AMAZING collaboration between military, USAID, and not-for-profit

Wow! I recently heard a speech by Dr. William H. Foege, a world renowned epidemiologist who was key to the campaign that basically has eradicated smallpox (of course, with the exception of in Afghanistan and a few other war-torn areas), among other incredibly notable achievements. In his speech, Dr. Foege claimed that there would be an anti-malarial vaccine produced within the next 2-3 years, which is astonishing news from a very credible source.

This morning's news brings the announcement that the military, USAID and a not-for-profit called IDRI are collaborating to produce an anti-malarial vaccine. It's an incredible story, and if the effort is successful, the world will be changed. Here's the press release URL: http://m.prnewswire.com/news-releases/idri-usaid-strike-new-collaboration-for-malaria-vaccine-development-127868588.html.

I'm (slowly) writing a piece about the military's role in global health, and this kind of activity illustrates the real contributions that the U.S. government, writ large, can make. I hope it is successful!

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.

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.

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.

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.

Unified Command Plan

The new Unified Command Plan was released recently, realigning responsibility for several nations, and more importantly, prioritizing stability, security and reconstruction operations (SSTRO) along with pandemic influenza.

First the pandemic influenza news is interesting because responsibility was given to NORTHCOM, the command that has responsibility for the U.S. area of operations. While the apparent intent of this move was to deliver this topic to one single agency for oversight, the discontinuity between the operational agencies of the military and the policy agencies may widen. Currently, the Assistant Secretary of Defense for Health Affairs (ASD(HA)) has responsibilities for surveillance operations. And, while not a Mars-Venus situation, NORTHCOM is miles away from D.C. both geographically and somewhat less, but not insignificantly, culturally. Pandemic Influenza response initiatives are wide and deep across the federal agencies, and it will be interesting to see how this apparent shift in responsibilities pans out.

Second, the prioritization of SSTR operations is interesting news. The reason for prioritizing stability operations (as they are called for short) is that the U.S. policy crowd would like to mitigate future conflict before it happens, and not always by application of the Bush doctrine. They would like the military to conduct operations that will create/support capable and legitimate governments. However, the use of the military for pre-conflict stability operations is an imaginative leap into an abyss for many in the military. With little evidence that using the military in this way actually creates any stability at all, other than hopeful anecdotes heard in conferences all across the land (validated by wonderful heart-warming photos of smiling children in dirty clothes and raggedy hair), the fighting force is asking the question--what are the priorities and where? The answer men, supposedly in the Department of State and U.S. AID, seem to be unhelpfully commenting in the media about what a bully DoD is for sucking up all the tax dollars, and not really stepping out with comprehensive and rationalized plans across any region at all. Aside from sniping at DoD, there also is much news from the Department of State about the Civilian Response Corps, which is supposedly a reserve force of willing and able civil servants who will march across the foreign lands (doing what?) in support of foreign programs. In other words, it seems as if there is a huge disconnect between the policy makers and the policy-executors, which is really nothing new.

This leads me to Afghanistan. The time is ripe for a broader prescription for what ails us in Afghanistan, but I have heard nothing from any quarter. The U.S. is engaged in two operations there: International Security Assistance Forces (ISAF), and Operation Enduring Freedom (OEF). The legal mandates for both do not allow expansive engagement with the multitudes working across the country. Instead we are restricted to building Afghanistan's own security forces, primarily. This is leading toward ineffective and piecemeal projects. Progress is slow. Painful. Yet where is the State Department? We need a comprehensive plan, with public diplomacy as a key driver. Keeping these two goals in mind, a plan must soon be articulated across the agencies so that the policy will finally connect with the execution. And even if the effort is messy, which is necessarily will be, we will finally at long last have taken the next step in this idea of stability operations.