Is it a battlespace or is it "humanitarian space"?

My colleague Dr. Gene Bonventre has been hard at work considering ways to get USAID to work with DoD. One of the irritating fundamental arguments I have heard from USAID/DoS and NGO personnel against DoD's work is that we are 'crowding the humanitarian space'. Part of the problem, in my view, is that DoD doesn't view where it works as "humanitarian space." Afghanistan, for example, is a "battlespace" in my view. Some USAID personnel do not share that view and believe the country to be a "humanitarian space" that is being poisoned by DoD. In fact, some would argue that DoD's presence in Afghanistan creates danger to their personnel. From the DoD perspective, the U.S. President ordered up a war against the Taliban who were lurking in Afghanistan.

But back to the brilliant Dr. Bonventre who used to work for DoD. He apparently has been slaving away on a committee to make recommendations about how we can all get along. The report is here: http://www.usaid.gov/km/seminars/2009/civilian_military_relations.pdf. I haven't read it thoroughly yet but it looks promising.

Also, Dr. Bonventre and another brilliant former military guy, Dr. Skip Burkle, have posted their views here, on the New Security Beat blog ( http://newsecuritybeat.blogspot.com/2009/07/who-does-development-guest-contributor.html?showComment=1248726308123#c3239810732797271218).

I take issue with Skip Burkle's blog in that he views the discussion from a development perspective (the title of the blog, after all), and he maintains that USAID is best for development actions. He criticizes Secretary Gates for asking for more civilian personnel positing that Gates was asking for the personnel to be under the control of the military. Finally he criticizes DoD for be inexpert at development which he calls "winning hearts and minds" and which I would argue is "counter insurgency" when referring to Afghanistan and Pakistan. Regardless of his critique I think the question is the wrong question.

I don't think we have the luxury to have "either/or" agencies any more. I have written about this before--I think Michele Flournoy hit the nail on the head with a proposal for a new breed of security expert. Or, you could have a new breed of development expert. Either way, staff at USAID who are being paid with my tax dollars should be promoting the US Government agenda, and part of that is our national security interests. Cognizance of what that is would be a good starting point. Much like we can no longer leave military actions in these hybrid wars to the combat arms dudes who view every problem as something to shoot and kill. The world has moved on, but perhaps our gut reactions have not.

Nat. Mus. of Health and Medicine - Resolved exhibit

Nat. Mus. of Health and Medicine - Resolved exhibit
Originally uploaded by etacar11

More from Flickr on Health and War.

Healthcare not Warfare protests in the U.S.

the health care perspective
Originally uploaded by redletterwoman

I was searching for visual evidence of the "healthcare not warfare" argument in the U.S. and have found several photos in Flickr. The issue, obviously, is perceived to be one of resources. It's an important debate.

Bullet wound (National Museum of Health and Medicine)

Bullet wound (National Museum of Health and Medicine)
Originally uploaded by Prof. Jas. Mundie

I was surfing for images about Health and War on Flickr and have come up with some oddities.....

War and Culture: Sarah Trigg and "Santa Susana with Mexican Border"

Santa Susana with Mexican Border
Originally uploaded by Trigg Studio

I stumbled across the work of Sarah Trigg in an online journal called "Cultural Politics" (URL:http://newsgrist.typepad.com/culturalpolitics/2009/05/sarah-trigg-daily-markings-on-the-face-of-the-earth.html#more) Trigg has produced a series that depicts the lines and traces of war etched on the earth and captured in images. This image is my favorite.

The Undersecretary of Defense for Policy takes on StratComm

USD Policy has been undergoing significant reorganization lately, and it's shape and function is not exactly clear to those of us on the 'outside'. The Office of the Undersecretary of Defense for Policy is perhaps "The Source" of power within the Pentagon, and the new Undersecretary, Michele Flournoy, is trying to shape her office to be more responsive to the global context, it seems. Those of us around D.C. not within USD(P) are waiting to understand the new organization and it's new direction. The Defense News reported last week (URL:http://www.defensenews.com/story.php?i=4190904&c=AME&s=TOP ) that Flournoy was going to put together a small team to shape communications both to Congress and to other US Govt agencies. The team will replace an office within USD(P) that used to be called "Support to Public Diplomacy". Flournoy disbanded the Support to Public Diplomacy office this year, seeking a fresh start to Strategic Communications efforts after the Support to Public Diplomacy office became embroiled in an internal conflict over it's issuances. (Apparently it was issuing 'propagandistic' information that soldiers in Afghanistan refused to use about casualty rates). While this all sounds rather archaic, it's not. The goal of the team is to coordinate Strategic Communications across DoD. I would suggest they start by reading the CENTCOM reports to Congress on progress in Afghanistan and Iraq. As I've blogged before the reports are pathetic at best, and do not show off the significant efforts in either theater of war.

As the U.S. tries to shape its global presence to positively effect and stabilize the international commons, it must be cognizant of its communications. It's all part of the "Smart Power" construct.

War, H1N1, and Personnel Readiness

This blog is about DoD's health communications, and the potential utility of a "whole of government response" to assist DoD with H1N1.

As H1N1 makes its way around the globe via public travel, and --troop deployments-- we also are apparently busy in Southern Command delivering protection kits to health care workers in Latin America (Click on the title of this blog for the story from Southcom). I have thought about this particular post for several days now because I am currently in training at a military base. Training at a military base involves heavy 'social' interaction. We eat together, do physical fitness training together, sit in a classroom, huddle around maps for harried planning discussions, congregate over a computer to produce briefing slides for the group, eat together some more, and live in a dorm-like setting. Social distancing is nearly impossible. A trip from my class room to the ladies' bathroom room requires that I touch 3 door handles/doors one way, or a total of six 'fomites' (things that carry germs by being touched repeatedly--like a door knob) for a round trip. While it might seem paranoid that I know this, apparently on this particular base there are verified cases of H1N1. We were told 22 cases when we first arrived. Yesterday, a class mate told me that someone in my class of about 125 students (but not in my particular section of 13 students) had fallen ill and was 'quarantined' to the back of the class. "WHAT?" I asked him. "Yah, the guy had to sit in the back of the class away from everyone-that's what I heard" said my colleague. We were warned, on the first day, that were we to fall ill, we would be quarantined and therefore miss more than the acceptable amount of course work with the end result of being expelled from the the course. Obviously the use of the word quarantine has strayed from its actual meaning.

There are real and potentially unpleasant results should we come down with H1N1. Most of us have been toiling for about a year now, and this is our last phase--to drop out now would be distressing. It might even mean that we would have to start all over because there are limited amounts of upcoming classes, and a limited amount of time to complete the entire course. (Therefore, my heightened sense of concern about the door handles is at least explainable, and perhaps entirely warranted. ) The dire warnings of quarantine therefore produce an incentive to not seek treatment for flu symptoms.

But getting back to the protection kits. While I completely understand the goodwill gesture of distributing protection kits, I am somewhat baffled by the institutional response of DoD. Rumors are starting to circulate about H1N1, with odd descriptions of quarantine and treatment (e.g. treatment with Tamiflu--one of the more dubious rumors) with a predictable amount of resulting confusion. This is how the military works, unfortunately.

So I went surfing through the publicly available DoD information on H1N1 is illuminating--it tells us to wash our hands, cover our nose and mouth when sneezing and stay at home if we get ill. The efficacy of face masks is unproven, therefore not among the recommended actions. Here's the DoD watchboard for H1N1: http://fhp.osd.mil/aiWatchboard/. Although we did receive a 'briefing' about H1N1 that told us that the symptoms of H1N1 are remarkably long lasting, and to cover our nose and mouths when we sneeze, we were not told about where to get more information, and the briefing concluded with the warning about quarantine.

Health communication seems to be the weak point in the DoD's response. While we are generous with our neighbors, I have to wonder if we are appropriately generous with ourselves? Is one website really an appropriate instutional response? Or, a briefing given to an officer with no public health background to present to a packed auditorium of students freshly arrived from disparate parts of the globe? Is this really the best we can do for ourselves? And, is this the appropriate level and style of communication considering the importance of troop readiness? After all, we are in the middle of two wars and troops cannot fight if they are sick. The military health system is stretched thin. Could the Public Health Service be useful here? Where is our "whole of government" response when we are trying to cope with a threat to our own national security right here at home?

While it could be argued that I'm thinking like Chicken Little and fretting over a falling sky, I suspect that our response to this relatively benign flu does not indicate a measured response should a more virulent flu appear this fall.

America's Global Health Influence from the Kaiser Family Foundation

I was discussing DoD's role in global public health with colleagues yesterday. Most people asking "what is DoD's lane" in global public health are from outside the DoD, and are part of NGOs, IOs, and other USG agencies. The Kaiser Family Foundation and CSIS are addressing the US government's role, and they have some interesting information posted on their website (http://globalhealth.kff.org). They not only have a break down of the monies spent by various agencies, they also have conducted a poll of American opinions about sustaining the substantial investment that the US is making around the globe.

I am beginning to think that the question of DoD's role in global public health is the wrong question, and is really being posed by people from within organizations that have options to either engage or not engage at will. The DoD, unlike other agencies, is not actually free to decide where it will engage, strategically speaking. Of course, at the tactical or programmatic level there are always decisions being made that have some effect. For example, the much-derided 'Medcaps'--somewhere at some level is a DoD employee who decides whether a medcap will be conducting in town X versus town Y. But at the strategic level, the DoD is engaged in Afghanistan and Iraq at the pleasure of our country's politicians. Not at the behest of Secretary Gates. Adding to this perspective of limited choice about the matter is the hierarchical nature of command. All military personnel understand that when the commander (at any level) says jump, everyone jumps. So, when a maneuver commander in Iraq tells his doc to go out and arrange a clinic in the nearby town, the doctor pretty much figures out how to do just that. There's only a very limited amount of free-will in the matter.

It has begun to occur to me that the question of DoD's role, as asked by those from within agencies where people at very low levels are directing programs and making independent decisions, and from within agencies that can decide to be in, say, Iraq, is being asked from the perspective and culture of will. The answer, from a DoD perspective, is that we go where we are told and do what we are told to do in the best way we can figure out. This answer is less than satisfactory to most questioners, and they keep asking.

So, I'm coming to the conclusion that the real discussion should be held at the point of contention: the competition on the ground or in the 'humanitarian space' as it is called. The real question, it seems to me, should be how can we mitigate profound confusion and misalignment of intent? The topic that nobody wants to address is right there: intent. The institutional bias of the Department of Defense will always make the health of other populations a secondary result or interest. In other words, the DoD is actually a health-destroying war-making organization. We know how to fight conflicts. Even in counter-insurgency when the goal is to secure populations and 'win hearts and minds', the DoD's focus will be on security. That's the fundamental nature of the beast. Not making foreign populations healthy. So, how do we create some order and sense of cooperation among the various actors? I think this is the more productive question.

The Long Silence is hereby officially broken: CNAS conference and H1N1

Haven't had a chance to blog for the past month, but I'm back. So much has gone on, it's hard to know where to start.

First, congratulations to Chris Albon for passing his oral exams, and now being ABD. Chris writes the War and Health blog.

H1N1
Second, the H1N1 epidemic. Guess who exported it to Kuwait via the war in Iraq? We did, apparently. Here's a report from Reuters: (URL http://www.reuters.com/article/healthNews/idUSTRE54M1G720090524)

KUWAIT (Reuters) - Eighteen U.S. soldiers in Kuwait have H1N1 flu, the first cases in the Gulf Arab oil-exporting region, a government official said on Sunday.

"(The soldiers) were confirmed with the virus upon their arrival from their country to the military base (in Kuwait)," Ibrahim al-Abdulhadi told Reuters.

Kuwait is a logistics base for the U.S. army for neighboring Iraq, where the U.S. military said there were no known cases yet of H1N1.

What are the implications of this? Obviously there are diplomatic issues, issues relating to quarantine, sovereignty and the war. Not insignificant.

CNAS

Next, I had the good fortune to attend the Center for New American Security's day-long conference on the counter-insurgency in Iraq and Afghanistan, the problems with North Korea, and a session tossed in about the security implications of natural resources. Kind of an odd mix. The session on natural resources completely bogged down and became dangerously close to sounding like a self-licking-ice-cream-cone argument. Senator Warner moderated the panel and was pleased to describe his previous legislation that demanded that DoD address resource issues in terms of security. The CNAS staffer leading the discussion, Sharon Burke, claimed that it was DoD's responsibility to both fight the nation's wars as well as mitigate potential future wars. (Oh, really? I didn't see that in the Constitution...I'll have to go look again). The panel consisted of two academics and one Navy Commander who is responding to the good Senator's legislation by addressing the security issues relating to resources for the upcoming QDR. Nobody else from DoE or EPA was present apparently. Is DoD really the answer to resource issues? While I don't think it's irrelevant for DoD to be engaged in the discussion, sticking a Navy commander up on the panel with no other USG representative potentially skews the argument. Obviously this problem would require a whole of government approach, but where was the rest of the government?

Quite in contrast to the resource discussion was a panel all about the North Korea problem. The panel consisted of CNAS staff and diplomats with nary a military member present. Really? So, DoD should focus on resources, but not North Korea? I asked about this at the really swell post-conference cocktail party and was told that CNAS had asked for a DoD rep, but the timing was short and none had been proffered. Too bad.

The lunch speaker was the Honorable Judith McHale who gave a terrible speech, reading in a soft voice from her notes, about public diplomacy. It was disappointing to me that when someone from the audience asked about the distinction between Public Diplomacy and Strategic Communications she couldn't answer the question. Oh oh. Obviously she has only been in the position for a couple of weeks, but I would have thought her staff might have briefed her up on what it is that her agency is supposed to do--public diplomacy. I've heard that staffs don't do that in the other governmental agencies.

Look to CNAS to enter the military health/military readiness arena shortly. The basic premise is that if you have a military force with PTSD and TBI and other health issues, readiness is declinated. The 'mavricky' team at CNAS (to borrow a term from the Palin SNL skits) has reached out to an officer who has been severely wounded and become an advocate for soldier's health while remaining in the military. He himself is somewhat mavricky and I look forward to seeing what comes of the effort.

I have much more to post--stay tuned. First I have to write a paper for Command and General Staff College.

President's Global Health Initiative

The President's Global Health Initiative is resoundingly vague. I see Tommy Thompson in the reference to neglected tropical diseases (really? that's one of our national priorities?), and Joseph Nye and other smart and snappy pol-fashionistas in the reference to smart power. Fortunately the Millenium Development Goals were snuck in there as a nod to gravitas.

You can view the President's statement by clicking on my title, or here's the URL: http://www.whitehouse.gov/the_press_office/Statement-by-the-President-on-Global-Health-Initiative/

DoD has issued several Reports to Congress

DoD is required to issue reports to Congress about Iraq, Afghanistan and Stability Operations in general.

From the Report on Iraq, it looks as if progress is being made, but not very much--certainly not enough to register in public opinion (available here: http://www.defenselink.mil/pubs/pdfs/Measuring_Stability_and_Security_in_Iraq_March_2009.pdf)

Healthcare
The Ministry of Health (MoH) faces serious human resource challenges across the spectrum of healthcare professionals and ancillary staff. With Iraq’s improved security environment, the MoH has worked diligently to encourage the return of expatriate physicians; the Minister estimates that more than 1,000 physicians returned to Iraq in 2008. To increase skills, the MoH has sent 75 Iraqi medical specialists and subspecialists to various U.S. hospitals and clinics for month-long clinical rotations. Jointly, the MNF-I surgeon and the MoH are finalizing plans to rotate Iraqi healthcare providers through Coalition force hospitals and clinics throughout Iraq. The U.S. Army Corps of Engineers has transitioned 133 new Public Health Clinics to the MoH, although full potential remains limited by poor staffing and the lack of adequate essential services (i.e., electricity, water, and sewage) in some provinces.

Health awareness initiatives and responses to disease outbreaks have been very effective this year, reducing cholera cases by 80%, from 4,700 cases in 2007 to 925 cases in 2008. The MoH is also increasingly able to identify, diagnose, and treat diseases independently. Despite this initial progress, national polling indicates that only 26% of Iraqis are either somewhat or very satisfied with health services, 11 percentage points lower than in November 2007.12

If you go back and read the December version of the same report, the content is basically the same, which makes me wonder about the reporting strategy, and what kind of plan is in place to articulate what is being done vice the objectives.

And here's DoD report on Afghanistan from January 2009: (http://www.defenselink.mil/pubs/OCTOBER_1230_FINAL.pdf) Things are similarly progressing in Afghanistan, though this report does not try to tie the efforts to public opinion, oddly enough. See my other posts on Afghanistan for the similar disconnect between public opinion in Afghanistan and the gains in health care.

Here is the "health" section of the January report: (pg 71)

The ANDS states that by 2010 the Basic Package of Health Services (BPHS) will cover at least 90 percent of the population and maternal mortality will be reduced by 15 percent. Afghanistan has made significant strides in increasing access to basic health care, and reducing overall morbidity and mortality rates. The country has seen improvements in child mortality rates and immunization rates. The MoPH developed the BPHS, a program that includes maternal and newborn health, child health and immunization, public nutrition, communicable diseases, mental health, disability, and supply of essential drugs. In September 2008, 80 percent of the population had access to the BPHS, up from 8 percent in 2001. In summer 2008 USAID and the GIRoA signed an agreement to provide up to $236 million over five years to finance additional health care services in 13 Afghan provinces, with the funds contracted and managed through internal GIRoA processes, for the first time.
Based on this precedent, the European Commission has also elected to now pass its funds through GIRoA-managed processes. In 2007, the Global Alliance for Vaccine and Immunization approved a GIRoA proposal for strengthening the health system, and awarded the Government with $34.1 million dollars between 2007 and December 2011. Current MoPH initiatives include a plan to establish 120 sub-center clinics and 80 mobile health teams. Two sub-center clinics and four mobile health teams were established in June 2008 in Kabul, Parwan, Panjshir and Kapisa
provinces.

Over the next five to seven years, the MoPH will require substantial international
aid; including funding, personnel, mentoring, and assistance; to continue providing the current level of services and to develop a plan to build a self-sustaining health care system in Afghanistan.

There are several important ideas presented in these two reports that are worth monitoring. First, that health is apparently a relatively minor contributor to stability. It seems that health is worth talking about, but not much. It strikes me as odd how much discussion in doctrine and in these reports focuses on economics, but I do not believe that there is a designated specialist in the Armed Forces' officer corps for "economist" (that's militarese for--don't think we have economists running around in uniform.) There is no clear discussion about the relative merit of the various efforts and how they might combine to affect improvements either in popular sentiment or in government capacity.

Another interesting idea here is that DoD has to report to Congress about its goings on, but I wonder what the feedback loop is. If you read the report on Iraq, one of the brilliant successes, apparently, is that the US forces have sent 75 medical specialists to one-month rotations in US hospitals. If I were a member of Congress I would ask if that really is the most notable thing to report, and if so, what strategy are we working on here that we think that sending 75 docs to a one-month rotation was going to make substantial strides in the counter insurgency and the rebuilding of Iraq? Perhaps it is significant, but from a close read I'm not sure I get it. My concern is not so much with the content of the report as it is with the strangeness of reporting. Why report at all?

If DoD has to report to Congress about what it and the other agencies are striving to do, when is Congress and the NSC going to provide clear leadership and signal to the American public and the rest of the USG that we are at war, people are dying on our side and theirs, and a withdrawal is not the simple solution we would wish it to be. Oh wait, that would be hard work, and maybe unpopular work.

USG, DoD, DoS and USAID response to the H1N1 flu

Here's the U.S. Pandemic Flu page: http://www.pandemicflu.gov/.

Interesting to note that Secretary Clinton, in a preamble to her briefing to Congress, acknowledged the DoS' role in the H1N1 outbreak:http://www.state.gov/secretary/rm/2009a/04/122462.htm .

And, USAID has let lose with $5M: http://www.usaid.gov/press/releases/2009/pr090428.html

Also, DoD has a "Pandemic Influenza Watchboard" available on the web: http://fhp.osd.mil/aiWatchboard/. One of the issues for DoD is personnel managment. Pandemic influenzas could reduce the 'readiness' of military personnel to do their jobs. Obviously this is not currently the issue, but the Military Health System has been diligently preparing rules, guidelines and practices. I wonder if the other agencies have done the same?

Civilian Response Corps

The Center for Technology and National Security has issued a report called Civilian Surge: Key to Complex Operation. (URL: http://www.ndu.edu/ctnsp/CivSurge_Book.htm). I received an email that summarizes the report well:

Edited by Hans Binnendijk and Patrick M. Cronin, the study recommends what
civilian capacity to build, how much of it is needed, and how to manage and
organize it. Major findings of the book include the following:

* The civilian response capacity force size would best be
served by 5,000 deployable, active-duty government civilians and 10,000
civilian reserves. The cost would be about $2 billion annually.
* The National Security Council's oversight role needs to be
significantly strengthened, the sine qua non of an effective,
whole-of-government approach. A new "cross-functional interagency team"
should be created to coordinate all complex operations.
* The military has adjusted well to the new, complex missions,
but its risks overstretch and needs its civilian partners to build up their
capacity to conduct complex operations.
* The State Department should focus on developing
"stabilization-savvy" diplomats, who should be plugged directly into
"seventh-floor" executive crisis management activities.
* The United States Agency for International Development
should be the operational agency charged with training and equipping
civilians for complex missions. It should be restructured and renamed the
Agency for Development and Reconstruction to reflect its main missions.
* Domestic civilian agencies have skills useful to overseas
complex operations, but special legislation and funding is required to allow
them to participate fully.
* Efforts to educate interagency personnel for complex
operations have stalled and need to be revitalized.
* Overreliance on civilian contractors to fill this need has
led to inadequate government oversight. A new contracting standard is needed
focused on maintaining agency core competencies.
* Homeland security events, such as the response to Hurricane
Katrina, are also complex operations that require collaboration and skill
sets similar to overseas operations. The United States needs to organize in
a way that takes maximum advantage of these synergies.
* Since the US is unlikely to engage in future complex
operations unilaterally, Washington needs to mobilize the civilian capacity
of its friends and allies.
* Connecting with nongovernmental organizations and local
actors is critical, along with maximum sharing of unclassified information
with civilians.


The first part of the report describes (as do most reports like this) a greatly reduced Department of State and USAID when compared to the Vietnam era. And obviously the report ultimately calls for a greatly improved cadre of trained professionals. Interestingly, Secretary Clinton has recently described in testimony before Congress, that the DoS is having trouble finding 500 civilians to go to Afghanistan, and I read in the Washington Post that there is a request before Secretary Gates for military reservists to fill some of the positions, but the reservists would wear civilian clothes and be "low profile" which I assume means unarmed.

I have mixed thoughts about this request, and this direction. First of all, the Army Reserve and Army National Guard have been used fairly heavily in the two conflicts, and are also serving as "backstops" to the active component when the active duty units deploy. Having said that, in reality, a few hundred soldiers is not such a stretch for the entire reserve force (all Services have Reservists), so at least the superficial requirement of finding a body to fill a slot should not be a big deal. What the military has a great deal of trouble doing is finding the right body with the right skills to fill a slot.

The problem for a Reservist (from my perspective) with this plan is that it would do nothing for a military career and in fact could damage it. Much like the civilian world, when a Reservist leaves his 'professional community' people forget who he is, and it becomes much more difficult to describe what he can bring to the table. General Officers are still made from people who followed the very traditional career path of platoon leader, operations officer, executive officer, commander, and so on. So, there is little incentive for the Reservist. At least an Army Reservist (not sure what it's like in the other Services.) Finally, I envision the "low profile" being a partial deterrent to Reservists. From my limited experience, apparently civilians do not have to follow the same force protection rules that the military follows and this might inhibit some from volunteering.

The call to create a civilian response corps has been circulating around D.C. for several years, and the DoS has started to create its own "civilian reserve force". I suspect that it is having trouble incentivizing its employees to join, and this gets back to a refrain often heard in the military: the military is at war, and the rest of the country is not. Were I a civilian living in my pleasant salubrious suburb here in D.C. with a nice comfortable job in the city, why would I want to risk my health, and my life to go to Iraq or Afghanistan? It's a realistic question that the USG must answer. Are we at war, and if so, what is the accountability of the rest of the USG and the rest of the nation for the outcome?

I heard a briefing given by then-retiring Major General Fastabend from the Army's operations division (G3/5/7) who made the point that the military is always accountable. From "winning the war" to protecting service members to protecting Afghan and Iraqi civilians. It's often a life and death accountability. But what about everyone else? I don't think the current administration has answered this question to itself or to the nation.

Swine Flu and Harley Feldbaum's report on US Global Health and National Security Policy

I am plugging away through the recently posted reports on the CSIS Global Health Policy Center page (see link on right hand bar). The first one up (picked because I am a long-time fan of the author and because of it's attractive slimness) by Harley Feldbaum, Associate Director of the Johns Hopkins SAIS Global Health and Foreign Policy Initiative, is a report on the U.S. policies addressing global health threats. Take the swine flu as a perfect example of what could be considered a "national security" threat.

Harley's report is really interesting though covers a tremendous amount of ground in a very brief period. His basic premise is:

1. That U.S. policymaking is complicated by dependence on health conditions in other countries, and a lack of understanding both domestically and abroad about health issues and their implications;

2. That the U.S. response to infectious disease/bioterrorism has over emphasized defensive medical countermeasures and treatment and under-invested in prevention, strengthening of public health systems and surveillance;

3. That improvements would be an increase in focus on global surveillance and response, attention to the WHO's International Health Regulations, and "putting a high priority on meeting the health needs of developing countries".

Wow. I am especially stunned by the final sentence. What Harley means is not really what the sentence says plucked out of the report like I have done here. Put in context, the essence of the argument is that instead of focusing on specific diseases which threaten the U.S., we would do better to examine the health needs of other countries and identify common ground. In the end making other countries more able to detect and deter disease will only help us. He uses Indonesia as an example--the Indonesian government will no longer participate in the WHO program for bird flu arguing that the U.S.'s program of developing drugs from virus samples donated by poor nations, which then are made available only to wealthy western nations is inequitable.

In theory I'd like to agree that we should place a high priority on meeting the health needs of developing countries. But I'm not sure I do.

For example, at the recent CSIS launch of their commission, there was discussion about chronic disease being one of the biggest looming health threats. Should we focus on assisting other countries with chronic diseases? If not, why not? Should we focus on tropical diseases that are not endemic to the U.S.? Why not? As Harley's report says: "Other major global health problems that do not directly threaten the U.S. population or strategic interests, including negelected tropical diseases, weak health systems, and maternal health, do not share the political spotlight and thus have received little attention or funding." (pg. 11) But, why is that bad? Or, why is that good? It's my tax money, after all. I can make arguments both ways on this sentence.

I think my issue here is that the report is too brief and covers a vast amount of territory. While it's attractive to make uncomplicated arguments, and I admittedly picked his report because it was thin, I am aware of the sweeping language and all the dangers that can attend such language.

The report is really well worth a read, and it touches on the most pressing contemporary problems relating to biosecurity. These are THE problems of today, elegantly presented.

CSIS Launches Commission on Global Health and Smart Power

I had the opportunity to attend a CSIS launch of their new Commission on Smart Global Health Policy. The idea of the Commission is to create an action plan that will seek ways to create a more strategic approach to the way the U.S. government does "health development" abroad. (Health development in its broadest sense.) (URL: http://www.csis.org/globalhealth/)

As I listened, several things occurred to me. First, that the audience questions tended to focus on the health of recipient populations, or the urgency of need in recipient populations. And therefore one of the underlying assumptions is that U.S. global health policy is intended to make people in other countries healthy. I would suggest that's only one piece of the pie. There are a couple other reasons why we do health development around the globe: 1) because it makes us, the American tax payer, feel good; 2) medicine is a way to engage with the rest of the world that is less ethically challenging than, say, dealing in arms--so it's an engagement strategy; 3) private industry (drug manufacturers) makes money from our efforts to build health systems abroad and has a hand in the development efforts. Those three reasons are just off the top of my head, and need to be articulated better, but I hope they are recognized by the Commission.

Next, there was talk about sustainability. Panelists discussed long-term solutions like creating "systems of delivery" that would endure and help communities for longer than just one intervention. Associated with this thread of discussion was discourse about sustainable funding and I link in the topic of chronic diseases. I thought this was an interesting discussion because there was little clarity (probably due to time constraints) about the taxpayer. The reason some diseases and causes are more popular than others is because Congress pays more out to defend the U.S. from diseases which appear to "threaten" the U.S. in some way. The U.S. taxpayer is not particularly interested in saving rural Chinese populations from obesity, say, whereas the taxpayer might be lots more compelled to take an interest in the next round of influenza.

Finally, the Commission includes a media person. Her focus was unclear to me--she only had a few moments to talk. She presented a view of the media that seemed to focus on their utility as an informational device for the recipient populations (cell phones, popular shows, games etc). I think that's the obvious part of the story and again, what's forgotten here is the U.S. taxpayer. It's obvious to me that the U.S. tax payer does not know what the US is doing abroad in terms of global health, and we do not have a "story line" that the media can tie in to. I think the reason we don't have a developed story line is because America hasn't developed a story and belief about it's good work. That story is what political leaders need to begin to develop in order to influence both U.S. populations as well as foreign populations. It will be a story that the media can help develop and tap in to. Until we do this, "Smart Global Health Power" will be a fractured effort.

DoD Conference on Health Security in Afghanistan

The Department of Defense is hosting a conference titled Building Health Security in Contemporary Afghanistan which is open to all. Details and registration are here: http://fhp.osd.mil/intlhealth/events.jsp?eventID=7.

The End State--do the ends justify the means?

I was in Command and General Staff College (which the Army has now mysteriously called "Intermediate Level Education" or ILE...how unromantic) this weekend and we are learning how to write a commander's intent. A commander's intent is how the commander tells his staff what he/she wants to do next, and in general terms, how it's going to get done and what the end looks like. Don't tune out yet, there's a tie-in here.

So, we learned that the commander's intent has three parts-- the purpose of the action-to-be (we are going to charge the hill so we can take that high ground and win the war); key tasks (fix bayonets and on my order charge up hill); and then a description of the end state (the enemy will be destroyed, and we will be hoisting our flag, and the sun will come out, doves will float around). The description of the end state, as it turns out, has three parts, too: a description of friendly forces, a description of the civilian population (where relevant), and importantly a description of the enemy forces.

The instructor had a slide up on the screen and we were glibly moving right through this topic when I suddenly came to the realization that the end state for our conflicts in Afghanistan and Iraq do not match up across the government, I don't think. I brought this up to the class because my colleagues are all talented and come from a variety of backgrounds. The intelligence guy challenged me and thought that the end state is well articulated and clear: obliterate Al Quaeda. Yes, I retorted, but do you think that's the end state envisioned by USAID and the Department of State? And, by the way, is that an appropriate end state? If you read Dave Kilcullen and Gallula others, insurgents don't just get destroyed and disappear as do conventional militaries. They remain active at a very low level for a long time, constrained by civil and international law and police actions, then eventually they peter out. Which end state do you think the Department of State uses? And for that matter, what's the end state that USAID uses? Do they even have an end state articulated?

I keep asking the question if the Department of State and USAID are fighting a counter insurgency of every DoS and USAID employee I meet. Some will argue that they are--USAID, it has been explained to me, is providing some kind of emergency funding as opposed to development funding in Afghanistan, proof of their counter insurgency effort. I remain unconvinced. Although the type of funding certainly is important, I wonder what the vision is for the use of the funds? Humanitarian assistance? Relief of suffering? Is that truly counter insurgency? What if you relieve the suffering of the insurgents themselves? I asked this same question of a civil affairs officer who explained (patiently) that the tasks laid out by the Department of State S/CRS can be matched up to the tasks and lines of effort the military uses. Yes, we can both build clinics, but if I'm building a clinic to co-opt the population and separate it from the bad guy, and USAID is building a clinic so everyone (even the bad guys) can be healthy, we are doing the same thing for two different ends. They might be complimentary actions but then again they might not be. And it seems to me that we need to first of all fight insurgents, and as a second priority make everyone healthy and happy.

If you look at War and Health, Chris posted a blog about humanitarian deaths in Afghanistan (here:http://warandhealth.com/attacks-on-humanitarians-in-afghanistan/#comments) . Off the top of my head I think there were about 150 hostages taken and 40 murders last year. USAID does not use the same force protection posture for its employees, and their "NGOs" are most certainly left to their own judgement. Are they really fighting a war? Do their development efforts measure up to trying to stabilize the population? Or, are their actions creating more instability by creating targets of opportunity? Also, is USAID working with the Minister of Public Health in Afghanistan, say, to target the most influential community members in order to spread approval of the central government's efforts? Or is USAID doing "good work" around the country, developing the health system equally so that "everyone" can receive a health benefit? The two actions might conflict.

I want to be clear that I remain unconvinced one way or another. I simply don't have enough information. I AM convinced, however, that until the entire US government decides to fight a counterinsurgency we will not win. The military cannot win a counter insurgency in a foreign country all by itself. It can only fight the symptoms of the counter insurgency. It's up to the political and developmental sectors to really win. I can only hope they understand this. Otherwise, we will have invested millions and even billions to develop structure for what eventually becomes another oppressive and despotic regime in Iraq and Afghanistan.

Health is a Security Issue.

The Center for Strategic and International Studies is one of the leading, if not The Leading, think tanks delving in to the health-diplomacy areas. They are initiating a Commission on Smart Global Health Policy which is focused on pushing the USG toward a global health strategy. Here's the announcement: http://www.csis.org/component/option,com_csis_events/task,view/id,2004/.

Intersecting with this, the Obama administration has initiated an interagency policy coordination committee on global health. The first order of business, apparently, is an inventory of which agency is doing what. There is discussion around D.C. about the focus of the US government's energies--on single diseases--and whether there are more appropriate strategies. The Institute of Medicine chimed in on this matter here:http://www.nap.edu/catalog.php?record_id=12506 in it's report to the Obama administration called "The U.S. Commitment to Global Health: Recommendations for the New Administration". The report calls on the President to "highlight health as a pillar of U.S. foreign policy," claiming "It is crucial for the reputation of the United States that the nation live up to its humanitarian responsibilities, despite current pressures on the U.S. economy, and assist low-income countries in safeguarding the health of their poorest members." OK, while this sounds really nice, it seems to be written in complete denial of the 48 million Americans who have no health care. Balancing the priorities of internal and external politics is key to national security. And it's no longer an either-or world. Internal IS external.

The health of our nation has strategic implications. For example, one of the biggest problems facing the Army Reserve component (which means the National Guard and the Army Reserve) is health. The U.S. Army has policies against deploying unhealthy service members. For example, if a service member seems to have a cavity that will become problematic within a year, that service member is considered non-deployable until the tooth is fixed. Because most Americans don't take care of their teeth, guess what the biggest health problem affecting deployments of Army Reserve component is? Right. Dental problems. While not an insignificant problem, I also want to caution that this is not a huge deterrent right now, but more of a useful example. If we don't have healthy Americans to serve in our Armed Forces we have a national security problem. And, so the discourse should be: how much should we spend on making our nation healthy vice making foreign populations healthy? Because first we need to be healthy to work and pay our taxes, defend our nation, promulgate foreign policy.

Where I'm going with this is that reports like the IOM's that place moral and policy imperative on creating healthy international communities should also recognize that we also need a healthy nation. The challenge is not calling for more attention to yet another cause. But calling for a balanced and integrated approach for attending to both a healthy nation as well as a healthy international community. It's easy to pick out a single disease or a couple of causes du jour. It's absolutely not easy to articulate the importance of health to national security internally and externally with a cogent explanation for action. But that, in fact, is what is needed.

Public Diplomacy+Military Medicine=the Comfort

The intersection of public diplomacy (typically a Department of State activity aimed to influence foreign populations) and military medicine is most easily identifiable in what the Navy is calling Humanitarian and Civic Assistance missions--the Comfort, the Mercy and so on. Under the new Maritime Strategy, the Navy is tackling the problem of how to do medical interventions with a goal of fostering good relations.

The Comfort has just set sail from Norfolk, and here is the blog:http://comfort2009.blogspot.com/.

Twitter, War, and Health

You MUST NOT miss War and Health's Twitter list. Go here, (do not pass Go enroute): http://warandhealth.com/armed-conflict-public-health-twitter/comment-page-1/#comment-826.

"Mendstate"--and the "end state" problem

I have been asked why I called this blog "Mendstate". One of the problems of the US effort in Afghanistan and Iraq (and way beyond) is an inability for all the various actors to agree on what the military calls an end state. What are the conditions that, when reached, will define a suitable "end state"? And, in the health sector, what is the role of health/medicine in attaining that end state? (Hence I derived the play on words "mendstate"--mend, end, and state....you get it, I'm sure.)

The Health and Fragile States Network (link on sidebar to right) has a series of documents posted from a Feb 2009 conference on health and security, one of which is a USAID document called "Health Programming in Post-Conflict Fragile States" that I find really fascinating. (Here's where you can find this document posted: http://www.basics.org/documents/Health_Programming_in_Post_Conflict_States_Waldman_Final.pdf) What's so fascinating about this document is the relatively cold way in which the authors delineate the argument that the goal of "health programming" in fragile states is not to make people healthy in the traditional sense. The goal of the programming is to create good governance and good government (which is created via legitimacy... see my earlier posts on legitimacy).

So, the first point the paper makes is that morbidity and mortality in post-conflict or during-conflict states is caused by violence, and therefore programs designed to create "health" (or, reduce morbidity and mortality) should therefore reduce violence:

...if the principal objective is to improve the population’s
health, perhaps disease control programs as they are usually conceived should not be
the health sector’s highest priority, at least in a context where conflict is
occurring or where the likelihood of a return to conflict is appreciable.
Instead, programs that aim to bring about a lasting ceasefire or that
contribute to the consolidation of an ongoing peace process are more
important in the immediate, highly fragile, post-conflict setting. (pg 2)

Nothing new, but a nice clear point to start the discussion.

The next point made is actually a two-fer: 1) that USAID's fragile states' strategy, therefore, is one which seeks to reduce instability by bolstering good governance and governments; and 2) that there is not enough emphasis placed on building civil society as well as governments. To do this there are two objectives, according to the paper, which should be pursued simultaneously: 1) a humanitarian objective of health care delivery, poverty reduction, education and so forth; and 2) political processes which accommodate dissent (this is my way of summarizing the suggestion in the document...it doesn't precisely address this point of accommodating dissent).

In summary, then, the USAID Fragile States Strategy has four priorities: enhance stability; improve security; encourage reform throughout areas of
governance; and develop institutional capacity. The question to be asked
(but not necessarily answered) in this paper is: what is health
programming’s role in addressing these priorities? (pg 3)

The authors then describe the trade offs between building legitimacy (which they suggest might come first, even at the expense of effectiveness, or what I termed 'performance' in my "legitimacy part II" post). Showing good intent, the authors propose, could be more important in developing political stability (and therefore reducing violence with a hoped-for commensurate reduction in morbidity and mortality) than actually putting effective "medical treatment" practices on the ground.

Next they tackle the problem of "equitability" which is a humanitarian assistance mantra that mandates that health care should be delivered equitably between all factions, regardless of race, creed, ethnicity, gender and so forth. Using a rather frank description of the Sudan as an example, the authors discuss how providing health care to the "haves" (vice the "have-nots") can contribute to peace-building and ultimately lower morbidity and mortality, as opposed to direct care to everyone equitably which in some cases may contribute to politically-driven violence, increasing morbidity and mortality.

Then a discussion follows about donor behavior, and the rift between relief and development donations and practices. The conclusion:

...others all suggest that a minimum of $15 per capita per year is required to implement a Basic Package of Health Services. While this amount is
frequently available to fund services provided through emergency and humanitarian assistance mechanisms, it is strangely true that once an emergency is deemed to have subsided, health sector funding is often reduced, while funding is increased to develop other aspects of state functions, such as elections, justice, and other infrastructure areas. It should go without saying that without adequate funding, no form of health sector programming will be successful at bringing about important changes in population health status, nor will the health sector be able to make a significant contribution to improving either the legitimacy of a new government or its effectiveness. (pg9)

And buried a bit earlier in the document, the authors make their point, I think, when they write:

As mentioned above, the focus has been on how to implement the same programs in different circumstances, rather than to look at how the circumstances
might determine the nature and design of the programs. Vaccinating 80 percent
of children is one thing, but achieving high vaccination levels in a way that
explicitly enhances the legitimacy (first) and effectiveness (later) of
government may mean settling for lower levels of achievement, at least in
some areas, paying greater attention to ensuring involvement of diverse
elements of civil society, establishing routine vaccination at local health
clinics, and so forth. Of course, it may also be the case, but hopefully not,
that vaccination programs are not as early a priority as they currently are.
How to make health system rehabilitation contribute to the attainment of
political objectives is challenging and context-specific. Clearly, though,
implanting programs designed for very different
settings is likely to be problematic, and donors need to keep their objectives clearly in mind. (pg 7)

What amazes me about this document is that it just simply ends. I'm not sure that these very important points are fully appreciated, socialized and rationalized throughout USAID, since I don't work there. But they absolutely do fit neatly in with counter insurgency strategy, and my previous questions about whether the rest of the government (USAID and the DoS) are fighting a counter insurgencies or doing business as usual (and sometimes in opposition to the counter insurgency) become slightly more salient suddenly.

I think the principles of development and counter-insurgency can converge at the point of recognizing the political origins (which are culturally derived) of problems and solutions. Here we can find room for debate and discussion as to how to describe objectives and end states, and we need to focus on developing clear thought about effecting change.

The British are getting it right!

Last month several colleagues of mine traveled to the UK to attend a conference on the UK's role in global health. The British government, it appears, have made significant progress in formulating a "whole of government approach." Presentations and documents can be found here: http://www.chathamhouse.org.uk/research/global_health/.

And, speaking of whole of government approaches....I had the good fortune to attend a conference on Irregular Warfare yesterday at the National Defense University. Although non-attributional, topics of general concern were: a) the inability of the U.S. Government to produce a whole of government approach (the discussed solution was a call for strong Congressional and Presidential mandate, tho there was a lot of sagacious anxiety that this would never come to pass since it appears as if the US as a whole is not really at war) in Afghanistan and Iraq; b) the use of special forces and general purpose forces in irregular warfare (the actual topic of the conference); c) several stabs at definitions of "irregular warfare"/"hybrid war"/"asymmetric war" with a certain amount of discussants thereafter abandoning attempts to be clear about these terms; d) the production of doctrine by the US military and the utility of that doctrine/the role of the doctrine; e) appropriate analysis of context -- a "how to suggestion" by one of the panels-- involving sociology.

It seems to me, from a purely anecdotal perspective, that sociology, anthropology and other previously dismissed "social sciences" are now ALL the vogue, with much side bar discussion about the Human Terrain Teams, their use (it was proposed that the data and knowledge it produces should be used earlier in the cycle of planning), and how to conceptualize "Irregular Warfare" from a sociological perspective. I have been in many meetings where the HTTs are discussed and whether regular intelligence units/agencies (called the G-2 in headquarters units) should incorporate this information rather than have stand-alone cells. These kinds of discussions are important and interesting, because they reflect the military's internal discussion about what needs to be institutionalized.

Then I went to an evening presentation by Dave Kilcullen on counterinsurgency sponsored by the Center for New American Security (URL: http://www.cnas.org/about) . Again, sociology played a role in Kilcullen's thinking, which is not really all that interesting in and of itself, but I was again struck by his calling out of sociological principals. Five years ago most guys in the military would not have cared a lick for sociology. Proof that the military can change is good. Kilcullen spoke in relatively broadly about what to do in Pakistan (as the real problem in Afghanistan), changes in strategy in Iraq and the magnitude of the problem in Iraq.

Charged up with coffee and all these ideas, I'm ready to tackle the world. Off to work!

Pause to reflect

I forgot to mention, unbelievably, that I saw a report that two US military nurses were in an armed attack in Afghanistan. Unfortunately one has died. I do not have permission to release names ( the families know by now) but am saddened by this report.

While my blog tends to be academic and long-winded, my heart and soul recognizes the human aspects of what we are engaged in. Sinews, bones and blood, tears and sweat. Us, the Iraqis, the Afghans, our coalition partners, and even Hamas, Hezbollah, and what's left of the FARC.

We each strive to create a world of our imagining and in doing so we create a world we cannot imagine.

Legitimacy part II

I've been away for a couple of weeks, partly due to taking Command and General Staff College on the weekends, and partly because I'm writing a paper for submission to a peer-reviewed journal. The topic of the paper is the topic of tonight's post on Legitimacy, part II.

I've been doing a lot of reading about legitimacy in the political science literature because counterinsurgency doctrine demands legitimizing the established government as a method of opposing the insurgents. Democracy is founded on the idea of 'legitimate' representation. So, I began to wonder what exactly is "legitimacy"?

As it turns out there are several theoretical models of legitimacy which are usually presented in lit reviews, beginning with Max Weber. I'm not going to go through all the models, here, at least not now. The models are useful and intriguing, and describe how legitimacy is essentially a relationship between a population and a government. Legitimacy of the government can be produced via coercion, on the "less legitimate/more unstable" side of the scale, or via consent on the "very legitimate/very stable" side of the scale. So first of all, in a counterinsurgency, we want popular consent--or at least we want the slider on the scale to rest more toward the "consent" side and less toward the "coercion" side. So far so good. Nothing revelatory.

Here's what I found, though, that I think is revelatory. In a journal article from March 1990, "Legitimacy, Religion, and Nationalism in the Middle East" author G. Hossein Razi makes the case that legitimacy is actually a 2-part construct. He doesn't exactly say this--this is my summarization. First, he says there are two basic meanings: 1) that legitimacy means the set of norms and values relating to politics which are sufficiently shared so that a political system becomes possible; and 2) that legitimacy deals with meanings of the purpose of the government, the rights and obligations of the government and the governed and the methods of selection, change and accountability of the government personnel. We normally use legitimacy with the second meaning.

And here comes my 'Ah Ha' moment. The second part of the legitimacy construct is "performance."

Razi says: "...there has been insufficient grasp of the difference between the nature and sources of legitimacy and those of performance (i.e., the production of goods and services and generation of organized instruments of physical compulsion)."(pg 71). He points out that "Success in performance areas... does not necessarily result in an increase in legitimacy....the simultaneous existence of a problem in legitimacy and a problem in performance "characterizes most of the 'crises'" of the Third World...."(pg 72)
(cite:G. Hossein Razi, Legitimacy, Religion , and Nationalism in the Middle East. The American Political Science Review. Vol 84, No. 1, March 1990. pp. 69-91)

To explain what this means in concrete terms: I was recently culling through poll data from the Asia Foundation on Afghanistan (available here:http://www.asiafoundation.org/country/afghanistan/2008-poll.php) . Although the government has performed well in health and education development, and the public recognizes the performance, the overall optimism about the way the country is going is declining. In fact, in spite of recognized gains, the public opinion about the performance of the central government has decreased from 80% positive in 2007 to 67% in 2008. (pg. 53). One would expect performance to be legitimizing by way of producing positive benefit to the people, and the people expressing satisfaction with that benefit. But this apparently not the case in Afghanistan.

It seems to me that a partial explanation is that perhaps the people of Afghanistan do not expect the central government to provide health care. First, there hasn't ever been a real central government for any meaningful stretch of time, and next, no quasi governmental agency ever provided health care. And the fact that the new government does provide health care is nice, but does not change their overall view of the government. It seems from the poll data that economic benefit is expected the most.

A second idea I had was that Afghanistan is a clientelistic political system with patrons collecting resources to dole out to their clients. Because Afghanistan has never had a health system (hence the name "reconstruction" is a fallacy), trading health benefits might not yet be widely perceived to be a useful trading tool. If it becomes a useful trading tool, then there might be commensurate importance placed on government performance in this area.

The problem here is that the use of medicine for counter insurgency and stability operations seems to not be functioning, at least this year. We know so little about legitimacy, that it is hard to posit a time frame for when development activities would actually "legitimize" the government. In fact I suspect that it's probably unique to the culture we are working with. We also don't understand the other variables in the system--I suspect that we don't even know what they are more less their relationships to each other. As with most other important questions of the day, I can say I conclude that "more research is needed."


I read another interesting journal article about health development in Guatemala that sums up everything pretty well, I think:

"Development strategies that attempt to make improvements in the lives of the rural poor without addressing the underlying structural causes of poverty serve to deflect attention away from the real needs of impoverished communities. Though the underlying ideology is that local people should have a voice in solving their own problems, the definitions of the problems and the determination of priorities are usually the prerogative of the outside agencies."

(Cite: Green, Linda Buckley. Consensus and Coercion: Primary Health Care and the Guatemalan State. Medical Anthropology Quarterly, New Series, Vol 3, No. 3, The Political Economy of Primary Health Care in Costa Rica, Guatemala, Nicaragua, and El Salvador (Sept 1989). pp 246-257.)

Who was Thomas Tackaberry? And other (provocative) Counterinsurgency questions

"Today [1968] the problem of war has dwarfed all others. Science and technology have created a situation which is unique in the history of mankind....In the last 5,500 years there have been 14,531 wars, for an average of 3.18 per year; and in the last twenty years the frequency has increased to 5.2 wars a year. With these statistics, one can safely extrapolate that wars will continue.

Since achievement of the supreme objective of preventing war looks dim, statesmen are fervently pursuing the goal of keeping hostilities at the lowest possible level of intensity.... Since employment of United States military forces in the classical sense is not appropriate, or required, other components of military counterinsurgency must be used. These include psychological operations, unconventional warfare, civic action and military aid, advice, and training. These capabilities have become the primary components of counterinsurgency. Furthermore, successful counterinsurgency is as much dependent on political, social, economic, and psychological factors as upon purely military factors and sometimes more so....

Whether one is concerned with programs to alleviate political, social, or economic sources of discontent [in a counterinsurgency], with techniques of indirect influence, or with the social and political environment in which actions occur, the kind of underlying knowledge required is the understanding and prediction of human behavior at the individual, political, and social group levels....

There has been much discussion about counterinsurgency, but very little directed toward an understanding of the art of insurgency or conspiracy.... Knowledge of how to prevent internal strife is a paramount need. An essential question that must be answered is: What should be the division of effort between repression or conciliation of dissident elements in a prerevolutionary situation? To what extent should one follow a hard or soft line, or a combination of the two, and in what ways and under what conditions...?

The military might of the United States can defeat the military symptoms of insurgency: the big challenge is to insure free, stable nations. In the final analysis, this is a fight for peoples' minds."

~Thomas H. Tackaberry; American Journal of Economics and Sociology; vol 27, No 1. January , 1968. p 1-8 (available on JSTOR). (LTG Thomas Tackaberry received a Distinguished Service Cross for his service in Korea and two more for service in Vietnam. He commanded the XVIII Airborne Corps.)


How is it that this was written 40 years ago and we haven't answered some of the basic questions posed? Tackaberry suggests that the military needed research to answer the basic questions of how people view themselves within their culture, how they decided to become 'revolutionaries', and what the military could do in a counterinsurgency.

I have been thinking about Tackaberry's final assessment that the US military can defeat the "military symptoms" of a counterinsurgency, but that it was going to take a lot more than the military's conventional armament. That's old news that we have recently re-discovered.

I am drawn to consider other options than a purely military response. For example, in this "whole of government" era, where the agencies must seek ways to work together, I am left wondering what is the Department of State's counterinsurgency doctrine or strategy, exactly? And, does the USAID realize that it is joined, whether willingly is another question, to the counterinsurgencies in Iraq and Afghanistan? Or, what about HHS, mentioned in the Iraq SOFA framework~ when DoD withdraws at the end of 2010, what counterinsurgency and stability actions will it take?

While these questions are certainly provocative, they are stimulated by the disturbing fact that LTG Tackaberry asked some of the same ones more than 50 years ago. Although he was interested primarily in providing the military with answers, he also recognized that more than the military was needed as a counterinsurgency response. I am just taking the logic to the appropriate conclusion.

Giving the Department of State more money is certainly a first step. But then we need a real strategy with real priorities. I understand that the DoS is ramping up its staff in Afghanistan and will make a plan. That sounds pretty good: I'm sure the Afghan desk is busy at the DoS and I know the one in DoD is swamped.

But really what I want to know is this: where is the Al Qeada desk?

Down with "Roles and Responsibilities"

I'll just get it right out: the endless discussions we are having in the government about "roles and responsibilities" of the various agencies are fantasies. I agree with Michele Flournoy in the Armed Forces Journal (In search of harmony: Orchestrating 'The Interagency' for the long war, available here: http://www.armedforcesjournal.com/2006/07/1857934.) She basically says that what we need are a new breed of national security professionals who are "development-diplomats" and "defense-development" experts and so forth (those are my terms, tho), and who are trained at a national security institute--like the National Defense University.

What I would like to see are 'functional' experts who understand global public health across the security domains of defense, development and diplomacy. I'd like to know that the government has a team of experts who sit next to each other and understand how the bad guys are using health as a commodity against the U.S., and what strategies the U.S. is using against them in return. And I'm not just talking about biosecurity either. How about an expert who understands how to reach out to other countries like China in order to partner and do good around the world?

Instead, we seem to be locked in a do-loop of discourse about how the DoD should not be working in the "humanitarian space", for example, because we make the world dangerous. And how USAID's problem is that it can't leave the FOB. And how the Department of State is so weak it couldn't lead its way to the bathroom down the hall. And then the NGO staff stand up at meetings and talk as if ALL NGOs were all working with the same pure motivation and intent, born from a "human rights" perspective that is shared world wide. And the message from all of this is that if only we all knew our roles and responsibilities, and would climb back in to those boxes, then life would be much less frustrating, our actions much more legitimate (see my previous post about legitimacy), and the world an all around better place. And it's the fault of the "other guys" that the world is not 'better' already. Unfortunately, that's just way too easy.

Call me a pragmatist, darn it, but the world is what it is, and what we need is a way to deal with it. A flexible, responsive and initiating way of dealing with it. That is going to take a new breed of national securitists who are sophisticated and smart.

The discourse must change: we need to stop with the "roles and responsibilities". We are all in this together--the "humanitarian space" is populated by NGOs, DoD, USAID, DoS, USDA, private security firms, IGOs and more. It's a cacophony. And there you have it. What we need are good rules for working together, and good processes to at least share knowledge of our often conflicting actions. We must understand that there are differing purposes for being in the humanitarian space, and therefore take different actions. The most reasonable thing we can do is figure out how to best deconflict those actions. It makes sense to have a USG strategy, coordinated across agencies for initiating action and for responding to changes, and "Roles and Responsibilities" is not going to get us there.

The USAID is sponosoring a 90-day assessment in Afghanistan of all USG health development work. I hope it talks about processes, coordination, and methods to at least communicate actions. I look forward to the result.

Health diplomacy explored

Funny how you run across things on the internet. Here's an important document from the Nuffield Trust about health and foreign policy: http://www.nuffieldtrust.org.uk/ecomm/files/040205Fidler.pdf authored in 2005 by David Fidler.

On Legitimacy

I was recently reminded of the vitriol between humanitarian NGOs and DoD. The basic argument is that DoD's actions "in the humanitarian space" cause violence, danger to the humanitarian workers and are generally viewed as illegitimate.

This is too easy of an argument to make, and it mires the discussion in the patterns established after WWII where the military does defense, the Dept of State does diplomacy, and where USAID does development and somehow all of those actions are conducted in distinct "lanes". I find this thinking to be old-fashioned and perhaps no longer useful.

I am doing reading about 'legitimacy' in order to understand the word and the practice-implications. My thoughts are very much influenced by Patrick Chabal and Jean-Pascal Daloz's book "Culture Troubles; Politics and the Interpretation of Meaning." (Available on Amazon. com). They posit that culture is a system of meanings, and not of values. By taking this view, they assert that descriptions of culture no longer, therefore would require "an explicit definition, in terms of norms, beliefs and values." (p 23). They quote Geertz "Culture, here, is not cults and customs, but the structures of meaning through which men give shape to their experience; and politics is not coups and constitutions, but one of the principal arenas in which such structures publicly unfold." (p 25).

So, where am I going here? Well, legitimacy of governments is one of the fundamentals of "stability" and therefore a tenet of US National Security Strategy and DoD's counter insurgency doctrine. Ideas of legitimacy are most likely created by cultures as shared meanings and understandings about governance and the relationship between the government and the individual in that culture. So I am looking for an understanding of "legitimacy" of systems outside our own Western view. For example, Afghanistan is a clientelistic society-- what does that mean for governance? What does that mean for the health of their people? I doubt that the people of Afghanistan have the same understanding and ideation of governance as I and my neighbors. Their expectations are different, meaning that development must fit in to their schema, rather than mine. Do the people of Afghanistan expect the central government to supply a health system? I would suspect they do not. We, in America, have the same debate at this very time over the lack of coverage of nearly 50 million people and what should be done. Most people do not expect the government to provide health care to the population. Working with the Minister of Public Health in Afghanistan to build the health system is admirable work, but is it legitimizing the government? Does it de-ligitimize the coalition efforts to be involved? Should only NGOs do this work? All these questions depend upon the cultural ideation of legitimacy and health institutions, I think.

I have not found clear writing on this topic yet, but will keep looking. Meanwhile, there are several thoughts about legitimacy that I read in an essay by Robert Grafstein "The Legitimacy of Political Institutions", Polity, Vol 14, No 1, 1981 p 51-69.

1. "A legitimate regime is more likely to be the stable ceteris paribus than an illegitimate one." (p 51)

2. "Legitimacy, in effect, is a highly efficient way to secure obedience and thus is conducive to stability." (p 51)

3. Legitimacy involves the correspondence "between the overall state of the legitimate political system (for example, stability based on conformity) and the citizens' evaluation of the system (for example, belief in its legitimacy). " (p 57)

4. Compliance is a "necessary feature". (p 57) And compliance involves persuasion on a scale from coercion all the way to appealing to self-interest or tradition.

The essay is primarily focused on Western ways of governance, and discusses liberal democracies, which Afghanistan is not. Nonetheless, I found these few points clarifying. More to follow.

Public Health and Afghanistan

I was perusing my book shelf for information about the formation of our own Public Health system in order to inform my thoughts about Afghanistan. I have an interesting publication from Pfizer called Milestones in Public Health. Reading through this history of the U.S. Public Health system, I was reminded of the Essential Public Health Functions:

1. Monitor health status to identify community health problems. This would mean that Afgh needs labs. And skilled workers.

2. Diagnose and investigate health problems and health hazards in the community. This means some kind of skilled and mobile health work force.

3. Inform, educate and empower people about health issues. Some kind of communication technique/vehicle.

4. Mobilize community partnerships to identify and solve health problems. Maybe more private sector engagement in Afgh as opposed to NGOs? Don't know.

5. Develop policies and plans that support individual and community health efforts. Two levels of analysis and planning.

6. Enforce laws and regulations that protect health and ensure safety. Hard in de-centralized, tribal territories, but something to keep in mind.

7. Link people to needed personal health services and assure the provision of health care when it is otherwise unavailable. This seems to be the primary focus at the moment.

8. Assure a competent public health and personal healthcare workforce. Goes with first three points and a big problem in Afgh.

9. Evaluate the effectiveness, accessibility, and quality of personal and population-based health services. This point should have gone before point #5 in my mind. But in any case, this would take MoPH resources.

10. Research new insights and innovative solutions to health problems. Same thoughts as for #9.

I like this list because these are what the military calls "lines of effort" and imply tasks like human capacity building. Lab building. Bringing in new partners. It provides a framework for considering how to build a health system, without prescribing the steps.

Afghanistan versus Western Perspective?

I haven't blogged in a while. My analysis is that the lack of blogging is the simple result of multiple causes: partly because I've caught a mid-winter cold, partly because I've been working to ready myself for an upcoming study on Afghanistan, and partly because I'm in an Army school on the weekends. Today, however, I am going to write down my thoughts about:

Afghanistan.

In spite of the unfortunate confluence of events and the resulting lack of blogging, I have been thinking about the intersection between health, politics and society in Afghanistan, in particular. I will be working on a 90-day USAID sponsored assessment of the US Government's health reconstruction efforts in Afghanistan. This work promises to be informative on a number of levels. I will try to blog about it as appropriate, without giving away the results and getting myself into trouble.

But first, by way of context, it strikes me that there are several fundamental ideas that should be considered in any assessment and framework for the way ahead. Here are some of my initial thoughts, culled from reading and talking with colleagues:

1. Top-down, bottom-up is the best strategy for the way ahead (I stole this from a USIP report on Afghanistan published by Seth Jones and Chris Fair who are both at RAND). Afghanistan has never had a strong central government, and from my reading, the Karzai government's efforts (as would any central government's efforts) are often viewed suspiciously. Therefore, the goal of any health reconstruction efforts must be to promote local and regional ties to the central government and demote the advancement of regional rulers who have further regionalism on their agenda. Not an easy undertaking, but one that apparently USAID and the Special Forces are using now at the provincial level. (For some good reading on this, see Sloan Mann's article on the small wars journal: http://smallwarsjournal.com/documents/79-mann.pdf. Perhaps this approach can be rolled in to a regional strategy.

2. Health care and health attitudes are somewhere pre-civil war US, I'm guessing...tho I'm not a medical historian. Basically, there is no health care system. So, a whole system has to be built. Without a strong central government. This makes me wonder about the viability of the central government's Basic Package of Health Services. The problem here is that the US Government likes to legitimize the central state, because we view the world (and desperately want the world to be) a state-based system. So, we ask the central government what needs to be done. Then we roll up our sleeves and help deliver. Unfortunately, the central government has little control outside Kabul, so this approach is problematic.

3. NGOs provide and have provided most of the care. Therefore, the public probably does not view health care as a legitimate governmental responsibility. It's something that outsiders provide.

4. The Afghan public was recently reported by an ABC poll to have turned away from a positive view of the U.S. Frankly, I'm a bit suspicious about the utility of these polls, but taking the findings in gross, it may be that the US has allied itself too strongly with the Karzai government in the public sentiment. Not sure.

Health people like to think that providing health care makes the US look good in the eyes of the populace. This is a bit naive, I'm afraid. People's sentiments are changeable, though the more stable views are pretty much driven by cultural norms. Hence application of health activities to improve public perception would necessarily have to play along cultural norms. Very tricky. But this supports the argument for bottom-up approaches. If the goal is to be well thought of in order to win the insurgency war, then we need to use current cultural norms (clientelistic, "corrupt" --in our eyes-- patrimonial systems). That implies, by logical extension, that we use health care development in these give-and-take situations to develop some amount of loyalty among the tribal divisions.

5. Everybody is in Afghanistan. (All kinds of nations, that is). Makes things complicated. Afghanistan is not divided up by ethnicity. It's divided by geography, apparently. Local power-leaders rule in geographical areas (valleys). That makes things complex, too.

6. The world economy just tanked, hence the lack of donor contributions should get worse. That means fewer resources. But this is OK, in my mind, since there is no health system, basically. Rather than focusing on hospitals and clinics, perhaps the whole of government effort could be more cheaply focused on hand washing, nutrition and basic sanitation practices. Sometimes fewer resources means more efficient expenditure.

With these points in mind, assessing the construction activities and creating a framework for the way ahead in Afghanistan should be a snap.

Law, Culture and Health

One of my newest and therefore most cherished hypotheses is that different cultures view governance differently than we do, and cultures also view health services provision differently. The idea that everyone all around the world expects (or SHOULD expect) their government to provide health care is bizarre. One of my subset favorite ideas du jour is that in countries like Afghanistan, where NGOs have been providing health care forever, and where there has never been a strong central government, it doesn't make sense to try to "legitimize" the central government by assisting it with providing health services. However, I'm just formulating this theory, you heard it here first, and I'm sure I'll be back to mull this over quite a bit in the future.

Anyhow, while I was poking around on the web, I came across Georgetown Law's Oneil Institute that has a global public health and law center. Here's the URL: http://www.law.georgetown.edu/oneillinstitute/index.html.

I was thinking about human rights law this weekend (doesn't everyone?), and about war. I have recently read an interesting piece by an Air Force Colonel that described the liberalization of International Law and how that affected war. So, I was thinking about how "the West" also considers war, pondering the idea that cultures also don't think of war the same way we do. It's probably not always an extension of policy by other means, to misquote Clauswitz, in everyone else's mind.

So, where am I going with all this? Well, it seems to me that the Global War on Terror, which is apparently now over somehow...according to the Obama administration...., is being articulated as a war against those who fight against the State-ordered international system. That's kind of a no-brainer, and if you step back, it's a bit startling too. But to move on, it seems to me that rushing hither and thither about the globe helping people develop their own health systems or handing out aspirins in the hope of creating healthy and stable communities might be a bit premature without a better understanding of what THEY think of health, their government and so forth.

I'm speculating, here, really. But it's as fair to speculate in this way as it is to speculate in terms of the benefits of 'health diplomacy' if one were only to focus on benefit to the other guy. Don't forget that there is a lot of gratification in doing good deeds all about.

I have strayed away from my thoughts about law, but they follow along this same vein. Law is the venue by which cultural imperatives express themselves. It would be interesting to study the changes in international health law to better understand international priorities...or at least priorities of the dominant actors in the international arena. Ah ha. Another possibility for a dissertation.