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.

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/.

Health diplomacy explored

Funny how you run across things on the internet. Here's an important document from the Nuffield Trust about health and foreign policy: http://www.nuffieldtrust.org.uk/ecomm/files/040205Fidler.pdf authored in 2005 by David Fidler.

Law, Culture and Health

One of my newest and therefore most cherished hypotheses is that different cultures view governance differently than we do, and cultures also view health services provision differently. The idea that everyone all around the world expects (or SHOULD expect) their government to provide health care is bizarre. One of my subset favorite ideas du jour is that in countries like Afghanistan, where NGOs have been providing health care forever, and where there has never been a strong central government, it doesn't make sense to try to "legitimize" the central government by assisting it with providing health services. However, I'm just formulating this theory, you heard it here first, and I'm sure I'll be back to mull this over quite a bit in the future.

Anyhow, while I was poking around on the web, I came across Georgetown Law's Oneil Institute that has a global public health and law center. Here's the URL: http://www.law.georgetown.edu/oneillinstitute/index.html.

I was thinking about human rights law this weekend (doesn't everyone?), and about war. I have recently read an interesting piece by an Air Force Colonel that described the liberalization of International Law and how that affected war. So, I was thinking about how "the West" also considers war, pondering the idea that cultures also don't think of war the same way we do. It's probably not always an extension of policy by other means, to misquote Clauswitz, in everyone else's mind.

So, where am I going with all this? Well, it seems to me that the Global War on Terror, which is apparently now over somehow...according to the Obama administration...., is being articulated as a war against those who fight against the State-ordered international system. That's kind of a no-brainer, and if you step back, it's a bit startling too. But to move on, it seems to me that rushing hither and thither about the globe helping people develop their own health systems or handing out aspirins in the hope of creating healthy and stable communities might be a bit premature without a better understanding of what THEY think of health, their government and so forth.

I'm speculating, here, really. But it's as fair to speculate in this way as it is to speculate in terms of the benefits of 'health diplomacy' if one were only to focus on benefit to the other guy. Don't forget that there is a lot of gratification in doing good deeds all about.

I have strayed away from my thoughts about law, but they follow along this same vein. Law is the venue by which cultural imperatives express themselves. It would be interesting to study the changes in international health law to better understand international priorities...or at least priorities of the dominant actors in the international arena. Ah ha. Another possibility for a dissertation.

"Health Diplomacy"--What is it? The NIC report "Strategic Implications of Global Health"

I went to an interesting round table last week and listened to a brief discussion about "health diplomacy" among other things. Most of the other people at the table were from DoD, State,NGOs and various academic-types. It was proposed that we take up the theme of "health diplomacy" at the next round table. Almost somehow in concert with this proposal, I see that the Chinese have revved up their hospital ship and are making some news. In fact, they even receive an honorable mention in the National Intelligence Council's assessment "Strategic Implications of Global Health" found here: http://www.dni.gov/nic/PDF_GIF_otherprod/ICA_Global_Health_2008.pdf.

Like most scary phrases, "health diplomacy" probably means something completely different to a DoD-person as compared to a USAID person, for example. And I wonder what an NGO person would think? The U.S. military's Mercy and Comfort ships are usually cited as "health diplomacy", whereas efforts in Iraq and Afghanistan and the Horn of Africa or even the Ukraine are not mentioned. While I'm not quibbling with the use of examples, I'm not comfortable letting it rest at merely the Mercy and the Comfort.

Although while "health diplomacy" is not defined in the NIC report, it is interesting to note that on page 7 of the report, the NIC assessment suggests that "More and better-publicized developed world medical diplomacy efforts -- for example, the U.S. Naval Ship Comfort's humanitarian tour of 12 Latin American countries in 2007 could mitigate such influence [of Cuba and Venezuela] while improving the health of citizens of poor countries. "

Using health as a commodity with which the U.S. (or other nations like Cuba, or even organizations with agendas like NGOs) can influence the world is not new. Much like Russia uses oil and the pipeline through the Caucasus as a commodity for manipulating the international order, the West is using health. I'm not sure that I have heard this discussed, since most of the people talking about the diplomacy-development and defense "health" triad are health people who really only want to make others happy and healthy members of the world. However there are some ethical implications, clearly, as well as "execution" and outcome implications. If the Mercy and the Comfort are merely symbols of the US' goodwill, for example, then I wonder if it would be better just to sail around with a bunch of pop stars--Britanny Spears and Bono maybe--making port calls giving free concers. Might be cheaper, and a better use of talent. Probably less ethically challenging anyhow.

In any case, "health diplomacy" is a topic of discussion in the NIC report, in spite of the lack of definition, or any evidence that using health as a diplomatic instrument is useful. But that's OK, it starts us all talking.

Course in Geneva on Health Diplomacy

While searching the web for PhD programs of interest, I came across an announcement from the Graduate Institute of International and Development Studies in Geneva for a one-week course in Health Development. It's only about $2500 for the week, not including airfare or room and board.

Here's the announcement: http://graduateinstitute.ch/executive/global-health-diplomacy.html!

See you there...

Militarizing health? Or "health-erizing" the military?

Well, I had my first comment on this blog, and it was smart and well appreciated! I even liked the teaser sentence: "addressing the Maslowian Hierarchy of Needs via legitimate organs of the Westphalian State, rather than create opportunities for the emergence of illegitimate power structures". Wow, who wouldn't be intrigued? I have often thought about, and at one point invested a bit of time toward a lit review on, Maslow's Heirarchy of Needs as it applies to the application of "smart power". The Army teaches us the PMESII model of assessing the current operational environment (Political, Military, Economic, Social, Infrastructure and Information). We invest huge amounts of energy and money to build economies and teach others how to have legitimate governments. Obviously these are important. But you can't go to work in your new government job and then spend your salary buying dinner if you are sick. And you'll notice that Maslow's Heirarchy of Needs is buried in the "S" portion of the analysis...deeply buried. I'd like to do an analysis that would describe the cost-benefits of public health system building vice building other governance structures. And obviously in practice it's not an either or situation, but it might be a worthwhile consideration that would modify our practices. What to do first and what sector should be focused on? Seems likely that first we would start with Maslow's Heirarchy of Needs and then over time shift focus or expand focus to other sectors. But maybe not. And, separately, I wonder if burying "health" in such an ambitious analysis describes what the military thinks of health care?

Now, on to today's topic, which is not unrelated. I was reading Defense Secretary Gates' transcript in the Jan-Feb 2008 issue of Military Review called "Beyond Guns and Steel:Reviving the Nonmilitary Instruments of American Power". This transcript was of a speech Secretary Gates delivered in November 2007. The speech is worth a read and has been languishing in a deep pile on my desk for a while, obviously. Secretary Gates discusses the need to invest in the foreign diplomatic efforts of the government. In it, he describes the military's use of anthropologists. Anthropologists are now being hired by the military to help describe and "translate" important cultural aspects of tribes in Iraq and Afghanistan, for example. (Their work is reaching more broadly than this, but this gives an idea). The professional field of anthropology has reacted very negatively to this trend, labeling the woman who is the primary proponent of this activity and saying that she is "militarizing anthropology". In his speech, Secretary Gates says that an unnamed person's response to this accusation is "...we're really anthropologizing the military." Ahhhh!! I like that.

In the same vein, the debate about DoD's role within the US Government's global public health engagement has a side-discussion that says that DoD is "militarizing public health". Global public health practitioners are all a twitter. Those that despise the military for whatever reason can repeat this mantra as some kind of justification for not working together.

DoD has been engaged in public health works around the world for.... at least decades (good topic for another post). To think that DoD will suddenly stop engaging in the world via delivery of health services is counter-factual and a denial of history. However the role that DoD plays can be shaped, and that's where I liked the idea of "health-erizing the military." In other words, perhaps its time that the other agencies help DoD understand that it has a talent. That helping peoples in other lands develop their public health systems might sometimes be an appropriate use of DoD resources, and an activity that will create healthier populations abroad and at home, legitimize governments, boost economies and hopefully give a good impression of America. It's not an either-or world: that there is still enough world for both USAID and DoD and the Dept of State to do good. Instead of complaining, why not grab the bull by the horns and give it a little shake? I can only hope that the incoming political appointees will reach out and grab ahold.