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!