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7 Conclusion Despite their similar ambitions to become more eco­ nom­ ically integrated and involved in the international community, the BRICS nations have differed considerably in their aspirations to develop effective public health systems. This became clear when the HIV/AIDS epidemic emerged in the 1980s, followed in the 1990s by the resurgence of tuberculosis and more recently by the obesity epidemic. Po­ liti­ cal leaders in all of the BRICS did not immediately respond to ­ these epidemics, for a variety of po­ liti­ cal and cultural reasons unique to each nation, and when they did respond, they differed in the timing and depth of their policy response to ­ these public health threats. What ­ factors accounted for the differences in policy outcomes? As I discussed in chapter 1, the existing lit­ er­ a­ ture has emphasized the importance of domestic electoral incentives, strong state capacity, and civil societal pressures as explanations for the timing and depth of policy responses to disease­ epidemics. But in the case of the BRICS, none of ­ these ­ factors ­ were impor­ tant. Instead, as I have argued in this book, the domestic policy response was ­ shaped, first, by the criticism, pressure, and policy expectations emanating from the international community and how po­ liti­ cal leaders responded to this, and then by the strength of bureaucratic–­ civil societal partnerships and how this, in turn, affected the bureaucracy’s ability to secure ongoing po­ liti­ cal and financial support. To better understand how and why the international community played such an impor­ tant role, I introduced the concept of geopo­liti­cal positioning. I define this as explaining the interests and incentives of po­ liti­ cal leaders to­ respond to international criticism and pressure through a stronger policy response to epidemics, the dif­ fer­ ent domestic and foreign policy strategies that Conclusion  249 this entails, and leaders’ willingness to pursue international financial and technical assistance to achieve their policy objectives. Geopo­ liti­ cal positioning has positive and negative ele­ ments. Positive geo­ po­liti­cal positioning emerges when governing elites positively respond to international criticism and pressure by immediately pursuing a stronger policy­ response to epidemics in order to increase their government’s international reputation in health, while at the same time pursuing international financial and technical assistance to ensure that their policies work effectively. To­ further enhance a nation’s international reputation, positive geopo­ liti­ cal positioning also emerges when leaders seek to engage in acts of global health­ diplomacy by providing foreign aid assistance to other nations striving to eradicate disease. As we saw in chapter 1, all of ­ these endeavors are ­ shaped by historical foreign policy pre­ ce­ dents, such as (1) governments’ attempts to increase their international reputation as effective developing states with sound public health systems; (2) governments’ willingness to engage in bilateral and multilateral cooperation, rather than striving to lead the world and establish international agendas; and (3) governments’ receptivity to international financial and technical assistance to develop effective economic and healthcare systems. Negative geopo­liti­cal positioning emerges when po­ liti­ cal leaders ignore international criticism and pressure and have no interest in building their nations’ international reputation in health, while at the same time refraining from pursuing international financial and technical assistance. Rather, po­ liti­ cal leaders strive to pursue reforms for their own reasons and at their own pace, regardless of international criticism and pressure. This kind of negative geopo­ liti­ cal positioning reflects a historical foreign policy commitment to assuming an international leadership role in diplomacy and, in some instances, reflects foreign policy commitments to solidifying governments as influential superpowers, while establishing their sovereignty and in­ de­ pen­ dence from international—­ especially western—­ influence. In this geopo­ liti­ cal context, governments improve their response to epidemics only when they are perceived as posing a threat to national security. And while governments in this position may provide foreign aid assistance in health, this ­ will be used only to enhance a government’s international and/or regional influence, rather than for improving its international reputation in health. Po­ liti­ cal leaders in Brazil, India, and China provide examples of positive geopo­ liti­ cal positioning. When confronting international criticism and pressure 250   Geopolitics in Health from influential institutions such as the WHO and the World Bank, ­ these leaders immediately pursued a stronger policy response to the HIV/AIDS and obesity epidemics to strengthen their international reputation in health. At the same time, they requested financial and technical assistance from ­ these international...


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