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!

USAID is going to be more effective

Robert Swope over at D3 (http://www.robertswope.com/) posted the contents of a speech by Rajiv Shah, the USAID Administrator. The upshot of the speech: USAID programs are going to be monitored and evaluated for their effectiveness. While I applaud this thought, I wonder how this will be accomplished. USAID is essentially a huge contracting agency. The agency cuts contracts with local NGOs (called "implementing partners") to do the work, and other contractors to see if the work was done (or they just let the implementing partner report about how the work was getting done). In one province in remote Afghanistan, for example, there were allegely more than 50 programs on going. There was one USAID representative and it was not his job to see if the women in the job program were actually getting the required literacy training or not. He spent his day at the FOB because he had no transportation. This is not the entire picture, by the way, of what USAID does--there were numerous incredibly dedicated individuals posted to remote and dangerous locations all by themselves living off the military (again-- a somewhat hostile relationship) doing great work. But in terms of contracting...no way USAID has any idea about what's going on in all those contracts all over Afghanistan. No Way. So, how to implement some kind of control? Well, that would require growing the organization to do monitoring. That's not going to happen obviously. We'll just have to wait to see how this plays out. It's a good idea, but I am not sure it's feasible.

Here's the speech:http://www.usaid.gov/press/speeches/2011/sp110119.html

The Great "Pointing of Fingers" Game: USAID and NGOs versus DoD.

The Washington Post ran a series two weeks ago about the issues surrounding the military's use of the Commander's Emergency Response Program monies to rebuild Iraq and Afghanistan. Nothing new was divulged--the program is unproven and therefore subject to attack. There is no real strategy for its use, and examples of wasted effort abound. Ho hum.

A letter to the editor appeared in response to the articles, which I have copied:

Washington Post
January 11, 2011
Military-Led Aid Projects Doomed To Fail In Afghanistan
It is no surprise that military aid projects in Afghanistan are "crumbling under Afghan stewardship" ["In Afghan hands, aid projects neglected," front page, Jan. 4]. The troops are armed with good intentions, but they often neglect basic development principles, owing to a lack of expertise on aid and mounting military and political pressures.

Afghanistan's National Solidarity Program is a better alternative. Under this proven model, called "community-driven reconstruction," local engagement and accountability are as important as bricks and mortar. Afghan staff members from agencies such as mine help organize village groups and determine what they need most and who will be responsible for the viability of a school, clinic or road. It's laborious work that emphasizes local knowledge and local ownership as well as sustained commitment - indispensable if Afghanistan development is to have any hope of success.

Military-led projects erode established humanitarian principles of impartiality and independence, fail to win hearts and minds and - we now know - are ineffective. The White House, the State Department, the Pentagon and Congress need to act on the growing evidence showing that the militarization of aid is folly.

Michael Kocher, New York
The writer is vice president for International Programs at the International Rescue Committee.
Editor's Note: The article by Josh Boak appeared in the Current News Early Bird, January 4, 2011.

The author is elegant in his ability to touch on all the "points" against DoD, making bizarre assertions based on faulty assumptions that are oft repeated. For example, in his editorial about Afghanistan, Mr. Kocher claims that "military-led projects erode established humanitarian practices...". I wonder if Mr. Kocher realizes that there is a war in Afghanistan? The military is not engaged in trying to influence the social development of Afghanistan for humanitarian reasons, but rather as a way to win the counter insurgency.

Second, the Afghan National Solidarity Program is not "proven", nor is it an alternative. Afghanistan is not a landscape that can only contain EITHER the military OR the Afghan National Solidary Program as the author seems to assert. And particularly since neither program is proven.

Finally, the conclusion that Congress et al should act on 'growing evidence' against militarization of aid is quite a leap of logic. Wait, I thought we were talking about Afghanistan?

The continued rhetoric from USAID and the NGOs against the military is provocative, for sure. However it's not neccessarily productive. What is needed is less provocation and more serious analysis and discourse about the complicated context we find ourselves in. The continued claims against the military's effectiveness at 'nation building' are well worth investigating. The pragmatic problem, however, is that there are no alternatives regardless of what any analysis would find. For example, in Afghanistan, it was my experience that USAID wouldn't work in areas which are too unsafe (undefined), and they also won't work in areas which are too safe and developed as it would be a waste of resources. Sure, the military is inefficient and cumbersome and makes mistakes. Inexpert. But what's the alternative? The cries from USAID and the NGOs would be more effective if they were backed up with an alternative course of action that is proven and effective. As the book "The White Man's Burden" describes, we have spent billions in aid and assistance, and yet the world seems no more friendly nor less impoverished.

The history of foreign aid: "Samaritan Diplomacy"?

Not only am I back from Afghanistan, where I had extremely limited access to the internet both in terms of time and actual connectivity, but I am also back from a 2 month long "victory lap," as a friend called it, of the U.S. I got to see great America, and it was great! Starting at the Statue of Liberty and heading west (with a northerly detour to Niagara falls) I got to see all those iconic US spots that I hadn't previously seen (the corn palace in Mitchell, SD; Mount Rushmore; Grand Canyon; Petrified Forest and the Painted Desert...you get the idea).

Now that Christmas is done and I can start to settle in, I am doing some reading. In my travels I found the third book of Daniel J. Boorstin's series called "The Americans", the third book is called "The Democractic Experience" published in 1974. At the end of the book he discusses "Samaritan Diplomacy" and the changes in US perspective from pre-Marshall plan when aid to other nations was considered unconstitutional, to post-Marshall plan when US aid was expanded beyond war reparations and European nations to under developed nations. (It was first expanded by Truman in his "fourth point".)

Boorstin starts this section off: "For most of the nation's history, the United States remained uncomfortable, inept and on the whole unsuccessful in diplomacy." (p 568) Interestingly, one of the first acts using the military for aid came in 1880 during one of the Irish potato famines. Congress passed a joint resolution that allowed the Secretary of the navy to use a naval vessel to carry volutary (privately donated) relief to the Irish. Later, this was regarded as a regrettable stretching of the Constitution to appease the Irish-American vote.

According to Boorstin, not until the Marshall plan was there enough political justification to use American tax money to assist other nations. The confusion of motives for the aid stems from this time: "The American institution of foreign aid was a by-product of World War II. It marked a new stage in American foreign policy in which charitable, fiscal, political, ideological, and military motives would be more confused than ever before. Incidentally, too, foreign aid would newly confuse the techniques, attitudes, and institutions of peace with those of war, and so would help open an era in American foreign relations when the American people were neither at war nor at peace." (p 574) Boorstin claims that "except in religious missions, the nation had no substantial precendent for a world-wide program of foreign aid....foreign aid now expressed faith that American wealth could raise the standard of living of people anywhere. A people with a higher, more nearly American standard of living, it was assumed, would be more apt to be democratic, and hence more apt to be peace-loving and friendly to the United States. Implied, also was the complementary assumption that poverty, misery and industrial backwardness would make any people less peaceful and less democratic, hence more prone to communism, and therefore more inclined to join the enemies of the United States." Of course, the assumptions have not always born out.

In fact, this discussion gave me pause, particularly in light of the steady drum beat of the Millenium Development Goals, the political and military discourse about globalization and "haves" versus "have nots", and the confusion over the common use of the term "humanitarian aid" (for purely humanitarian reasons? or for political motives?)

Also relevant, the theory of counter insurgency calls for massive development expenditures in dangerous areas in order to create sympathies for the legitimate government, in order to assist people attain their basic life needs--water food shelter--so they feel better about their government and 'buy in' to it's legitimacy, lay down arms and stop harboring terrorists. But, as pointed out in the Washington Post front page yesterday, it's not that easy. USAID and the US State Department in Afghanistan, for example, only want the military to provide "security" so they can provide development assistance. Yet their vision of security and the military version are disparate. And sometimes discussions about where to deliver development assistance veer toward the absurd when geographical areas are deemed "too safe" for development assistance and other areas not safe enough. USAID doesn't want to deliver aid where it's unsafe, and they don't want to waste their aid on places where it's too safe. And they damn sure don't want the military to meddle in their humanitarian space (as they call the battlefield) by delivering aid or creating development projects.

Boorstin had it right. It's a confusion that is not about to go away. Are we confusing the world with our own confusion? Is "smart power" truly smart?

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.

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.

"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.