Volume 1, Issue 4
International Theory and Diplomacy Current Trends and Practical Value
Paul Sharp
The Changing Contours of Japan’s Africa Diplomacy Scarlett cornelissen
may 2015 March 2015
chief publisher Eugène Matos De lara
editor
Benjamin Miller
Academic advisors Arne ruckert Dave Van Ginhoven
Associate publisher Amelia baxter
Associate editors Eric Wilkinson Mete Edurcan Guillaume lacombe-Kishibe
Lead designer
Pierre-Alexandre Lubin
Contact Us by email at: bordercrossing.info@gmail.com (submissions)
Letter from the editor We try to expand our borders each month. In a way, this is what’s required when you are trying to cover a field as broad and dynamic as diplomacy. At the same time, we are always looking to build on what we have already done. After all, our goal is conversation and what kind of conversation would it be if none of our authors “spoke” to one another? Towards that first goal, we turn to two as yet uncharted territories: diplomatic theory (see Dr. Sharp’s piece) and Japanese-African relations (see Dr. Cornelissen’s piece). The first brings you back to basics as it tries to answer the question “what can diplomatic theory actually contribute to diplomacy?” The answer, I think you’ll find, is useful precisely because of its modesty. The second calls our attention to a fascinating and often overlooked set of relationships going through a period of significant growth and shift. Cornelissen’s conclusions are as optimistic as they are unsettling, but regardless of how they leave you feeling, you will surely be intrigued. Towards the second goal, we continue our “diplomat’s guide to…” sensibility with an overview of the key challenges in refugee diplomacy. Prof. Maley’s article will likely serve as a quick reference for the diplomat looking for a succinct statement of the perennial problems in this fraught area of diplomacy. We also return to the topic of global health diplomacy articulated in our first issue with a call to action for the role of surgery in the Sustainable Development Goals. In contrast to our usual scholarly authors, this call to action comes to us from “Scholars of the Future”. This is an experiment for Border-Crossing, but we are confident that the directly practical implications of the piece are compelling. We leave it to you, our readers, to give us feedback on whether you would like to hear more from “Scholars of the Future”. Finally, we have some engaging speculation over the race to replace Ban Ki-Moon. This short, nuanced analysis will likely provide you with much food for thought as conversations across the world continue. Benjamin Miller
In person at: 19 rue le gallois gatineau, quebec, j8v 2h3, canada
www.diplomatmagazine.nl
4
Border Crossing
Contents 6-
The Changing Contours of Japan’s Africa Diplomacy Scarlett Cornelissen
10- International Theory and Diplomacy Current Trends and Practical Value
PAul Sharp
14- The UN and Europe: Ban and Beyond Richard gowan 16- Refugee Diplomacy: Some Challenges William maley 20-
Access to Surgery in Developing Countries: Barriers, the Millennium Development Goals, and the Post-2015 Development Agenda Ben Li Tanishq Suryavanshi
MAY 2015
5
The Changing Contours of Japan’s Africa Diplomacy
Scarlett Cornelissen is Professor in the Department of Political Science at Stellenbosch University in South Africa, where she teaches International Relations and International Political Economy. Her research interests relate to Japan’s economic and diplomatic relations with African states.
Scarlett Cornelissen When, in the latter weeks of April, Prime Minister Shinzo Abe of Japan delivered a speech at the Asian-African Summit in Jakarta as part of the 60th anniversary of the Bandung Conference, most observers focused on what he had to say about Japan’s history with Asia, rather than on the state’s relations with Africa. Yet what most observers do not seem to appreciate enough, is how, under Mr. Abe, Japan’s diplomatic engagements with Africa have changed course over the past number of years and the way in which this not only reflects important new tendencies in Japan’s overall foreign policy, but indeed helps reinforce those tendencies. The Abe-led administration is largely seen to be bolder, even hawkish in its dealings with Asian neighbours and in recent years Japan has followed a more assertive security agenda in the region and beyond. This has translated into a bolder
6
Border Crossing
diplomacy in Africa, concerted efforts to position Japan more prominently on the continent, and a bigger emphasis on security matters in Japan-Africa relations, incorporating both conventional and unconventional security concerns. To be sure, other factors have also had major influences on Japan’s current reorientation to the African continent. Two important factors that should be singled out include pressures on Japan’s domestic energy security in the wake of the triple disasters of 11 March 2011, and a desire not to be overshadowed as an economic and diplomatic actor in Africa by other East Asian powers, most notably China, but increasingly also South Korea. It is noteworthy that in recent years Japanese authorities have placed greater emphasis on nurturing business links with African counterparts, with the Tokyo International Conference on African Development (TICAD) promoted as a vehicle
for advancing closer investment and trade ties. Also, since taking office, Mr. Abe has visited several African states, for instance undertaking official visits to Cote d’Ivoire, Mozambique, and Ethiopia in January 2014. These visits do not approximate the frequency by which China’s heads of state are received by African counterparts. But the fact that Mr. Abe is one of only three Japanese incumbents who have been to the African continent makes the visits significant. Historical context The current directions in Japan’s engagement with the African continent are important when viewed against a historical backdrop. Although a signatory of the Bandung Declaration of 1955 and ostensibly sharing a similar future vision of peaceful co-existence, sovereignty, and territorial integrity as the African states present at the Bandung Conference, Japan’s economic and political paths and loyalties diverged significantly from that
of newly decolonising Africa. This separation is clearly evident in Japan’s diplomacy to the continent since the 1960s, which has been variously described by scholars as ‘distant’, ‘disinterested’, ‘aloof ’, and selectively strategic. The writer Jun Morikawa’s depiction of Japan’s ‘dual Africa policy’ followed between the 1960s and the late 1980s remains influential. It describes how, in this period, Japanese authorities applied two distinctive strategies in diplomatic dealings with the African continent, one aimed at maintaining strong, if politically complicated, relations with minority-led South Africa, and the other intended to appease other African states that criticised Japan for its ties to the apartheid regime. Thus, while Japan’s ‘white Africa’ diplomacy was based on trade and the import of scarce minerals from South Africa, the Asian state’s ‘black Africa’ diplomacy saw the development of a strategic and long-standing aid relationship between Japan and the continent. Further, as noted by Kweku Ampiah, in the past, Japanese diplomats have used the sentiments of Bandung in rather cynical fashion to serve broader foreign policy goals. This included frequently invoking notions of a common Afro-Asian identity with voting blocs in the United Nations (UN) in order to garner support for Japan’s bids for UN Security Council seats. The range of events in the international arena precipitated by the end of the Cold War and the demise of the apartheid
regime created necessary conditions for a significant change in Japan’s relations with Africa. Over the past two and a half decades major features in Japan’s Africa diplomacy included: the development of a ‘partnership agenda’ to bolster African growth through key institutions such as the UN and G7/G8; the creation of a multilateral aid and development platform in the form of the TICAD (first established in 1993); and especially in recent years, attempts to enhance Japan’s economic presence in Africa. Concerning the latter point, for instance, it is noteworthy that the last TICAD gathering, held in 2013, centred strongly on building out business and investment ties between Japan and Africa, with Japanese officials placing much emphasis on the value that Africa’s current turn in fortunes holds for Japan’s own economic recovery. It has been suggested that Japan’s newer focus on Africa, its more strategic use of soft power tools such as the TICAD, and its push for a position in the growing African market are in large part motivated by national interests, which include concerns over China’s rising influence on the continent. The Japanese government’s recent decision to shorten the five-year cycle of TICAD meetings to three years and to hold the next one on African soil is perhaps testimony to this. China’s Forum on China Africa Cooperation, although established later than TICAD, has been held on rotating basis every three years in China and in Africa, and has become a major platform
for China’s diplomacy with the continent. Shifting dynamics There are also other geopolitical dynamics at play and factors distinctive to the leadership of Mr. Abe that explain specific dimensions that have emerged in the Japan-Africa relationship of late. It is significant, for instance, that in 2011 the Japanese government sanctioned the stationing of Japan’s Self-Defence Forces (SDF) in Djibouti in the Horn of Africa, the first permanent overseas base of the SDF in the post-war era. The base is used as a coordination point for multi-national anti-piracy operations off the Somali coast and it is intended to help secure Japanese sea freight in the Gulf of Aden. Further, in 2013 Japan announced that it would dispatch military attachés to key African embassies following insurgent attacks on an Algerian gas facility earlier that year in which Japanese nationals were killed. At the time, these announcements did not prompt much public debate in Japan over their implications for creeping–and constitutionally questionable– militarisation in Japan’s foreign policy, but they presaged stronger decisions by Mr Abe’s Cabinet in mid-2014 to reinterpret key provisions of Japan’s pacifist Constitution as grounds for invoking Japan’s right to self-defence. There have been indications that the constitutional reinterpretation and the more expansive powers enjoyed by the SDF would be principally
MAY 2015
7
tested in peacekeeping operations, several of them likely to be in Africa. In this way, dealing with security challenges in Africa legitimates some important and rather worrisome developments in Japan’s foreign policy. The shift to the right in Japanese politics witnessed during the Abe era has in unexpected fashion drawn more attention to Africa. While there are positive aspects to this, such as politicians’ drive to strengthen economic as well as development links, the implications of the emerging security links between Japan and the continent are unclear. References 1 See discussion by Inoguchi, Takashi (2014). ‘A call for a new Japanese foreign policy: The dilemmas of a stakeholder state’, International Affairs, 90, 4: 943-58. 2 See Cornelissen, Scarlett (2014). ‘South Africa’s economic ties with north-east Asia’, in Gilbert Khadiagala; Prishani Naidoo; Devan Pillay and Rogers Southall (eds.) The New South African Review 4: A Fragile Democracy – Twenty Years On. Johannesburg: Wits University Press. 3 Japan Ministry of Foreign Affairs (2013). Yokohama Declaration 2013. Hand in Hand With a More Dynamic Africa. Tokyo: MOFA. 5 See discussion by Brautigam, Deborah (2010). The Dragon’s Gift: The Real Story of China in Africa. New York: Oxford University Press.
8
Border Crossing
18, 4: 461-470. 4 Other visits were undertaken by Prime Ministers Yoshiro Mori and Junichiro Koizumi, respectively in 2001 and 2006. 5 Alden, Chris and Katsumi Hirano (eds.) (2003). Japan and South Africa in a Globalising World: A Distant Mirror. Aldershot: Ashgate; Ampiah, Kweku (1997). The Dynamics of Japan’s Relations with Africa: South Africa, Tanzania and Nigeria. London: Routledge, Sato, Makoto and Chris Alden (2004). ‘La diplomatie Japonaise de l’aide et l’Afrique’, Afrique Contemporaine, 4, 212 : 13-31. 6 Morikawa, Jun (1997). Japan and Africa: Big Politics and Diplomacy. London: Hurst & Co. 7 Ampiah, Kweku (2007). The Political and Moral Imperatives of the Bandung Conference of 1955: The Reactions of US, UK and Japan. London: Global Oriental. Also see discussion by Osada, Masako (2003). Sanctions and Honorary Whites: Diplomatic Policies and Economic Realities in Relations between Japan and South Africa. Westport: Praeger. 8 See overviews by Amakusa, Pedro (2014). Japan’s Foreign Aid to Africa: Angola and Mozambique within the TICAD Process. London: Routledge; and Cornelissen, Scarlett (2012). ‘Selling Africa:Japan’s G8 politics and its Africa diplomacy’, Global Governance,
9 Abe, Shinzo (2014). ‘“Japan’s diplomacy towards Africa: Strengthening each individual one by one,” Speech by Mr. Abe on the occasion of his visit to the Federal Democratic Republic of Ethiopia, 14 January.’ Tokyo. MOFA. 10 Hirano, Katsumi (2012). ‘TICAD and the national interest of Japan’, Japanese Studies, 32, 2: 183-99. 11 Nikkei, 24 August 2014, http://www.nikkei.com/ article/DGXLASFS15H22_ T20C14A8PE8000/, accessed 20 November 2014. 12 Ligami, Isabel (2015). ‘Kenya likely to host Tokyo summit’, The East African, 21 February. 13 Brautigam, Deborah, op cit. 14 Maruyama, Yusuke (2014). ‘SDF to play more significant role in U.N. peacekeeping missions, says Abe,’ The Asahi Shimbun, 27 September.
International Theory and Diplomacy Current Trends and Practical Value Paul Sharp is Professor of Political Science at the University of Minnesota Duluth and Senior Visiting Fellow at Clingendael, the Netherlands Institute of International Relations. He is co-founding editor of The Hague Journal of Diplomacy, and co-editor of Palgrave-Macmillan’s Diplomacy and International Relations series. He is the author of Diplomatic Theory of International Relations(Cambridge: 2009) and Thatcher’s Diplomacy (Basingstoke: 1997). Most recently, he co-edited American Diplomacy (New York: 2012) with Geoffrey Wiseman and is currently working on The Sage Hand Book of Diplomacy (London: 2016) with Costas Constantinou and Pauline Kerr.
Paul Sharp International Theory 101 International relations theory is an important subfield in the study of International Relations (IR). Those engaged in it are interested in how and why things happen as they do international relations, as well as how international actors ought to act as a consequence if they want to be good, wise, successful or all three. IR theorists tell us that all claims about international relations and diplo macy rest on some sort of theory. As a result, two questions become relevant: are the theoretical assumptions upon which a claim is based explicit and tenable, and do the inferences and arguments which are subsequently made follow logically from the starting assumptions? Behind these questions, however, great differences exist on very basic issues. Some IR theorists see themselves following the classical scientific model of inquiry: generating data to test hypotheses which allow them to explain and predict what is likely to
10
Border Crossing
happen at high levels of generality when specified conditions hold. For example, they ask questions about how a state’s behaviour in an international system may be related to the distribution of power in that system and to the state’s own internal arrangements. Other theorists, in contrast, reject this approach to human affairs by claiming that rather than discovering patterns and regularities immanent in the world, such an approach imposes frameworks upon it. Is the claim that states are the most important international actors to be understood as empirically verifiable or part of a politically significant but empirically irresolvable argument? In this approach, the relationship between a world “out there” and the ideas and language in which people seek to describe that world is complex. Indeed, some theorists argue that there may not even be an “out there” beyond our ideas about it in any meaningful sense. These theorists take people’s understandings of the world and their places within it as the point of departure for theoretical inquiry.
The irrelevance of Diplomacy? Despite the differences, most IR theorists have agreed that diplomacy—understood as the processes and institutions by which states represent themselves and their interests to each other—is not important to an understanding of what happens in international relations. A range of possible reasons exists for this. IR has been a social science and thus at pains to uncover the great patterns and regularities which are assumed to lie beneath the narratives of individual heroes and villains that people tell themselves about how peace and security are safeguarded or threatened. It is biased towards structure—the apparently gravitational forces exerted by a distribution of military power or the logic of a particular form of economic accumulation—and against agency—the wise statesmen and wicked dictators who claim to be in control. Diplomats may be necessary since someone has to deliver the messages, but most theorists agree that they are unlikely to account for
much variance in outcomes. Secondly, those IR theorists who actually have been interested in agency have done diplomacy few favours. Whether working in the classical tradition (Hans Morgenthau and Henry Kissinger) or employing behavioural and psychological insights (Thomas Schelling or William Zartman), their focus has remained steadfastly on the men at the top. The hero statesmen with vision and courage remain the focus. Diplomats have remained ephemeral and diplomacy invisible. Finally, IR has largely been an enterprise of North American, and in particular United States provenance. As a consequence, claims that IR’s neglect of diplomacy is related to America’s historic suspicion of diplomats, their reluctance to distinguish between diplomacy and foreign policy, as well as their preference for military and economic forms of influence have intuitive appeal. On this view, dominant powers extend their influence to the leading ideas of their time. France elevated diplomacy. Britain defended it. The US depreciated it.
The “Practice Turn” Since the end of the Cold War and the start of US’s relative decline, interest in diplomacy has increased among international theorists. In spite of claims that it is out of date and irrelevant, diplomacy persists in the face of existential challenges and domestic asphyxiation. The new states created after the Cold War all established new diplomatic services, and newly influential actors in international relations sought ways to achieve some level of diplomatic representation. As a result, what diplomacy does and why it needs to be done have been revisited, especially by scholars who adhere to what is known as the “practice turn” in social theory (such as Sending, Pouliot, Neumann, and Adler-Nissen). Social structures may exert a profound influence on how people act, but where do these structures come from? They are produced and enacted on a daily basis by people and especially by diplomats. Critical approaches to practice stress the gap between what is supposed to be going on in diplomacy and what diplomats actually spend their
time doing. For example, diplomats espouse the principles of sovereign equality and non-intervention, while enacting a practical hierarchy among states that often results in countries meddling in each other’s internal affairs. More sympathetic approaches explore the extent to which diplomacy generates distinctive views of international relations and how to handle them, both of which are undervalued and should be promoted (Sharp, Jonsson, and Hall).
Diplomacy’s Transformative Potential Other theorists examine diplomatic innovation and its potentially transformative consequences for international relations generally. The revolutions in information and communication technologies have profound effects that inhibit certain established diplomatic practices like secrecy while enabling new ones like building temporary coalitions for particular ends. Indeed, it appears possible that anyone who can maintain a website can also be a diplomatic actor. Public diplomacy has
MAY 2015
11
received the most attention, not least because governments interested in exploiting soft power and research foundations interested in democratizing international relations have been willing to finance this sort of work. In addition, the European Union has provided an extended opportunity for examining what happens to diplomacy when the distinction between the world inside states and the world outside them begins to break down. When, for example, do diplomatic relations give way to political relations? Finally, the rise of new/old great powers has facilitated a renewed interest in the way both their leaders and scholars understand international relations. China, for example, purports to be interested in a very conventional form of state, foreign ministry, and embassy-based diplomacy, even in regard to public diplomacy which it sees almost exclusively in terms of the opportunities it provides for strategic communication. Chinese IR scholars tend to anchor their work in the constitution of relationships, rather than the distribution of power and interests. As a consequence, they assign far more importance to the study of diplomacy in both its conventional and novel forms than do most of their Western counterparts.
Conclusion What then does international theory have to offer those who actually practice diplomacy? In the past, diplomats, and more often their managers and trainers, had to work hard to uncover useful insights and techniques: game theory’s attempts to capture the logic of bargaining situations; democratic peace
12
Border Crossing
theory’s attempts to demonstrate that the relations between representative governments are more peaceful than with non-representvvative governments; foreign policy theory’s attempts to capture and harness structural power and soft power; and above all, managerial theory’s advice on how to set up complex organizations as well as act effectively within and between them. What they did not look at was what international theory had to tell them about diplomacy. Diplomats interested in IR tended to look at foreign policy, grand strategy, and international history, or else they became diplomatic raconteurs, telling their stories to students. Accordingly, the discovery of diplomacy by international theorists was welcomed, along with books, courses, and other resources. Nevertheless, that anticipation has generally been followed by disappointment. The academic literature seems to tell diplomats what they already know about themselves, only at great length and in unnecessarily complex language. It often joins the chorus of those who say diplomacy must adapt or perish with the latter being no great loss to anyone but diplomats. And sometimes it deals with matters which diplomats barely recognize as diplomacy: the presentation of relations between indigenous peoples in film, the organization of global sporting events, and the recounting of introspective voyages of self-discovery. This should not be surprising. IR scholars and international theorists in particular, do not seek to be useful to diplomats in narrowly instrumental terms, even when they study diplomacy. Some of them are profoundly suspicious of state-based diplomacy
for reasons which are familiar even if they do not elicit general consent. Others are much less critical and even supportive, but their work is not directed at making sense of diplomacy to diplomats. Their target is a broader audience composed of their colleagues and society at large. Their work may seem to spell out what diplomats already intuitively know from experience. Diplomats, however, are notoriously ineffective in their own defence, in part because they are impatient with those who do not easily grasp the value of what they do. In an era when technological developments, popular expectations, and financial exigencies conspire to call the value of professional diplomacy into question, diplomats should look to those best placed to make an old argument for new times.
references
1 Rebecca Adler-Nissen, “Late
Sovereign Diplomacy,” The Hague Journal of Diplomacy, 4, 2, 121-141. Henry A Kissinger, Diplomacy (New York: 1994).
2 Hans J Morgenthau, Politics Among Nations (New York: 1948). Ole Jacob Sending, Vincent Pouliot and Iver B. Neumann, “The Future of Diplomacy,” International Journal, Summer, 2011, 527-542.
3 Paul Sharp, Diplomatic Theory of International Relations (Cambridge, 2009).
Consider border crossing for the publication and peer review of your academic work
Contact us By Email At:
bordercrossing.info@gmail.com
Mastermind China’s The UN and Europe: Merging and Beyond Energy Ban Diplomacy Richard Gowan is Research Director at New York University’s Center on International Cooperation and a Senior Policy Fellow at the European Council on Foreign Relations. He also teaches at Columbia University’s School of International and Public Affairs and writes a week column for World Politics Review (www.worldpoliticsreview.com).
Richard Gowan After eight years as SecretaryGeneral of the United Nations, Ban Ki-moon is not an especially wellknown figure in Europe. This low profile may have been a blessing. The Secretary-General’s two immediate predecessors, Boutros Boutros-Ghali and Kofi Annan, were central players in the Balkan wars during the 1990s. Both bore some of the blame for the disastrous peacekeeping failures in Bosnia, although Annan deserves credit for launching the UN administration in Kosovo in 1999. Ban, by contrast, had to navigate the controversy over Kosovo’s unilateral declaration of independence in 2008. Russia backed Serbia’s rejection of this claim, and another Balkan war briefly seemed to be a threat. Ban quietly made it possible for the EU to replace the UN as the leading international agency in Kosovo, helping to defuse the stand-off. This was classic Ban. A selfconfessed diplomat’s diplomat, the
14
Border Crossing
former South Korean foreign minister has always felt happier with quiet diplomacy than grand gestures. He has been widely criticized for this tendency, and has gradually become more outspoken over challenges such as the humanitarian crisis in Syria. Nonetheless, his soft-spoken style was probably the only feasible approach to Kosovo. Russian diplomats, perceiving Ban as being on the West’s side, muttered about driving him from office early. Ban also felt that the EU was strong enough to manage its own crises. Although the UN still has a few duties in Europe such as mediating in Cyprus, it is far more heavily engaged in Africa and the Middle East. While Ban has visited Europe regularly, he has largely done so to attend summits and conferences, or to drum up funds from donors like the Netherlands and the Nordic countries. Yet European crises have started to encroach on the UN’s agenda once again. Over the last year, the Security
Council has held a series of angry but pointless meetings over Ukraine as Russia has tried to fend off criticisms from the West. Ban visited Moscow to meet with Vladimir Putin early in the Ukrainian crisis, but could get little out of him. A UN envoy was briefly held by armed men in Crimea. Since then, UN officials have played a minor role in tracking the conflict by reporting on the deteriorating human rights situation in Crimea but have had little leverage over Kiev or Moscow. The UN has a far greater role in handling the multiple crises south of Europe, from peacekeeping in Mali to mediation in Syria and Libya as well as helping the flood of migrants heading to Europe from these warzones across the Mediterranean. While European governments are groping towards a common approach to the Mediterranean crisis, the UN is likely to play a major humanitarian and political role in the Middle East and North Africa for years to come. Ban, who
was personally moved by the courage of the original young protestors in Tunisia and Egypt in 2011, has little choice but to keep trying to help the Arab world for the rest of his time in office. But his term is coming to a close; he will leave the UN at the end of 2016. UN officials speculate that he is eyeing a bid for the presidency back in South Korea. Whoever replaces Ban will have to offer fresh ideas for how the UN can deal with the crises in Eastern Europe and the Mediterranean more effectively. This is especially sensitive because the UN’s unwritten rules suggest that the next SecretaryGeneral should come from Eastern Europe. A small host of politicians from the region have signaled an interest in the job, including former Slovene president Danilo Türk, Serbian ex-foreign minister Vuk Jeremic and thewidely respected European Commissioner Kristaliina Georgieva. But it is hard to identify a politician from the region who will be acceptable to not only the EU and U.S. but also Russia, which could easily block the whole selection process next year. Some UN observers believe that it will be necessary to find a Secretary-General from elsewhere. Helen Clark, the former prime minister of New Zealand and current chief of the UN Development Programme, is a particularly prominent nonEuropean candidate. Other potential runners from Latin America and Africa are biding their time before entering the fray. Encouraging Clark and
Georgieva, the Obama administration has sent early signals that it wants to support a woman for the post, a historic first that could be one of the President’s last significant foreign policy choices. Yet even if Ban Ki-moon is followed by a politician with no real prior knowledge of Europe, she or he will almost certainly end up spending a lot of time on European security issues. This will mean not only long sessions in Brussels meeting rooms but also more high-stakes trips for tricky talks in Moscow and heartrending public visits to refugee camps from Syria to the Sahel. One conundrum that Ban has failed to resolve is how to persuade many European countries to increase their spending on aid to the levels necessary to assist the vulnerable in the Arab world. The UN is billions of dollars below its funding targets for Syria. Even well-intentioned EU politicians admit that their voters are growing increasingly skeptical about sending aid outside Europe in a period of domestic austerity. The next Secretary-General will have to push European leaders and citizens to offer more help to their suffering neighbors.
Yet whoever replaces Ban Ki-moon could do worse than asking Merkel for advice on the job. The Chancellor has, after all, had to maneuver to keep the EU together in the face of mounting economic and foreign policy challenges. The next UN Secretary-General will have to do something similar, but on a global scale. Like Ban, Merkel is a fan of subtle maneuvers. She is also quite good at them, and has immense contacts and personal power. Perhaps she should consider a move to New York after all.
There is a recurrent but extremely suspect rumor around the corridors of the UN that German Chancellor Angela Merkel might put herself for the job. This probably doesn’t have any basis in fact; unlike many national leaders who dream of a nice retirement job in New York, Merkel has never shown much interest in UN matters.
MAY 2015
15
Refugee Diplomacy: Some Challenges William Maley is Professor of Diplomacy, Asia-Pacific College of Diplomacy, The Australian National University. He is author of Rescuing Afghanistan (2006), and The Afghanistan Wars (2009), and co-editor of Global Governance and Diplomacy: Worlds Apart? (2008), and Theorising the Responsibility to Protect (2015).
William Maley One major ethical defence of a world of sovereign states is that states exist to protect the interests of their citizens. However, we all know that in the real world this does not always happen. All too often, states can persecute their own citizens or they can fail to prevent others from doing so. When this happens, it is unsurprising that some of the victims of such persecution seek to flee to other parts of the world to obtain refuge. Many states, by ratifying or acceding to the 1951 Convention Relating to the Status of Refugees, have committed themselves not to return refugees to places where they would experience persecution. Until the twentieth century, refugees rarely figured on the agenda of international diplomacy. Individual exiles, of course, were a familiar phenomenon; indeed, the Pilgrims who are venerated as founders of modern America fell into this category, as did more controversial figures such as Marx and Lenin.
16
Border Crossing
However, it took the mass flows out of Bolshevik Russia followed by the plight of persecuted Jews in Nazi Germany to highlight refugee movements as political challenges demanding political and diplomatic solutions.
for political attention to root causes, he won little support; at the July 1938 Evian Conference on Jewish refugees, the Australian delegate even remarked that ‘as we have no racial problem, we are not desirous of importing one’.
One approach was to hand the problem over to energetic individuals. The polar explorer Fridtjof Nansen served as the League of Nations ‘High Commissioner’ for Russian refugees in Europe and inaugurated the so-called ‘Nansen passport’, a document that allowed refugees to travel without having to petition their own governments for support. The Nazi regime posed a more intractable challenge, and the American James G. McDonald (who from October 1933 to December 1935 served as High Commissioner for refugees coming from Germany) argued in his resignation letter that ‘considerations of diplomatic correctness must yield to those of common humanity’. But in calling
The post-World War II period, overshadowed by the horrors of the Holocaust, saw steps to establish more institutionalised mechanisms of addressing refugee problems. One example, the 1951 Convention, established a legal framework supplying rights for refugees and imposing duties upon state parties to assist them. Just before the Convention was drafted, the United Nations General Assembly set up the office of the United Nations High Commissioner for Refugees (UNHCR), which has now become an established feature of the international landscape. In November 1957, the General Assembly established an Executive Committee (‘ExCom’) for UNHCR, which brings together key
UN member states with interests in refugee issues for a meeting held around October of each year where refugee challenges are canvassed and indicative ‘Conclusions’ can be adopted. ExCom has now become a major venue for ‘refugee diplomacy’. Unfortunately, ‘refugee diplomacy’ is becoming more and more fraught. In its UNHCR Global Appeal 2015 Update, UNHCR identified a total ‘population of concern’ of 42,873,743 persons, with a refugee total of 11,699,278 and the balance mainly made up of internallydisplaced persons (IDPs) assisted by UNHCR (23,925,555), returned IDPs (1,356,182), asylum seekers (1,172,824), and persons under UNHCR’s ‘statelessness mandate’ (3,469,250). As an agency, UNHCR has worked tirelessly to assist refugees, promoting voluntary repatriation, settlement in country of first asylum, or resettlement to more remote states as ‘durable solutions’ for refugees. However,
two factors have seriously complicated these approaches. On the one hand, globalisation has exposed refugees to visions of parts of the world in which greater degrees of freedom, justice and political stability prevail. This has undermined the notion that victims of persecution are obliged to accept the wretched consequences of a ‘birthright lottery’ that consigns them to lives of misery, squalor, and violence. Refugees are increasingly reluctant to be ‘warehoused’ for years, their lives in limbo while they wait to see whether a ‘durable solution’ will come their way. Furthermore, the border controls thrown up by developed countries enjoy a diminishing legitimacy in the eyes of those whom they serve to exclude. On the other hand, UNHCR estimated in 2014 that some 960,000 refugees were in need of resettlement. However, in 2013 only 71,411 UNHCR resettlement departures had occurred, and fully 10,665 of these comprised refugees from Bhutan, hardly the neediest of
refugee populations. In such circumstances, it is entirely predictable that refugees will seek solutions of their own, and that the market will provide services to assist them. Thus, in the face of inaction on the part of states, people smuggling has surged as a mechanism for people seeking to escape from persecution, and states—although seeking to drape their policies in humanitarian language—increasingly depict refugees not as victims to be assisted, but threats to be resisted. Domestic politics also come into play. Of course, the bulk of the burden of caring for refugees is currently carried by poor developing countries where refugees often initially flee, as well as by UNHCR. Unfortunately, there are political forces at loose in developed countries that would like to keep this asymmetrical distribution of responsibility in place. Especially in the post 9/11 environment, antiimmigrant sentiment often stretches to refugees as well, and political leaders may well fear the loss of
MAY 2015
17
votes to far-right forces such as the National Front in France if they do not pay lip service to such parties’ agendas. Thus, in August 2001 the Australian government sent commandos to board a Norwegian vessel, the M.V. Tampa, in order to prevent it from bringing Afghan refugees rescued from a sinking boat in the waters of the Indian Ocean to Australia. This was transparently a move to win votes in the approaching Australian election which the incumbent Australian government, further buoyed by the fears sparked by the 9/11 terrorist attacks, went on to win. What this case also exposed was how reluctant some Western states are to become countries of first asylum: their preferred approach is to fund relief elsewhere, and to ‘cherry pick’ refugee populations with a view to resettling the more educated and sophisticated at the expense of the unskilled and the disabled. The effect, however, is to create deep tensions in what passes for an international system of ‘burden sharing’. When good-will prevails, negotiated systems of burden sharing can offer genuine solutions to seemingly intractable problems. The 1989 ‘Comprehensive Plan of Action’ for Vietnamese refugees in Southeast Asia proved effective in dealing with such a problem, but only because a small number of Western countries were prepared to do some ‘heavy lifting’, committing to resettle those asylum seekers processed in the region who
18
Border Crossing
were found to be refugees within the meaning of the term in the 1951 Convention. This is a good model for addressing many current refugee challenges. Recently, however, some rather more distasteful approaches have been adopted by developed countries, in some cases fairly shamelessly exploiting the asymmetries of power that mark the international system. Australia’s ‘Pacific Solution’ outsourcing refugee processing to failed or fragile states such as Nauru and Papua New Guinea comes rapidly to mind. Yet in its desperation to outsource its responsibilities, Australia actually made itself vulnerable to the demands of Nauru, temporarily reversing the asymmetries of power that normally marked the bilateral relationship between the two states. In order to secure the cooperation of Nauru in 2001, the Australian Government had to pay more than US$1 million to Nauru to cover the unpaid bills in Australian hospitals of Nauruan citizens, who were thus relieved of the burden of private debts; a clearer case of bribery would be hard to find. It is of course no secret that stronger states can use their weight to try to get what they want. But those that do so recklessly may find that their recklessness comes back to haunt them. Following the election to office of the Abbott government in Australia in 2013, the new Minister for Immigration
and Border Protection embarked on an exercise known as ‘Operation Sovereign Borders’ to force boats carrying asylum seekers back to Indonesia. This involved unauthorised (even if accidental) incursions into Indonesian territorial waters, and an overarching rhetoric that showed little or no interest in how Indonesia might view what was being attempted. By 2015, the tables had turned. Australia was a supplicant to Jakarta seeking the commuting of death sentences against two convicted Australian drug traffickers, but the Indonesian president showed little interest even in responding to requests for a telephone conversation with the Australian Prime Minister. A senior Indonesian minister, Tedjo Edhy Purdijatno, even canvassed the possibility of letting a ‘human tsunami’ of asylum seekers depart in Australia’s direction. Refugee issues, as this case shows, are just one part of a much broader pattern of international engagement and addressing them by unilateral initiatives to block refugee movements is unlikely to prove effective in the long run. States may claim to be saving lives through unilateral actions of this kind, but such claims are both shallow and spurious. Unilateral action does not address the fear of persecution which causes refugees to flee, and rather than saving refugees it forces them into what may be even more dangerous routes of escape. This is an outcome of which no contemporary government should feel proud.
MAY 2015
19
Access to Surgery in Developing Countries: Barriers, the Millennium Development Goals, and the Post-2015 Development Agenda Ben Li is a second year student in the Bachelor of Health Sciences (Honours) program at McMaster University in Canada, specializing in Biomedical Sciences. He is currently a research assistant at the Global Strategy Lab supporting a range of analytical, empirical and big data studies evaluating global strategies for addressing transnational health threats. Tanishq Suryavanshi is going into his third year of the Bachelor of Health Sciences (Honours) program, with a specialization in Global Health. His interests and experiences span the fields of medicine, technology and business, which he hopes to utilize to solve major problems in global health. Tanishq is also a professionally trained chef, and can often be found in the kitchen during his time off.
Ben Li Tanishq Suryavanshi Current state of surgery in developing countries There is a growing body of evidence suggesting that improving access to surgery in developing countries can significantly reduce the global burden of disease. In 2008, only 3.5% of the 234 million major surgeries performed worldwide took place in the poorest countries, whose people account for 35% of the world’s population (1). Although 11% of the global disease burden is treatable by surgery, two billion people lack access to surgical care (1). These discouraging figures demonstrate that there are large global inequalities in access to surgery. Since countless deaths can be avoided with timely surgical interventions, it is time for the international community
20
Border Crossing
to recognize and prioritize this health crisis. With the Millennium Development Goals (MDGs) coming to an end in 2015, its successor in the post-2015 Development Agenda and Sustainable Development Goals (SDGs) are slowly taking shape. Many of the proposed goals are health-related, yet there is little mention of the role surgery will play in achieving these goals (2). Given that a significant proportion of the global burden of disease can be reduced by more effective and equal distribution of surgical services, it is clear that surgical care needs to play a more important role in the post-2015 era. Barriers to Access to Surgical Care in Developing Countries The noted disparities in access to surgery between developing and developed nations can be
explained through several barriers. These barriers can be cultural, financial, or structural, each posing unique challenges. Cultural barriers involve the acceptability of a certain treatment, often stemming from various cultural beliefs. For example, when the advertised name of an eye surgery in Nigeria was modified to remove mention of the term “surgery,� the number of patients willing to enroll in treatment increased significantly (3). This demonstrates a lack of willingness to undertake surgical procedures in certain areas, manifested through a cultural fear of these treatments (4). These factors pose difficult challenges in providing global access to surgical care and must be approached in a respectful, culturally-sensitive manner. On the other hand, financial barriers relate to the affordability of treatments. This encompasses both direct costs associated with
treatments and indirect costs from the presence of sickness. Many governments in developing countries do not provide “safety nets” to fund treatments (5). Paired with the widespread implementation of cash-first policies in hospitals, which demand deposits or payment before providing treatment, this lack of a safety net forces many citizens to pay for treatments out of their own pockets (3,6). As a result, many citizens are often unable to afford treatments or forced to owe large debts to hospitals, thereby reducing their propensity to pursue further treatment (7). Finally, structural barriers are chiefly concerned with the accessibility of surgical services. For example, some studies show that more than 63% of civilians travel more than 10 kilometers to receive medical treatment (3). Often paired with minimal access to motorized transport, the results can be devastating. Furthermore, some hospitals do not have access to the proper materials such as clean water, oxygen, or anesthetics to safely perform surgery. Even more surprisingly, centers that do have the required resources often lack trained specialists (3). These barriers pose many unique problems in achieving adequate access to surgery in developing countries and force us to rethink what exactly is meant by access to surgery. Surgical procedures must be available and affordable, as well as acceptable to the cultural values of different nations. Thus, to ensure the long-term sustainability of efforts to
improve global access to surgery, we must turn to the Millennium Development Goals and the post-2015 Development Agenda. Surgery and the Millennium Development Goals In 2000, the United Nations established the Millennium Development Goals (MDGs), eight international development goals created to serve as a blueprint for international development (8). Three of these goals related directly to improving health outcomes, focusing on areas such as child mortality, maternal health and prevalent communicable diseases (figure 1). Unfortunately, there is little mention of the importance of surgery in reaching these goals (9).
Figure 1: Overview of the Millennium Development Goals, adapted from (8). Although significant strides have been made towards achieving the MDGs, much more can be done for the health-related MDGs four, five, and six. For example, in sub-Saharan African countries, child and maternal mortality rates remain high and access to maternal and reproductive health aremains low (10). Given that obstructed labour accounts for
8% of global maternal deaths, obstetric surgery is essential in reaching goal four (9). Furthermore, congenital abnormalities result in 3.2 million deaths and disabilities every year (11). Many of these conditions, such as congenital heart defects, cleft palates, and clubfoot, can be effectively treated by early surgical intervention (12). Surgery can also play a role in achieving goal six, as male circumcision reduces the risk of men acquiring HIV through heterosexual sex by 60% (13–15). The lack of mention of surgery’s role in the MDGs may be due to the misconception that surgery is considered less cost-effective than other medical interventions, such as primary care and drug treatments. However, it is important to recognize that not all surgical procedures are as extensive as open heart or brain surgery. In fact, basic surgical services are very cost effective. For example, various studies quantified the cost-effectiveness of medical interventions in terms of their cost per disability-adjusted life years (DALYs) averted (16), where one DALY represents one healthy year of life lost due to early death or disability. The results show that the cost/DALY for many basic surgical procedures, such as cataract surgery, inguinal hernia repair, and cleft palate repair were approximately one-tenth the cost/DALY for other common health interventions, such as oral rehydration therapy, breast feeding promotion campaigns, and anti-retroviral therapy for HIV. Compared to many public prevention strategies and drug
MAY 2015
21
therapies, basic surgical procedures can be much more cost-effective. Therefore, initiatives aimed at improving access to surgery in developing countries are not only necessary, but also practical. Realizing that the global burden of surgical disease is considerable yet neglected, the World Health Organization (WHO) established the Global Initiative for Emergency and Essential Surgical Care (GIEESC) in 2005 (17). This organization aims to improve global collaboration on reducing death and disability from surgical conditions in low- and middle-income countries (LMICs) (17). Unfortunately, due to the lack of sponsorship from donors, the program has been ineffective in achieving its goals (18). This stems from the perception that surgical programs lie outside the traditional purview of public health, which has largely been focused on distribution of medicines and vaccinations for the past century (18). To reshape the global perception on surgical access, it is necessary to clearly state its importance on the international stage in the post-2015 Development Agenda and SDGs. Surgery and the Post-2015 Development Agenda With the post-2015 Development Agenda and SDGs being adopted by the end of this year, it is a critical time period for global health. The priorities of the SDGs will be determined by a variety of
22
Border Crossing
bodies including the United Nations, governments, academic institutions and civil society representatives (19). Overall, there are a few broad strategies for reducing the barriers to surgical access in developing countries. These strategies include using metric-based standards to measure progress in surgical care, improving the financing and advocacy dedicated to surgery, creating support mechanisms for strengthening human capital in global surgery, and improving public education and awareness to reduce the cultural hesitancies associated with surgery (20). It is important that groups contributing to the SDGs consider these strategies, and incorporate them into the proposed goals. Following the Rio +20 summit in 2012, the UN proposed a set of seventeen SDGs and accompanying targets for each goal. Goal three strives to «ensure healthy lives and promote well-being for all at all ages,» and includes specific areas of focus, such as maternal and newborn mortality rates, death and disability from traffic accidents, and communicable diseases (21). Curiously, the targets of goal three aim to provide essential medicines and vaccines for all, but not surgical care. Given that surgery is essential in tackling the aforementioned problems, the SDGs must clearly mention the importance of global access to surgery. For example, one target under goal three could involve reducing the number of individuals without access to surgery in half by 2030, through
incorporating the broad strategies mentioned earlier. Given that the evidence supporting global surgery is apparent, the biggest obstacle is convincing decision-makers of its importance and addressing the misconception that surgery is less essential than medicines and vaccines (22-25). We strongly urge global leaders, policymakers, negotiators, and public health professionals to reconsider the importance of surgical care in global health. We must take action now to prioritize improvement of global access to surgery in developing countries in the post-2015 development agenda, if we hope to reach our goals in international development. References 1 Funk LM, Weiser TG, Berry WR, Lipsitz SR, Merry AF, Enright AC, et al. Global operating theatre distribution and pulse oximetry supply: an estimation from reported data. Lancet [Internet]. 2010 Sep 25 [cited 2014 Dec 2];376(9746):1055–61. Available from: http://www.thelancet.com/journals/a/article/PIIS0140-6736(10)60392-3/ fulltext 2 A renewed global partnership for development: UN system task team on the post-2015 UN development agenda [Internet]. [cited 2014 Dec 3]. Available from: http://www.un.org/en/development/ desa/policy/ untaskteam_undf/glob_dev_rep_2013.pdf 3 Ologunde R, Maruthappu M, Shanmugarajah K, Shalhoub J. Surgical care in low and middle-income countries: burden and barriers. Int J Surg [Internet]. Elsevier; 2014 Jan 8 [cited 2014 Nov 16];12(8):858–63. Available from: http://www.journal-surgery.net/ article/S1743919114002076/fulltext 4 Ojabo CO, Alao O. Cataract surgery: limitations and barriers in Makurdi, Benue
State. Niger J Med [Internet]. [cited 2014 Dec 1];18(3):250–5. Available from: http://www.ncbi.nlm.nih. gov/pubmed/20120639 5 Grimes CE, Bowman KG, Dodgion CM, Lavy CBD. Systematic review of barriers to surgical care in low-income and middle-income countries. World J Surg [Internet]. 2011 May [cited 2015 Apr 15];35(5):941– 50. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21360305 6 Macharia W, Njeru E, Muli-Musiime F, Nantulya V. Severe road traffic injuries in Kenya, quality of care and access [Internet]. African Health Sciences. Makerere University Medical School (Uganda); 2009 [cited 2014 Dec 1]. Available from: http:// www.ajol.info/index.php/ahs/article/ view/43772 7 Lewallen S, Courtright P. Recognising and reducing barriers to cataract surgery. Community Eye Health [Internet]. 2000 Jan [cited 2014 Dec 1];13(34):20–1. Available from: http:// www.pubmedcentral.nih.gov/articlerender. fcgi?artid=1705969&tool=pmcentrez&rendertype=abstract 8 United Nations Millennium Development Goals. United Nations; [cited 2014 Nov 20]; Available from: http://www. un.org/millenniumgoals/ 9 A crucial role for surgery in reaching the UN millennium development goals. PLoS Med [Internet]. 2008 Aug 26 [cited 2015 Apr 9];5(8):e182. Available from: http:// www.pubmedcentral.nih.gov/articlerender. fcgi?artid=2522259&tool=pmcentrez&rendertype=abstract 10 Millennium Development Goals: 2014 Progress Chart [Internet]. [cited 2014 Nov 29]. Available from: http://www.un.org/ millenniumgoals/2014 MDG report/ MDG 2014 Progress Chart_English.pdf 11 WHO | Congenital anomalies. World Health Organization; [cited 2015 Apr 15]; Available from: http://www.who.int/mediacentre/factsheets/fs370/en/ 12 Czeizel AE. Birth defects are preventable. Int J Med Sci [Internet]. 2005 Jan [cited 2015 Apr 15];2(3):91–2. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1168872&tool=pmcentrez&rendertype=abstract
13. Bailey RC, Moses S, Parker CB, Agot K, Maclean I, Krieger JN, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet [Internet]. 2007 Feb 24 [cited 2015 Feb 15];369(9562):643–56. Available from: http://www.ncbi.nlm.nih. gov/pubmed/17321310 14 Gray RH, Kigozi G, Serwadda D, Makumbi F, Watya S, Nalugoda F, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet [Internet]. 2007 Feb 24 [cited 2015 Feb 13];369(9562):657–66. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17321311 15 Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLoS Med [Internet]. 2005 Nov [cited 2015 Apr 9];2(11):e298. Available from: http:// www.pubmedcentral.nih.gov/articlerender. fcgi?artid=1262556&tool=pmcentrez&rendertype=abstract 16 Grimes CE, Henry JA, Maraka J, Mkandawire NC, Cotton M. Cost-effectiveness of surgery in low- and middle-income countries: a systematic review. World J Surg [Internet]. 2014 Jan [cited 2014 Nov 14];38(1):252–63. Available from: http:// www.ncbi.nlm.nih.gov/pubmed/24101020 17 Kushner AL, Cherian MN, Noel L, Spiegel DA, Groth S, Etienne C. Addressing the Millennium Development Goals from a surgical perspective: essential surgery and anesthesia in 8 low- and middle-income countries. Arch Surg [Internet]. American Medical Association; 2010 Feb 1 [cited 2014 Nov 9];145(2):154–9. Available from: http://archsurg.jamanetwork.com/ article.aspx?articleid=405721 18 Spiegel DA, Abdullah F, Price RR, Gosselin RA, Bickler SW. World Health Organization Global Initiative for Emergency and Essential Surgical Care: 2011 and beyond. World J Surg [Internet]. 2013 Jul [cited 2015 Apr 15];37(7):1462–9. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=4263501&tool=pmcentrez&rendertype=abstract
anesthesia for the Post-2015 Development Agenda: operative capacities of 78 district hospitals in 7 low- and middle-income countries. Surgery [Internet]. 2014 Mar [cited 2015 Apr 9];155(3):365–73. Available from: http://www.sciencedirect.com/ science/article/pii/S0039606013005394 20 Ologunde R, Holmer H. The Post-2015 Development Agenda: The Role of Surgical Care in Improving Health. World J Surg. 2014 Mar 25;38(10):2738–9. 21 Greenberg, Sarah L.M., Maine, Rebecca G., Gillies, Rowan, Hagander, Lars E., Meara JG. Surgery: A post-2015 Millennium Development Goal priority [Internet]. [cited 2014 Dec 3]. Available from: http:// www.worldwewant2015.org/node/298620 22 Shillcutt SD, Sanders DL, Teresa Butrón-Vila M, Kingsnorth AN. Cost-effectiveness of inguinal hernia surgery in northwestern Ecuador. World J Surg [Internet]. 2013 Jan [cited 2015 Apr 9];37(1):32– 41. Available from: http://www.ncbi.nlm. nih.gov/pubmed/23073503 23 McCord C, Chowdhury Q. A cost effective small hospital in Bangladesh: what it can mean for emergency obstetric care. Int J Gynaecol Obstet [Internet]. 2003 Apr [cited 2015 Apr 9];81(1):83–92. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12676406 24 Gosselin RA, Thind A, Bellardinelli A. Cost/DALY Averted in a Small Hospital in Sierra Leone: What Is the Relative Contribution of Different Services? World J Surg [Internet]. 2006 Mar 8 [cited 2015 Apr 9];30(4):505–11. Available from: http:// www.ncbi.nlm.nih.gov/pubmed/16528459 25 Kushner AL, Cherian MN, Noel L, Spiegel DA, Groth S, Etienne C. Addressing the Millennium Development Goals from a surgical perspective: essential surgery and anesthesia in 8 low- and middle-income countries. Arch Surg [Internet]. 2010 Feb [cited 2015 Apr 9];145(2):154–9. Available from: http://www.ncbi.nlm.nih. gov/pubmed/20157083
19 LeBrun DG, Chackungal S, Chao TE, Knowlton LM, Linden AF, Notrica MR, et al. Prioritizing essential surgery and safe
MAY 2015
23