
Moral Imperatives and the Global Public Good
Morality and ‘doing the right thing’ were cited as drivers in President Bush’s decision to
champion PEPFAR. Suggestions that PEPFAR emerged as an effort to cast a better light on the
Administration which was engaged in the post 9/11 Iraq War were raised and refuted by a few
participants. Policy decisions, while also examining the necessary scientific data to ensure that
an initiative could be successfully implemented, looked more broadly at the potential to mitigate
a crisis, stabilize governments abroad, and mitigate the losses of the core workforce (teachers,
doctors, engineers, etc.) who were losing their lives due to HIV/AIDS. Participant 11 stated that
“the U.S. position on global health security should be that we have two enormous global public
good issues to confront. One is climate change and the other is pandemics.” The collective
action of many came together like a symphony to deliver value as a moral imperative and with
the goal of sustaining a culture and its community in the affected regions.
The role of the United States in addressing global health challenges and the devastation
caused by HIV/AIDS also drew Congress into the moral conversation. “Investing in global
public goods is also highly compatible with US attitudes regarding the role of government”
(Brainard, 2002, p. 14). The fight against HIV/AIDS drew bipartisan support which was
interpreted as a positive sign of the prospect of financing global health initiatives and for
political support in the out-years (Brainard, 2002).
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The impact of HIV/AIDS on families, a workforce (and future generations), in Africa
shone the light on the personal and economic impact of this disease. The interventions to address
the crisis focused on treatment which creates a longer time horizon in measuring outcomes than
other treatable disease states. Pursuing treatment as a strategy also demonstrated consideration of
the importance of maintaining the integrity of families so that children weren’t orphaned. Ethics
entered the policy discussion as a way of examining if treatment (prolongation of life) was the
right or best approach. The alternative, which meant foregoing treatment, was grim. Doing
nothing for an incurable disease leads to death. The role of donors in this ecosystem enhanced
the funding available to eradicate disease threats. However, as with all investments, there is a
need to examine the risk-benefit associated with engaging in a program. Health is an investment
and donors were being asked to consider investing in a treatment for a disease that wasn’t
curable. That is a different concept to investing in a disease that is focused on eradication and a
cure. To be equitable, the program strategy must include an affordability element so that it
wasn’t cost-prohibitive for those countries whose citizens were the most impoverished, yet in
need of treatment and aid for prevention. Reducing the cost of antiretrovirals was the final
catalyst needed to bring this program to fruition.
Champions and Leaders
Specific champions, within the United States and in-country (where the HIV/AIDS
epidemic was underway), were identified by participants as key drivers of the successful
implementation of the Global Fund to Fight AIDS, Malaria, and Tuberculosis and PEPFAR.
Participant 1 said that “you need a champion who cares deeply about the issues.”
With PEPFAR, the tone was set early to “think big” (Gerson, 2008, p. 1). Participant 2
said “PEPFAR was a White House led initiative”. Some names rose to the top as Champions
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and Leaders. For PEPFAR, they included President George W. Bush, Mr. Joshua Bolten (Deputy
Chief of Staff and former Policy Director for George W. Bush when he ran for President), Dr.
Anthony Fauci (Director, U.S. National Institute of Allergy and Infectious Diseases), Dr. Mark
Dybul (Deputy, National Institutes of Health), Secretary Tommy Thompson (HHS), and Dr.
Peter Mugyenyi (Head, Joint Clinical Research Center, Uganda) (Donnelly, 2012). Participant
13 stated that “Dr. Fauci was at the center of it all.”
For PEPFAR to be actualized, it had to be led from the highest office in the U.S.
government: the U.S. president’s office. Several participants described how leadership from the
Office of the President influenced and led to actionable outcomes across U.S. government
departments and to the process of achieving a bipartisan consensus to fund PEPFAR in
Congress. A champion can then draw in other champions and leaders. An example of this is cited
by Donnelly (2012) when Drs Fauci and Dybul sought to validate their plan for AIDS treatment
prior to PEPFAR being rolled out by the White House. Designated experts in HIV/AIDS were
invited to a private meeting in Washington, DC to review Drs Fauci’s and Dybul’s proposal. The
relationships that they had established over a period of years with each of the invited guests
contributed to each of them prioritizing participation in the meeting. Each participant is named,
and the meeting is described in more detail in Donnelly (2012). As this core of champions and
leaders was built, they coalesced around a common vision, set goals, and drove hard and fast
toward the implementation of the initiative.
While this research focuses on U.S. foreign policy, it is important to also acknowledge
the critical role that in-country (foreign) leaders played in advancing the prevention and
treatment initiatives for their communities. These are bilateral and multilateral activities that
require champions and leaders across an ecosystem to achieve collective success.
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The Role of Elites in Policy Action
Countless stories showcased the role of individual leaders in driving policy action. The
elites acted in anticipatory ways to gather critical information, to bridge the narratives between
domestic and international elites by making trips to the affected regions and subsequently
serving as the interface with the President and executive office staff. Within Congress, the
negotiation process that occurs in the formulation of legislation was shepherded by key leaders
such as Senator Bill Frist, a physician and former liaison to the Bush campaign, Congresswoman
Barbara Lee, and others whose personal accounting of detailed events are captured more fully in
autobiographical sources. Elites, given their career experiences, move between government and
private sector roles that served as accelerators in these initiatives from the standpoint of having
established and trusted relationships in place. In crisis situations, this can be invaluable.
Diplomats as Global Connectors
The in-country Diplomats played a critical role in shaping the narrative of the HIV/AIDS
crisis, bringing in-country insights and nuanced situations to the attention of country leaders and
U.S. government officials. Diplomats are described by Participant 2 as a “high level advocate”.
Health in foreign policy acts as a bridge to other objectives in foreign policy. Embassy
leaders were critical in establishing strong networks and trusted relationships with country
leaders and working with affiliated USG partners to enable the successful implementation of
PEPFAR.
Frist (2015) stated that “health increasingly constitutes an essential component of foreign
policy in many countries, and as a growing number of diplomats and elected officials have
started to realize that health warrants a prominent place on the global agenda” (McInnes et al.,
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2020, p. 109). Diplomats serve essential functions in leading the advancement of transnational
health policy initiatives.
Empowered Decision Making and Delegated Authority
The recounting of the implementation of PEPFAR included numerous stories and
observations of how the Executive Office’s prioritization of the program gave emphasis to the
decision-making and authority of the individuals responsible for operationalizing the program.
Examples of this included specific titles that were given to decision makers. When given an
Assistant Secretary or Undersecretary title intra-departmentally, it created access for the
individuals to participate in certain meetings as well as to be listened to more readily in the
respective role/position. The stature of the title was described by several participants as an
essential step in garnering access and encouraging others to coalesce around the decision
making.
Wicked Problems and Design Thinking
The challenges shaping how health gets into U.S. foreign policy have perpetuated for
decades. The COVID-19 pandemic offers an opportunity to refresh our policy ideology, integrate
our USG systems to effectively respond to short and long arc global health events, and to
develop a modernized approach to cultivating global health and foreign policy leaders for the 21
st

century. Participant 5 said that we need to “reestablish White House leadership on pandemics
and biosecurity, to make the State Department a more agile player, and to up its game in terms
of how we use diplomacy to build coalitions. We need to build on the scientific independence of
CDC, NIH, and FDA. They’ve been politicized.”
Design thinking, while not uniformly defined, is intended to overcome bureaucratic
thinking about policy problems and to conceptualize the ideation from various perspectives.
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Within the public sector, gaps in design thinking skillsets with USG organizations can constrain
new ways of thinking about policy problems (Mintrom & Luetjens, 2016). Design thinking can
be utilized to overcome siloed thinking within USG organizations, its associated bureaucratic
barriers, and disestablish hierarchical relationships. To successfully implement design thinking to
improve the process of policymaking, it requires human capital management strategies to ensure
that policy analysts are skilled to effectively work across agencies and jurisdictions in the
development of policies (Mintrom & Luetjens, 2016). Implementing a pilot project across two
organizations who manage global health (e.g., Department of State and HHS) may be a way to
phase in design thinking but within a manageable scale initially. The sub-themes below present
some of the organizational and policymaking challenges that have contributed to cross-agency or
cross-jurisdictional optimization. The subthemes are associated to wicked problems and design
thinking because they address the barriers that contribute to routinization in thinking. When new
policy problems come along, such as the pandemic, routinization can limit the agility of
organizations that is essential to adapting to new and emerging transnational policy priorities.
Inefficiencies in Existing USG Bureaucracies and Resource Utilization
A general sentiment was shared about the challenges in working with existing USG
bureaucracies. Health sits across several governmental organizations and sometimes the roles
and responsibilities of who is responsible for what or who wants to be responsible for what can
result in deferring action on global health issues. Adding clarity to how global health issues are
strategically and diplomatically led, from the top down, will aid in optimizing the utilization of
resources in place to support global health strategic priorities. Participant 6 stated that to
overcome inefficiencies and barriers with existing USG organizations, you need to “throw out
all the legacy systems and policies and procedures that hamper you. It’s tough to create
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something new when there are people (within the USG organizations) who have a history and
experience with the existing systems so their default will always be to go back to those systems.”
There are a range of approaches to overcoming inefficiencies. A key decision is to ensure that
whoever is placed in charge is empowered to “cut through the bureaucratic morass”
(Participant 6). Considerations should also be given to appointing personnel to key positions in
global health who have a broad view of the topic.
A sentiment arose that if, for example, someone hails from a background of infectious
disease and is placed in a leadership position, the person’s tendency will be to “pay attention to
that” (Participant 4). It may also contribute to inefficiencies in how resources are utilized
vertically and horizontally across the USG. For example, Participant 13 stated that “if you want
to deal with a crisis better you need to institutionalize the parts in between the crisis…everybody
from every department knows what part of the plan” they are responsible for. Kingdon (2011)
reminds us crises, as problems, can serve as focusing events. We need to institutionalize the
lifecycle conceptual framework of global health events to ensure that the problem doesn’t fade or
get removed from a list of vulnerabilities.
Cultivate 21st Century Global Health and Foreign Policy Leaders
There is a need to re-envision the training and career incentives of the U.S. public health
workforce and the strategy that frames its mission. As Participant 13 stated, “you have to change
the priorities to the more transnational issues such as climate, science, health. The only way to
make that happen, realistically, is to change the incentives in the State Department for career
advancement.” This would include broadening the foundation of their training within academic
institutions. Participant 1 expressed a similar sentiment, “the people who are involved in defense
(meaning the Department of Defense), their expertise tends not to be in the health arena.” A
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barrier to prioritizing global health resides in the personnel system for foreign policy
practitioners. Advancing past these wicked, protracted problems requires a new way of thinking
about global health issues. To align with the organization design changes, the workforce
readiness needs to be modernized as well.
Enhance and Sustain U.S. Global Health Infrastructure
This refers to a level of readiness across the U.S. global health infrastructure as a way of
mitigating the cycles of complacency in theme 8. As the United States works to strengthen its
public health infrastructure (post-pandemic) and the effort to strengthen global health system
infrastructure advances, Participant 1 emphasized the” importance of designing strategies to
align with communities and to leverage existing infrastructure to reach the community-in-need.”
Coordination between public health and the Department of Defense is essential in the areas
where their work overlaps. Training together would facilitate this readiness. Solutions need to be
community-based.
Pivotal and Seminal Changes
Research participants collectively voiced their observations of moments-in-time where
the creation of or implementation of PEPFAR and/or Global Fund initiatives hung on a specific
event within a causal chain, a specific person, or persons’ actions, or propelled forward due to a
significant turning point.
Strategic Scientific Interventions
Community-based studies and data collected by U.S. personnel in Africa were used to
drive policy formulation and program design leading up to the implementation of PEPFAR.
Participant 1 said that “you had applied research, you had policy development, and you had
program implementation, and they fed into each other.” Host country relationships and
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infrastructure are essential in providing critical links, to the affected or at-risk community, in
garnering trust to implement clinical trials. The scientists who are expert in these areas are highly
valued by those who have interacted with them.
National security preparedness is buttressed by science and research in the areas of
bioterror and pandemics. Research on HIV/AIDS that contributed to the strategic deployment of
PEPFAR antiretroviral treatment was underway in the late 1990’s. Research work on HIV/AIDS
that began in the 1990’s laid a scientific foundation that was critical to enabling the accelerated
response to the HIV/AIDS crisis in 2001-2003. It provides examples of progress in preparedness
by having scientists on-the-ground in the affected areas which was accompanied by diplomatic
leadership support. (Bernard, 2013). Without having a scientific foundation to springboard from,
the efforts to render treatment in an accelerated fashion during an epidemic would have been
stalled.
Lowering the Cost of Antiretroviral Drugs
Reducing the cost of antiretroviral drugs to treat HIV was critical to the success of
PEPFAR. Without the reduction in the cost, the program would not have been accessible to those
affected. Participant 2 recalled that the initial cost of the antiretroviral drug was “$10,000 per
person per year.”
In July 1999, Vice President Al Gore was campaigning for President. Along several of
the stops, AIDS activists raised concerns about the exclusory agreements with U.S.
pharmaceutical companies as a barrier to providing lower costs drugs to HIV/AIDS victims
abroad. (“Political Briefing; Gore Is Followed by AIDS Protesters” B. Drummond Ayers, Jr.,
New York Times, July 2, 1999). At the announcement of PEPFAR’s $15 billion commitment to
prevent and treat HIV/AIDS, some activists were skeptical (Kolker, 2018). They interpreted this
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as the U.S. intent to funnel money to the pharmaceutical manufacturers who were charging
unreasonable amounts for the critical antiretroviral drugs (Kolker, 2018).
According to Bush (2010), technology in the pharmaceutical industry enabled the drug
price to “decline from $12,000 a year to under $300. For $25 a month, America could extend an
AIDS patient’s life for years” (p. 338). Several participants echoed the point that reducing the
cost of the antiretroviral drug was a pivotal moment in the efforts to deliver treatment to affected
countries abroad.
The Securitization of Health: Anthrax Attacks and 9/11
The anthrax attacks in November and December 2001 brought health prominently onto
the health-security agenda. Bioterror is a classically recognized human security risk. According
to one participant, along with globalization and transnational issues, the prominence of public
health rose on the 2003 Presidential national security agenda as contrasted to 2002. This was due
largely to the anthrax scare. This moment also reflected a pivotal change in an approach to
foreign policy after the Cold War. The United States needed to create a strategy for
vulnerabilities that could reach U.S. soil as contrasted to planning under the Clinton
Administration’s NSS, prior to the end of the Cold War, which drew assumptions about threats
“over there” (Participant 8). The anthrax scares and 9/11 attacks required a change in
assumptions.
The 9/11 attacks also acted as a turning point in shaping the Presidential agenda. “Before
9/11 those interests (meaning national policy) had found their outlet in the domestic issues such
as education. After 9/11, it was clear that his emotional intensity would rise on international
issues, and fall on domestic ones” (Zelikow, 2011, p. 107). Three key agenda items shaped the
U.S. policy agenda between 2001-02. They included: “intensification of counterterror work;
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homeland security; fight global poverty and disease (conceptually a novel feature of Bush’s post
9/11 agenda, yet also one of the least noticed or understood)” (Zelikow, 2011 p. 108). This
highlighted another example where the importance of health was being folded into the
President’s agenda.
The anthrax ‘scares’ in the United States, received through postal shipments in the form
of spores, put the United States in a position where they needed to respond quickly to this
bioterror event. The only known drug to treat against anthrax was ciprofloxacin. The United
States was concerned about high prices and potential shortages of the drug which led Secretary
Tommy Thompson to engage in a licensing threat to the manufacturer of the drug (McInnes et
al., 2020). The summary of this policy discussion which contemplated moral, ethical, legal, and
intellectual property considerations, is summarized by Resnik & De Ville (2002). This moment-
in-time “changed the tenor of debates around AIDS drugs” (McInnes et al., 2020, p. 614). The
World Trade Organization (WTO) members were not in favor of the U.S. approach toward
“compulsory licensing” (McInnes et al., 2020, p. 614) and instead established the Doha
Declaration which led the way for generic medicines to be used in the treatment of HIV/AIDS
abroad. The Declaration was also critical because it “provided the legal reassurance to suppliers
of generic medicines in countries where the products were patent protected” (McInnes et al.,
2020, p. 615). The devastating impact of HIV/AIDS on humanity was described by Donnelly
(2012) as “worldwide, thirty-six million people estimated to be living with HIV/AIDS. Some
twenty-two million men, women, and children had already died from it; and 15,000 people were
infected with HIV every day” (p. 1391). The security implications of AIDS were raised due to
the sheer numbers of adults who were dying and leaving children orphaned: “13 million” (Aspen
Strategy Group Papers, Foege, p. 21). The magnitude of the impact raised concerns that the
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affected areas in Africa could lead to a destabilized region which was a security concern for the
United States. (Aspen Strategy Group Papers, Foege). Participant 1 stated that “other factors
came into play…economic development, defense…that were more important I think or seen more
strategically than health. …HIV and global HIV as a strategic issue for defense because
societies that are massively disrupted with the death of parents, enormous numbers of
orphans…if society and the economy get disrupted then that can also cause instability, in not just
governments but societies.”
In January 2000, the UN General Assembly, the “United Nations Security Council met to
discuss the global security impact of HIV/AIDS. It was the first Security Council session on a
health issue in more than 4,000 meetings” (Bernard, 2013, p. 1). Participant 2 highlighted that,
“Vice President Al Gore spoke on behalf of the US and Secretary General, Kofi Annan spoke. It
was the first time that the UN Security Council had ever dealt with a health problem as a matter
of international peace and security”.
Unlike anthrax, HIV is believed to originate from a zoonotic infection from primates in
Africa. The origins of the disease are believed to be traceable back as far as 100 years ago
(McInnes et al., 2020). Two very different threats which necessitated that the United States play
a global leadership role in bringing resources to fight two fronts simultaneously.
Leveraging Innovation to Overcome Bureaucracies
Governmental bureaucracies can create unnecessary barriers to nuanced and complex
global health policy problems. Innovation, when unveiled in a developing community, can mean
that you harness the power of the human resources on the ground to engage in workable,
common-sense, trusted solutions. For the HIV/AIDS crisis, that meant mobilizing the existing
infrastructure of science and research in the respective countries, leveraging existing delivery
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systems of care, and working with the community to identify the trusted resources that would
enable a prevention and treatment strategy for HIV/AIDS to work. Developing countries present
a challenge to scientists as they often lack sufficient infrastructure to deliver robust capabilities
to affected areas. (Aspen Strategy Group Papers, Foege).
One innovation that provided a work-around to barriers to access included working with
trusted partners abroad who were already delivering services to their communities. The networks
and trusted relationships of faith-based organizations contributed positively to the
implementation of HIV/AIDS prevention and treatment programs (Igoe, 2018). Established in-
country networks provide a capability of scaling up quickly. When establishing new programs
globally, a first step should be to assess the existing infrastructure that can be leveraged. Doing
so offers an opportunity to limit bureaucratic barriers.
Advocacy and Collective Action
Activists and Hollywood elites contributed to the attention placed publicly on the
HIV/AIDS crisis domestically. Activists played a critical role in intervening in the cost of
antiretroviral drugs to make them more affordable for treatment initiatives internationally. Faith-
based organizations were “quite helpful in getting Congressional and other support for PEPFAR,
said Dr. Fauci” (Igoe, 2018, p. 9). The efforts by groups who led the advocacy for HIV/AIDS
served as a catalyst to drive the pharmaceutical industry to respond to public outcry (McInnes et
al., 2020). This was instrumental in driving broader access to antiretroviral medicines.
Cycles of Complacency in Public Health Events
A common theme across participants was the sentiment that once a crisis-related public
health event passes it, and the sense of readiness for future events, fades into the background.
Participant 13 stated that “when a crisis happens, it makes everybody pay attention. If you want
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to deal with a crisis better, you need to institutionalize the parts in between the crises”. It was
emphasized that a structure such as a “working group run out of the National Security Council
(NSC) for the next pandemic” would facilitate “every department knowing what part of the plan
they’re responsible for.”
These cycles of complacency explain why applying Fidler’s (2005) continuum of high-
low politic has limitations to this research. Global health events do not follow a linear rise-and-
fall pattern. Utilizing a lifecycle approach instead of a continuum, I developed a conceptual
framework for prioritizing health in U.S. foreign policy. Pivoting the conceptualization of public
health events from a continuum to a lifecycle seeks to overcome these cycles of complacency.
The way that this happens is by starting with a different set of assumptions. A lifecycle, in
contrast to a continuum, assumes that a global health event can become a threat at any stage of a
lifecycle. It does not require the event to rise or fall on a continuum.
The Time Horizon between Global Health Events
Global health events, by nature, have episodic peaks and troughs. Some participants felt
that this contributed to health not being placed on equal political importance as security and
economics. Yet, as we are experiencing during the COVID-19 pandemic, when the peak returns,
it requires an ‘all hands-on deck’ response. On the heels of this pandemic, Participant 13 stated
that “it’s going to fade back again unless they keep that kind of high priority at the White
House.”
Finding a state of planning and readiness that adjusted the peak and trough line of the
health event itself toward the middle would help to mitigate the swings in readiness that have
occurred in the past few decades. Unless a champion comes along, particularly at the level of the
President, the prioritization of health as a global policy agenda priority falls to the side until
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another crisis moment emerges. There was a sentiment expressed that human beings want to rid
themselves of memories from bad experiences as soon as the event no longer impacts them.
When issues arise abroad, such as the HIV/AIDS epidemic, it becomes more challenging for the
U.S. leadership to engage the public because the bad experience is not affecting them locally and
the problem is not readily urgent to them.
Blind Spots in U.S. National Security and Foreign Policy Planning
An inconsistent style of planning and funding for readiness associated with global health
events leads to blind spots in the NSS and subsequent foreign policy planning.
The traditional security matrix that is used to assess threats has contributed to blurred
lines of engagement between health policy, diplomacy, and national security experts when it
comes to health-related events. This may be due to the differing schools-of-thought that underlie
the assumptions forming the heuristics of each practice. An example of a security heuristic
matrix is provided by Liotta & Owen (2006) in Table (7) below.
Table 7. Features of Traditional vs. Human Security
Type of Security Referent Object Responsibility to
Protect
Possible Threats
Traditional Security The State The Integrity of
the State
Interstate War, Nuclear
Proliferation,
Revolution
Human Security The Individual The Integrity of
the Individual
Disease, Poverty,
Natural Disaster,
Violence, Landmines,
Human Rights Abuses
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Health events are complex and dynamic in nature. The drivers arising from globalization
are expanding the threats and vulnerabilities associated with human security (e.g., climate
change). The ad-hoc nature of health events may make them less conforming to a traditional
security matrix threat assessment. According to Liotta and Owen (2006) draw distinctions
between threats and vulnerabilities. They suggest that threat is more well-defined and that actors
share a socialized understanding of what constitutes a threat. In contrast, a vulnerability is not
equally understood, it is not viewed the same by all when trying to sort out if it is a threat or not
and can lead to conflict by parties who are negotiating the lines between threats and
vulnerabilities (Liotta and Owen, 2006). This mirrors what we see in the United States when
global health issues, from a foreign policy priority perspective, are perceived differently at the
bright line the NSC and others.
Some vulnerabilities arise over time. The HIV/AIDS epidemic was an example of this.
Liotta and Owen define this as a “creeping vulnerability” (p. 47). It’s essential to include
creeping vulnerabilities into the strategic thinking about national security threats. A creeping
vulnerability has a long arc and can become a threat. Creeping vulnerabilities rely on a
sustainable level of readiness in U.S. national strategic planning to mitigate its threat potential.
A debate about how narrowly or broadly to define national security arose during the
Clinton Administration as the Cold War came to an end. A Department of Defense or military
conceptualization of a national security threat may be more traditional in nature as its shaped by
its mission and mandate within the Goldwater-Nicholas Act. A broad definition of a national
security threat may be anything that hurts life, liberty, and the pursuit of happiness. Through the
definition of assertive multilateralism, described by Secretary of State Albright (Boys, 2012), the
United States broadened its definition of security and focused on using its power and national
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interests on issues such as “concern for failed states, concern to promote democracy, human
rights” and aimed to do this “through multilateral organizations” (Participant 8). The role of
the executive branch in framing policy is critical to shaping the NSS. If a policy definition of
security is too broad or not socialized across government, it can stall the process of garnering
consensus within the USG and become a political and public relations challenge (Gellman,
2000). Blind spots emerge when the assumptions underlying what constitutes a security threats
do not adequately anticipate the dynamic and confluent global environment.
McInnes and Rushton (2011) examined the securitization of the HIV/AIDS crisis and
proposed “three contributions to securitization theory. The three contributions are: securitization
can be a multi-level process, with distinct securitizing actors and audiences at each level;
securitization can best be understood as a continuum rather than a binary condition, and that
different members of an audience may place an issue at varying points along the spectrum; and
that claims or evidence about an empirical reality form a crucial part of securitization speech
acts, securitization can be undermined, a dynamic that we show in practice in the HIV/AIDS
case” (p. 115). There are debates about whether securitization of health has helped or hurt its
case. It can be used to garner broad support of a global health issue. However, securitization can
also lead to untoward responses where hard power may be engaged for something that could be
better served by a soft power solution. Securitization can also be politicized.
There are two centers of gravity in securitization theory. McInnes and Rushton (2011)
describe them as the process that is used to securitize something and the acts of speech whose
narrative shapes the nature of an issue. These distinct centers that are at the heart of the
securitization theory debate, emerged during participant interviews (McInnes and Rushton,
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2011). A detailed timeline of the events leading to the securitization of HIV/AIDS can be found
in McInnes and Rushton’s (2011) article.
According to Hearne (2008), “the traditionalist security mindset typically has focused
attention on the more immediate identifiable threats that are believed to require a more state-
centered, and often hard-power, response” (p. 223). It was identified as the “blurred and bloody
border” (Participant 8) where interdisciplinary conversations arise to determine what constitutes
a national security threat. That is the same bright line where negotiation about threats and
vulnerabilities takes place. Conflict within this negotiation process can occur.
In contrast, global health threats which in today’s conversation around climate health can
constitute threats to humans, threats to an environment, and subsequent regional destabilization.
These threats may take time to develop in a longer arc (Hearne, 2008). Blind spots can result if a
planning assumption or prioritization is focused primarily on near term threats. The nature of the
longer arc threat may contribute to cycles of complacency because the near-term threats garnered
more attention and resources. We need to plan for both.
Ad Hoc Crisis Planning and Recovery
Cycling between adverse public health events has not led to a robust and ready
infrastructure to respond to subsequent public health or health security events. Participant 1
stated that it’s time to “rethink about what it means to have a public health infrastructure.” The
topic of infrastructure and sustained readiness has gone mainstream during the pandemic.
Variations in readiness have led to an ad-hoc ramping up style of planning and recovery. For
example, Participant 13 stated that “it was a very difficult time between 1998 and 9/11 to get the
political environment interested in health as a security issue.” The key barrier was described as
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“health, from a Department of State point of view was mostly technical assistance to developing
countries and vaccinations…mostly USAID oriented.”
Several participants expressed frustration over this pattern of planning when events of the
past have offered sufficient learning to convey the value of being ready. They used the term ad-
hoc. There was also a feeling that it would be more cost-effective in the long run to maintain a
‘ready infrastructure’ that could also be cross purposed domestically during periods when there
was no crisis underway.
Public Perceptions Shape Transnational Cooperation
Global health initiatives, as presented in the two cases in this research, have expanded the
range of actors involved in the setting the global health policy agenda beyond the nation state.
Stone and Ladi (2015), describe the processes that result from the state and non-state actor
negotiations on transnational issues. Public engagement around transnational policy issues can
drive agendas of the nation state.
Terrorism versus Health
This sub-theme was raised by a couple of participants. The public support for a
transnational issue depends upon their perception of a threat. If a threat is ‘over there’ then it
may not garner the same level of public engagement as a domestic threat. The events of 9/11
imprinted the threat of terrorism in the minds of U.S. citizens and sent shockwaves around the
globe. Participant 5 stated that “People want us to be prepared for terrorism, they’re worried
about terrorism. They were not until now worried about the pandemic and I think that both what
the leaders said and what the public believes feed on each other.”
Health, as a threat, does not resonate in the same way to the public as terrorism does.
Participant 1 stated that “society is generally attracted more to causes of ill health or mortality
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than to initiatives for specific populations.” The pandemic of 2020 may have lasting effects that
raise the public’s perception of health as a threat.
Religious Beliefs
A general theme highlighted across participants was the value alignment between religion
and Christian beliefs that compelled charitable actions toward helping women and children
affected by HIV/AIDS. The recognition that a disproportionate number of women and children
were being affected by HIV/AIDS changed the momentum from it being couched as strictly a
disease contracted by homosexuals.
Politicization of Women and Girls
Power influences economic development priorities which can further marginalize those in
the lower economic or educational status (McInnes et al., 2020). This can include the role that
gender plays (culturally) in the distribution of health services to women and girls. It may be more
limited than those provided to men (McInnes et al., 2020). More attention is needed to establish
equitable policies for women and girls.
Countries vary in the way that they view the rights of men and women. For some
countries, as was seen during the HIV/AIDS epidemic, women were exposed to the disease due
to extramarital sex by their husbands. According to Salaam-Blyther (2007), a woman did not
have the same rights as a man which left her vulnerable to disease risks. During the HIV/AIDS
crisis abroad, women did not share the same access to health services as men. In one African
country, there were reports of mistreatment of women (as compared to men) and a lack of access
to resources to finance health care services. (Aspen Strategy Group Papers, Epstein). The
entrance of non-state actors to the global health arena has helped to shape the human rights
discussions for women and girls which appears to be driving attention to policy inclusion as well
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(McInnes et al., 2020). Non-state actors can also include accountability expectations in their
financial agreements. A 2019 report on “the work of Global Health 50/50, showed that when
organizations focus on the health needs of women and girls, they frequently do so without
mention of the terminology of gender” (McInnes et al., 2020). The concluding point is that while
there has been progress in this area, more needs to be done to achieve sustainable, consistent, and
equitable global health policymaking for women and girls. Public perceptions, as was seen
during the HIV/AIDS epidemic, can influence the actions of policymakers through their
advocacy coalitions. We have seen how the role of fake news during the pandemic has shaped
public perceptions. Transnational cooperation is aided by reliable and trusted sources of data and
narratives that don’t use fear as the basis for action.
Modernize U.S. Foreign Policy and Strategy
Participants conveyed a vested interest in strengthening U.S. policy and strategies in
global health, particularly amid a pandemic. Participant 13 expressed that” the biggest issue that
you need to be concerned about is what happens between crises.” Their collective experiences,
within the domestic or international policy arena, inspired a measure of optimism about how and
when windows of opportunity emerge. The opportunity to seize on those moments, such as they
did during the HIV/AIDS epidemic, and the lessons learned serve as a success story that should
be leveraged as a model template for addressing this global health event of 2020 and future
global health threats. The pandemic is a catalyst that is driving the need to modernize U.S.
foreign policy and strategy on health. The sub-themes reflect areas where policy deliberation is
needed to position the United States strategically and diplomatically in a post-pandemic world.
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Reconcile the Post-Cold War Definition of Security
This sub-theme emerged across a few research participants. The meaning of it is that in a
Cold War era, security strategies and plans were built around assumptions relating to scenarios
for conflicts in which the United States might engage in abroad. Those strategies largely focused
on Russia. When the Berlin Wall fell, the U.S. defense strategies needed to be built off of new
assumptions in a post-Cold War era. The National Security Strategy (NSS), in its statutory roots,
is influenced by what constitutes a security risk. Participant 2 suggested that “it’s unrealistic to
try to begin to formulate a National Security Strategy (NSS) with a domestic focus that doesn’t
immediately look at how the things we’re trying to do in the United States will be impacted by
things that are happening abroad.”
Participant 6 stated that “there is a need for the short-term, the political and security
concerns (which are real-word emerging all the time), but to have an eye on the long term as
well.”
A few participants expressed a sentiment that the definition of a security threat was still
evolving away from the Cold War era mentality. This theme can be triangulated to Zelikow
(2003) in his discussion of “the rivalry of world powers” (p. 23). A strategy of bilateral
cooperation alone is no longer consistent with the world movement toward globalization. “The
United States must challenge its present and future partners to join common tasks that transcend
narrow concerns, offering the networks of American allies in Europe and Asia real opportunities
to share the responsibilities of global leadership” (p. 23). The risk of expanding the definition of
security threat too broadly is that it potentially triggers a hard power action when the soft power
options for diplomatic intervention are not optimized first. Threats require measured responses.
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Hard Power versus Soft Power Ideology
Hard power is often associated with military or defense. Hard power actions may result in
unintended regional conflicts which can further strain diplomatic relations. It can include specific
actions by the United States that are focused on deterring unwanted actions by other countries.
The strategic steps may include deploying our military personnel to specific operations or
invoking sanctions on trade which has an untoward economic impact on the respective country
or countries (McInnes et al., 2020). Soft power, in contrast, relies heavily on human dialogue and
negotiation as a way of mitigating a hard power action. There is also “smart power which is a
combination of hard and soft power” (McInnes et al., 2020, p. 104). There was a sentiment
expressed by a participant that, from a risk assessment perspective, terrorism and soft power
strategic priorities are not appropriated equally in national strategic planning or in resources
allocated to respond to/support each priority. Resource allocation is weighted heavily toward
hard power or defense vs. soft power diplomacy. Participant 5 stated that, “People want us to be
prepared for terrorism, they’re worried about terrorism. They were not, until now, worried
about a pandemic.”
The term compassionate conservatism emerged as a foreign policy theme during the Bush
Administration in mid-2001 (Leffler & Legrow, 2011). This approach to foreign policy grew out
of campaign rhetoric during George W. Bush’s run for President. The shift to a compassionate
approach in foreign policy was another signal of moving away from a Cold War mentality in the
NSS. It also provided a segue toward seeing global health issues as catalysts to regional
instability abroad. The United States needed an NSS that assumed threats that were ‘over there’
could move to the domestic front. Transnational threats are reshaping how hard and soft power
are utilized as threat mitigation strategies. Globalization has created interdependencies
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economically and global cooperation should be a desired outcome where possible. Hard power or
soft power strategies must be measured against tradeoffs
Balance U.S. Strategic Objectives against Tradeoffs
The United States has an important role to play the world. Globalization and multilateral
agreements rely on global cooperation. As contrasted to a unilateral or bilateral agreement,
strategic objectives must be balanced against tradeoffs when more parties are involved in the
agreement. Participant 5 stated that “diplomacy teaches us that it’s often more about
relationship than it is about the short-term gain. If you could have a coalition of people who trust
each other, who’ve earned each other’s confidence, who know each other’s strengths and
weaknesses, that the sense of winning is much less important if you have a common long-term
purpose…that is the win.” This is GHD.
For Congressional leaders, foreign policy issues do not bear the scrutiny that domestic
issues do. Participant 3 stated that “while global health has enjoyed pretty strong bipartisan
support and funding, there’s always going to be pressure on the funding side”. Examples where
funding may be prioritized toward other strategic priorities include “a bilateral relationship with
a country or to a multilateral organization writ large. Those bigger issues could be deemed more
important or be given more priority at times than a health issue.”
The pandemic of 2020 has blurred the lines between domestic and foreign policy issues.
The vulnerabilities in the global supply chain were evident at the outset of the pandemic. Going
forward, we can anticipate more discussion on this topic of balancing strategic objectives against
tradeoffs particularly as U.S. vulnerabilities have been exposed.
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Bridge the Interdisciplinary Divide
Several participants stated that the State Department does not view health as a priority
within foreign policy. While key departments are placed within the State Department to address
Global Health Diplomacy issues, the participants had not observed that the Department as a
collective treating health similarly as other foreign policy priorities. Participant 13 stated that
“the State Department is usually more than happy to allow them [HHS] to deal with their issues,
because what they do is classic diplomacy on issues they care about, political and military,
economic”.
In the case of PEPFAR, President Bush’s prioritization of this initiative gave it greater
attention by those within the State Department. Working across the disciplinary divide (security,
economics/trade, and health) is a nuanced skill. Participant 4 stated that to move to a whole-of-
government approach policy on health “needs leadership at the federal level of people who have
a concept of this, recognize the need for this, and who can think outside of the siloed boxes of
agency”. Health, like economics and security, should not be viewed as something strictly
relegated to organizations that bear the title of health (HHS, CDC, etc). It needs to be socialized
within the State Department as something beyond a humanitarian/aid issue.
Diplomats have practical real-world experiences in working though complex problems,
across cultures, and without a ‘handbook’. In other words, some things can’t be taught; they must
be learned from experiences. They bear a critical role in bridging the domestic and international
policy divide.
Break Down Organizational Silos and Vertical Programs
This sub-theme focuses on the internal structure of USG organizations. Large scale
public health events offer opportunities to build systems back better that are based on lessons
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learned from the events. Participant 2 observed that “utilizing a vertical program model that
specializes in a single disease leads to an uncoordinated approach to pandemics. Strengthening
our public health system is a way to build toward the future and to enable readiness”.
Reflecting upon the HIV/AIDS pandemic and normalizing it within the current COVID-
19 pandemic, it is essential that the United States move away from organizational designs where
workers focus only on specific diseases and programs supporting these diseases and move to a
more integrated design. This is particularly relevant when there is a need for readiness in
circumstances like the COVID pandemic. Or, when HIV/AIDS came along.
Foster Interagency Coordination and Learning
The policy process that supports the conceptualization of health within foreign policy
includes negotiation “of the strategy among state actors (health, foreign affairs, and development
government departments)” (Gagnon and Labonté, 2013, p. 17). While their work focused on the
global health policymaking process in the UK, a finding from their research was that the
negotiation process among various governmental stakeholders to achieve consensus on a national
strategy was a “difficult process”, but “an important way of building common understanding
across government and broke down silos to working together” (Gagnon and Labonté, 2013, p.
17). Their work focused specifically on GHD. Developing global health strategies, and
associated processes, at the state level were argued to be a form of GHD (Gagnon and Labonté,
2013).
Fostering interagency coordination and learning is an important step in breaking down
silos that contribute to barriers in the foreign policymaking process. Participant 6 stated that
interagency coordination may benefit from “throwing out the legacy systems and policies and
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procedures that hamper you.” The people within the organizations “have a history and an
experience with existing systems so their default will always go back to those systems”.
The role of the policy entrepreneur in brokering this process was highlighted as a key part
of advancing negotiations. The recent addition in 2021 by the Biden Administration of a policy
entrepreneur to the NSC signals a step toward integrating health more fully into U.S. foreign
policy.
To evolve USG organizations toward new ways of coordinating, interagency, it will
require organizational change agents, external and internal fiscal drivers that incent the need to
change to reduce the cost of doing business and embracing the value of innovation. Participant 1
offered a suggestion that we “need another part of the U.S. government that’s helping to make
sure that countries are stable and that they’re dealing with their health issues. We need a core
public health workforce, otherwise you are not able to respond to your outbreaks”.
The notion of establishing new organizations within the USG was not shared by all
participants. Some felt that it was more important to get the people to work through the issues as
opposed to creating new structures to promote what could be solved if the right people were in
place to do so. Maintaining confidence in existing institutions must be balanced against changes
in organization structure.
Conclusions to Research Questions
The themes identified in the findings of this research can be used as a framework for U.S.
foreign policy planning. Lessons from the two cases, PEPFAR and the Global Fund, give
insights into the factors that optimize or constrain the advancement of health on the foreign
policy agenda. A Cold War mentality, or approach to national security strategic planning,
continues to phase in across USG entities as the conceptualization of what meets the definition of
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a security threat is actualized. The experiences of the pandemic and increasing policy attention to
climate health will continue to challenge new ways of thinking about traditional and human
security threats.
The key catalyst that drives the movement of an inchoate agenda to an actualized
initiative is the presence of champions and leaders. When an initiative is raised to a level of
prominence that is aligned with power and authority, it signals to the organizational governance
(across the U.S. government, for example) that the agenda item is a priority. Likewise, the
champion and associated leaders put sweat equity into networking, advocating, leveraging data,
and measuring risk to scale quickly while working to optimize success. Woven into the
leadership framework is a human element that drives passion for the agenda. The human element
is moral reasoning. These two leadership attributes, passion for the agenda and moral reasoning,
can act as magnetizing traits to draw other interested parties that can bring additional resources
in support of the agenda and help to shape the narrative domestically and with transnational
partners.
An inchoate agenda arises from the foundation that is in place and established by
collective action and labored efforts at the programmatic level. Programs alone cannot evolve to
broad policy without champions and leaders engaging to harness greater resources and
commitments, and to propel an issue onto the national and international stage. The latter
accelerates the agenda item and brings it to full shape as a policy priority. Problems that
contributed to the health policy agenda rising in prominence included the concomitant risks
associated with an HIV/AIDS epidemic and a bioterror threat from the anthrax scares.

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Research question: Under what conditions does U.S. foreign policy decision-making
advance the health policy agenda and for what value or purpose?
The research findings highlight that a primary condition that is necessary to stimulate
foreign policy decision making to advance a health policy agenda is for it to be a priority led by
the President. The champion must have the power and collective of elites in the right place, at the
right time to drive the prioritization of an issue. Garnering a bicameral, bipartisan consensus is
necessary to support the health policy agenda and to ensure sufficient resources are available to
implement a policy initiative abroad.
The securitization of health on a global stage, coupled with a humanitarian and economic
crisis due to HIV/AIDS, served as a window of opportunity to advance the health policy agenda
for the purpose of preventing and treating (not curing) men, women, and children afflicted with
HIV/AIDS. Several pivotal/seminal changes served as accelerating events in U.S. foreign policy
decision making. Seminal events can create a change that influences the assumptions driving
foreign policy decision making and reframe the ‘why’ behind the value or purpose for action. In
these cases, influencing assumptions included the moral imperative and health as an investment.
Neither reflected a state-of-play where inaction could suffice.
An area where more work is needed to shore up the interdisciplinary connections
between security and health policy leaders includes the game along the “blurred and bloody
border” (Participant 8). The border is described as the intersection of two foci. It is a place two
policy ideologies merge at a bordering line; yet their definitions of what constitute health as an
NSS foreign policy issue are not always aligned. Some strategies to address this have been to
broaden the definition of what constitutes a foreign policy priority issue in health. The risk is
that, for public health practitioners, this could expand to mean non-communicable diseases (e.g.,
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obesity). Broadening the definition of what constitutes a national security priority or heightened
foreign policy issue goes counter to solving the problem of where health fits in a national
security strategy and foreign policy agenda. This space needs to be harmonized such that the
matrix of decision making used in the security realm pivots to viewing transnational health
threats within a transnational lifecycle. The long arc horizon associated with HIV/AIDS
(domestically and internationally) is filled with stories of messengers who tried to draw attention
to this health policy agenda item within U.S. foreign policy. Yet, it did not yield the level of
foreign policy engagement of this health policy issue until there was a convergence of a
champion, leaders in the right place at the right time, and the coalitions and advocates who
shaped a narrative that HIV/AIDS wasn’t a disease that afflicted only gay men domestically. It
affected women, children, and families. Country leaders, likewise, played a role in raising
awareness of the HIV/AIDS crisis in global forums. Celebrity activists became public figures of
HIV/AIDS advocacy and used their influence to engage with policy makers. Scientists used data
to objectively inform policy makers about the state of readiness to succeed in delivering
treatments to affected areas.
A barrier to advancing health as a foreign policy priority includes health being parsed as
an issue that is a subject-matter specific topic and not viewed more broadly as a foreign policy
priority. This assumption sets the course for how topics of health are sorted within foreign policy
and who gets tasked with addressing them. One contributing factor to this assumption can be
accounted for in the transition from the Cold War era to the Post-Cold War era application of
health. Some ideology may remain. A development focus was predominant in the former. 9/11,
the anthrax scares, the pandemic, and the effects of climate change have acted as catalysts to this
new era of Post-Cold War considerations of health in U.S. foreign policy.
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Research sub-question #1: What do Zelikow-Allison’s models contribute to our
understanding of foreign policy decision making?
Zelikow-Allison’s models are applicable to foreign affairs (Zelikow & Allison, 1999, p.
vii) and are used for analysis of both foreign and domestic experiences (Zelikow & Allison,
1999, p. ix). The period of the post-Cold War drove changes to the models which led to the
second edition of “Essence of Decision” in 1999. My responses to this sub-question are broken
into individual responses, one Model at a time.
Regarding Model I, Rational Actor was evident in foreign policy decision making when
deciding upon the strategies for when to pursue bilateralism and multilateralism. Bilateralism
relies on mutual cooperation between two nation states. Given the fewer number of actors
involved in bilateralism vs multilateralism, the nation state retains some power and leverage in
the final bilateral agreement. Multilateralism, as we’ve observed with the Global Fund
implementation, involves more participants (state and non-state actors) and nation states need to
strike a balance between being a partner in international cooperation while also protecting the
investment of its own resources and financing. Bilateral and multilateral agreements are tools in
diplomatic engagement. In today’s world, the global ecosystem is more accommodating of
multilateralism as the range of actors involved in global health issues necessitates greater
cooperation to achieve broader impact. The pandemic of 2020 has highlighted this on the issue of
timeliness of access to vaccines, distribution channels, and equitable access.
Model II, Organizational Behavior, was at play in the way existing USG organizations
responded to new initiatives, such as PEPFAR and later the Millennium Challenge Corporation
(n.d.) in 2004. Barriers to implementing new organizations and programs arose when people and
processes met the news of the National Institutes of Health (NIH) plan to provide “lifesaving
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drugs to those affected with AIDS in Africa” (Gerson, 2008, p. 1) with skepticism. (Gerson,
2008, p. 2). The skepticism arose from “the NSC and the Office of Management and Budget”
(Gerson, 2008, p. 2). These barriers were anticipated in how the White House chose to roll-out
PEPFAR: only a handful of people were told about the program before it was announced by
President Bush in his State of the Union address (Gerson, 2008). This barrier can be found in
what Zelikow and Allison (1999) describe as organizations defaulting to conditioned approaches
and tools from the past despite being exposed to new experiences. There are also differing
organizational models and approaches to priority setting utilized across Department of State and
HHS. Department of State is the lead agency in U.S. foreign policy and traditional diplomacy. Its
priorities go beyond health in foreign policy and encompass economics, trade, and security. The
latter is worked in close coordination with the NSC. The international development activities of
the USG reside with USAID within Department of State. Global health diplomacy, while housed
in Department of State alongside PEPFAR administration, has been moved around to different
sections within Department of State and its prioritization (resourcing and leadership commitment
to) has continued to change Administration-to-Administration.
HHS is the lead agency for domestic and global public health policy issues. Health
attaches who support diplomats in U.S. embassies abroad (Department of State) provides an
example of HHS and Department of State cooperation. But they are separate departments with
unique organizational cultures. When issues of health emerge in foreign policy, participants
described a tendency to ‘punt’ anything associated with health to HHS. Communication
interdepartmentally and between disciplines needs to be constructed in a way that supports a
clear understanding of the significance of a health policy issue, so the importance of the message
is not lost in translation to foreign policy or security leaders. The goal of this is to find a common
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language across disciplines to prioritize and communicate strategic and policy priorities where
governance is shared more effectively. This example ties back to Model II because it is an
example of how the routinization of organizational decision-making can contribute to important
messages about global health risks or opportunities being missed. Organizational participants
need to be socialized to other disciplines to overcome inherent tendencies toward routinization.
An example of Model III, Governmental Politics, is evident in the rise of health on the
global policy agenda when examining ‘health as an investment’. Zelikow and Allison (1999)
discuss the principal-agent problem which is described as when a “principal, the decision maker,
engages additional participants (the agents) to advise in making decisions or taking actions” (p.
272.) “In most complex decision processes, the individuals that principals engage as agents also
have interests, information, and expertise that cannot simply be transmitted to a principal” (pp.
272-273). The limitations of the principal-agent relationship were identified as a barrier that
needs to be overcome. Participant 6 said “the fundamental flaw that’s at the heart of all aid
programs that we need to overcome is this creation of this donor/recipient relationship.” Health
as an investment, for some, is viewed as an opportunity to “make money. You need to get rid of
the principal-agent problem or you minimize it or change it.”
Several participants made comments about ‘following the money’. The inference was that
money (both the holder of the purse and the amount) shapes expectations of the investor,
meaning that the donor nation can provide the money with conditions for acceptance, and the
prospective recipient countries may also tailor their behavior to optimize chances of receiving
money. Adding accountability and outcomes to the investment has strengthened bilateral and
multilateral agreements. This ties back to Model III as an example of general propositions (p.
305) where “international and intranational relations where certain nations may attempt to
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achieve an international objective by direct participation in another country’s intranational
game” (p. 309). Money can be used to influence participation and with broader international
objectives in mind.
Research sub-question #2: What policy windows of opportunity exist in which to advance
health as a strategic priority within U.S. foreign policy?
The policy windows of opportunity for health to advance as a strategic priority in U.S.
foreign policy begin by placing health on the executive agenda politically. This gives way for it
to be incorporated, in some form, within the NSS document. Kingdon (2011) describes two types
of agenda that constitute problems that policymakers or non-state actors have identified as
priorities. Windows of opportunity for each of these agenda types vary. A decision agenda rises
to the level of legislative action because the stakeholders have identified it as a high priority item
(Kingdon, 2011). A governmental agenda item emerges from within government (Kingdon,
2011). The cases included in this research revealed that the policy windows of opportunity were
enabled by the problem stream (the gravity and emergent nature of the global health threat
associated with the HIV/AIDS pandemic) and the political stream (the policy elites who gained
first-hand knowledge of the human and economic devastation in the HIV/AIDS affected regions
coupled with the advocates who were instrumental in reshaping the narrative about HIV/AIDS
affecting heterosexual relationships, women and children).
The problem stream intensified further when the anthrax scare occurred on the heels of
9/ll. This bioterror threat exposed a vulnerability on the pharmaceutical supply side which
triggered an economic/trade solution in opening the market up to access the antibiotics needed to
mitigate the human illness associated with an anthrax exposure.
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The pandemic provides another window of opportunity for “big leaps” (Kingdon, 2011,
p. 247) in aligning the three streams for a policy window of opportunity. The case examples in
this research reveal that a champion or leader at the executive level is needed to set the agenda
and to drive policy action. This once-in-a-century pandemic has created a spotlight on global
health. That alone is a policy window of opportunity for advancing health in U.S. foreign policy.
As Kingdon (2011) cautions, a window of opportunity is only open for a moment in time.
At the time of this writing, the key policymaking bodies are all focused on economic
recovery from the pandemic, domestically and globally. Health is also on the decision agenda.
To advance a policy agenda and couple the streams, policy entrepreneurs must play an active
role as they did with the advocacy for PEPFAR. In that case, bottlenecks to the policy window of
opportunity were kept secret to avoid the risk of USG bureaucracies creating unnecessary
barriers to its policy positioning. The executive branch took the lead and only shared what was
happening with a few people (Gerson, 2008). While the age of technology may not allow for
such secrecy in modern times, the pandemic presents an opportunity for another “precedent
setting presidential decision” (Kingdon, 2011, p. 191) to leapfrog health more prominently into
the U.S. foreign policy agenda.
Research sub-question #3: How has the prioritization of health as a high politic issue in
U.S. foreign policy impacted GHD?
Conducting this research amid a pandemic required a careful balance to avoid the
introduction of bias into participant responses. There was a uniform recognition across
participants that the pandemic was having an altering effect on global economics, self-
sufficiency, interdependencies in the global supply chain, and increased attention to where health
currently sits on a level of prioritization within U.S. foreign policy. This dissertation, however, is
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bounded primarily to a specific period from 2001-2003. Respondents toggled between the ‘then-
and-now’ in giving insight to whether health is prioritized in U.S. foreign policy and how that
impacts GHD. The rise of health on the foreign policy agenda does not equate it to a high politic
issue. It becomes high politic when a champion takes hold of the policy issue and drives its
prioritization within U.S. foreign policy.
A key impact on GHD has been the confluence of domestic and international agendas on
issues pertaining to health, which has necessitated transnational statecraft. Diplomats play a key
role in bridging transnational policy formulation and execution. They are the ‘tip of the spear’.
Crisis events associated with health create a surge effect of interdisciplinary collaboration.
Globalization will continue to act as a driver on GHD where a sustained level of interdisciplinary
collaboration will be needed rather than a crisis-oriented approach. Health as an investment and a
mission driven interest in fostering equity in foreign policies (as was seen in the issues associated
with the response to the HIV/AIDS epidemic) will continue to draw interested parties who share
similar interests into the non-state actor pool. The level of investment in the global health
ecosystem by non-state actors is creating a paradigm shift in the power of the nation state (and
associated fiscal contributions). The nature of this paradigm shift is caused by how much money
the non-state actors contribute to global health issues comparatively to nation states and the
influence they are gaining with global governance organizations. Their entrance into the global
health ecosystem is also driving change, partnerships, and increased attention to global health
risks which is a positive outcome. This will drive politics and negotiation for which GHD will
need to play a role in moderating negotiations and influencing international regulatory
frameworks.
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There is much to be sorted out as the United States resumes its affiliation with the World
Health Organization in 2021. As an interconnected world, we must work to reduce the ambiguity
in policies, such as those related to global health. We must utilize input from all sectors (public,
private, and plural) to ensure that we achieve a balanced solution (Mintzberg, 2015). GHD will
grow in complexity as the range of actors in the global health ecosystem diversifies and the
disproportionate financial contributions to the global ecosystem by non-state actors move to out-
pace those of the nation state. This will strengthen their power and influence on the global health
policy agenda. The pandemic has intensified the conversation around health on the foreign policy
agenda and we are poised to begin another era of health in U.S. foreign policy.
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CHAPTER 6. CONTINUED DEVELOPMENT OF HEALTH POLICY
This chapter will be used to tell the story of the Global Fund and PEPFAR to explain the
precipitating events, how the policy was developed and implemented, and to introduce a new
conceptual framework for the prioritization of health in U.S. foreign policy. This research is
valuable to individuals and organizations who are retooling statecraft and strategies associated
with health in U.S. foreign policy. Conclusions and implications for policymakers are provided
in the remaining sections of this chapter.
The importance of this research has been amplified by the pandemic which will drive
reflection and decision making on U.S. foreign policy priorities in the future. The data gleaned
from the historical reflection on the implementation periods of the Global Fund and PEPFAR is
useful in informing 21
st
century global health and global health security policy design.
Telling the Story of the Global Fund and PEPFAR
In the 1990s, U.S. foreign policy lacked a global health security strategy. The NSS had
not yet reflected a pivot from Cold War ideology. U.S. foreign policy during this era emphasized
humanitarian assistance as the key foreign policy lever for global health issues. Conceptualizing
foreign policy implementation on global health issues can go counter to expected outcomes when
operationalized in the real world. An example of this was the Rwandan Refugee Crisis in 1999 in
which a genocide “killed approximately 800,000 Tutsi and moderate Hutu” (Wagner, 2009, p.
365). A lesson learned from the Rwandan Refugee Crisis was that the U.S. military’s primary
mission of warfighting (hard power) can go counter to a private stakeholder’s primary mission
when engaging in a joint humanitarian assistance response (Lange, 1998).
One explanation for this may be that the coordination of military and civilian responses to
global health events are organized under different policy mandates and intergovernmental
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relationships that need to be harmonized. Coordinating diplomatic responses to global health
events can result in a more transactional, potentially more narrowly defined response (military)
as contrasted to the civilian responses where the personnel presence is ongoing. The Clinton
Administration sent military to respond in the humanitarian crisis in Rwanda. In a civil-military
cooperation event, it’s critical that the Diplomats are involved in highlighting the pitfalls where
actions may have unintended risks to foreign policy strategies. The events of Black Hawk Down
in Somalia during the Clinton Administration are an example of this. What begins as a
humanitarian assistance event with military personnel can have unintended consequences in
engaging our DoD in a conflict and further destabilizing a Region. These events are important to
highlight because they reflect how the conceptualization of foreign policy in the NSS is impacted
by having its origins in the Goldwater-Nicholas Act of 1986. If a policy frame for global health
is absent, then when the crisis occurs it can up-end the whole foreign policy strategy. Black
Hawk Down constrained the United States in moving forward with its diplomatic strategy of
assertive multilateralism. It also led to a deferred humanitarian assistance and Congressional
action in response to the Rwanda Refugee Crisis.
Domestically, the role of prominent public figures raised awareness of HIV/AIDS in the
United States. They included Rock Hudson (an actor who died of AIDS in the late 1980s),
Elizabeth Taylor (actress and humanitarian), and Larry Kramer (playwright and activist). In the
1990s, the deaths of Elizabeth Glaser (wife of an actor who contracted the disease from a blood
transfusion) and Arthur Ashe (professional tennis champion who contracted the disease from a
blood transfusion) reshaped the narrative of HIV/AIDS being attributed solely to homosexual
lifestyles or intravenous drug use. Bono, singer and activist, raised awareness of HIV/AIDS
internationally. With an increasing public awareness that HIV/AIDS could affect women in
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heterosexual relationships (from one affected partner to another) and children through childbirth,
the domestic narrative of the HIV/AIDS epidemic pivoted to a more compassionate stance on
those affected by the disease. It was no longer strictly a disease viewed by conservatives as one
that emerged in the homosexual community because of illicit behavior, but as a disease that
could potentially affect anyone. This pivot served as a catalyst to unite unlikely bedfellows in the
battle to prevent and treat HIV/AIDS.
Global health wasn’t described by participants as a high politic issue at the time, but it
also wasn’t out-of-sight from a policy perspective. The entrance of non-state actors into the
global health ecosystem, such as the Gates Foundation in the late 1990s, drew attention to the
fiscal resources which focused on disease-specific priorities and brought an increased interest on
global health as an investment. A World Development Report (The World Bank, 1993) provided
an evidenced-based rationale for investing in global health. It highlighted three priorities that
included linking economic prosperity to good health in families, focused government spending
on disease prevention and treatment through robust public health efforts and promoting
competition in government procurements while also engaging the private sector to foster
diversity in the delivery of services. A report by the World Bank sought to provide governments
with recommendations on how to confront AIDS and prioritize its response to the epidemic (The
World Bank, 1997). As the growth in stakeholder interest in global health investment grew, this
further shaped the ecosystem on how and where state and non-state actors had increasing
influence over global health policy priorities.
The World Bank engaged more fully in the health sector because it had become a major
portion of the Gross Domestic Product (GDP). This raised its interest in the role that health
would play in influencing economic policies. The World Bank serves as a development lender to
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governments. Health is a sector that relies on government engagement to succeed. These three
factors drove the World Bank’s interest in the health sector in the 1990s (Abbasi, 1999). It also
piqued the interest of wealthier nations and non-state actors to pursue investments in global
health.
Concurrent with this economic and investment interest in the health sector was the public
health focus on the Global Burden of Disease study which was produced in 1993 by the Harvard
School of Public Health in collaboration with The World Bank and the WHO (Murray et al.,
2001). While other diseases were more prevalent than HIV/AIDS in the Global Burden of
Disease study, the increased security and political interest in the epidemic in Africa elevated it as
a priority. The risk to human capital in affected areas due to the high rates of death raised
concerns about its impact on social development and economic stability. Money alone wasn’t
going to solve the problem. A global policy solution was required, and Africa needed assistance
to build the capacity to respond to the epidemic. This further acted as a catalyst in driving U.S.
transnational policy interest in health beyond what had been solely a domestic concern. Rationale
for policy doesn’t rely solely on the public health data. The impact of public health events on the
global economic good also drives policy engagement. Burnside and Dollar (2004) emphasized
the importance of having sound policies associated with aid distribution.
A global policy solution to the HIV/AIDS epidemic emerged with the establishment of
the Global Fund to Fight HIV/AIDS, Tb, and Malaria. In the next section, the events leading to
its establishment and associated world events are detailed.
How the Global Fund Originated
The Global Fund has its origins in the UN Declaration of Commitment on HIV/AIDS,
developed in the June 2001 meeting of the UN, and the Declaration is useful in understanding
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the events that eventually led to its formal establishment. According to the UN Declaration of
Commitment, “by the end of 2000, 36.1 million people worldwide were living with HIV/AIDS,
90 per cent in developing countries and 75 per cent in sub-Saharan Africa. Noting with grave
concern that all people, rich and poor, without distinction as to age, gender or race, are affected
by the HIV/AIDS epidemic, further noting that people in developing countries are the most
affected and that women, young adults and children, in particular girls, are the most vulnerable”
(United Nations General Assembly, 2001). Another source describes that, at the beginning of the
21
st
century, “worldwide, 36 million people were estimated to be living with HIV/AIDS. Some
22 million men, women, and children had already died from it; and 15,000 were infected with
HIV every day” (Donnelly, 2012, p. 1391). It’s important to note that the Global Fund focuses on
3 diseases: HIV/AIDS, Tuberculosis, and Malaria. The rationale for this emerged at the G8
Summit at Okinawa, Japan in 2000 where ideation evolved from a purely HIV/AIDS disease
threat to including tuberculosis which is considered an opportunistic infection which contributes
to the death of HIV/AIDS affected persons.
The U.S. domestic narrative that attached homosexual lifestyles and behaviors with
HIV/AIDS pivoted to an international narrative where society’s most vulnerable were also at risk
of contracting the disease, including those in heterosexual relationships. The dying included
those who served as core pillars for the continuity of their own communities: teachers, public
workers, and military. There was no treatment or cure available to those afflicted with
HIV/AIDS until antiretroviral (ARV) therapies were discovered in 1996 (Carpenter et al., 1997).
Prior to this discovery, it was considered a death sentence.
The path to the establishment of the Global Fund spanned several years and involved a
series of domestic and international events that are summarized in a Congressional Research
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Service Report developed by Copson and Salaam (2005). The events leading to the establishment
highlight the transnational nature of policymaking in this multilateral organization. It’s a
complex process that involves global stakeholders who coalesced around a common area of
interest and/or concern. This is a similar situation to what we are facing on the heels of a
pandemic.
The order of events is as follows:
• May 1998: At the G8 Summit in Birmingham, England, France proposed an international
fund to provide AIDS treatment to the developing world, but it was not well received.
• August 1999, 106
th
Congress: Representative Barbara Lee introduced the AIDS Marshall
Plan fund for Africa Act (H.R. 2765). No vote was taken on this measure.
• January 2000, 106
th
Congress: Representative James Leach introduced the Global AIDS
and Tb Relief Act of 2000 (H.R. 3519). This measure passed the House and Senate and
was signed into law in August 2000 to become P.L. 106-264.
• April 26, 2001: UN Secretary General Kofi Annan, in his speech to African leaders used
the term “Global Fund” and referenced “$7-10 billion dollars in a war chest” to fight
against AIDS (Copson & Salaam, March 2005, p. CRS-2).
• May 11, 2001: President Bush made a Founding Pledge of $200M to the Global Fund and
recommended that the fund should be established as a public-private partnership and not
as a part of the UN. Secretary General Kofi Annan disagreed. However, the end-result
was the establishment of a more flexible, equitable governance model established outside
of the UN in Geneva, Switzerland. Disputes among countries did occur as the debate over
governance was eventually decided.
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• June 2001: the Global Fund was created and endorsed by the UN General Assembly. The
General Assembly makes the political declaration on issues concerning international
security and peace (www.un.org/en/model-united-nations/general-assembly).
• July 2001: the G8 plus Russia approved the Global Fund at their summit in Genoa, Italy.
• October 2001: a Trans-Working Group (TWG) was formed by the United Nations
General Assembly to establish the principles and operational plan for the organization
(The Global Fund, n.d.).
• December 2001: the enabling documents for corporate governance of the Global Fund
were created.
• January 2002: the Global Fund was established as an independent funding organization in
Geneva, Switzerland following negotiations about its governance structure with donors
and developing country’s governments, NGOs in the private sector, and the UN. A
primary mission was to generate grants focused on decreasing the infectious diseases
listed in its title: HIV/AIDS, Tb, and Malaria. In its first five years, it set an accelerated
“scale-up” with a goal of funding HIV treatment using “anti-retroviral therapy for
500,000 patients over five years” (Copson & Salaam, 2005). An Executive Director, Dr.
Richard Feachem was selected to run the newly established Global Fund and he was
given the title of Undersecretary General of the United Nations. Providing authority and
access through appropriate leadership titles is an important strategic step to scaling new
multilateral organizations. Building trust with stakeholders is critical to the successful
operationalization in a global arena.
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• May 27, 2003: Congress passes the HIV/AIDS, Tb, and Malaria Act of 2003 (P.L. 108-
25) which authorized “up to $1B as an FY2004 contribution to the Global Fund” (Copson
& Salaam, 2005).
In addition to the timeline presented in the report by Copson and Salaam (2005), this
section discusses details of pivotal changes that occurred in tandem to the summits and events
associated with the establishment of the Global Fund. These changes also added significance in
accelerating the global response to the HIV/AIDS epidemic and are intending to provide a
broader picture of the dynamic activities associated with multilateral diplomatic engagements.
On July 17, 2000, the UN Security Council adopted resolution 1308 on HIV/AIDS and declared
that the epidemic presented a security risk (UNAIDS, 2000). This represented the first time that
the UN Security Council had discussed a health issue. It may also have served as a pivotal
moment for creating a legacy for UN Secretary General Kofi Annan. Vice President Al Gore
served as President of the Council and representative of the United States
(www.un.org/press/en/2000/20000110.sc6781.doc.html) along with U.S. Ambassador to the UN,
Richard Holbrooke. The U.S. echoed the security concerns associated with the HIV/AIDS
epidemic and the regional risks for the continent of Africa. The Executive Director of UNAIDS,
Peter Piot, suggested that strong political leadership was having a positive impact in areas of
Africa where the epidemic was unfolding. He also challenged the Council to consider that
additional funding (in billions of dollars) was a worthy investment given that a similar
investment was made to combat the “Y2K virus”
(www.un.org/press/en/2000/20000110.sc6781.doc.html). The securitization of the HIV/AIDS
epidemic is believed to be what drove the establishment of the Global Fund and PEPFAR.
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This root stage of linking health to security did not garner a consensus of support. Some
felt that it set health issues on a path that would drive a militarized response which carried
inherent risks of mission creep. In Uganda, for example, the impending threats to economic
stability due to the HIV/AIDS epidemic weren’t observed by in-country diplomats; thus, leaving
a feeling that linking health to security was more of a political strategy than a security threat. The
UN Security Council actions did elevate the HIV/AIDS epidemic to a global political space of
action.
Access to anti-retroviral therapies was a key priority of activists who advocated for those
affected by HIV/AIDS. Activists pressured the Clinton Administration to reduce the price of the
ARV drugs, in particular Vice President Gore, when they showed up at a presidential campaign
rally (Weisman, 1999). Activists rallied the pharmaceutical industry to make the ARV drugs
more affordable and to promote equal access to ARV treatments by low-income countries. An
economic solution to an international pricing barrier associated with pharmaceuticals emerged
with the Doha Declaration on the TRIPS Agreement and Public Health, passed by the World
Trade Organization (WTO) in November 2001. This changed regulatory and trade barriers for
medicines that were essential in the public health response to the epidemic (WTO, n.d.). A
catalyst for the Doha Declaration was the anthrax scares in the United States in 2001. Access to
an antibiotic, ciproflaxin, which is used to treat anthrax exposure was in short supply. This
agreement helped to remedy challenges in accessing medicines that were critical to treating
diseases. The WTO Doha Declaration and the UN Declaration of Commitment were realized
because of a global cooperative effort supported by public engagement on HIV/AIDS.
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The events of 9/11 and the U.S. decision to go to war with Iraq created tension in the G8
meetings. France, a leader in the establishment of the Global Fund and prominent donor,
opposed the war. This led to tensions between President Bush and President Chirac during the
G8 Summit in 2003 at Evian-les-Bains, France and protests of the summit. The country leaders
were eventually able to align their interests toward a common vision for the Global Fund. Each
country gets one vote in this multilateral model which leads to compromise and a balance
between large and smaller countries’ considerations. The Global Fund served as a critical
transatlantic bridge for donor investments and actively worked to balance the U.S. political
stakeholders (Congress, the political party priorities represented by Republicans and Democrats,
and the differing interests presented between the House and the Senate).
In these research case examples and reflecting on the Model III: Governmental Politics
(Zelikow & Allison, 1999), the level of complexity of negotiations was amplified as the
stakeholder interactions occurred domestically, internationally, and transnationally. This can be
depicted as having three separate board games running simultaneously and interdependently.
Each of the board games includes a defined set of rules and norms, a range of actors (state and
non-state), and power that creates the dynamic that shapes preferences. There were many
organizations involved in the USG in implementing the epidemic response which resulted in
competing priorities and autonomous decision-making. This is what Zelikow and Allison (1999)
describe as the “agency problem” (p. 271). The agency problem results when the decision-
making is influenced by the individual interests of multiple participants and it becomes more
difficult to reach a consensus decision (Zelikow and Allison, 1999).
The “principal-agent problem”, which is an example of the agency problem, is an issue
that emerges from the field of economics. The principle-agent issue was cited by one participant
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during the interviews as a key problem in multilateralism. The principal is the decision maker
(Zelikow & Allison, 1999, p. 272). The agent is a participant that is supposed to be working on
behalf of the principal. Special interests may drive agents to pursue a decision or influence a
decision based on individual preferences. This can lead to misalignment with the principal
(organization) and can mean that the agent used his/her power to shape a policy decision.
Considering health as an investment, principles and agents can become misaligned where one
prioritizes the economic interest as the priority for the investment whereas the other may be
driven more by the moral principles for the investment. If viewing a problem strictly from an
economist’s lens, recommendations for action may be based strictly on data and may not
incorporate the complexity of factors associated with health as a U.S. foreign policy issue. It’s
important that a foreign policy strategy consider the potential diplomatic consequences
associated with assessing decisions from a unitary actor lens vs a more complex assessment of a
multiplicity of stakeholders who have short and long-range strategic priorities. Reflecting on the
Global Fund, the agency problem, and the principal-agent problem (Zelikow & Allison, 1999, p.
272) offer explanatory value in understanding why stakeholder negotiation of an independent
and neutral governance model was an important step in shaping how decisions would be made
by the organization.
In the next section, circumstances leading to the establishment of PEPFAR are explained.
How the PEPFAR Policy Development Unfolded
The origins of U.S. foreign policy are found in the NSS. In the Clinton Administration
there was a focus on assertive multilateralism. When the Bush Administration came into office,
the foreign policy focus was on compassionate conservatism. The role of 9/11 and anthrax scares
in 2001 led the United States to focus on a foreign policy strategy that sought to address risks
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before reaching U.S. shores. The HIV/AIDS epidemic seized the attention of President Bush and
drove the prioritization of PEPFAR on his policy agenda. Influenced by two scientists, Dr.
Anthony Fauci and Dr. Mark Dybul, the scientific data presented an opportunity to proceed with
a basic care package ARV treatment in affected regions of Africa and focus on saving lives.
While HIV/AIDS is not curable, the focus on public health and equity policy criterion offered
promise in the fight against this devastating disease that was affecting women and children in
addition to males. HHS Secretary Tommy Thompson was credited for his vision and effective
leadership in harnessing the power of a coalition to advocate for the establishment of an
organization within the USG to treat HIV/AIDS. The moral imperative drove President Bush’s
policy decision to champion PEPFAR.
The NSS during the Bush Presidency pivoted from the Cold War strategy and built
assumptions focused on threats beyond Russia. It drew the United States further into engaging
with transnational policy issues. The ideation considered the risks associated with failing states
(and economic destabilization regionally) vs a strategy focused on hard power dominance. The
development of the NSS reflects the strategies and foreign policy priorities of the President and
can include language that specifically supports a priority for a USG agency. This highlights the
Executive Branch (President’s) prioritization of a particular issue which influenced policy action
on key initiatives: the Global Fund, PEPFAR, and the Millennium Challenge Corporation
(MCC). The 2002 NSS emphasized the importance of human dignity. The subsequent NSS in
2006 moved further into the policy considerations necessitated by the impact of globalization
and highlighted economic growth and the role of development in advancing democratic values
(to name a few).
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Diplomats in East Africa played a key role in facilitating in-country visits for
Washington, DC delegations who travelled to HIV/AIDS affected areas in Africa to assess the
unfolding current state of affairs. U.S. Ambassador to Botswana John Lange hosted a delegation
in April 2002. The delegation of 50 people was led by HHS Secretary Tommy Thompson and
Dr. Anthony Fauci, Director of the National Institute of Allergy and Infectious Diseases
(NIAID), and other experts in global health. HHS Secretary Thompson provided a report of the
visit to President Bush. This visit served as a catalyst for the Congressionally funded
International Mother and Child HIV Prevention Initiative which President Bush announced on
June 19, 2002 to support access to care and treatment of HIV/AIDS in women and children. A
White House press release accompanying this announcement introduced the initiative as a
complement to the Global Fund efforts (The White House, 2002).
Successful prevention of mother-to-child-transmission had already been shown through
treatment initiatives trialed in Africa. Medicines, purchased from the CDC, were made available
in the homes and provided by community resources, such as motorcycle delivery. Community-
led and community trusted resources through the Joint Clinical Research Center (JCRC), a
Uganda based clinic led by Dr. Peter Mugyenyi, were leveraged to promote access and
compliance (Kolker, 2018). Ongoing research during this time by HHS/CDC scientists informed
the policy formulation of PEPFAR and built on decades worth of research in the field. President
Bush committed to funds to support the cost- effective treatment of those affected with
HIV/AIDS in Uganda.
Diplomats strengthened in-country relationships with leaders of nation states and
community leaders, and they worked closely with HHS/CDC scientists based in Uganda who
supported the Ministry of Health and partnered with The AIDS Support Organization (TASO) in
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Africa in ongoing research of HIV. This work was underway during the Clinton Administration
and continued into the Bush Administration. A detailed accounting of the in-country work by
CDC scientists can be found in testimony by Dr. Jonathan Mermin to the Senate Committee on
Foreign Relations and Subcommittee on African Affairs in which he presented a Progress Report
on HHS/CDC efforts to fight HIV/AIDS in Africa. He was responsible for running the
community-based HHS/CDC Global AIDS Program (GAP) in Uganda (Mermin, 2007).
White House interest in pursuing a treatment strategy for HIV/AIDS in Africa was met
with bureaucratic resistance. The USAID Administrator, Andrew Natsios, expressed bureaucratic
doubt that an HIV treatment program could be implemented in sub-Saharan Africa. His comment
was “Africans don’t know what Western time is” and alluded to them not having watches which
suggested that they would not comply with a treatment protocol of anti-retroviral medications.
(Saldinger & Igoe, 2018).
How the PEPFAR Policy Decision was Made
The policy decision to pursue PEPFAR was unusual and a highly unconventional process
in which a handful of people in the White House bypassed the usual bureaucratic process and
influenced another set of people in the White House. As PEPFAR was being developed, the
White House kept the plan largely secret (Gerson, 2008). The rationale for this was to “prevent
an ambitious plan from being watered down or bogged down in the normal, inertial processes of
government” (Gerson, 2008, p. 2). There was an imperative to utilize the time necessary to
validate that an initiative like PEPFAR could be effective in preventing and treating HIV/AIDS
if implemented in selected countries. Drs. Fauci and Dybul led this effort to gain affirmation that
a program like PEPFAR could succeed and they relied on input from public health experts and
from their in-country visits to Africa.
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At a State of the Union address on January 29, 2003, President Bush announced PEPFAR
which would be a “5 year, $15 billion initiative to turn the tide in combating the global
HIV/AIDS epidemic” (The White House, 2003, para. 1). As a Model 1: Rational Actor
(Zelikow-Allison, 1999) example, President Bush and his team led the decision-making from the
White House on behalf of the nation state, similar to President Kennedy leading the decision-
making on the Cuban Missile Crisis from the Executive Branch (Zelikow & Allison, 1999). The
primary strategic concern facing the United States that led to their leadership, engagement, and
request for funding for two signature global health initiatives, the Global Fund and PEPFAR,
included the staggering rise in death rates caused by an incurable disease and the anthrax scares
of 2001. The rational alternative was for the United States to take a leadership and diplomatic
role in this humanitarian crisis. The timing of this significant funding following other financial
obligations that the United States had while in the midst of a war was of interest. The success in
achieving this level of multi-year commitment to PEPFAR is attributable to the role of
champions, described in Theme 1 in Chapter 5. Successful implementation was made possible by
leveraging experienced diplomats who moved progressively and laterally through different roles
within the USG which gave breadth to knowledge on the HIV/AIDS epidemic, helped to shortcut
bureaucracies, and provided diplomatic expertise transnationally. An example of the value of
diplomatic expertise can be found in a 2018 article entitled “A Diplomat’s Perspective on Use of
Science and Evidence in Implementing PEPFAR”. It describes President Bush’s visit to Uganda
in July 2003 shortly after PEFPAR was announced. Uganda played an important role in shaping
the plan for HIV treatment given the existing infrastructure and scientific collaborations
described in Section 2. According to Kolker (2018), who served as Ambassador to Uganda, “the
HIV treatment model for PEPFAR was developed with Uganda in mind” (p. 4).
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Congress, as the policymaking body for the US, played a critical and bipartisan role in
passing the enabling statute that included PEPFAR and the Global Fund: P.L. 108-25. Unlikely
alliances emerged in the process of developing and advancing this legislation. Evangelical
Christians, celebrity activists such as Bono, and HIV/AIDS activists came together to support
efforts to prevent and treat HIV/AIDS. Progressive and conservative Congressional members
were moved by the moral imperative to prevent the deaths of women and children at-risk of HIV
exposure. Civil society also served a key role in advocating for action on the HIV/AIDS
epidemic. An example of advocates who shaped policy on HIV/AIDS included the Global Health
Council. Dr. Nils Daulaire was President and CEO of the organization during this period. As an
international non-profit, the Global Health Council was positioned to work across a range of
state and non-state stakeholders on the HIV/AIDS initiatives, for example, and leverage
established relationships with Congressional members to raise awareness of the geopolitical
nature of global health issues.
On the Senate side, key leaders who were instrumental in working with the White House
to pass the legislation include Senator Bill Frist who served as Senate Majority Leader in 2003.
Senator John Kerry and Congresswoman Barbara Lee (U.S. House of Representatives) were
highlighted as Congressional champions. Andy Olson served as Legislative Counsel to Senator
Frist and had previously worked on the Bush campaign. After political discourse on issues such
as the use of condoms in preventive care and a preference by conservatives for abstinence,
bipartisan support was achieved with some members choosing to break from party line voting.
Concurrent with the efforts of social HIV/AIDS activists, the role of global, celebrity activists
like Bono helped to shape individual policy positions of some Congressional members on the
HIV/AIDS crisis by sharing his first-hand experiences from travel to the affected regions in
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Africa. Three key staff in Senator Frist’s office who were instrumental in working on the Frist
legislation included Allen Moore (Deputy Chief of Staff and Policy Director, Office of Senator
Frist), Dr. Kenneth Bernard (Public Health and Bioterror Expert on loan from HHS), and Nancy
Stetson (Foreign Relations Committee Staff, Office of Senator Kerry).
Catalysts that led to Congressional action on this issue included an awareness of the
number of deaths (including women and children) caused by AIDS, the impact that this
destabilization was having, or could have, on the global economy, and the subsequent
securitization of health by the UN. Domestically, greater awareness of the threat of AIDS
emerged when famous people like Arthur Ashe, the tennis legend, and Elizabeth Glaser, died
from contaminated blood products. On the heels of 9/11, a domestic terror event, this amped up
the concern that global health threats could quickly become domestic health threats. Participant
12 noted that prior to PEPFAR, “health was not a concern for the national security
establishment”. Policy entrepreneurs within Congress were key to the stream alignment that
enabled the window of opportunity to pass P.L. 108-25. Within Congress, negotiations for
support were navigated between progressives and conservatives. The role of non-state actors also
came into play in influencing lawmakers to view HIV/AIDS as a disease affecting heterosexual
and homosexual relationships. This resulted in a softening up of the policy stream and facilitated
stream alignment (Kingdon, 2011). Policy entrepreneurs are critical to creating policy windows
of opportunity.
The Office of the Global AIDS Coordinator was established in Department of State and
not in USAID. The White House was instrumental in this decision-making. Some participants
later described this arrangement as being “in but not of” the State Department. This
organizational model for PEPFAR was innovative and unique and allowed its leaders to have
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power and flexibility in scaling up. There was no standard operating procedure for the epidemic.
Health experts inside and outside of government were leveraged to establish the office leading to
a team with significant experience diplomatically and in public health. Randall Tobias was
selected to lead the office and was given the title of Ambassador. This was an important step in
empowering the office to carry out an initiative that was a priority for the President and to
overcome potential USG bureaucratic hurdles. He was supported in his leadership role by
Ambassador John Lange, Deputy Global AIDS Coordinator and Dr. Joseph O’Neill as the
Deputy Coordinator and Chief Medical Officer. In subsequent Presidential Administrations, the
Office and position title changed names and authorities.
It is important to note that HHS established an Office of Global Affairs (OGA) in 2002. It
supports the Secretary of HHS, then Tommy Thompson, on global health issues. It also serves as
the hub for GHD within the USG. HHS serves a complementary role to the Department of State
in advancing U.S. foreign policy strategies on global health. OGA emerged at a critical time
when Secretary Thompson was actively engaged in assessing the impact of the HIV/AIDS
epidemic in Africa concurrently with the anthrax/bioterror attacks in the United States. Details
about OGA’s history and purpose were summarized in a report by the Center for Strategic and
International Studies (CSIS) (Bliss, 2014).
Kingdon (2011) describes the processes in public policy making as: “setting the agenda,
specifying alternatives, an authoritative decision on a choice (e.g., a presidential decision), and
the implementation of the decision” (pp. 2-3). Just because an item ends up on agenda, it doesn’t
necessarily lead to a political action (Kingdon, 2011). A problem, like the HIV/AIDS epidemic,
rises to the attention of public and private officials particularly as the intensity of the issue rises
on the agenda (Kingdon, 2011). “The president, and his closest advisers, have as their agenda the
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‘biggest items’, things like international crises, major legislative initiatives, the state of the
economy, and major budgetary decisions” (p. 3). Actors in the politics stream in 2001-2003 were
balancing several large-scale events: 9/11 (terrorism), anthrax scares, the HIV/AIDS epidemic
which was accompanied by the SARS outbreak in April 2003. Those in the policy stream, which
involved the engagement of power elites both inside and outside of government, were aware of
the growing concerns of global AIDS. The problem stream was being informed by data from
scientists, Dr. Fauci and Dr. Dybul. Kingdon’s (2011) description of how an item rises to the
level of an agenda is reflected in my findings when examining the HIV/AIDS crisis.
In the next section, a new conceptual framework for health in U.S. foreign policy will be
presented and discussed. Global events have led to new assumptions in how health is
conceptualized in U.S. foreign policy.
A Conceptual Framework
The conceptual framework derived from this research and presented in this section
depicts a transnational ecosystem and highlights the role of diplomats in bridging relevant policy
domains. The framework builds upon past work by Fidler (2005) which uses a high-to-low
politic continuum to gauge when health becomes prioritized within foreign policy. In contrast to
the continuum, the conceptual framework in this research moves to a lifecycle conceptualization
(a closed circle) which shifts policy design to a focus on a sustainable level of USG
infrastructure and readiness which strives to mitigate the cycles of complacency that lead to ad
hoc responses and peril. Health, within the high politic debate, is front-and-center during this
current pandemic. My research aids policymakers in shaping the role of health in foreign policy
decision-making by developing a conceptual framework to aid in explaining the complexity of
transnational global health policy events.
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Figure 10. A Conceptual Framework for the Prioritization of Health in U.S. Foreign Policy: A
Dynamic Transnational Lifecycle
The lifecycle is depicted in the conceptual framework as a closed blue loop which
intersects with the area of the nucleus of the framework and across the domestic and
international area of activity. This lifecycle loop is metaphorical and not theoretical. It is
intended to focus attention on transnational planning for global health threats. There are no
implicit stages in this lifecycle loop as each health event is nuanced with variables that contribute
to risk. The lifecycle loop suggests the need for a constant state of readiness in health, not an ad-
hoc approach. This constant, already at play, drives a certain level of readiness to be resourced
and planned for. It will require a mindset shift. We also need to move beyond a flat matrix for
drawing comparisons between traditional and human security. A lifecycle model is more
dynamic and dimensional than a matrix because it draws on assumptions that health events
require an ongoing level of readiness as opposed to a static state where readiness only occurs
when an event rises to a higher level of importance or risk. We need to socialize the concept that
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health disasters are not equal to environmental disasters/events (e.g., hurricanes) as these can be
regional. Health disasters, as we are seeing with the COVID-19 pandemic, when played out
globally are seemingly much more complex than regional disasters. They require nuanced
planning.
Key to optimizing the prioritization of health in U.S. foreign policy will be the
development of strategies to mitigate conflict at what is described as the blurred and bloody
border: the negotiation between hard power and soft power ideologies and mandates. At the
blurred and bloody border, power elites bring resources to address the problem or policy conflict.
The champion is key to opening policy windows of opportunity. Organizations move the
resources. Stakeholders drive accountability and aid in shaping the policy. Integration of these
activities can be depicted as a fluid back-and-forth as the potential for the confluence of the
streams (problem, politics, and policy) is influenced by the actions of stakeholders engaged
within each stream of activity. Global health policy issues, in contrast to wholly domestic health
policy issues, leverage global power linkages to generate power. Power elites are depicted in the
policy stream of Kingdon’s MSF (Kingdon, 2011). Negotiation happens across domains and
between stakeholders domestically and transnationally. Power, as leverage to drive toward
windows of opportunity is gathered up to achieve momentum toward the window of opportunity.
This essential role of power elites in negotiating policy issues is essential for shaping the role of
health at the blurred/bloody border in this conceptual framework. They have insights of the
interplay between health, security, and economics transnationally, are strategic decision makers,
and can weigh-and-measure short and long arc risks/benefits to the United States.
According to Jabareen (2009), “a conceptual framework is defined as a network of linked
concepts that together provide a comprehensive understanding of a phenomenon. Conceptual
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frameworks are not merely collections of concepts but, rather, constructs in which each concept
plays an integral role. They provide not a causal/analytical setting but, rather, an interpretative
approach to social reality” (p. 51). Jabareen’s (2009) research clarifies that my interpretation of
concepts and themes may vary from another researcher’s interpretation. “Finally, they are not
determinist frameworks” (p. 57). Jabareen (2009) notes that the advantage of conceptual
frameworks includes “flexibility, capacity to modification, and understanding” (p. 58). To
advance GHD as an applied practice (Brown et al., 2018), a framework should provide value to
the interdisciplinary and complex ecosystem within which it is practiced. This conceptual
framework draws inferences from the findings in this research. The inferences are that diplomats
serve key roles as global connectors across a transnational ecosystem. To mitigate cycles of
complacency in global health events, the grand strategy should conceptualize health risks and
opportunities along short and long arc horizons.
The nucleus of the lifecycle is depicted inside the red dotted line in the center of the
transnational ecosystem. It serves as the gathering space for the deliberations around the
securitization of health. Within this collective group, it is essential for a knowledge broker with
wisdom and insights on bioterror, pandemics, and human security to act as the negotiator and
champion at-the-table. Working alongside other experts in the field of security and economics,
the confluence of domestic and international health policy threats must be assessed
synergistically as opposed to domestic or foreign. As a result of the findings in this research, my
key contribution to practice is the development of a conceptual framework for the prioritization
of health in U.S. foreign policy.
A lifecycle approach is also trending in the field of cybersecurity strategy as seen in a
development by the European Network and Information Security Agency (ENISA) approach. It
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may serve as a template for conceptualizing how health (as a security issue or an associated
component of cybersecurity issues) can be reframed within a risk lifecycle versus trying to fit it
into the existing security threat assessment matrix. The ENISA four phase recommendation for
lifecycle of national cybersecurity strategy is shown below in Figure 11. This framework draws
on assumptions that strategies require ongoing development and review as real-world events
necessitate. It is not based on a single encounter. Supplementing a traditional security matrix
model with a lifecycle model may aid in overcoming the cycles of complacency in global health
events that were identified by research participants.
Figure 11. The ENISA Four-Phase Recommendation for Lifecycle of National Cybersecurity
Strategy
Source: Kovács, 2018, p. 117.
Conclusions
This research incorporates different perspectives from a diverse research participant
group who, through their roles and lived experiences, shaped the story of how the Global Fund
and PEPFAR were created. The process of how the decision was made by the White House to
pursue an effective response to the HIV/AIDS epidemic is one that is unconventional where a
handful of people bypassed bureaucratic hurdles and capitalized on a window of opportunity
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(Kingdon, 2007). The window of opportunity (Kingdon, 2011) that opened for PEPFAR was
achieved by the coming together of policy entrepreneurs and scientists. Presidential leadership
and engagement, coupled with the increased importance of transnational issues such as terrorism,
accelerated the prioritization of PEPFAR USG-wide. It drew attention to the role of
entrepreneurs in seizing opportunities to scale initiatives within USG organizations. The role of
non-state actors in influencing the policy process has also been highlighted. Looking forward
with a post-Cold War, transnational lens, opportunities to apply this research are described in the
sections that follow.
Implications for Policy
The key contribution to literature that my research achieves is that it presents a new
conceptualization of GHD and U.S. foreign policy decision-making at a time when global health
issues have emerged as a leading U.S. foreign policy and transnational challenge. My research is
unique because it incorporates a transnational view of policy, not just a domestic lens, whereas
most literature I’ve found chooses one or the other (domestic or global). It examines two cases
(multilateral and bilateral). It builds upon past work which includes a scholarly deliberation of
health (high politic and low politic), presented by Fidler (2005) and security (health and human).
This research integrates the policymaking view into a lifecycle concept which can be applied
across interdisciplinary domains (health, politics, international relations, policymaking, decision
making, etc.).
Building upon the high politic-low politic continuum of health (Fidler, 2005), this
research has revealed that the prioritization of health alongside security and economics within
U.S. foreign policy requires a different measure. My rationale for this statement is based upon
my analysis of the findings and narratives provided by participants. The NSS derives its
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framework (initially) from a political foundation (e.g., a presidential campaign). Politics, from
the outset, can enable or constrain a global health policy issue as a priority or not. The
Goldwater-Nichols Act of 1986, explained in Chapter 2 of this dissertation, is oriented toward a
Department of Defense framework or hard power ideology. Coupling the two together, politics
and hard power already positions global health issues in a lower politic tier. Incorporating global
health into the NSS document relies upon messengers from the respective ‘USG health
organization nodes’ to shape the content on health as a strategy priority within U.S. foreign
policy. There is a process of interdisciplinary translation that is necessary to bridge the
professional domain language for a normalized assessment of what constitutes a national threat.
Incorporating aspects of health into the NSS gives credence to the respective leaders engaged in
global health across the USG. It highlights the Executive Branch relationship to an issue. It sets
the policy framework that takes shape downstream (e.g., interagency) and through policy
diffusion transnationally (e.g., through the diplomats).
Security and the high or low politic of it, fits more readily into a matrixed assessment
tool. A matrix is defined as “the ‘intersection’ of two lists, set up as rows and columns” (Miles et
al., 2018, p. 109). Hard power ideology and training, aligned to Department of Defense, security,
and intelligence professionals, leverages a security matrix to classify a threat as a traditional
security threat or a human security threat (Liotta & Owen, 2006). In an updated matrix, Smythe
(2013) offers three types of non-traditional security threats. They include failed and fragile
states, global terrorism, and trans-national political challenges, which are further subdivided into
human behavior and natural processes. This research, however, was focused on British Columbia
and Australia, not the United States. It would be useful to compare a similar U.S. study on this
same topic if one can be made accessible in an unclassified literature source. It would make a
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difference in understanding in more detail where the United States currently incorporates human
security threats in relation to traditional security threats in a threat assessment tool. Leveraging
insights on this topic from an international body of literature offers a comparative lens for an
examination of U.S. health security prioritization.
A key question that the United States is facing in 2021 is how to pivot toward a post-
pandemic foreign policy strategy. An interim NSS released by the Biden Administration gives
indications of the pivot from hard power to soft power diplomacy. The pandemic shone a light
on the complexity of global health events. It highlighted the interdependencies of the global
economic market where individual agents with differing strategic objectives will bargain for self-
interests. It was evident during the scarcity of ventilators and protective equipment necessary to
support the acute phases of the pandemic. In the final NSS, attention will need to be on a foreign
policy strategy that optimizes the diplomatic operationalization of health. The assumptions
driving policy formulation cannot be constrained by past routines or ideology that frames
decision-making as traditional security vs. human security.
Health threats are complex and may have a longer time horizon before rising to a high
threat level, yet they require a keen focus on them lest we cycle back around with an immature
infrastructure to respond. Likewise, economic risks or trade risks can be quantified more readily
than health by economic analyses or fiscal comparisons. Health, in contrast doesn’t speak as
loudly as terrorism or money. However, as we’ve observed with the COVID-19 pandemic of
2020, when it does raise its head, it rings all the bells of risk and negative impact that align to the
matrixed boxes of assessment and analyses that fit more statically into security and economics.
This research has revealed that there are barriers to raising and/or keeping health at a
level of high politic. One key barrier is cycles of complacency. Health issues are treated more
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like hurricanes or as disaster preparedness events. The concept of health within a broader
ecosystem has not been well-socialized within the USG. Health disasters are not equal to
environmental events, like hurricanes, and therefore should not be bucketed as such.
Infrastructure and resources to support global health disasters, like the pandemic, require
nuanced planning.
An observation by some participants in this research is that health, when arising as a
foreign policy issue, is viewed as someone else’s area of work or something to cast off to the
folks who work in health. Organizationally within the U.S. government, that spans across several
organizations (e.g., State Department (USAID), Health and Human Services, CDC, Office of
Global Affairs, Health Attaches in the U.S. Embassies). The relationship that health threats play
in the bigger picture may be lost when viewed from an individual disciplinary perspective. This
creates risk.
Leadership roles associated with global health policy and program are not always
empowered to have a seat-at-the-table alongside security and economic leaders. Thus,
organizationally within the executive leadership hierarchy of the USG, there is a structural
barrier that creates a limiting factor for health to rise along the high politic continuum (Fidler,
2005). From this research, I have identified that health can be high on a policy agenda, but not
rise to the level of high politic. A champion is essential.
To overcome the fixed matrix models of analysis for national security threats and the
high politic-low politic continuum, I propose that health belongs in a conceptual framework that
utilizes a lifecycle model. Such a model is more dynamic, draws upon interdisciplinary findings
obtained from research participant data, and reflects the intersecting points in which the strategic
decision-making about health is conceptualized alongside security and economics. The human
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decision-making element that enables or disables the messaging by those closest to the areas of
opportunity, or concerns identified and expressed by GHD experts, can be overcome by
reorienting the prioritization of health within a lifecycle model. For example, a key frustration by
participants in this research is that they weren’t being heard. Sometimes their messaging about
threats and vulnerabilities has taken decades to finally get an anchor in a seat of authority at the
table alongside security and economics. This appears to be due to cycles of complacency where
health does not remain a policy priority in a steady or ready state.
Not having a ‘seat-at-the-table’ of executive decision making disempowers health as a
priority within the U.S. policy agenda. Our diplomats and leaders abroad benefit from a cohesive
governance structure within the USG that prioritizes health through empowered leaders who are
in positions of authority, and are titled appropriately, to influence Presidential advisers and to
drive resource harmonization. Doing so allows for a synthesized approach to examining global
health threats and opportunities from a system perspective vs. a programmatic perspective.
This research builds upon the integrated observations of the Zelikow and Allison (1999)
text. I see the champion leader bringing resources to the table (e.g., power). Integration of
Models I-III happens in a fluid back and forth environment. The champion aids the window of
opportunity (Kingdon, 2007). The organization moves the resources. Stakeholders (e.g., non-
state actors) drive accountability and policy-shaping. In Model II, the organization operates as a
constant relying upon policies and processes that are standardized, and routine and the byproduct
of their efforts is described as outputs (Zelikow and Allison, 1999). Zelikow and Allison (1999)
clarify that groups of individuals who come together for a purpose that is transient, temporary, or
ad hoc, do not meet the definition of an organization. Therefore, it does not apply in ad hoc
circumstances. Negotiation has a shaping effect on policy outcomes and is driven by activity
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generated in Models I and III. Champions, leaders, allies of Model I (the nation state) and
stakeholders (state and non-state actors engaged in politics) in Model III actively pursue
outcomes that align to their strategic objectives and desired policy preferences.
When applying Zelikow and Allison (1999) to the Global Fund case, globalization
creates some neutralization of the nation state’s power as power is diffused in multilateral
structures. The Global Fund, which the U.S. helped to establish, has its own Board of Directors,
and was conceived as a neutral organization outside of the United Nations (UN) and is
headquartered in Geneva, Switzerland (Copson & Salaam, 2005). When stakeholders attempt to
generate power, they too need champions (e.g., Bono) to bring ‘star power’ attention and action
on a cause. This is an example of Model III. Domestically, however, there appears to be less
reliance by stakeholders upon the power of global elites to generate the public power of the
media.
GHD lacks a governance framework, a grounded theory, and a unifying definition to
guide the practice. The accelerated pace of globalization is dissolving the distinction between
domestic and foreign policy issues. The pandemic, coupled with the backdrop of climate change,
has amplified our interconnectedness as a global society. Perceived threats can be fueled by fear
which can further work to categorize health threats as security risks. Contextualizing threats in
this manner may also contribute to cycles of complacency as public perception and attention to
threats wanes over time. Public perceptions influence policy action which can also foster an ebb
and flow of resources. The moral imperative that drove responsiveness to the HIV/AIDS
epidemic, rallied around the global public good, may encourage long term investment and
international cooperation on the wicked problems facing the world today. Embracing a
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framework that prioritizes the principles of human rights can be used to harmonize the often-
competing objectives of advancing national interests vs. prioritizing the collective good.
Paradigm shifts, or changes in the way ideas have been conceptualized in the past, create
the catalyst for the individual and collective movement of conscious evolution. The new
paradigm emphasizes the interconnectedness of all beings. This shift draws together scientists
and practitioners into a system of thinking. Our actions as human beings impact our sustainable
life system. As Hubbard (1998) reminds us, we need to achieve a global mind change to
“understand and develop the new worldview called conscious evolution” (p. 9). Highly partisan
periods, such as we are experiencing in 2021, can create challenges in arriving at consensus on
policies. When human society, as a priority, is positioned behind the priorities of capitalism, it
leads to an imbalance in how policies are conceived. It leads to decisions and consequences
reflective of profit over value (McIntosh, 2017). The role of science and data is useful in swaying
public support and in getting leaders to champion causes. Science and data shaped the
formulation of the policy choices reflected in the implementation of PEPFAR and it will be
essential to continue to invest in science and data so that policymakers can make informed
choices on global health issues in the future.
In the US, we lack a consensus in the prioritization of health in foreign policy between
our President, Congress, and members of the public. Utilizing insights from complex adaptive
systems (CAS), we are seeing in this pandemic that there are common challenges being faced in
the global environment and it will be up to nations, collectively, to find the best governance
approach to creating sustainable solutions (Berkes, 2017).
The U.S. political and foreign policy environment will be shaped by the effects of the
pandemic. Global governance by organizations such as the World Health Organization (WHO)
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was under attack politically in the United States in 2020 amid a reduced funding schema by the
U.S. executive leadership as the United States took a position to withdraw from the WHO. While
the tides have turned following a U.S. presidential election, efforts will continue to examine the
country contributions by affiliated members of the WHO and address the changes in incentives
that are needed to foster compliance with the International Health Regulations (IHR). GHD
policy entrepreneurs will play a key role in shaping policy opportunities between nation states
and advancing health in all things as a global policy priority alongside security and economics.
Through this research, I can contribute positively to that objective. To achieve sound foreign
policy design, the assumptions that drive the strategies need to be based on an interdisciplinary
approach. In this research, I’ve sought to amplify the interdependencies that exist in our world
today and to offer a new conceptual design for approaching decision-making on global health
issues which is built from past experiences of diplomats, scientists, activists, policymakers, and
others. These shared problems require shared solutions. Diplomats are key in operationalizing
U.S. foreign policy and bridging transnational strategic planning.
Given what we’ve learned, here are a few things that have transpired since the bounded
timeframe of this research that have implications for health in U.S. foreign policy going forward.
I included references to the International Health Regulations (IHR), the Global Health Security
Agenda (GHSA) and the Global Health Security Strategy (GHSS) in Chapter 4 under the
heading “Review of Public Documents”. A Congressional Research Service Report, dated
December 19, 2014, provided an update on two of them: the Global Health Security Agenda
(2014-2019) and International Health Regulations (2005). The date of this report preceded the
pandemic. The GHSA is focused on accelerating compliance to the IHR. The IHR includes a
provision “for all WHO Member States to notify WHO of any event that may constitute a Public
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Health Emergency of International Concern (PHEIC)” (Salaam-Blyther, T. December 19, 2014,
p. 1). This provision was highlighted following the outbreak of COVID-19 when there were
concerns that China had not complied with the IHR. The GHSA is focused on strengthening the
IHR provisions and examining ways to assist poorer countries with resources to enable their
compliance (Salaam-Blyther, T. December 19, 2014).
A second Congressional Research Service Report entitled The Global Health Security
Agenda (GHSA): 2020-2024, which was published on March 16, 2020, describes how the
participating countries to the GHSA extended it through 2024. The extension of the GHSA
includes a framework and a well-defined governance structure. The NSC designates a staff
member to serve as the Chair of a GHSA Interagency Review Council (Salaam-Blyther, T.,
March 16, 2020, p. 2). The Congressional Research Service Report acknowledges the USG ad
hoc approach to pandemic preparedness and has suggested that this is an issue for Congressional
review (p. 2). The GHSS was released in 2019 during President Trump’s Administration and
further amplified the U.S. commitment to the GHSA (Salaam-Blyther, T. March 16, 2020). Each
of these documents serves to advance U.S. efforts to strengthen foreign policies pertaining to
health which have been implemented after the 2001-2003 bounded timeframe. That said, they
will remain relevant to the U.S. efforts to build upon the lessons learned (and learning) from the
COVID-19 pandemic regarding how they plan to engage globally on issues of governance,
international cooperation, and transnational diplomatic engagement in the future. Additionally,
an interim NSS has been released by the Biden Administration. It has some relational tones to
the 2003 NSS as it pertains to the language supporting human dignity and is a placeholder for a
larger pivot from hard power to soft power diplomacy and an integration of domestic and
international policy priorities.
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Strategies need to be agreed upon by those at the blurred and bloody border (depicted in
the conceptual framework). This negotiation at the border is described as being ad-hoc and
people dependent. Dependencies can be buffered by selecting individuals in key roles who bear
sufficient knowledge of the topic, are keen on the political realities and strategic implications,
and are committed to upholding the principles that shape effective policies. It may also be
beneficial to bring artificial intelligence (AI) modeling (beyond health disease modeling) in as a
future area of research and to mitigate the individual lens or biases that shape assumptions. There
may be an opportunity to move from using the Zelikow-Allison conceptual models (1999) in a
retrospective analysis of decision making to research their application in a prospective analysis.
The models have been utilized to explain decision making in historical case scenarios across a
range of sectors. A prospective application, in contrast, would use assumptions derived from
patterns of decision making gleaned from Zelikow-Allison’s retrospective analytical research
(1999) to model future predictors of decision making. Emerging research in the field of
Prospective Multi-Attribute Decision Making (PMADM) (Zolfani et al., 2016) may be a useful
tool for organizing the retrospective case insights from Zelikow-Allison’s Models (1999), such
as the selection of alternatives in decision making, and could aid in prospectively identifying a
range of alternatives in decision making that can be applied to future global health events in an
increasingly complex global ecosystem.
Modeling can aid in prediction vs. deflection. This means that decision-making tools can
aid in supporting decision-making more predictably as opposed to having an issue that is cast off
as a lower priority based on bias or human preferences. With modeling, you can look for trend
lines in global health foreign policy decision making and assess how time (over the years) has
changed this trend trajectory, or how technology is influencing decision-making. Globalization is
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increasing the complexity of global health diplomacy as well as the number of variables
associated with each situation. Leveraging technology (computerized models and AI) can work
to inform decision-making and strategies for the nation state to shape global health readiness and
responses more predictably in the future.
Recommendations for Policymakers
Everything I’ve covered is relevant in today’s world. A pandemic continues to rage as
COVID-19 variants emerge and countries grapple with access to vaccines, economic recovery,
and public health messaging. Headlines of an ABC news story read “Global leaders call for new
pandemic treaty and WW2 style collaboration for future global health emergencies” (Davies, G.
March 30, 2021, p. 1.). The COVID-19 pandemic has sparked renewed interest in international
cooperation to pursue an international treaty that refreshes a multilateral system that was
conceptualized on the heels of two world wars. The strategies behind the international
cooperation were “to bring countries together, to dispel temptations of isolationism and
nationalism and to address the challenges that could only be achieved together in the spirit of
solidarity and co-operation, namely peace, prosperity, health and security” (Davies, G. March 30,
2021, p. 3). When resources such as medicines and treatment are not equitably distributed,
conflict can ensue. This was the case with the HIV/AIDS epidemic as well. AIDS activists and
evangelical groups were credited with raising the attention of the crisis and putting pressure on
President Bush to act. They also demonstrated their effectiveness in working together to advance
the care and treatment of HIV affected individuals. Transnational partners worked together to
ensure access to antiretroviral drugs, but it took a cooperative international effort to overcome
barriers to cost and international trade regulations.
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Wicked policy problems benefit from gaining insights from interdisciplinary models and
frameworks. Insights gained from the data collection stage of this research show that global
health issues in U.S. foreign policy have travelled along a protracted course of complacency,
event-to-event. In some instances, the issues of concern didn’t rise to a higher level of attention
despite decades of messaging. Likewise, the organizational domains responsible for health
within the USG need to streamline and enhance interagency collaboration to foster a more agile
and sustainable resource model to accommodate the short and long arc horizons of transnational
health policy issues.
Health is organized by program functions across the USG. This can lead to a fragmented
approach when evaluating the prioritization of health within U.S. foreign policy and national
security due to differing views. Conceptualization of policy prioritization relating to health
requires a synthesized approach. Changing to a lifecycle conceptualization vs high politic-low
politic continuum (Fidler, 2005) more clearly reflects the need to have ‘engagement at all times’
not just at the polar ends of the continuum.
Additionally, there is a need to reevaluate whether using a security matrix threat
assessment approach accommodates the complexity and dynamism of global health events.
Lessons in why this is important can be derived from Ingram et al. (2007) in their work on social
construction and policy design. The interdisciplinary conflicts about where health fits as a policy
priority within U.S. foreign policy can be explained by political power, beliefs of whether an
issue or group is deserving of higher or lower policy status and underlying social norms (Ingram
et al., 2007). This debate between security, defense, and health policy practitioners was evident
when examining the barriers to health as a high politic issue. This is that barrier space described
as the blurred and bloody border.
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Within a matrix design, “when political power and perceived deservedness are
intersected, a two-by-two of four quadrants of target populations is illuminated: advantaged
(high power/high deservedness), contenders (high power/low deservedness), dependents (low
power/high deservedness) and deviants (low power/low deservedness). The approach further
proposes that both the perceived deservedness and political power of target groups will not only
impact policy designs, but also influence future policy stasis and change” (Ingram et al., 2014, p.
129). If health is not perceived as a priority in foreign policy, this suggests that health may be
relegated to a low power/low deservedness quadrant in the matrix. This perception may
contribute to flaws in policy design from the outset. When examining the construction of the
NSS, this starting point of foreign policy construction must include a process that mitigates these
biases toward health based on the disciplines and/or community of practice engaged in the
policymaking. “The two-dimensional typology”, political power and perceived deservedness,
“explains why belief systems have an impact on policy, but it also examines why belief systems
alone may not be enough to explain an actor’s or a coalition’s actions, if power is not
considered” (Sievers & Jones, 2020, pp. 5-6). In short, social construction and policy design
reflects a transparently normative approach which focuses on how political power manifests
itself in policy designs via dominant value paradigms (Schneider and Ingram, 1993). Having a
health policy expert represented on the NSC is a beneficial step in influencing the political power
of social construction and policy design for health in U.S. foreign policy.
Future areas of research opportunity include the use of change prediction strategies (an
engineering concept/design) or artificial intelligence (AI) for the purpose of integrating threats
and risks of global health into national security strategy planning. In my research, I came across
bits and pieces of interdisciplinary work (e.g., cybersecurity strategy planning and engineering
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conceptual heuristic design methods) as approaches that may be useful in overlaying atop of a
similarly complex arena of global health.
My purpose in suggesting this as a future area of research is because the human/USG
organizational process of raising a global health issue to the level of a traditional national
security threat seems to be fraught with variables based on whichever domain of practice is
discerning the threat. It seems that there might be value in modeling/AI that could take some of
the human element out of the debate and normalize the interdisciplinary decision-making and
analysis of the risk. Let the data speak and that might normalize the differing viewpoints between
the hard power and soft power ideological frames.
The U.S. Office of Personnel Management (OPM) and the private sector might want to
consider doing a joint study that examines the training and career pathway incentives of global
health and foreign policy positions within the USG. Global health sits within a complex
ecosystem: public health, development, biosecurity, transnational policy issues, interdisciplinary
collaboration, networking, and the collective action of inter- and intra-organizational programs
and planning. There is a need to examine how the academic preparation and the career pathway
incentives align to these dynamic roles and if the progression to leadership within the foreign
service reflects the value and prioritization of global health as an advanceable career pathway.
Access to science and data that enable an accelerated scaling in response to transnational
security threats requires a ready and able public health infrastructure. Participant 1 said that “it
takes over ten years for a new scientific intervention to make it into the public or into the medical
practice. Everyone talks about that being a shame”. The UN General Assembly committed to a
2030 objective of providing universal health coverage for all. As global leaders tackle the wicked
problems that have come to light during this recent pandemic, I anticipate that the scaling of
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scientific discoveries and treatments will be an important part of that discussion. The case of
PEPFAR offers model examples of how having ongoing science and research embedded within
communities abroad will be critical to supporting the UN General Assembly 2030 objective.
Diplomacy and diplomats as global connectors will play an essential role in helping the
U.S. to navigate its foreign policy in the coming years. Their success in devising cogent
strategies for advancing U.S. foreign policy would be optimized by overcoming a critical barrier
within the State Department. Global health needs to be mainstreamed as a diplomatic priority
within the organization. Traditional diplomacy needs to incorporate GHD. To achieve this
transformative change, it needs to be led by the President. There are signs in the interim National
Security Strategy, published on March 3, 2021, that a transformation is underway. It includes a
statement that the “Biden Administration contends the lines between foreign and domestic policy
have been blurred to the point of nonexistence” (McInnis, K.J., March 29, 2021, p. 1). There is a
pivot toward integrating domestic policy priorities more fully with international policy priorities
– toward a transnational strategic focus. This consideration of global collective action is a move
toward soft power instead of hard power diplomacy and reflects the increasing complexity of the
global health ecosystem and the growing number of stakeholders involved in the policy design.
The role and preferences of the nation state will need to be sorted out as well.
“The utility of GHD must be responsive to the ever-changing global political
environment and thus may be objectionable to those who believe that GHD should focus
exclusively on global health objectives” (Novotny et al., 2013, p. 312). GHD is front-and-center
as the pandemic rages. This represents a new era of health in U.S. foreign policy.
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APPENDIX A. STUDY MEMORANDUM
MEMORANDUM

To: (Participant)
From: Coral T. Andrews, USC DPPD Doctoral Candidate
Date: _______________
Subject: Research Summary

Global Health Diplomacy is the phenomenon of interest in my dissertation
research. I will examine U.S. foreign policy decision-making as applied to
two initiatives: The President’s Emergency Fund for AIDS Relief (PEPFAR)
and The Global Fund to Fight AIDS, Tuberculosis, and Malaria.

My overall research inquiry is: how from an inchoate agenda do a few things
emerge? The historical periods of 2001-2003 will be utilized to explore policy
and decision-making events. The U.S. National Security Strategy will serve
as a mental framework.

The purpose of my research is to analyze the complex nature of foreign
policy to determine under what conditions the decision-making process
advances the health policy agenda and for what value.

Applications of Research to Practice: my research will aid policymakers in
shaping the role of health in U.S. foreign policy decision-making. I will
develop a conceptual framework that can be utilized to explain the
complexity of transnational global health policy events.

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APPENDIX B. RESEARCH PARTICIPANTS
The participant list reflects the format for naming that was preferred by each individual
participant.
Emily Bass, journalist, activist, historian, and author of “To End a Plague: America’s Fight to
End AIDS in Africa”.

RADM Kenneth Bernard, MD, USPHS (ret.)

Nils Daulaire (MD, MPH) is a Distinguished Visiting Scholar at the Harvard T.H. Chan School
of Public Health. Previously he was Assistant Secretary for Global Affairs at the U.S.
Department of Health and Human Services and served as the U.S. representative on the
Executive Board of the World Health Organization.

Sir Richard Feachem, Professor Emeritus of Global Health, Institute for Global Health
Sciences, University of California San Francisco

Peter D. Feaver, Professor of Political Science
Peter D. Feaver (Ph.D., Harvard, 1990) is a Professor of Political Science and Public Policy at
Duke University. He is Director of the Duke Program in American Grand Strategy. Feaver is
author of Armed Servants: Agency, Oversight, and Civil-Military Relations (Harvard Press,
2003) and of Guarding the Guardians: Civilian Control of Nuclear Weapons in the United States
(Cornell University Press, 1992). He is co-author: with Christopher Gelpi and Jason Reifler, of
Paying the Human Costs of War (Princeton Press, 2009); with Susan Wasiolek and Anne
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Crossman, of Getting the Best Out of College (Ten Speed Press, 2008, 2nd edition 2012); and
with Christopher Gelpi, of Choosing Your Battles: American Civil-Military Relations and the
Use of Force (Princeton Press, 2004). He is co-editor, with Richard H. Kohn, of Soldiers and
Civilians: The Civil-Military Gap and American National Security (MIT Press, 2001). He has
published numerous other monographs, scholarly articles, book chapters, and policy pieces on
grand strategy, American foreign policy, public opinion, nuclear proliferation, civil-military
relations, and cybersecurity.
From June 2005 to July 2007, Feaver served as Special Advisor for Strategic Planning and
Institutional Reform on the National Security Council Staff at the White House where his
responsibilities included the national security strategy, regional strategy reviews, and other
political-military issues. In 1993-94, Feaver served as Director for Defense Policy and Arms
Control on the National Security Council at the White House where his responsibilities included
the national security strategy review, counterproliferation policy, regional nuclear arms control,
and other defense policy issues. He is a member of the Aspen Strategy Group and is a contributor
to “Shadow Government” at ForeignPolicy.com
(Source: https://scholars.duke.edu/person/pfeaver)

Sofia Gruskin, JD, MIA University of Southern California (USC)
Professor, Keck School of Medicine and Gould School of Law
Director, Institute on Inequalities in Global Health
Sofia Gruskin directs the USC Institute on Inequalities in Global Health (IIGH). She is Professor
of Preventive Medicine and Chief of the Disease Prevention, Policy and Global Health Division
at the Keck School of Medicine, Professor of Law and Preventive Medicine at the Gould School
209
of Law, and an affiliate faculty member with the Spatial Sciences Institute at the USC Dornsife
College of Letters, Arts and Sciences. Within USC, she is highly engaged in university service
including as co-chair of the USC Senate Sustainability Committee, a member of the Joint
Academic Senate and Provost Task Force on Interdisciplinary Communities, and primary
convener of the USC Law & Global Health Collaboration.
Gruskin currently sits on numerous international boards and committees including the
PEPFAR Scientific Advisory Board, the Lancet Commission on Gender and Global Health, the
IUSSP Steering Committee to Strengthen Civil Registration and Vital Statistics Systems, and the
Lancet Commission on Health and Human Rights. She is co-coordinator of the Rights-Oriented
Research and Education Network for Sexual and Reproductive Health, an international network
of sexual and reproductive health and rights researchers and advocates from the Global South
and the Global North. Professor Gruskin has published extensively, including several books,
training manuals and edited journal volumes, and more than 200 articles and chapters covering a
wide range of topics. She is an associate editor for Global Public Health, on the editorial
advisory board for Revue Internationale des Études du Développement, a trustee of Sexual and
Reproductive Health Matters, and was an associate editor of the American Journal of Public
Health and editor in chief for Health and Human Rights both for over a decade.
A pioneer in bringing together multi-disciplinary approaches to global health, Gruskin’s
work, which ranges from global policy to the grassroots level, has been instrumental in
developing the conceptual, methodological, and empirical links between health and human
rights, with a focus on HIV/AIDS, sexual and reproductive health, child and adolescent health,
gender-based violence, non-communicable disease and health systems.
210
Current research partners include the LA Mayor Eric Garcetti’s Office of International
Affairs, the United Nations Development Programme, the World Health Organization, Global
Fund to Fight AIDS, Tuberculosis, and Malaria, Open Society Foundations, Global Action for
Trans Equality, and local organizations and universities in Bangladesh, Brazil, Kenya, India,
Indonesia, Malaysia, South Africa, and Vietnam.
In recent years, Gruskin served on the board of directors for the Guttmacher Institute, the
Institute of Medicine’s Committee on the Outcome and Impact Evaluation of Global HIV/AIDS
Programs Implemented under the Lantos/Hyde Act of 2008, the UN Technical Advisory Group
for the High-Level Working Group on the Health and Human Rights of Women, Children and
Adolescents, the Technical Advisory Group of the UN Global Commission on HIV and the Law,
the UNAIDS Reference Group on HIV and Human Rights, the Global Advisory Board on Sexual
Health and Wellbeing, and the USC Senate Executive Board. Gruskin was with Harvard
University’s T.H. Chan School of Public Health for many years; director of the Program on
International Health and Human Rights and associate professor in the department of Global
Health and Population; and co-founder and co-director of the Interdepartmental Program on
Women, Gender and Health.
(Source: https://www.globalhealth.usc.edu/about/our-team/core-faculty/sofia-gruskin/)
Jennifer Kates, PhD
Kaiser Family Foundation (KFF), Washington, DC
Dr. Jen Kates is Senior Vice President and Director of Global Health & HIV Policy at KFF,
where she oversees policy analysis and research focused on the U.S. government’s role in global
health and on the global and domestic HIV epidemics. Widely regarded as an expert in the field,
she regularly publishes and presents on global health and HIV policy issues and is particularly
211
known for her work analyzing donor government investments in global health; assessing and
mapping the U.S. government’s global health architecture, programs, and funding; and tracking
and analyzing major U.S. HIV programs and financing, and key trends in the HIV epidemic, an
area she has been working in for close to thirty years. Prior to joining KFF in 1998, Dr. Kates
was a Senior Associate with The Lewin Group, a health care consulting firm, where she focused
on HIV policy, strategic planning/health systems analysis, and health care for vulnerable
populations. Among other prior positions, she directed the Office of Lesbian, Gay, and Bisexual
Concerns at Princeton University.
Dr. Kates has served on numerous federal and private sector advisory committees on
global health and HIV issues, including PEPFAR’s Scientific Advisory Board, the NIH Office of
AIDS Research Advisory Council, the CDC/HRSA Advisory Committee on HIV, Viral Hepatitis
and STD Prevention and Treatment (CHACHSPT), the board of the Global Fund to Fight AIDS,
Tuberculosis and Malaria, and the Governing Council of the International AIDS Society. She is
also a lecturer at the Johns Hopkins School of Advanced International Studies.
Dr. Kates received her Ph.D. in Health Policy from George Washington University. She
holds a Bachelor’s degree from Dartmouth College, a Master’s degree in Public Affairs from the
Princeton School of Public and International Affairs and a Master’s degree in Political Science
from the University of Massachusetts.
(Source: https://www.kff.org/person/jennifer-kates/)

212
Ambassador (Ret.) Jimmy Kolker
U.S. ambassador to Uganda 2002-2005
Deputy Global AIDS coordinator 2005-2007
Assistant Secretary, Global Affairs, U.S. Dept of Health & Human Services 2011-2017

Ambassador John E. Lange (Ret.)
Senior Fellow, Global Health Diplomacy
United Nations Foundation
Ambassador John E. Lange (Ret.) is Senior Fellow for Global Health Diplomacy at the United
Nations Foundation, where he focuses on issues related to global health security and the work of
the World Health Organization. He has held leadership positions in the Global Polio Eradication
Initiative and the Measles & Rubella Initiative. Earlier, he spent four years at the Bill & Melinda
Gates Foundation engaging in high-level global health advocacy with African governments.
Lange had a distinguished 28-year career in the Foreign Service at the U.S. Department
of State, where he was a pioneer in the field of global health diplomacy and a leader in pandemic
preparedness and response. He was the State Department’s Special Representative on Avian and
Pandemic Influenza from 2006-2009. He also served tours of duty as Deputy Inspector General;
Deputy U.S. Global AIDS Coordinator at the inception of the President’s Emergency Plan for
AIDS Relief; and U.S. Ambassador to Botswana and Special Representative to the Southern
African Development Community (1999-2002), where HIV/AIDS was his signature issue. Lange
led the U.S. Embassy in Dar es Salaam, Tanzania, as Chargé d’Affaires at the time of the August
7, 1998, terrorist bombing, for which he received the State Department’s Distinguished Honor
213
Award. Earlier, he had tours of duty at the U.S. Mission to the United Nations in Geneva and the
American Embassies in Lomé, Togo; Paris, France; and Mexico City, Mexico.
He has an M.S. degree from the National War College and J.D. and B.A. degrees from
the University of Wisconsin-Madison.

Jonathan Mermin, MD, MPH
Rear Admiral, USPHS
Director, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Centers for Disease Control and Prevention

Allen Moore
Allen Moore received his introduction to global health as a Peace Corps volunteer in the
Bolivian Andes in the late 1960s: He was a foot soldier in the global effort to eradicate smallpox
and he taught reproductive health to Bolivian miners. Inspired by Peace Corps service, after
Stanford Business School he took the unconventional path of going to Washington to work for
the Department of Health, Education, and Welfare. There followed a Washington career that
included President Ford’s White House Domestic Policy staff; eleven years in the U.S. Senate as
legislative director for Senator John Danforth (R-MO) and then Chief of Staff of the Senate
Commerce Committee; and Under Secretary of Commerce for International Trade
Administration for President Reagan. Outside government, he worked as the president of a
national trade association and as a partner in two Washington consulting firms. After 12 years in
the private sector, Moore returned to the U.S. Senate to be policy director for Senate Majority
Leader Bill Frist, M.D. (R-TN). During that time, he was closely and directly involved in the
214
creation of PEPFAR and the Global Fund to Fight AIDS, TB, and Malaria. Upon leaving
government in 2005, he worked exclusively in global health at the Bill and Melinda Gates
Foundation, the Global Health Council, the Center for Strategic and International Studies (CSIS),
the Stimson Center, and as a faculty member at the George Washington University global health
program. Moore has also been closely involved in refugee issues as a long-time member of the
Board of Advisors of the International Rescue Committee (IRC). Moore lives in northern
Virginia with his wife, Rev. Kathleen Moore. They have eight children and stepchildren, and 13
grandchildren.

Tim Morrison, Senior Fellow
Tim Morrison is a senior fellow at Hudson Institute, specializing in Asia-Pacific security, missile
defense, nuclear deterrent modernization, and arms control.
Morrison currently serves on the U.S. Strategic Command Strategic Advisory Group; the
Lawrence Livermore National Laboratory Expert Review Committees for the Weapons and
Complex Integration Directorate; and the Sandia National Laboratory External Advisory Board
for Global Security.
Most recently, Mr. Morrison was deputy assistant to the president for national security in
the Trump administration. He served as senior director on the National Security Council for
European affairs, where he was responsible for coordinating U.S. government policy for 52
countries and three multilateral organizations. Prior to that post, he was senior director for
counterproliferation and biodefense, where he coordinated policy on arms control, North Korean
and Iranian weapons of mass destruction programs, export controls and technology transfers, and
implementation of the Trump administration’s Conventional Arms Transfer policy.
215
For 17 years, Mr. Morrison worked in a variety of roles on Capitol Hill. From 2011
through July 2018, he served on the House Armed Services Committee staff, initially as staff
director of the Subcommittee on Strategic Forces and ultimately as policy director of the
Committee. As policy director, Mr. Morrison led implementation of Chairman Mac Thornberry’s
priorities, including overseeing implementation of the Trump administration’s National Security
Strategy and National Defense Strategy, prohibition of Chinese Communist Party-linked
information technology and video surveillance technology, and House-passage of the Foreign
Investment Risk Review Modernization Act (FIRRMA) and the Export Control Reform Act
(ECRA) as part of the Fiscal Year 2019 National Defense Authorization Act.
From 2007 until 2011, Mr. Morrison was the national security advisor to U.S. Senator
Jon Kyl (AZ), the Senate Republican Whip, where he assisted in coordinating national security
policy and strategy for the Senate Republican Conference and led policy initiatives on nuclear
weapons, arms control, export controls, and economic sanctions.
Mr. Morrison has a B.A. in political science and history from the University of
Minnesota. He also has a J.D. from the George Washington University Law School. He is an
intelligence officer in the United States Navy Reserve, serving since 2011.
(Source: https://www.hudson.org/experts/1301-tim-morrison)

Thomas E. Novotny MD MPH DSc (hon)
Professor Emeritus of Public Health
San Diego State University School of Public Health
San Diego CA
216
Dr. Novotny is Professor Emeritus of Epidemiology and Biostatistics at the San Diego State
University (SDSU) School of Public Health. He is a graduate of the University of Nebraska
Medical Center (MD 1973) and Johns Hopkins Bloomberg School of Public Health (MPH
Epidemiology 1992). He served as a CDC epidemiologist in the Office on Smoking and Health
and as Deputy Assistant Secretary for Health in the U.S. Department of Health and Human
Services. He co-directed the Joint PhD program in Global Health at SDSU/UCSD from 2009-
2015, and he has done extensive research on tobacco and the environment. In 2010, he founded
the Cigarette Butt Pollution Project, a research, educational, and advocacy non-profit
organization that addresses tobacco’s impact on the environment.

Ambassador John Simon
Founding Partner, Total Impact Capital
Prior to starting TOTAL (formerly known as Total Impact Advisors), Ambassador Simon was a
visiting fellow at the Center for Global Development, where he co-authored More than Money, a
report on impact investing as a development tool. Previously, he held a variety of posts in the
U.S. federal government, including serving most recently as the United States Ambassador to the
African Union and the Executive Vice President of the Overseas Private Investment Corporation
(OPIC). At OPIC, Ambassador Simon championed the Agency’s involvement in the social
impact investment marketplace, spearheading efforts to finance housing in Africa, small and
medium businesses in Liberia, and a large-scale renewable power plant in Liberia. Ambassador
Simon led the Agency’s effort to develop a series of social development funds for Africa, which
resulted in the creation of four private equity funds focused on achieving extraordinary social
results as well as strong financial performance.
217
Ambassador Simon also served as Special Assistant to the President and Senior Director
for Relief, Stabilization, and Development for the National Security Council (NSC) at the White
House, the first to hold this post. During his tenure at the NSC, Ambassador Simon oversaw the
implementation of groundbreaking development initiatives, including the Millennium Challenge
Account, the President’s Emergency Plan for AIDS Relief, the Multilateral Debt Relief
Initiative, and the President’s Malaria Initiative. He was also responsible for the U.S.
government response to international humanitarian disasters, such as the 2005 South Asia
Earthquake.
From 2002 to 2003, Ambassador Simon was Deputy Assistant Administrator at the
United States Agency for International Development, overseeing the agency’s development
information and evaluation units. Earlier in his career, he served as Director of Business Finance
and Strategic Planning at Harvard Pilgrim Health Care and worked for the Commonwealth of
Massachusetts’ Executive Office for Administration and Finance in several capacities, including
Deputy Director for Research and Development.
Ambassador Simon received his bachelor’s degree from Princeton University and a
master’s degree in public policy from Harvard University.
(Source: https://www.totalimpactcapital.com/simon)
218
APPENDIX C. INTERVIEW GUIDE
Qualitative Component
Script: “Thank you for agreeing to speak with me and for signing the consent form. Your identity
remains confidential. This virtual interview focuses on the conditions under which U.S. foreign
policy decision-making (FPDM) advances the health policy agenda and for what purpose or
value. The research findings will be used to develop a conceptual framework to guide elected
officials in future actions focused on health in U.S. foreign policy; to make sense of the foreign
policy decision-making events that led to the President’s Emergency Fund for AIDS Relief
(PEPFAR) & The Global Fund to Fight AIDS, Tuberculosis, and Malaria; and to advance the
applied practice of Global Health Diplomacy (GHD).”
Knowledge
1. To begin, can you tell me about your policy-making role for these two initiatives as it relates
to the health policy agenda and U.S. foreign policy decision-making (FPDM)? Probe: Tell me
more about a few issues that you feel influenced their policy development between 2001-2003.
Barriers and Opportunities
2. What do you feel are the primary barriers to advancing the health policy agenda as a U.S.
foreign policy priority? Probe: Can you indicate which barriers might be caused by politics
(political trends), power (agenda setting), or process (policy formulation)? Which of these is the
dominant barrier?
3. What do you see as the primary opportunities to advance ‘health’ as a U.S. foreign policy
priority? Probe: How do politics (political trends), power (agenda setting) or process (policy
formulation) influence the opportunities that policymakers pursue? Which of these is the
dominant opportunity influencer?
219
Agenda Setting and Decision Making
4. Has ‘health’ become a high politic issue, one of equal political importance, in U.S. foreign
policy alongside security and economics? Probe: Can you offer examples of why or why not?
Social Networks and Coalitions
5. State and non-state actors engage around U.S. foreign policy issues related to ‘health’. What
role have social networks and coalitions played in shaping your decision making about why
‘health’ gets incorporated into U.S. foreign policy decision-making and for what purpose? Probe:
Can you describe how these collaborations can advance Global Health Diplomacy (GHD) in the
future?
Closing
6. Is there anything else that you think we should discuss?
Thank you for your sharing your experience and insights on this research project. Here is a
handout that describes the focus of this project. I really appreciate your help.
220
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241
VITA AUCTORIS
Coral Andrews graduated from the University of Southern California Sol Price School of
Public Policy with a Doctor of Policy, Planning, and Development degree (2021). She holds a
Master of Business Administration from New Hampshire College (1989) and a Bachelor of
Science in Nursing from the University of South Alabama (1983). She has served in executive
roles in the public, private, and plural sectors. Within the U.S. Department of Defense, her work
as a senior officer in the U.S. Navy culminated with joint service working alongside global
partners in international relations and diplomacy. In the private and plural sectors, she has served
at the forefront of domestic health policy design and implementation.

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Asset Metadata

Creator Andrews, Coral Teresa (author)

Core Title Global health diplomacy: a new era of health in U.S. foreign policy

School School of Policy, Planning and Development

Degree Doctor of Policy, Planning & Development

Degree Program Planning and Development,Policy

Degree Conferral Date 2021-08

Publication Date 07/23/2021

Defense Date 04/26/2021

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag agenda setting,Ambassador,and Malaria,Centers for Disease Control (CDC),comparative politics,complacency,conceptual decision making models,conceptual framework,Congress,Cuban Missile Crisis,Department of State,diplomacy,diplomat,epidemic,Foreign policy,foreign policy decision making,foreign policy powers,foreign service,G20,G7,G8,Global Fund to Fight AIDS,global governance,global health diplomacy,global health policy,Global Health Security Agenda (GHSA),Global Health Security Strategy (GHSS),Goldwater-Nichols Act of 1986,Graham Allison,hard power,Health and Human Services (HHS),health security,international cooperation,International Health Regulations (IHR),International Relations,John Kingdon,Kingdon's Multiple Streams Framework,narratives,National Security Council (NSC),National Security Strategy (NSS),non-state actors,OAI-PMH Harvest,Office of Global Affairs (OGA),pandemic,phenomenological,Philip Zelikow,policy formulation,politics,Power,president,President's Emergency Plan for AIDS Relief (PEPFAR),Public health,qualitative,rational choice theory,soft power,state actors,statecraft,Sustainable Development Goals (SDGs),transnational,Tuberculosis,UNAID,United Nations (UN),USAID,White House,window of opportunity,World Health Assembly,World Health Organization (WHO)

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Robertson, Peter J. (committee chair), Withers, Mellissa (committee member), Zelikow, Philip (committee member)

Creator Email ctandrew@usc.edu,ctandrews33@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC15268639

Unique identifier UC15268639

Legacy Identifier etd-AndrewsCor-9851

Document Type Dissertation

Format application/pdf (imt)

Rights Andrews, Coral Teresa

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the author, as the original true and official version of the work, but does not grant the reader permission to use the work if the desired use is covered by copyright. It is the author, as rights holder, who must provide use permission if such use is covered by copyright. The original signature page accompanying the original submission of the work to the USC Libraries is retained by the USC Libraries and a copy of it may be obtained by authorized requesters contacting the repository e-mail address given.

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA

Repository Email cisadmin@lib.usc.edu