+

Boots and Birkenstocks:Can civil - military cooperation improve global health?

Gene Bonventre, M.DConsultant Global Health Mini-University – October 9, 2009

+Overview

Defense - Diplomacy - Development: the 3 Ds

Global health in the 3 Ds

Department of Defense health programs Impact on global health

Opportunities to coordinate with the military

Obstacles to coordination and potential solutions

+D D D

Defense - Diplomacy - Development

3

D D

+USAID/DoD Spending in Afghanistan

0

5

10

15

20

25

30

35

2001 2002 2003 2004 2005 2006 2007 2008

USAID

DoD

Source: Oxfam America, 2009www.oxfamamerica.org Field report from Afghanistan

Billionsof U.S. $

+US Foreign Assistance Framework

Prevent or mitigate state failure and violent conflict

Encourage reduced need for future assistance by introducing prevention and mitigation strategies

Goals Stable environment for good governance Increased availability of essential social services Progress in developing policies and institutions that promote economic

growth and poverty reduction

5

+

Defense Diplomacy

Development

Missions and Objectives

+U.S. Government Funding for Global Health

The U.S. Government’s Global Health Policy Architecture. April 2009Henry J. Kaiser Family Foundation www.kff.org

+Department of Defense Health Programs Defense Health Program

$46 billion plus, to keep soldiers, families, retirees healthy: www.health.mil Medical research: $900 million annually

International Health: http://fhp.osd.mil/intlhealth/

Defense HIV/AIDS Prevention Program $100 million annually to prevent HIV in foreign militaries www.med.navy.mil/sites/nhrc/dhapp/Pages/default.aspx

Armed Forces Health Surveillance Center Surveillance/reporting of diseases/injuries in soldiers: http://afhsc.army.mil Global Emerging Infections Surveillance and Response System: www.geis.fhp.osd.mil

Surveillance/response in US military & foreign civilian populations Overseas research labs in Cairo, Jakarta, Nairobi, Lima and Bangkok

Hospital Ship Visits $10-20 million per mission: www.mercy.navy.mil, www.comfort.navy.mil Expanding to warships

+Department of Defense Programs that impact Global Health

Commander’s Emergency Response Program (CERP) Primary purpose: urgent relief & reconstruction - $1.5 billion BUT: Iraq: $523 million total spent on 1800 health projects

378 primary health care centers, 138 hospital projects

Overseas, Humanitarian, Disaster and Civic Aid (OHDACA) program Primary purpose: access, influence & building capacity for disaster response

$83 million annually, plus supplementals for major disaster response BUT: 54% of projects - Clinic/hospital reconstruction, water/sanitation, disaster

medicine training, healthcare training, direct medical services to civilians

Humanitarian and Civic Assistance Program Primary purpose: training of military medical personnel $9-11 million annual average, but no set limit

www.dsca.mil, www.ohasis.org

+Quantifying DoD’s Impact on Global Health

For humanitarian missions, DoD must report to Congress Total number of funds obligated Number of completed transportation missions Description of transfer of non-lethal supplies

For medical training missions DoD must report to Congress Amount of money expended List of countries where training takes place Short description of activities

www.dsca.mil

Uniformed Services University reviewed 1000 after action reports and lessons learned, 1996-2007 0.7% mention impact, assessment or measures of effectiveness

+DoD’s Global Health Policy

+Military Motivations for Global Health Activities Access to strategically important areas

Influence in strategically important populations Relationship-building “Health diplomacy”

Reduce vulnerability to extremism “Get between the population and the bad guys” “Deliver assistance before the Wahabbists do”

“Eyes on the bad guys”

Training

Recruiting incentive

Ultimate goal: security and stability Evidence?

+DoD is not of one mind on this

“Counterinsurgency operations can be characterized as armed social work.”

U.S. Army Field Manual 3-24, Counterinsurgency, December 2006

“The U.S. military should never be mistaken for a Peace Corps with guns.”

Secretary of Defense Robert Gates

+Opportunities

USAID review of humanitarian projects Primary objective: ensure short-term DoD projects do not undermine

long-term development Secondary objective: identify synergies where DoD can fill gaps

Logistics, transportation, access

Share Monitoring & Evaluation expertise

Tandem field visits

USAID review of DoD policy and doctrine Humanitarian assistance guidance message Joint doctrine, service doctrine

+Entry Points Inside the beltway

Office of the Assistant Secretary of Defense for Health Affairs Office of Partnership Strategy and Stability Operations (Policy)

Civil-Military Initiative Civil-Military sub-Interagency Policy Committee

Operational issues & access to combatant commands: Joint Staff J-5 Doctrine: Joint Staff J-7, Joint Forces Command J-7 (Norfolk, VA) USAID Office of Military Affairs

Regional level Geographic Combatant Commands

Senior Development Advisors Command Surgeons Humanitarian Assistance program managers

Country level Office of Defense Cooperation Security Assistance Office Civil Affairs liaison officers

+Obstacles….and Potential Solutions

Coordination is an unnatural act between non-consenting adults Must be value-added to both agencies

USAID lack of resources Use new mission requirements to justify manpower increases USAID must lead US government development activities Proactive choice of activities beneficial to USAID, rather than reactive to DoD requests

USAID (and DoD) lack of civil-military training Use Office of Military Affairs expertise Leverage common training venues, especially for new accessions Career incentives for liaison positions

DoD lack of Monitoring & Evaluation Pilot project in non-controversial area to demonstrate benefit Contract out a common USAID-DoD assessment, but start during mission planning

Civilian-Military Relations, July 2009 on www.usaid.gov/km/seminars/index.html

+ DiscussionGene Bonventre bonventre@yahoo.com (202) 248-2173

17

+References1. Title 10 US Code Section 2561 Humanitarian Assistance

www.law.cornell.edu/uscode/10/usc_sec_10_00002561----000-.html

2. Title 10 Section 401 Humanitarian and Civic Assistance www.law.cornell.edu/uscode/uscode10/usc_sec_10_00000401----000-.html

3. Bourdeaux M et al. The Department of Defense’s Involvement in Civilian Assistance, Part I: A quantitative description of the projects funded by the U.S. Department of Defense’s Overseas Humanitarian, Disaster and Civic Aid program. Disaster Medicine and Public Health Preparedness, in press.

4. Bonventre EV. Monitoring and Evaluation of DoD Humanitarian Assistance Programs. Military Review, Jan-Feb 2008, P.68-72

5. Reaves EJ et al. Implementation of evidence-based humanitarian programs in military-led missions. Disaster Medicine & Public Health Preparedness 2008: 2(4); 230-236

6. Kates J, Fischer J & Lief E. The U.S. government’s global health policy architecture: Structure, programs and funding. Henry J Kaiser Family Foundation, April 2009 on www.kff.org/globalhealth/7881.cfm

7. Bonventre E, Hicks K & Okutani S. U.S. National Security and Global Health. Center for Strategic and International Studies, April 2009 on http://csis.org/publication/us-national-security-and-global-health

8. Civilian-Military Relations: An LTL Strategies study group consensus report. July 2009, USAID and LTL Strategies on www.usaid.gov/km/seminars/index.html