Dimensions of International Cooperation for Health : still a controversial issue ?

This essay stresses the importance of undertaking a critical analysis of international cooperation for health based upon reflections on diplomacy, acknowledging the ethical limits and possibilities of cooperation within this context. It emphasizes the importance of adopting an historical perspective, highlighting the circumstances surrounding the consolidation of the current international system, whereby, after two world wars, the victorious countries created the United Nations Organization, which today brings together all the world's nations, notwithstanding the fact that the majority of countries are in favor of significant changes to its institutional framework. It also stresses the importance of the bioethics dimension, despite the systematic disregard of principles adopted in relevant UN documents, especially in view of inequalities pari passu with asymmetries of knowledge and enjoyment of innovations that separate nations. This reflection also suggests that South-South cooperation is fundamental to the analysis of the inequality and dependence that demarcate North-South and East-West bipolarity. These reflections are, in short, important guiding elements for deepening analysis and resolutions in the arena of international cooperation for health, leaving aside catastrophic visions and idealistic illusions.


Introduction
The Universal Declaration on Bioethics and Human Rights 1 was adopted by acclamation by the General Conference of the United Nations Organization for Education, Science and Culture (UNESCO) in October 2005.It represents a major milestone in the discussions and resolutions concerning health in the field of international relations at the dawn of the new century that lie at the heart of the worldwide movement for human rights, which gained prominence after World War II.It is interesting to note that UN-ESCO stands out among other UN agencies for having approved not only the above declaration, but also the Universal Declaration on the Human Genome and Human Rights 2 , in 1997, and the guidelines for its implementation, two years later.
However, an ethical perspective on international relations in health was already present in the origins of the World Health Organization (WHO).The preamble of its constitution, which entered into force on April 7, 1948, sets out nine principles that underlie the purpose of cooperation between countries to promote and protect the health of all peoples.The second of these principles recognizes health as a fundamental human right, while the subsequent ones outline the commitments undertaken by the contracting parties to uphold this right: [...] The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.
The health of all peoples is fundamental to the attainment of peace and security and is dependent on the fullest co-operation of individuals and States.
The achievement of any State in the promotion and protection of health is of value to all [...] 3 .
One could ponder whether such commitments, enshrined in the middle of the last century, are in hibernation?This rather unpleasant hypothesis might explain the conspicuous absence of the founding principles of the WHO in the preamble of the Universal Declaration on Bioethics and Human Rights.Another important milestone that this UNESCO document fails to mention is the Alma-Ata Declaration, approved by the International Conference on Primary Health Care held by the WHO and the United Nations Children's Fund (UNICEF) in 1978, 30 years on from the formal establishment of the World Health Organization.This declaration proposes "[...] the reduction of the gap between the health status of the developing and developed countries" and the implementation of primary health care "[...] in a spirit of technical cooperation and in keeping with a New International Economic Order" 4 .
These considerations demonstrate the commitment of various intergovernmental agencies in the face of concerns over the global health situation and trends and, in particular, the important role played by bioethics in these debates and their practical ramifications; concerns that continue to grow in the face of technological advances and innovation in the healthcare field.
It is important to examine these issues from an historical perspective.The bipolar East-West and North-South geopolitical framework that emerged after the Second World War underwent a deep shift during the transition to the new century.However, the predominant features of international relations remain: inequality and dependence in economic, political, and military relations, which separate a core group of countries among the two hundred countries that make up the United Nations system.These features modulate processes of cooperation and external assistance in the global arena.The nominal variety of these processes only serves to disguise patterns of dependence and heteronomy, contraposing the principles of equality and autonomy that should underlie relations between countries involved in these processes.
During the second half of the last century, international relations, including cooperation processes, were architected around these two geopolitical axes: the ideologically oriented East-West, which brought together countries aligned with capitalism under the leadership of the United States, versus the socialist bloc, under the aegis of the Soviet Union; and the North-South, founded on stage of development criteria or economic power, a factor associated with the historical, cultural and environmental characteristics of countries situated at the opposite poles of an "[...] abyss of wealth and health that separates the rich from the poor" 5 .
Early doubts flourished within the context of inequality and dependence in economic, political, and military relations in this bipolar world 6 regarding the nature of cooperation proposals, calling into question the horizontality of such relations and their effectiveness in delivering beneficial results for poorer countries.
A new political landscape took shape at the turn of the twenty-first century, presenting world-system scholars with a number of chal-lenges [5][6][7][8][9][10] .General aspects of this shift can be enumerated as follows, without any pretension to depth of interpretation, with the aim of outlining the most noteworthy changes in the global arena during this historical transition: the collapse of Soviet communism; repeated economic crises in the Capitalist Bloc; independence of European colonies in Africa and Asia; the emergence of countries previously classified as underdeveloped that came to be called middle-income or emerging economies; the consolidation of China's global influence; and, overshadowing the former aspects, the permanence of the United States as the world's center of power.
A new element has recently emerged within this shifting political landscape: the establishment of relations between developing countries as part of an historic movement taking place over the last two decades that has brought together nations mainly from the southern hemisphere.This process constitutes the formation of the Global South, term coined by the UNDP 11 to characterize a geopolitical framework in which Southern Hemisphere countries seek to reorient their international assistance policies in order to pursue their own development plans.One particular aspect under the label of South-South cooperation lying at the heart of this process is fundamental to this analysis: the emergence and consolidation of relations between these countries reflect their aspirations to overcome the inequality and dependence that demarcate North-South and East-West bipolarity.The expression of this movement in the process of international health cooperation reveals a convergence between the motivation behind the foreign policy of these countries and the altruistic postulates of international solidarity geared towards overcoming the unfortunate consequences of inequality as regards the health of their population 12 .
The new focus that South-South cooperation brings to the area of health emerged within this process, morally tainted by the principle of solidarity and geared towards reducing inequality among these countries.It therefore amounts to a proposal that is in keeping with the postulate of health as a human right, rather than just the outcome of the development process to be stimulated by cooperation or external assistance.As such, the real experiences of this new cooperation paradigm need to tackle the bioethical challenges generated at the intersection between diplomatic interests and the principles of equity, justice, and solidarity in the arena of health as a human right 13 .
Gaps in living conditions and health between and within countries are associated with patterns of wealth and poverty in parallel with asymmetries of knowledge and enjoyment of innovations that separate nations and the citizens within them.Such gaps call for ethical reflection on their origin and debate about alternative ways of closing this void.As such, the questions regarding health vis-à-vis scientific and technological development posed lately in the international arena are characterized as bioethical challenges, moving beyond the area of health, where they have their origins, to become the concern of the field of international relations.These challenges call for a multidisciplinary approach to the formulation, execution, and evaluation of international cooperation initiatives, founded on solidarity, consensus and fairness in relations between partner countries in the face of the current global health situation and trends 14 .
Thus, the theme of this essay is shaped around the doctrine of recognition that holds that technical cooperation between countries within the institutional scope of the United Nations presupposes balance and harmony in international relations, both in the political and economic sphere and technical and scientific sphere.However, as mentioned beforehand, these assumptions should be considered in the light of contexts in which foreign policies of states are intertwined; otherwise, the external assistance practices developed under the mantle of the doctrine of international solidarity are likely to have little impact on development processes in the countries that depend on this support, or, which is more serious, traditional forms of colonialism under the new expression of coloniality of life denounced by Nascimento and Garrafa 15 are likely to resurface, subjugating the scientific and technological development of most vulnerable countries to the interests of the most powerful countries, causing dire consequences for the health of the population.
It is essential to highlight another key aspect of this discussion: the broadening of the scope of bioethics at the turn of the new century.The original meaning of bioethics as a "bridge to the future" was proffered by Potter 16 in his seminal book of the same name published in 1971.The reinterpretation of this approach as a set of universally applicable values focusing on essentially biomedical matters was enshrined eight years later by Beauchamp and Childress 17 in mainstream bioethics.This version became widely accepted, despite the restrictive nature of the methodology applied to health worker/patient and researcher and company/research participant relationships.However, the response to mainstream bioethics resulted in the broadening of its agenda of reflections and practical applications by assimilating topics from the area of health, social and environmental sciences as central concerns of the biomedical and biotechnological fields 18 .In Brazil, this facet of bioethics emerged in close connection with the public health field, under the name "bioethics of intervention", disseminated by the Unesco Chair of Bioethics at the University of Brasilia.
Conciliating this new perspective of bioethics and the South-South cooperation focus is an exercise in reflection that should not be conducted naively, ignoring the persistent hegemony of the acceptation of technical assistance within North-South cooperation and the concept of mainstream bioethics.It is also important to note that this perspective amounts to an interdisciplinary approach that embodies elements pertaining to each one of these disciplines: health, in the dimension that emphasizes the community over the individual; diplomacy, from a perspective that gives priority to multilateral relations within the United Nations system; and bioethics, under the Latin American epistemological statute of bioethics of intervention.
Hence, it is our intention here to draw attention to the importance of undertaking an analysis of international cooperation -as an instrument for promoting solidarity in the relations between countries -, while at the same time promoting reflection upon diplomacy, in order to effectively establish the ethical limits and possibilities of international cooperation, especially in the area of health.
In this regard, in conclusion, it is important to reaffirm the two main pillars of the present reflection that provide a basis for addressing the central theme: the importance of an historical perspective and the relevance of the bioethical dimension.The first aspect includes the circumstances that led to the foundation and consolidation of the current international system, when, beset by the grotesque repetition of two world wars in the first four decades of the last century, the victorious countries held the United Nations Conference on International Organization in San Francisco between 25 April and 26 June 1945.The representatives of the 50 countries, including Brazil, drew up a proposal to create the United Nations, which eventually came to incorporate all the world's nations, whose central purpose is to avoid war and preserve peace.The Charter of the United Nations proclaims the importance of promoting cooperation as both aim and an instrument or process to foster "peaceful and friendly relations among nations based on the principle of respect for equal rights and self-determination of peoples…" 19 .The conference also resulted in the creation of an institutional framework for global governance that, although beleaguered by an eternal crisis of survival, remains to the present day.Key issues that should be taken up in any analysis of the vicissitudes of international cooperation, particularly in the area of health, are linked to the eternal crisis that besets the prevailing international system, whereby the majority of countries either do not feel comfortable or are strongly favorable to radical changes to its organizational structure and regulations.
The second key point that is fundamental to any critical analysis of international cooperation for health concerns my initial assertion regarding the role of the Universal Declaration on Bioethics and Human Rights 1 in addressing this question, notably Articles 13, 15, 21, and 24 of this memorable document.Despite their normative or dogmatic appearance, it is important to underscore the essential meaning embedded in each of these articles: solidarity as the mainstay of international cooperation; sharing of benefits resulting from the advancement of knowledge and its applications; unrestricted respect for mutually agreed regulations concerning collective needs, as well concerted efforts by governments to combat transgressions against regulations; and, the unassailable assumption by states of their obligations under the declaration to ensure fulfillment.
These reflections are important guiding elements for deepening analysis and resolutions in the arena of international cooperation for health, leaving aside both catastrophic visions of the current situation and idealistic illusions formulated without taking due consideration of such assumptions.