President Obama’s re-election means that several recent international development initiatives from his administration suddenly have four more years bear fruit. These include the Feed the Future effort to improve global food security, and USAID Forward, an effort to improve the effectiveness of the US Agency for International Development. One Obama initiative will not get that chance, however. The president’s Global Health Initiative (GHI) has already come to an end as a stand-alone effort that the State Department office eliminated. This is a disappointment, but it is also a unique opportunity to improve health in middle-income countries. President Obama said all the right things about supporting global health when he launched the Global Health Initiative in 2009. The new integrated approach to global health was an improvement over attacking health problems one by one. But additional funding never came, just new ways of regulating existing US funds. We watched with regret as the initiative was slowly folded in with other global health programs. It is now official that GHI will be rolled into three existing bodies – USAID, the Center for Disease Control and Prevention, and the office of the Global AIDS Coordinator. This though, is where things get interesting. At the State Department, in place of GHI, the administration will establish an Office of Global Health Diplomacy (GHD). The loss of GHI is genuinely disappointing, but the gain of a formal structure for global health diplomacy could outweigh it. Global health problems are evolving fast and the distribution of global poverty has shifted. This is exactly the time that a well-implemented global health diplomacy effort from the US could make a huge difference. To date, the role of global health in American foreign policy has been pretty much owned by USAID. (Now is probably a good time to mention that I am currently employed by a USAID-funded health project.) That has worked pretty well. USAID has the technical background and the links to Ministries of Health to lead the American global health conversation. In situations where there is little or no donor money, though, there’s no opportunity for USAID to be present as an advocate for health. With USAID gone from Russia, for example, who will advocate for better HIV care? Russia has the fastest growing rate of HIV in the world, and thus far no effective way of addressing it. You could argue that’s a good thing. Donor-driven development doesn’t have a great track record. It’s pretty exciting to see countries empowered and prosperous to set their own development agenda. It’s not an exclusively good thing, though. It also leaves governments free to make any terrible decision they want to. Very often, they do make terrible decisions about health. They ignore the health sector altogether, see it as a source of revenue, or try to support health in all the wrong ways. Building a cancer center in the capital won’t help anyone if doctors and patients don’t have the knowledge to catch cancer early enough for effective treatment. Putting high-tech tuberculosis diagnostics in every town won’t reduce the TB rate if patients can’t afford treatment. These poor decisions stand because global health in middle income countries is frequently overlooked. In poor countries, bilateral and multilateral donors play the role of champions for health. Because the pool of money for health – and everything else – is small, USAID’s health sector funding both has impact and gets policymakers to think about health. That doesn’t happen in middle income countries. Most middle income countries aren’t receiving aid any more. If they are still receiving aid, the amounts of money involved aren’t large enough to be accompanied by influence. There is a clear role here for a diplomatic approach. The Office of Global Health Diplomacy could be the bearer of tough messages about health and accountability. Here’s one: a nation should not be taken seriously as a global power if it’s still undermining other countries by exporting drug-resistant tuberculosis or polio. Here’s another: the ability to exert state power well enough to vaccinate children for measles is a decent proxy for the ability to main a stable environment for private investment. GHD could back up those tough messages with short-term technical assistance if needed. I would love to see a strong office of Global Health Diplomacy led by a global ambassador with a background in health. The office could keep health on the agenda of US embassies around the world by providing talking points and guidance for including health into day to day diplomatic work. It could send knowledgeable emissaries to major global health events. And an ambassador for global health could do high-level visits that made it clear that talking health seriously is one of the conditions of becoming a global power. As far as I know, no other nation has a dedicated office for health diplomacy. This would be a chance for the US to do something groundbreaking. Done well, an office of Global Health Diplomacy could re-establish American leadership on global health and get middle-income countries to take health seriously as part of their path to prosperity. It’s not a rush of new money for vaccinations or HIV, true. But it’s an opportunity to do something totally new and important for global health.