Introduction
For much of the post-Cold War era, health diplomacy was categorised by scholars as a quintessential instrument of “soft power”—a benign means to build goodwill and foster stability through humanitarian assistance. However, the geopolitical tectonic plates have shifted as we are no longer in an era of purely benevolent aid; we are in an era of sharp power and strategic competition. Today, health diplomacy must be redefined not merely as an act of charity, but as a critical domain of national security. For sovereign nations, particularly in the Global South, the reliance on foreign actors for the biological survival of their citizenry has become a profound vulnerability—one that exposes them to coercion, manipulation, and foreign malign influence.
The Security Imperative and the Trap of Dependence
In the eyes of national security strategists, health is no longer defined simply by the absence of disease, but by the maintenance of state capacity and legitimacy. A government that cannot protect its population from biological threats—whether natural pathogens or chronic pandemics—loses its mandate to rule. In this context, health diplomacy transforms into a tool of statecraft. It comes in the form of vaccine donations, infrastructure projects, and long-term funding commitments. While often helpful, these forms of aid can serve as vectors for malign influence when they create “strategic dependency.”
This dependency acts as a geopolitical tether. When a nation relies on a foreign donor for its essential medical supply chains, it effectively hands over a “kill switch” to that donor. Malign actors can leverage this reliance to extract political concessions, enforce alignment at international forums like the UN, or manipulate the domestic policies of the recipient state. The recipient is forced into a humiliating calculus: compromise on sovereign decisions or risk the collapse of their healthcare system.[SA1]
Two recent historical examples illustrate the danger of this posture.
First, consider the precarious situation of African nations dependent on foreign financing for HIV/AIDS and STI programs. Millions of lives across the continent rely on the generosity of initiatives like the United States’ President’s Emergency Plan for AIDS Relief (PEPFAR[SA2] ) and the Global Fund. However, this aid often comes with ideological strings attached. Recently, we have witnessed severe diplomatic friction where Western donors have threatened to withhold or redirect funds in response to local legislation regarding cultural and social issues, such as the Anti-Homosexuality Act in Uganda. Regardless of one’s stance on the legislation itself, the security implication is stark: foreign powers utilised their control over life-saving antiretrovirals as a coercive lever to influence the domestic legislative process of a sovereign state.
Second, the COVID-19 pandemic shattered the illusion of global solidarity. When the crisis peaked, the “liberal international order” devolved into “vaccine nationalism.” Industrialised nations, justified by their primary obligation to their own citizens, hoarded vaccines, effectively buying up the global supply. As noted by the World Health Organisation’s Director-General, this resulted in a “catastrophic moral failure,” leaving dependent nations in the Global South defenceless. This episode served as a brutal lesson in realism: in a moment of existential crisis, foreign charity evaporates, and nations without sovereign health capabilities are left to die.
The Intelligence Goldmine: Elite Medical Tourism
Perhaps the most overlooked vector for malign influence is the routine travel of high-ranking elected and non-elected officials to foreign capitals for medical treatment. Justified by the argument that local infrastructure lacks specific specialists or equipment, this phenomenon represents a catastrophic intelligence failure. When a head of state or military chief enters a foreign hospital, they are effectively handing over their biological data to the host nation’s intelligence services.
This “medical tourism” creates distinct security risks:
- Intelligence Exposure & Coercion: Foreign intelligence agencies can harvest DNA, psychological profiles, and detailed medical histories. This data reveals physical weaknesses or terminal conditions that can be leveraged for blackmail or to predict a leader’s lifespan, influencing succession planning in the host country’s favour.
- Elite Detachment: The movement of huge sums of public funds to foreign private clinics signals a profound lack of confidence in the domestic healthcare system. This demoralizes local medical experts and fuels public resentment, widening the gap between the rulers and the ruled.
- Targeted Influence: Foreign facilities often offer “VIP packages” tailored specifically for the elite class. These are not merely commercial promotions but influence operations designed to cultivate dependency and gratitude among decision-makers, isolating them further from the reality of their own nation’s crumbling health infrastructure.
Policy Recommendations: The Path to Health Sovereignty
To immunise themselves against such coercion, nations must pivot from a posture of dependency to one of “minimum viable autonomy.”
- Invest in “Sovereign Care” Infrastructure:
Governments must treat the upgrading of local health infrastructure as a national security priority, not just a social service. Recommendations include establishing a “National Centre of Excellence”—a military-grade or university teaching hospital equipped to treat complex cases domestically. This stops the capital flight of medical tourism and ensures that the biological data of the nation’s leadership remains a state secret, protected from foreign surveillance.
- Raise the Bar
It is imperative for governments to raise the bar for national health care to a sovereignty status to guard against future pandemic travel restrictions and expensive health tourism abroad in normal times. This would involve establishment of regional level 4 health facilities and a national all-purpose state of the art facility equipped and secured with VIP clearance.
- Domesticate the Essentials:
Governments must prioritise the domestic financing of “strategic health commodities.” While donors may continue to fund soft costs like training or technical assistance, the physical medicines (ARVs, insulin, antibiotics) must be purchased with national funds. This ensures that if a donor withdraws due to a diplomatic row, the medicine does not stop flowing.
- Regional Manufacturing:
Reliance on distant supply chains is a security risk. Nations must support regional bodies, such as the Africa Centres for Disease Control and Prevention (Africa CDC), in their push for regional manufacturing [4]. A bloc of nations purchasing locally produced generics offers a “bulk shield” against external pressure.
Conclusion
Health is no longer a sidebar to foreign policy; it is the foundation of the state’s survival. As long as a nation’s immune system is subsidised by a foreign power, its sovereignty remains abstract. The withdrawal of aid or the hoarding of vaccines are not anomalies; they are features of an international system where states prioritise their own interests. To protect against malign influence, vulnerable nations must stop viewing health budgets as charity to be solicited, and start viewing them as defence budgets to be secured.
References
Africa Centres for Disease Control and Prevention (Africa CDC). (2022). The New Public Health Order: Africa’s health security agenda. African Union.
Al Jazeera (2023). Uganda defiant after World Bank halts funding over anti-LGBTQ law. Al Jazeera. https://www.aljazeera.com/news/2023/8/10/uganda-defiant-after-world-bank-halts-funding-over-anti-lgbtq-law
Alvestegui, P. (2025). Policy Conditionality in Africa: Advocating for Change. IE International Policy Review
Physicians for Human Rights (2025). On the Brink of Catastrophe: U.S. Foreign Aid Disruption to HIV Services in Tanzania and Uganda. PHR. https://phr.org/our-work/resources/on-the-brink-of-catastrophe-u-s-foreign-aid-disruption-to-hiv-services-in-tanzania-and-uganda/
Radio France Internationale (RFI) (2025). Au Sénégal, la lutte contre le VIH ralentie par la suspension du financement américain. RFI. https://www.rfi.fr/fr/afrique/20251201-au-s%C3%A9n%C3%A9gal-la-lutte-contre-le-vih-ralentie-par-la-suspension-du-financement-am%C3%A9ricain
Radio France Internationale (RFI) (2025). Au Kenya, la fin de l’aide américaine pénalise la lutte contre le VIH. RFI. https://www.rfi.fr/fr/afrique/20251201-au-kenya-la-fin-de-l-aide-am%C3%A9ricaine-p%C3%A9nalise-la-lutte-contre-le-vih
[SA1]This is an excellent statement. I believe you can also consider the treatment of key political and public actors (like the President, VP, CoS, Speaker of Parliament and CJ etc) abroad as dangerous incidents, where the medical history and treatment outcomes are controlled by foreign institutions
[SA2]What is pepfar?
