Learning from soft power.

The limitations of direct military intervention—“hard power”—for achieving foreign policy are increasingly highlighted by international events. Policy makers, military leaders, and intelligence experts now recognise the crucial role of preventive policy approaches—“soft power”—to tackle the multifaceted, upstream causes of conflict and instability. Soft power encompasses diplomacy, development, trade agreements, sanctions, foreign aid, and the promotion of education, women’s rights, and democracy. It prioritises prevention, the shaping of international affairs to pre-empt or minimise crises before they arise, and is supported by bipartisan commissions, independent agencies, and the military. Hard power is reserved as a last resort. Used early and efficiently, soft power not only provides effective and diverse policy options, but it costs far less and risks fewer lives. These hard learnt lessons in national security provide eye opening parallels to a second, major industrial complex: the healthcare system. The modern approach to health emphasises “hard healing”—the reactive, individualised treatment of risk factors and diseases. Like the military, healthcare systems benefit from highly trained, dedicated personnel who use complex, advanced, and dizzyingly expensive technologies to achieve a proximal aim: treating a disease. And they both primarily respond to, rather than prevent, major crises. This is expensive and inefficient. Just as military interventions may resolve acute crises but leave behind fragile or deteriorating circumstances, medical care may resolve acute health exacerbations but does not tackle root sociocultural, economic, and environmental determinants of chronic disease. Both systems also represent massive industrial complexes that incentivise self sustaining growth and high tech intervention rather than prevention. In many countries, these are the most costly systems: in the US, for example, annual military expenditures approach $700bn (£440bn; €610bn) and health system expenditures are $2900bn—together making up 23% of gross domestic product. We propose the concept of “soft healing.” Like soft power, soft healing prioritises proactive prevention rather than reactive treatment and uses a range of strategies, not only the healthcare system, to promote wellbeing (box).Tools range from education and advocacy to economic incentives and multinational approaches. Examples of successful strategies include air and water regulatory standards to reduce contaminants and taxation and better and sanitation and surveillance systems to prevent infectious outbreaks. Just as soft power operates outside the military system to minimise conflict, improve national security, and reduce the need for costly, extended military campaigns, soft healing strategies complement the healthcare system to reduce population risk, improve health, and minimise the need for inefficient, costly medical treatments. The healthcare system must also be used for soft healing, analogous to deploying the military for peacekeepingmissions rather than full scale military intervention. Soft healingmust be prioritised in the health system to encourage behavioural and lifestyle changes in the population. This might be achieved with integrated clinical teams, quality benchmarks, and reimbursement structures. Hard healing continues to dominate health policy and resources, despite the long history of advocacy for population health approaches by people such as Geoffrey Rose. Historical tradition, institutional incentives, and resource allocation are obstacles to balanced national approaches. In most nations, spending on public health and population research is dwarfed by healthcare, with billions of dollars being invested in precision medicine, drugs and medical devices, healthcare financing, incentive reform, and an ever expanding medical-industrial complex. These approaches can improve health but are often expensive, inefficient, and incremental. Meanwhile, soft healing approaches outside the healthcare system remain largely overlooked for tackling the pressing concerns of our time: diet, food systems, and lifestyle. Correcting these imbalances will require concerted, sustained efforts to reform strategic planning, re-allocate both money and personnel, and encourage private sector and multinational efforts. Moreover, better surveillance and communication systems are needed to inform decision makers. We believe soft power provides a refreshing analogy for promoting the fundamental need for soft healing. Use of soft power enhances influence, promotes stability, reduces costly military interventions, and strengthens national security.