Global health is a product of the Western postwar liberal international order—an order that is today besieged, says Stephen Morrison

In the past two decades, we have witnessed an expansion of investments into global health that have been rooted in humanitarianism, the rule of law, and democracy. Underlying this action have been the principles of multilateralism, alliances, and partnerships. It has been consistently argued that investments outside home borders will not only save and improve lives but also promote economic growth and the stability of communities.

In surprising and unforeseen ways, global health also benefited enormously from the post 9/11 counter terror doctrine that came to dominate the security strategies of the major Western powers. That doctrine aggressively advanced the argument that uncontrolled infectious diseases pose major transnational threats. It put a spotlight on smaller countries beset by weaker governance and fragile infrastructure, where grave health challenges can fuel armed, internal violence. Counter terror gave rise to the belief that focused investments—“smart power”—would achieve concrete results in improving lives while also winning hearts and minds in a global struggle.

Today, the western liberal international order is under siege and eroding, with grave long term consequences for global health. The principal driver is a widespread populist nationalism, in the United States, the United Kingdom, across Europe, Brazil, and elsewhere. Rooted in societal discontent, alienation, and economic marginality, an anti-global outlook espouses a deep suspicion of traditional diplomacy, migrants, foreign aid, trade and security alliances, science and public health, and multilateral partners. Sovereignty is the dominant, vaunted principle. Rhetoric focuses on protecting the homeland from invasion, from “theft” through errant trade relationships, and from outdated foreign entanglements that distract us from home priorities. The preference is for relationships that are transactional and short term, that reward friends and punish foes, and that bring material rewards at home. Getting agreement on what are authoritative facts has become highly problematic. Women’s reproductive rights are under threat in the US and across the world.

Counter terror has faded as the dominant security doctrine, including the belief that foreign aid is an important counter terror tool. The over-riding concern of Washington’s new national security strategy seems to be about competition among the US, China, and Russia.

Africa, centre of most donors’ global health investments, is an afterthought, if a thought at all. The Ebola outbreak in eastern Congo, the first in an active war zone, is now in its fifth month. Efforts to contain and arrest the outbreak are not going well, and it has been difficult to rally high level attention in Washington, London, and European capitals. Official US civilian experts are not permitted to operate in the epicentre of the outbreak, in the face of security threats. Other Western donors have quietly followed the same path.

The old liberal consensus is now explicitly broken. What this disruption will ultimately mean for global health is still an open question, as is true of the larger question of what is to replace the old order. The staying power of populist nationalism remains uncertain. But it is safe to predict that this disruption won’t disappear anytime soon and is likely to have several lasting effects. It will stop further progress on many of the gains achieved over recent years, and in some areas it will significantly reverse progress and weaken the major operational institutions. It will have a sharp dampening effect on finance, including the viability of international financial mechanisms, and will make concerted, coordinated international action slower and more arduous. It will raise the risk that health security crises like the one now unfolding in eastern Congo will escalate at a high cost.

Outwardly, the situation currently might not look so bad for global health—which accounts for the apparent lack of panic—but that should not be reason for complacency. By contrast with trade and security alliances, major global health programmes and institutions have not been targeted up to now, and the leadership of WHO, Gavi, the Vaccine Alliance, the President’s Emergency Plan for AIDS Relief, and the Global Fund to Fight AIDS, Tuberculosis, and Malaria remained reasonably strong. Germany, France, Canada, and Japan continue to be visibly active and committed. Major bilateral agencies, such as the Department for International Development, USAID, and the Centers for Disease Control and Prevention have not yet suffered major setbacks. But these realities do not reflect the widespread nervousness and uncertainty that surrounds global health. Nor have they stood in the way of the steady, dangerous erosion of budgets and the continued assault upon annual budgets and multilateral partners.

Global health’s exceptionalism up to now, reliant on a range of constituencies that have defended these investments (legislators, advocates, faith community, private sector, foundations) may be only temporary and may mask deep underlying risks of regression. The erosion of the Western international order is disquieting. It erases the common normative consensus and creates confusion, uncertainty, fear, and inhibitions. It stifles creativity and innovation, and significantly weakens the ability of advanced economies to act with any clear headed consensus and sense of purpose to meet the multiple, far flung, pressing global health challenges. It greatly limits the ability of those key states to think and act expansively about achieving Universal Health Coverage, tackling non-communicable diseases, and carrying forward the unfinished business on HIV, TB, malaria, polio, and maternal and child health.

In the face of this disruption, incentives are stacked heavily in favour of defending the status quo, holding on to what one has, and lowering one’s visibility and risk.

Global health partisans are innately optimistic, and few believe that all will be lost. Many are still in denial that the decay of the Western order is real, advanced, and a grave threat. The disruption will likely do deep damage, and as that process unfolds, it may trigger a counter reaction that seeks to rescue things, hopefully soon enough for corrective actions to be possible.

In the US and elsewhere, the disruption has already begun to stir a democratic response. Thinking is centred outside government circles, among political scientists, parliamentarians, and civil organisations. This emerging crisis provides an opportunity for an updated global health vision that could be focused in the wider effort to create a liberal counter argument to populist nationalism. Certain themes will be central: the need for a reaffirmation of core values, including the rights of vulnerable refugee and displaced populations, and the shared threat of a world that could be over-run by human crises and unmanaged health security challenges. Existing programmes need to be refreshed, and made more accountable and resilient, guided by clearer end goals and targets for partner countries to assume ownership. To be most effective to anxious and sceptical voters in donor countries, this vision needs to connect with trade and security goals, including competition with China and Russia. And it has to be communicated convincingly and intelligibly. The usual language used to discuss global health is an impediment to persuading the average citizen of its importance.

J Stephen Morrison is senior vice president at the Center for Strategic and International Studies and director of its Global Health Policy Center.

Competing interests: none.