Health imperatives in foreign policy: the case of Malaysia Simon Barraclough a & Kai-Lit Phua b

Abstract Malaysia’s global, regional and bilateral international health relations are surveyed against the historical backdrop of the country’s foreign policy. Malaysia has always participated in multilateral agencies, most notably the World Health Organization, as such agencies are part of the longstanding fabric of “good international citizenship”. The threats of infectious diseases to human health and economic activity have caused an intensification and an organizational formalization of Malaysian health diplomacy, both regionally and bilaterally. Such diplomacy has also established a basis for developing a wider set of cooperative relationships that go beyond responding to the threat of pandemics. As Malaysia approaches “developed” status, its health sector is becoming increasingly integrated into the global economy through joint research and development ventures and transnational investment. At the same time, it will have the technological, financial and human resources to play an expanded altruistic role in global and regional health.

Bulletin of the World Health Organization 2007;85:225-229.

الرتجمة العربية لهذه الخالصة يف نهاية النص الكامل لهذه املقالة. .Une traduction en français de ce résumé figure à la fin de l’article. Al final del artículo se facilita una traducción al español

Introduction Elements of this hierarchy are international linkages and recognition reflected in Malaysia’s international for Malaysian technical leadership in Health has increasingly become a signifi- health relations. Its professed foreign these specialized areas. cant element in foreign policy for both policy priorities include socioeco- Malaysia’s regional role in assisting major and smaller countries, extending nomic and political linkages within its the development of WHO’s Framework beyond their formal membership in immediate geographical region, and Convention on Tobacco Control illus- global health agencies to feature more in particular with the Association of trates the importance of international prominently in regional and bilateral Southeast Asian Nations (ASEAN); health diplomacy in furthering public relations. In this article, this phenom- self-identifying as an Islamic country; health and the influence that such in- enon is explored through a case study of and undertaking a broad commitment ternational agreements can have upon Malaysia that examines the motivations to global citizenship through member- public policy in individual countries. A for health diplomacy, and illustrates ship in the United Nations and other meeting in Penang in 2001, hosted by the institutions and mechanisms for its international bodies, including the the Malaysian Government, WHO and conduct. It is argued that the narrow Commonwealth of Nations. While the National Poison Centre of Univer- imperatives of national security imposed seeking an engagement with, and open- siti Sains Malaysia, not only galvanized by fears of contagious diseases are giv- ness to, the global economy, Malaysia regional support for the framework but ing way to a broader, more positive and also reserves the right to criticize what also helped strengthen domestic efforts collaborative diplomacy of health, with it sees as the unjust consequences of to engage the Malaysian Government the potential for increased altruism. economic globalization, many of which with this global initiative. The meeting This study’s conclusions are applicable have ramifications for human health.2 decided that regional meetings would to other middle-income countries of be based upon membership of ASEAN similar size. Malaysia and WHO groupings, rather than those of WHO. In exploring connections between This decision to bypass WHO regional health and foreign policy, Fidler has sug- Malaysia is actively involved in WHO arrangements highlights a longstand- gested a useful hierarchy of functions.1 and is affiliated to the Western Pacific ing logistical problem for Malaysia and The principal goal of foreign policy is to Region. The country office for Brunei other ASEAN countries in their partici- ensure national security; this is followed Darussalam, Malaysia and Singapore pation in WHO. Indonesia, Myanmar by a concern with serving economic is located in Kuala Lumpur. There are and Thailand are grouped within the interests through promoting trade, com- seven WHO collaborating centres in South-East Asia Region, while the other merce and investment. These goals are, Malaysia, most of which are govern- members of ASEAN are in the Western in turn, furthered by the fostering of ment agencies. They are concerned with Pacific Region. order and stability. Finally, human rights research into health systems, pharmaceu- The 2001 meeting resulted in the may be served through the provision of ticals and tropical contagious diseases. Penang Declaration, which called for humanitarian assistance. Such collaborations provide valuable the establishment of “mechanisms for

a School of Public Health, La Trobe University, Bundoora, Victoria 3086, Australia. Correspondence to Simon Barraclough (email: [email protected]). b Monash University Malaysia, Petaling Jaya, Malaysia. Ref. No. 06-037119 (Submitted: 3 October 2006 – Final revised version received: 15 January 2007 – Accepted: 17 January 2007)

Bulletin of the World Health Organization | March 2007, 85 (3) 225 Special theme — Health and foreign policy Health imperatives and foreign policy: Malaysia Simon Barraclough & Kai-Lit Phua regional cooperation to facilitate a con- The Commonwealth of the Muslim world through this vehicle. solidated global response to the tobacco Nations The organization’s mandate has been menace”.3 The Declaration, forwarded to extended to embrace cooperation in so- the 2002 meeting of ASEAN health min- The Commonwealth of Nations has a cioeconomic matters, including health, isters in Vientiane, also urged ASEAN significant commitment to international and the organization’s health ministers countries to seek assistance from WHO health. Within the Commonwealth meet regularly. However, its health ac- and other UN and international bodies Secretariat in London, the Health Sec- tivities have been limited and Malaysia’s to implement the framework conven- tion has merged with the Gender and participation has been modest. In 2005, tion.3 Education Sections to form the Social a scheme funded through the Islamic Transformations Programmes Division; Development Bank was established 6 The Association of this new division coordinates health ini- to combat diseases in member states. tiatives. The organization is committed Malaysia has been praised by the organi- Southeast Asian Nations to the Millennium Development Goals, zation’s secretary-general for its support Malaysia was a founding member of which include action on maternal and for the eradication of polio in Muslim ASEAN, the regional body central to child health as well as disease control countries where it is still endemic.6 5 Malaysian foreign policy. Although es- and eradication. Although its involvement in the tablished in 1967 as a regional security Although Malaysia has been a organization’s health activities provides organization seeking to keep south-east member of the Commonwealth since an opportunity for altruism, it also of- Asia free of conflict between the major its independence from Britain, its par- fers the potential for contributing to powers, its role was expanded to encom- ticipation has waxed and waned. With the Malaysian Government’s policy of pass economic and sociocultural func- Britain’s military disengagement from encouraging the export of health-related tions, including health. ASEAN health the region in the early 1970s, the Com- goods and services, and promoting joint ministers hold regular formal meetings. monwealth had little functional use for ventures in health. Members of the orga- In 2000, the Yogyakarta Declaration on a regionally focused Malaysian foreign nization provide a ready market for halal the Healthy ASEAN 2020 strategy was policy. In Malaysia’s immediate region, (lawful for Muslims) therapeutic prod- ucts, including vaccines. In 2001, the posited as the basis for cooperation be- Brunei Darussalam and Singapore are health minister of Malaysia conducted tween member countries, as well as with the only two other members of both the a diplomatic mission to Jordan; part international health agencies. Commonwealth and ASEAN. of this mission included promoting the The seventh ASEAN meeting of In the late 1980s, Prime Minister Malaysian health industry. The visit re- health ministers, hosted by Malaysia in Mahathir bin Mohamed revived Malaysia’s engagement with the Commonwealth, sulted in a memorandum of understand- 2004 with the theme “health without ing on bilateral health cooperation.7 frontiers”, was particularly relevant for especially as a forum for championing foreign affairs and health. This meet- the interests of developing countries. In 1989 Malaysia hosted the Common- ing endorsed continuing cooperation Bilateral health relations wealth Heads of Government Meeting. between members not only to counter Malaysia has developed a range of bilat- An important health-related outcome of infectious diseases but also to deal with eral health relationships with bordering the meeting was the Langkawi Declara- the health ramifications of international countries, as well as with others both tion on the Environment. trade agreements, to encourage joint within and beyond the region. Of par- However, the Commonwealth’s food standards policies and to harmonize ticular concern to Malaysia in develop- health initiatives have limited conse- health services standards and regula- ing these bilateral ties has been the threat quences for Malaysia. Commonwealth tion. It was also agreed that ASEAN posed by infectious diseases, especially health ministers meet annually on the countries would work with WHO and since several hundred thousand foreign eve of WHO’s World Health Assembly other UN agencies to examine the rec- workers have entered Malaysia and play in Geneva. Occasionally Malaysia is ommendations of the Commission on a vital role in the country’s economy. involved in Commonwealth-initiated The smuggling of illicit and counterfeit Macroeconomics and Health to monitor projects. In 2002 Malaysia became the drugs and contraband cigarettes has also health-related Millennium Development principal sponsor of the Common- been of serious concern. Goals.4 wealth’s Global Information Hub for Malaysia has signed several bilateral Despite the positive pronounce- Integrated Medicine, which provides an agreements that deal with cross-border ments of ASEAN health ministers electronic database of traditional and issues, including health. In 1997 a mem- about regional cooperation, it must be complementary medicine. orandum of understanding concerning recognized that there have also been health cooperation between Thailand some significant health-related tensions Islamic diplomacy and and Malaysia was signed in Kuala Lum- between Malaysia and some of its neigh- pur. Regular meetings of health officials bours. The burning of Indonesian forests health have included the nineteenth meeting to clear land has caused regular and seri- Malaysia helped establish the Organiza- of the Thailand–Malaysia Border Health ous pollution over the Malay peninsula. tion of the Islamic Conference in 1969. Goodwill Committee, which in 2006 Malaysia’s treatment of foreign workers, This body, composed of 57 countries discussed issues including the smuggling which has included imposing higher fees with headquarters in Jeddah, was formed of illegal and counterfeit drugs, infec- for non-citizens using public hospitals, to promote cooperation between coun- tious diseases, maternal and child health, also has been a source of diplomatic ten- tries with an Islamic identity. Malaysia and the human resources development sion with Indonesia. conducts elements of its diplomacy with through exchange visits.8

226 Bulletin of the World Health Organization | March 2007, 85 (3) Special theme — Health and foreign policy Simon Barraclough & Kai-Lit Phua Health imperatives and foreign policy: Malaysia

In December 2003, in the wake of previously unknown viral illness among workers came. He also noted the diplo- the severe acute respiratory syndrome pig farmers in Perak and Negri Sembilan matic significance of the attendance of (SARS) epidemic, Brunei Darussalam led to 101 deaths in Malaysia and the Wen Jiabao, China’s new premier.17 and Malaysia initiated bilateral health death of an abattoir worker in Singapore. Coordinated international dialogue, meetings. They agreed to establish work- In an effort to control the spread of the planning and action helped to defuse ing groups for future joint projects and disease, hundreds of thousands of pigs some of the precipitate “fear response” by for a memorandum of understanding were slaughtered and the export of pig national governments in the early stages to strengthen and formalize future co- meat was suspended, causing serious of the SARS outbreak; these responses operation on health.9 A year later, the damage to a major Malaysian export had included the blanket refusal of entry health ministers instigated joint co- industry. to some south-east Asian countries of operation not only on communicable This incident highlighted Malaysia’s the nationals of countries affected by the diseases but also laboratory facilities, dependence upon international coop- disease. In addition, stronger health link- health surveillance, food safety, tobacco eration in dealing with a major health ages were forged both within ASEAN control and the cross-border movement crisis as well as the benefits of links with and between this regional grouping and of patients.10 WHO. The WHO Collaborating Centre China, Japan and the Republic of Korea. Health relations with Singapore for Arbovirus Reference and Research The SARS outbreak led the Government (as with relations on some other issues) at the University of Malaya mobilized of the Russian Federation, a country have been marked by tensions. In 2003, the WHO network for assistance. A geographically extending to Asia, to seek Malaysian health officials criticized team from the United States’ Centers formal links with ASEAN in the inter- Singapore for allowing four people with ests of preventing the spread of future for Disease Control and Prevention 18 symptoms of SARS to enter Malaysia; provided on-site assistance. Australia infectious disease outbreaks. the officials also rejected Singapore’s also organized a range of experts from In the case of Malaysia, cooperating suggestion that officers be placed at each human and animal health agencies to with China to counter SARS contributed to stronger bilateral health links as well other’s border crossing points to monitor support Malaysian diagnostic and con- 11 as restoring Malaysian health authori- screening activities. Despite such dis- trol efforts.15 The close collaboration ties’ confidence in China, as the latter agreements, regular high-level bilateral between Malaysian and Australian health country had been suspected of not fully meetings were held to deal with SARS, authorities occurred despite diplomatic disclosing the prevalence of the disease. and bilateral commitments to mutual tensions between the governments of In April 2004, Chinese Vice Minister cooperation and collaboration were re- the two countries during Prime Minister 12 for Health Zhu Qinsheng attended the affirmed. In January 2004, during a Mahathir’s incumbency. ministerial delegation to Singapore led first bilateral meeting on health in Kuala In April 2003, Malaysia played a by Prime Minister Abdullah Badawi, of- Lumpur. There the Malaysian health prominent regional role in responding ficials pledged cooperation to deal with minister expressed the hope that: to the outbreak of SARS. It hosted the the threat of avian influenza.13 “... both our countries will be able to first special meeting on SARS of the In May 2004, China and Malaysia help each other in many areas, including ASEAN+3 ministers of health in Kuala used Prime Minister Badawi’s visit to training and capacity-building, informa- Lumpur. (ASEAN+3 is an expanded commemorate the thirtieth anniversary tion exchange and electronic database grouping comprising the members of of the establishment of diplomatic rela- development, cross-border control of in- ASEAN as well as China, Japan and tions between the countries and to reaf- fectious diseases, research, pharmaceuti- Korea.) At this meeting, participants firm their memorandum of understand- cals and traditional and complementary agreed to take comprehensive transbor- 19 ing on public-health cooperation; they medicine”. also announced a mutual mechanism for der action to contain the disease and to reporting epidemics.14 facilitate the exchange of information. Malaysia is a member of the Asia-Pacific They also affirmed their intention to Economic Cooperation (APEC) group, Contagious disease and follow WHO’s travel guidelines and a 21-member body formed in 1989 to initiated the establishment of an ASEAN promote regional economic develop- health cooperation research centre on controlling com- ment by fostering trade liberalization 16 Much Malaysian health diplomacy can municable diseases. Two months later, and technical cooperation. Even before be categorized as safeguarding national Kuala Lumpur was the venue for WHO’s SARS, APEC had issued a report on security regarding contagious diseases. international conference on SARS. threats posed by infectious diseases to The Ministry of Health instituted the It is indicative of national percep- trade and travel, concluding that both International Health Unit to implement tions of the threat posed to the region human health and competitiveness of the provisions of WHO’s International by SARS and the need for decisive health APEC’s economies were at risk if ap- Health Regulations as well as Malaysia’s diplomacy that all ASEAN heads of gov- propriate actions were not taken.20 Prevention and Control of Infectious ernment attended a subsequent summit Faced with the serious economic Diseases Act of 1988. Malaysia has meeting in Bangkok in 2003. Malaysia ramifications of SARS, APEC initiated also been actively involved in negotia- was represented by Abdullah Badawi, a security action plan. In addition, the tions to revise the International Health then acting prime minister. He used the health ministers of APEC met in June Regulations. occasion to explain Malaysian policy 2003 and established a Health Task Between 1998 and 1999, Malaysia on medical screening for immigrant Force.21 Confronted with further threats experienced one of its most serious workers, a matter of sensitivity among from contagious diseases, an APEC outbreaks of contagious disease when a the ASEAN countries from which these ministerial meeting on avian influenza

Bulletin of the World Health Organization | March 2007, 85 (3) 227 Special theme — Health and foreign policy Health imperatives and foreign policy: Malaysia Simon Barraclough & Kai-Lit Phua pandemics was convened in Viet Nam in by the Ministry of Foreign Affairs. Al- undertaken by Malaysia look beyond a May 2006 to consolidate planning and though the ministry has a substantive di- focus on national security. Malaysia is communication protocols.22 vision concerned with the Organization expanding its international engagement In terms of Malaysia’s international of the Islamic Conference and a centre in health-related research, development, health relations, APEC has provided a to deal with the threat of terrorism, it education and training. Foreign invest- further forum for health diplomacy as has yet to establish a health division. ment is attracted to its health industries, well as a network extending beyond the Rather, health diplomacy is coordinated and health tourism is being promoted immediate region. APEC’s involvement principally by means of interministerial to attract foreign patients and generate in health matters also reinforced the working parties and liaison between the export earnings. Malaysia has embraced economic imperatives of international health and foreign affairs ministries. globalization and is a member of the cooperation for health protection and The historical origins of global World Trade Organization, yet it has advancement. health agencies can be traced back to demonstrated independence when act- common action taken in the face of ing in the interests of its citizens’ health. Concluding observations contagious diseases; this led to the real- In 2003 it became the first country to This brief survey has explored the health ization that cooperation can be extended issue a compulsory import licence for imperatives evident in Malaysian foreign to research and preventative activities as generic antiretroviral drugs under the 23 policy and also some of the changes in well as the sharing of knowledge. This World Trade Organization’s Trade-related Malaysian health diplomacy, which has pattern is evident in Malaysia’s interna- Aspects of Intellectual Property Rights both expanded and intensified during tional engagements in health. The threat agreement. the past two decades. The salience of of infectious diseases, and in particular Malaysia’s continuing economic health in Malaysia’s foreign policy has SARS, human immunodeficiency virus prosperity, its substantial experience with been demonstrated by Prime Minister (HIV) and avian influenza, has been the successfully developing primary health- Abdullah Badawi’s participation in sev- major imperative for Malaysia’s partici- care services in rural areas, its record of eral regional summits and bilateral meet- pation in regional forums. assisting neighbours in the wake of natu- ings, by the increasing acknowledgement For the most part, Malaysia’s health ral disasters and its aspirations to act as of the need for health cooperation in diplomacy, unlike some other areas of an advocate for the interests of develop- official diplomatic communiqués, by the foreign policy, has been relatively free of ing countries all point to an increasing hosting of health conferences and meet- serious international conflict. Malaysia altruistic role in international health. ings in Malaysia, by the health minister’s has projected an image as a trusted and Many of the region’s poorer countries, involvement in diplomatic missions and active partner in the control of infec- and those farther afield, stand to benefit by the negotiation of health-related docu- tious diseases and a supporter of insti- from Malaysian assistance and technol- ments with neighbouring countries. tutional arrangements to further both ogy transfer in the field of health. O Despite these developments, Malay- regional and global health. Yet many sian health diplomacy is not coordinated of the international health initiatives Competing interests: None declared.

Résumé Impératifs sanitaires et politique étrangère : le cas de la Malaisie Les relations mondiales, régionales et bilatérales de la Malaisie en au niveau bilatéral. Cette diplomatie a également jeté les bases matière de santé internationale sont examinées dans le contexte d’un éventail plus large de liens de coopération qui dépassent historique de sa politique étrangère. La Malaisie a toujours participé le simple cadre de la réaction à la menace de pandémies. A aux organisations multilatérales, et en particulier à l’Organisation mesure qu’elle se rapproche de la situation d’un pays développé, mondiale de la Santé (OMS), cette participation allant de soi la Malaisie a progressivement intégré son secteur sanitaire à dans un pays qui se considère comme membre à part entière l’économie mondiale par le biais d’entreprises communes de de la communauté internationale. Les menaces que font peser recherche-développement et d’investissements transnationaux. les maladies infectieuses sur la santé et l’activité économique Parallèlement, elle disposera des ressources technologiques, ont conduit la Malaisie à intensifier sa diplomatie sanitaire et à financières et humaines nécessaires pour jouer un rôle altruiste lui donner un caractère plus formel, au niveau régional comme plus étendu dans la santé régionale et mondiale.

228 Bulletin of the World Health Organization | March 2007, 85 (3) Special theme — Health and foreign policy Simon Barraclough & Kai-Lit Phua Health imperatives and foreign policy: Malaysia

Resumen Los imperativos sanitarios en la política exterior: el caso de Malasia Se analizan las relaciones de salud mundiales, regionales y nivel regional como a nivel bilateral. Esa diplomacia ha sentado bilaterales internacionales de Malasia con el telón de fondo además las bases para el desarrollo de un conjunto más amplio de histórico de la política exterior del país. Malasia siempre ha relaciones de cooperación que van más allá de la mera respuesta participado en organismos multilaterales, sobre todo en la a las amenazas de pandemias. Conforme Malasia se aproxima al Organización Mundial de la Salud (OMS), pues tales organismos estatus de país «desarrollado», su sector de la salud se integra cada forman parte de la urdimbre de larga data de la «buena ciudadanía vez más en la economía mundial gracias a las iniciativas conjuntas internacional». Las amenazas que suponen las enfermedades de investigación y desarrollo y a las inversiones transnacionales. infecciosas para la salud humana y la actividad económica han Al mismo tiempo, el país dispondrá de los recursos tecnológicos, causado una intensificación y una formalización organizacional financieros y humanos necesarios para desempeñar una función de la diplomacia de Malasia en el terreno de la salud, tanto a altruista ampliada en la salud mundial y regional.

ملخص املحتِّامت الصحية يف السياسة الخارجية: ++حالة ماليزيا درست العالقات الصحية الدولية والثنائية األطراف واإلقليمية والعاملية الدبلوماسية األساس إلعداد مجموعة أكرث اتساعاً من العالقات التعاونية التي يف مسح أخذ باعتباره ما تحمله السياسة الخارجية يف ماليزيا من ظالل تتجاوز االستجابة للتهديد بالجائحات. ومع بلوغ ماليزيا حالتها املتطورة، تاريخية. فقد ساهمت وباستمرار يف الوكاالت املتعددة األطراف، والسيَّام فقد أصبح القطاع الصحي فيها مندرجاً أكرث ضمن االقتصاد العاملي من خالل يف منظمة الصحة العاملية، فمثل هذه الوكاالت تعد جزءاً الزماً من لحمة البحوث املشرتكة واملشاريع التنموية العابرة للبلدان. ويف الوقت نفسه، املواطَنَةالصالحة عىل الصعيد الدويل. وقد أدت تهديدات األمراض املعدية سيكون لديها املوارد البرشية واملالية والتقنية ألداء دور إيثاري واسع يف لصحة الناس ولفعالياتهم االقتصادية إىل تكثيف وتنظيم هيكيل للدبلوماسية الصحة العاملية واإلقليمية. الصحية يف ماليزيا عىل الصعيد اإلقليمي والثنايئ األطراف. وقد وطدت هذه

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