Two-fer: Libya and Legitimacy

Today's post has two themes: Libya (and where are the hospital ships?), and Legitimacy worries.

Yesterday's Washington Post ran a front-page photo of Libyans on board a ferry. The caption read that the ferry has been turned into a hospital ship, essentially. Which, of course, prompted me to figure out where is the Comfort and the Mercy. Odd that we are sending armed drones and special advisers, 'humanitarian defense equipment' like body armor and HMMWV's. But no relief capability. It strikes me as perhaps short sighted. Though, maybe not. I'll get to that in a moment.

Anyhow, I was looking around on the web to see where the Mercy and Comfort are, and found this interesting blog: http://blog.usni.org/2010/01/25/time-to-reactivate-the-usns-mercy-t-ah-19/

There was quite a lively debate about the Mercy and the Comfort. The Mercy website is not forthcoming with information about where it is at the moment, and it seems as if it might be in dry dock (from surfing various web pages). Here's the Mercy's web page: http://www.med.navy.mil/sites/usnsmercy/Pages/default.aspx

It seems like "soft power" is not an option at this moment, and I wonder why. Maybe our doctrine is too muddled? Maybe sending a hospital ship full of interagency partners to a war zone is a non-starter? Maybe we don't have an agile-enough capability? The Chinese hospital ship, the "Peace Ark" is nowhere to be found, at the moment, either. Tho I did find a note that the Chinese had offered it to the Japanese. (Yes, that's not a typo.) China is "all about" Aftica--it's resources will provide power to the Chinese for decades to come (while we are distractedly thinking of power in terms of military might). I was suprised that I didn't see the Peace Ark being offered up.

Back to my thoughts about the non-crisis humanitarian assistance missions of these ships: I was chatting with a colleague recently who has thought a lot about the legitimacy of governments-- or, the lack of legitimacy where these hospital ships do their service. It suddenly dawned on me that the U.S. might be cutting off its nose to spite its face, in a manner, with these non-crisis humanitarian missions. So, for example, in the context where DoD sends a hospital ship to a country that is not in conflict to provide medical care, there is a greater risk of further exposing the inability of the country's legitimate government to provide basic services to its citizens. Sort of an awkward sentence, so let me try again. What I'm suggesting is that in countries where there are fragile governments (most really poor countries), dependence on foreign assistance is generally endemic. There are typically a gazillion donors and NGOs earnestly working hard to help the people, and the people do not expect their own government to provide medical care (hypothetically).Even though DoD gets permission from the host-nation, I wonder if stopping in and doing some non-emergency humanitarian action might be good for the people who received the care, it might make us feel good about ourselves, but harming the overall system? Are we deligitimizing the already-fragile government? Has anyone studied this? Or are we happy to be doing great deeds of service, and hoping it all works out in the end.

That's the twofer today.

"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.

Legitimacy part II

I've been away for a couple of weeks, partly due to taking Command and General Staff College on the weekends, and partly because I'm writing a paper for submission to a peer-reviewed journal. The topic of the paper is the topic of tonight's post on Legitimacy, part II.

I've been doing a lot of reading about legitimacy in the political science literature because counterinsurgency doctrine demands legitimizing the established government as a method of opposing the insurgents. Democracy is founded on the idea of 'legitimate' representation. So, I began to wonder what exactly is "legitimacy"?

As it turns out there are several theoretical models of legitimacy which are usually presented in lit reviews, beginning with Max Weber. I'm not going to go through all the models, here, at least not now. The models are useful and intriguing, and describe how legitimacy is essentially a relationship between a population and a government. Legitimacy of the government can be produced via coercion, on the "less legitimate/more unstable" side of the scale, or via consent on the "very legitimate/very stable" side of the scale. So first of all, in a counterinsurgency, we want popular consent--or at least we want the slider on the scale to rest more toward the "consent" side and less toward the "coercion" side. So far so good. Nothing revelatory.

Here's what I found, though, that I think is revelatory. In a journal article from March 1990, "Legitimacy, Religion, and Nationalism in the Middle East" author G. Hossein Razi makes the case that legitimacy is actually a 2-part construct. He doesn't exactly say this--this is my summarization. First, he says there are two basic meanings: 1) that legitimacy means the set of norms and values relating to politics which are sufficiently shared so that a political system becomes possible; and 2) that legitimacy deals with meanings of the purpose of the government, the rights and obligations of the government and the governed and the methods of selection, change and accountability of the government personnel. We normally use legitimacy with the second meaning.

And here comes my 'Ah Ha' moment. The second part of the legitimacy construct is "performance."

Razi says: "...there has been insufficient grasp of the difference between the nature and sources of legitimacy and those of performance (i.e., the production of goods and services and generation of organized instruments of physical compulsion)."(pg 71). He points out that "Success in performance areas... does not necessarily result in an increase in legitimacy....the simultaneous existence of a problem in legitimacy and a problem in performance "characterizes most of the 'crises'" of the Third World...."(pg 72)
(cite:G. Hossein Razi, Legitimacy, Religion , and Nationalism in the Middle East. The American Political Science Review. Vol 84, No. 1, March 1990. pp. 69-91)

To explain what this means in concrete terms: I was recently culling through poll data from the Asia Foundation on Afghanistan (available here:http://www.asiafoundation.org/country/afghanistan/2008-poll.php) . Although the government has performed well in health and education development, and the public recognizes the performance, the overall optimism about the way the country is going is declining. In fact, in spite of recognized gains, the public opinion about the performance of the central government has decreased from 80% positive in 2007 to 67% in 2008. (pg. 53). One would expect performance to be legitimizing by way of producing positive benefit to the people, and the people expressing satisfaction with that benefit. But this apparently not the case in Afghanistan.

It seems to me that a partial explanation is that perhaps the people of Afghanistan do not expect the central government to provide health care. First, there hasn't ever been a real central government for any meaningful stretch of time, and next, no quasi governmental agency ever provided health care. And the fact that the new government does provide health care is nice, but does not change their overall view of the government. It seems from the poll data that economic benefit is expected the most.

A second idea I had was that Afghanistan is a clientelistic political system with patrons collecting resources to dole out to their clients. Because Afghanistan has never had a health system (hence the name "reconstruction" is a fallacy), trading health benefits might not yet be widely perceived to be a useful trading tool. If it becomes a useful trading tool, then there might be commensurate importance placed on government performance in this area.

The problem here is that the use of medicine for counter insurgency and stability operations seems to not be functioning, at least this year. We know so little about legitimacy, that it is hard to posit a time frame for when development activities would actually "legitimize" the government. In fact I suspect that it's probably unique to the culture we are working with. We also don't understand the other variables in the system--I suspect that we don't even know what they are more less their relationships to each other. As with most other important questions of the day, I can say I conclude that "more research is needed."


I read another interesting journal article about health development in Guatemala that sums up everything pretty well, I think:

"Development strategies that attempt to make improvements in the lives of the rural poor without addressing the underlying structural causes of poverty serve to deflect attention away from the real needs of impoverished communities. Though the underlying ideology is that local people should have a voice in solving their own problems, the definitions of the problems and the determination of priorities are usually the prerogative of the outside agencies."

(Cite: Green, Linda Buckley. Consensus and Coercion: Primary Health Care and the Guatemalan State. Medical Anthropology Quarterly, New Series, Vol 3, No. 3, The Political Economy of Primary Health Care in Costa Rica, Guatemala, Nicaragua, and El Salvador (Sept 1989). pp 246-257.)

On Legitimacy

I was recently reminded of the vitriol between humanitarian NGOs and DoD. The basic argument is that DoD's actions "in the humanitarian space" cause violence, danger to the humanitarian workers and are generally viewed as illegitimate.

This is too easy of an argument to make, and it mires the discussion in the patterns established after WWII where the military does defense, the Dept of State does diplomacy, and where USAID does development and somehow all of those actions are conducted in distinct "lanes". I find this thinking to be old-fashioned and perhaps no longer useful.

I am doing reading about 'legitimacy' in order to understand the word and the practice-implications. My thoughts are very much influenced by Patrick Chabal and Jean-Pascal Daloz's book "Culture Troubles; Politics and the Interpretation of Meaning." (Available on Amazon. com). They posit that culture is a system of meanings, and not of values. By taking this view, they assert that descriptions of culture no longer, therefore would require "an explicit definition, in terms of norms, beliefs and values." (p 23). They quote Geertz "Culture, here, is not cults and customs, but the structures of meaning through which men give shape to their experience; and politics is not coups and constitutions, but one of the principal arenas in which such structures publicly unfold." (p 25).

So, where am I going here? Well, legitimacy of governments is one of the fundamentals of "stability" and therefore a tenet of US National Security Strategy and DoD's counter insurgency doctrine. Ideas of legitimacy are most likely created by cultures as shared meanings and understandings about governance and the relationship between the government and the individual in that culture. So I am looking for an understanding of "legitimacy" of systems outside our own Western view. For example, Afghanistan is a clientelistic society-- what does that mean for governance? What does that mean for the health of their people? I doubt that the people of Afghanistan have the same understanding and ideation of governance as I and my neighbors. Their expectations are different, meaning that development must fit in to their schema, rather than mine. Do the people of Afghanistan expect the central government to supply a health system? I would suspect they do not. We, in America, have the same debate at this very time over the lack of coverage of nearly 50 million people and what should be done. Most people do not expect the government to provide health care to the population. Working with the Minister of Public Health in Afghanistan to build the health system is admirable work, but is it legitimizing the government? Does it de-ligitimize the coalition efforts to be involved? Should only NGOs do this work? All these questions depend upon the cultural ideation of legitimacy and health institutions, I think.

I have not found clear writing on this topic yet, but will keep looking. Meanwhile, there are several thoughts about legitimacy that I read in an essay by Robert Grafstein "The Legitimacy of Political Institutions", Polity, Vol 14, No 1, 1981 p 51-69.

1. "A legitimate regime is more likely to be the stable ceteris paribus than an illegitimate one." (p 51)

2. "Legitimacy, in effect, is a highly efficient way to secure obedience and thus is conducive to stability." (p 51)

3. Legitimacy involves the correspondence "between the overall state of the legitimate political system (for example, stability based on conformity) and the citizens' evaluation of the system (for example, belief in its legitimacy). " (p 57)

4. Compliance is a "necessary feature". (p 57) And compliance involves persuasion on a scale from coercion all the way to appealing to self-interest or tradition.

The essay is primarily focused on Western ways of governance, and discusses liberal democracies, which Afghanistan is not. Nonetheless, I found these few points clarifying. More to follow.