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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
+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
+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
+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
+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