By Arslan Ayan[1]

Abstract

Despite its status as a so-called middle power, Canada’s traditional global health leadership is definitely worthy of respect. Since the Liberal government came into office in 2015, however, global health and developmental assistance have fallen to record lows and the issue of global health was excluded from the main themes of Canada's G7 presidency in 2018. This paper examines what it means for the Canadian government to pay little attention to global health and it formulates a set of four recommendations that, if implemented, will allow Canada to continue to show leadership in a domain where it has traditionally excelled.

1. Introduction

The following paper has been prepared in order to stimulate discussion of how best to move forward in the context of the Canadian government’s failure to include the issue of global health among the main themes of Canada's G7 presidency in 2018.Despite its status as a so-called middle power in international affairs, Canada’s traditional global health leadership is definitely worthy of respect. The country’s funding for global health grew from around $180 million in 1997 to $970.1 million in 2016.[2] Between 2006-2015, Canada had invested around $10 billion in global health, of which some 50 percent came from NGOs, foundations, multilateral funds or banks.[3]In terms of development assistance for health as a percentage of gross national income, Canada (0·058%) came in third among G7 countries in 2015.[4] The incumbent government has also pledged $785million for 2017-2019 to the fund to save millions of people around the world.[5]As Canada assumes the G7 Presidency in 2018, however, we have witnessed that it has failed to prioritize the issue of global health in the G7 process. The prime minister announced that the country will advance domestic and international priorities framed by a total of five key themes.[6]  Global health is not one of them. Additionally, existing data shows that Canada’s both global health and development assistance has fallen to record lows since the Liberal government came into office in 2015.[7]

This policy paper examines what it means for Canada to pay little attention to global health, and it formulates a set of four recommendations that, if implemented, will allow the Canadian government to continue to show leadership in a domain where it has traditionally excelled. The issue of global health has always been important to Canada because health is a part and parcel of Canadians’ national identity. With their unique health care system which serves as a model for many nations around the world, Canadians have paid significant attention to health even when security and terrorism issues dominated the world’s agenda after the tragic 9/11 attacks in the US.[8]Also, despite its middle power status and limited financial and military resources, Canada’s global health initiatives  have made it possible to exert influence well beyond its geographical boundaries. This paper calls on the Canadian government 1) to revise the themes for Canada's 2018 G7 Presidency, prioritizing global health while including a G7 Health Ministers meeting to the ministerial meetings calendar; 2) to increase the already-promised $785million for 2017-2019 up to 25 percent in order to reach the average of the time period of 2005-20163) to take initiative to provide leadership for the formation of a leading intergovernmental health institute to backup the crucial role played by the U.S. Centers for Disease Control (CDC) in more than 40 countries around the world, and 4) to host follow-up meetings on global health after the next G7 summit.

2. What is global health?

Global health is not a new phenomenon. Over the course of the past three decades, much ink has been spilled by a wide range of International Relationsscholars, analysts regarding the health issues that transcend national borders, political and economic policies of states. According to Ilona Kickbush, a German political scientist best known for her contribution to health promotion and global health, global health refers to all “health issues that transcend national boundaries and governments and call for actions on the global forces that determine the health of people.”[9] Carol Holtz, a professor of nursing. Kennesaw State University, on the other hand, offers a related but different definition: “Global health is an area of study, research and practice that places a priority on improving health and achieving equity in health for all people worldwide.”[10]

3. Canada’s position on Global health: Why does it matter?

Regardless of the differences in its definition, global health is directly linked to national and individual security, economic productivity and growth in developed countries including Canada. It has, therefore, always been at the forefront of the foreign and domestic policy agendas of the past Canadian governments. Between 2006 - 2015, Canada invested around $10 billion in global health.[11] In terms of development assistance for health as a percentage of gross national income, Canada (0·058%) came in third among G7 countries in 2015.[12]On this basis, it is safe to argue that Canada’s global health policy has been shaped in an intermestic context. In developing this argument, this section will briefly examine why the country’s attributes are significantly important to the issue of global health.

3.1. Health as an agent of Canadian foreign policy

First of all, the global health initiative is an agent of influence. Despite its middle power status and limited financial and military resources, Canada’s use of soft power[13] has made it possible to exert influence well beyond its geographical boundaries. The fact that the incumbent Canadian government has adopted “progressive values, driven by appreciation for diversity, equality,” [14] openness, human rights and individual freedoms, gives a great hint about Canada’s position and limits in the international system. Adam Chapnick wrote that “the promotion of the human security agenda is designed to increase Canada's status in the international community and allow it to climb into that higher group of powers.”[15] Keeping global health and development assistance at record lows, and failing to prioritize global health in the 2018 G7 agenda clearly has weakened one of  Canada’s most important apparatuses to achieve such a goal. The fact that many developed countries like the US turn inwards these days could give Canada a unique opportunity to “show leadership in a domain where [it has] traditionally excelled.”[16] Currently, the world’s nations are enjoying a relative healthy security umbrella by the United States. However, the Trump administration’s “shifting stance on human rights, and shrinking foreign policy workforce have concerning implications for planning and carrying out U.S. global health programs,” not to mention the significant cut to US global health funding in 2018.[17]The fact that Trump’s proposed cut for the global health is unprecedented (over $2 billion) is a clear indication of further radical changes in the US’s foreign policy in the near future. Who will fill the space from which the US is driven by Trump? Canada can be one of the biggest candidates to step into this relative “power vacuum,” not due to its ability to achieve its goals by force, aka hard power, but mostly because of its soft power. Stepping up to promote global health in that sense could be an opportunity for a middle powerlike Canada that partly depends on soft power diplomacy to alter the behavior of others to get what they want.

3.2. Global health is intermestic

The world is changing. During the Cold War, the school of international relations had largely been equated with sovereign states and their positions in the international system. The advocates of the realist theory have invariably proposed a competitive and conflictual system in which security is only purchased by increments in material power.[18] The concept of “human security,” however, represents a certain break from this traditional realist thinking. It attempts to redefine the role of states and material power, arguing that the traditional military-based approach may be “one of the principle sources of people’s insecurity, if not the dominant one.”[19] With the broadening and deepening of this concept, security is no longer merely understood as the protection of state interests through the use of material power-based strategies. Instead, it now includes new dimensions, such as personal and political liberties, right to health care, individual safety from spread of global diseases, government-sponsored organized violence, etc.[20] In the contemporary world, national and individual security is always on a knife’s edge. This is because threats are becoming increasingly common and diversified. States are no longer merely concerned with threats posed by other states or non-state actors, but also often troubled with emerging infectious diseases and other health issues. With the increasing impact of the complex process known as globalization, even the countries with the most secure borders arguably arerendered helpless in the face of the spread of some of the deadliest infectious diseases.[21]

Thanks to unprecedented improvement in transportation technology, millions of people now enjoy the privilege of moving across national borders and continents for a variety of reasons including tourism, business and medical treatment. For instance, in 2015, the Toronto Pearson Airport welcomed some 44.3 million passengers in 2015 while over 21 million passengers travelled through Vancouver airport in the same year.[22]These numbers include passengers from underdeveloped regions like sub-Saharan Africa where infectious diseases such as malaria and HIV/AIDS cause almost 69% of deaths.[23]Also, Canada is one of the top 10 importers of food in the world. Most of the fresh fruits and vegetables come from countries like Honduras, Colombia, Guatemala, Costa Rica, and South Africa. It is therefore no surprise that protecting the health and safety of Canadians has been a costly process for the Canadian governmentfor decades as 10.1% of its gross domestic product (GDP) is being spent on health[24]. This is one of the highest in the world, according to the Organization for Economic Cooperation and Development (OECD)[25].

4. Final Remarks and Policy Recommendations

This policy paper has so far examined why global health is important for Canada. What follows is a set of four recommendations that, if implemented, will allow the Canadian government to assume leadership in a domain where it has traditionally excelled. Why now? Because 1) the world is on the brink of losing US leadership in global health, therefore 2) vulnerability to global health threats is likely to increase, and 3) Canada assumes the Presidency of the G7.

Recommendation 1- Revise the themes for Canada's 2018 G7 Presidency; prioritize global health and include a G7 Health Ministers meeting.

The existing G7 themes will focus on five key issues:

1) Investing in growth that works for everyone;

2) Preparing for jobs of the future;

3) Advancing gender equality and women’s empowerment;

4) Working together on climate change, oceans and clean energy;

5) Building a more peaceful and secure world.[26]

"It's going to be an amazing time to highlight some of the values and priorities that Canada has on the world stage," Prime Minister Trudeau said during a Facebook live address on December 14, 2017.He, however, failed to mention global health among these values and priorities. Canada's 2018 G7 Presidency could give the country an unprecedented opportunity to lead the way for the world to open a new page at a moment when the US’ health leadership is on its way for a suspension by the Trump administration. After each recent global disease outbreak, such as Zika and Ebola, global and national responses “have been reactionary, uncoordinated, ineffective and highly costly.”[27]Canada’s G7 Presidency could give the world a chance to start over with a clean slate, fixing uncoordinated, ineffective processes.

Recommendation 2- The 2018 Canadian federal budget should increase the already-promised $785million for 2017-2019 up to 25 percent in order to reach the average of the time period 2005-2016. While prioritizing global health and including a G7 Health Ministers meeting to the G7 process, such a move would consolidate Canada’s commitment to global health issues.[28]

Recommendation 3-Provide leadership for the formation of a leading intergovernmental health institute to back up the crucial role played by the U.S. Centers for Disease Control (CDC) in more than 40 countries around the world. The CDC budget cut by the Trump administration is likely to impede its global role to investigate outbreaks and provide early assistance to stop their spread. This is a clear indication that the world may soon lose the US health security umbrella.  The formation of an intergovernmental health institute would end CDC’s obligatory monopoly on preemptive maneuvers against the spread of fatal diseases.

Recommendation 4- A leadership role needs to be taken to host follow-up meetings on global health. Julio Frenk and Suerie Moon rightly argue that globalization has “intensified cross-border health threats, leading to a situation of health interdependence- the notion that no nation or organization is able to address single-handedly the health threats it faces but it instead must rely to some degree on others to mount an effective response.”[29]Such meetings would pave the way for further collaboration with other key actors, such as WHO as the lead intergovernmental organization, the UK, the US, the EU and others that are developing health strategies.[30]As Professor Joseph Nye, who first introduced the term soft power 28 years ago stated, "power with others can be more effective than power over others".

4.1. Benefits

-A G7 Presidency with global health priorities will give the world a chance to start over with a clean slate, fixing uncoordinated, ineffective initiatives in case of future global disease outbreaks.

- An increase in the global health budget will strengthen the global health research, provide employment, and set the stage for greater success.

- A Canada-led intergovernmental health institute will strengthen CDC’s preemptive efforts against the spread of fatal diseases. 

- Follow-up meetings led by Canada will increase collaboration, coordination and cooperation.

4.2. Costs

- A perceived leadership in global health will bring extra economic costs.

- Such a long-term goal could pave the way for negligence on other existing commitments and  immediate domestic problems.

-Investing in such a long-term goal may also pave the way for political frictions between the government and opposition.

Arslan Ayan is a PhD candidate at York University. He earned his master’s in the International Relations Department of Istanbul's Fatih University with a thesis focusing on the stance of the State of Israel towards material power, which he is extending into a book in Turkish, titled “Gücü Yeniden Tanimlamak: Bundan Sonra Nereye?" His research interests lie in the area of state-centric security issues and power politics, with a special focus on International Relations theories.

Bibliography

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Chapnick, Adam, “The Canadian Middle Power Myth,” International Journal 55/2 (Spring, 2000).

Christie, Ryerson, "Critical Voices and Human Security: To Endure, to Engage or to Critique?," Security Dialogue 41 (2010).

Frazer, Jendayi et al., Global Health and the Future Role of the United States (Washington DC: National Academies Press, 2017).

Frenk, Julio, Suerie Moon, “Governance Challanges in Global Health,” New England Journal of Medicine 368(10) (2013).

Global Affairs Canada, Report to Parliament on the Government of Canada’s Official Development Assistance 2015-2016, 2016, (7), Ottawa.

Holtzi, Carol, “Global Health: An Introduction,” in Global Health Care: Issues and Policies, 3rd ed. (Burlington: Jones&Bartlett Learning, 2017).

Jimenez, Joseph, “3 ways to improve healthcare in Africa,” World Economic Forum, last modified January 21, 2015, www.weforum.org/agenda/2015/01/3-ways-to-improve-healthcare-in-africa/

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Kenny, Nuala, What Good Is Health Care: Reflections on the Canadian Experience (Ottawa: CHA Press, 2002).

Kickbusch, Ilona, “The Need for a European Strategy on Global Health,” Scandinavian Journal of Public Health 34 (2006).

Kirton, John, James Orbinski and Jenilee Guebert, The Case for a Global Health Strategy for Canada, (Toronto: Munk Centre for International StudiesUniversity of Toronto, 2010).

Nixon,Stephanie, Kelley Lee, Zulfiqar A. Bhutta, James Blanchard, Slim Haddad, Steven J. Hoffman, Peter Tugwell, “Canada’s Global Health Role: Supporting Equity and Global Citizenship as a Middle Power,” The Lancet, (2018) accessed March 5 2018. http://dx.doi.org/10.1016/S0140-6736(18)30322-2

“OECD Health at a Glance 2009: Key findings for Canada,” Organization for Economic Co-operation and Development, accessed March 10, 2018 http://www.oecd.org/canada/oecdhealthataglance2009keyfindingsforcanada.htm

Peoples, Columba and Nick Vaughan-Williams, “Chapter 10: Human Security and Development,” in Critical Security Studies: An Introduction, edited by Columba Peoples and Nick Vaughan-Williams (New York: Routledge, 2015) 123.

“Prime Minister unveils themes for Canada’s 2018 G7 Presidency,” last modified December 14, 2017, https://pm.gc.ca/eng/news/2017/12/14/prime-minister-unveils-themes-canadas-2018-g7-presidency

Saker, Lance, Kelley Lee, Barbara Cannito, Anna Gilmore, Diarmid H. Campbell-Lendrumet al., Globalization and infectious diseases: A review of the linkages, (Geneva: TDR, 2004).

Timothy, Evans, “Canada and Global Health: Accelerate Leadership Now,” Lancet, (2018) accessed March 5 2018 https://doi.org/10.1016/S0140-6736(18)30178-8.

Toronto Pearson statistics: https://www.torontopearson.com/en/gtaa/statistics/#

[1]arslan05@yorku.ca / https://yorku.academia.edu/ArslanAyan /York University

[2]Stephanie Nixon et al.,“Canada’s Global Health Role: Supporting Equity and Global Citizenship as a Middle Power,” The Lancet, (2018) accessed March 5 2018. http://dx.doi.org/10.1016/S0140-6736(18)30322-2

[3]Nixonet al., 32.

[4]Nixonet al., 32.

[5]Global Affairs Canada, Report to Parliament on the Government of Canada’s Official Development Assistance 2015-2016, 2016, (7), Ottawa.

[6]“Prime Minister unveils themes for Canada’s 2018 G7 Presidency,” last modified December 14, 2017, https://pm.gc.ca/eng/news/2017/12/14/prime-minister-unveils-themes-canadas-2018-g7-presidency

[7]Evans Timothy, “Canada and Global Health: Accelerate Leadership Now,” Lancet, (2018)accessed March 5 2018 https://doi.org/10.1016/S0140-6736(18)30178-8

[8]Nuala Kenny, What Good Is Health Care: Reflections on the Canadian Experience (Ottawa: CHA Press, 2002) 43.

[9]Ilona Kickbusch, “The Need for a European Strategy on Global Health,”Scandinavian Journal of Public Health 34 (2006): 561–565.

[10]Carol Holtzi,“Global Health: An Introduction,” in Global Health Care: Issues and Policies, 3rd ed. (Burlington: Jones&Bartlett Learning, 2017), 3.

[11]Nixonet al., 32.

[12]Nixonet al., 32.

[13] According to Joseph Nye, the first person to popularize the term in 1990s, soft power is “ability to persuade through culture, values and ideas, as opposed to doing so through the use of coercion.” See Joseph S. Nye, Soft Power: The Means To Success In World Politics (USA: Public Affairs, 2005)

[14]Nixonet al., 29.

[15]Adam Chapnick, “The Canadian Middle Power Myth,” International Journal 55/2 (Spring, 2000): 206

[16] Halimah Beaulieu, “Renewing Canada's leadership in global health,“ Simon Fraser University, last modifiedMarch 1, 2018, www.sfu.ca/sfunews/stories/2018/03/renewing-canada-s-leadership-in-global-health.html

[17]Jen Kates, Josh Michaud, Ashley Kirzinger, Cailey Muñana, “A Check Up on U.S. Global Health Policy, After One Year of the Trump Administration,” Kaiser Family Foundation, last modifiedJanuary 29, 2018.

www.kff.org/global-health-policy/issue-brief/a-check-up-on-u-s-global-health-policy-after-one-year-of-the-trump-administration/

[18] Realism as a school of thought in international relations theory, is mainly composed of several different theoretical approaches, which sometimes fall into disagreements over amount of power that a state requires to be secure and the way it is to obtain security. See “Conceptual framework: Offensive realism vs Defensive Realism,” in Ayan, Arslan. A Comparative Look at Israeli Stance towards Power through the Lens of Offensive Realism and Defensive Realism, (Istanbul: Fatih University Press, 2016), 7.

[19]Ryerson Christie, "Critical Voices and Human Security: To Endure, to Engage or to Critique?," Security Dialogue 41 (2010): 178

[20]Peoples, Columba and Nick Vaughan-Williams, “Chapter 10: Human Security and Development,” in Critical Security Studies: An Introduction, edited by Columba Peoples and Nick Vaughan-Williams (New York: Routledge, 2015) 123.

[21]Lance Saker et al.,Globalization and infectious diseases: A review of the linkages, (Geneva: TDR, 2004), 9-12

[22]See Toronto Pearson statistics: https://www.torontopearson.com/en/gtaa/statistics/#

[23]Joseph Jimenez, “3 ways to improve healthcare in Africa,”World Economic Forum, last modifiedJanuary 21, 2015, www.weforum.org/agenda/2015/01/3-ways-to-improve-healthcare-in-africa/

[24] John Kirton, James Orbinski and Jenilee Guebert, The Case for a Global Health Strategy for Canada, (Toronto: Munk Centre for International StudiesUniversity of Toronto, 2010), 13.

[25] “OECD Health at a Glance 2009: Key findings for Canada,” Organization for Economic Co-operation and Development, accessed March 10, 2018http://www.oecd.org/canada/oecdhealthataglance2009keyfindingsforcanada.htm

[26]“Prime Minister unveils themes for Canada’s 2018 G7 Presidency,” last modified December 14, 2017, https://pm.gc.ca/eng/news/2017/12/14/prime-minister-unveils-themes-canadas-2018-g7-presidency

[27] Jendayi E. Frazer et al., Global Health and the Future Role of the United States (Washington DC: National Academies Press, 2017), 4.

[28]Kirton et al., 23-24.

[29]Julio Frenk, Suerie Moon, “Governance Challanges in Global Health,” New England Journal of Medicine 368(10) (2013): 936.

[30]Kirton et al., 24.