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.