Saturday, May 9, 2009

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:

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:

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: ( 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

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.

Sunday, May 3, 2009

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

Here's the U.S. Pandemic Flu page:

Interesting to note that Secretary Clinton, in a preamble to her briefing to Congress, acknowledged the DoS' role in the H1N1 outbreak: .

And, USAID has let lose with $5M:

Also, DoD has a "Pandemic Influenza Watchboard" available on the web: 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: 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.