+ Boots and Birkenstocks: Can civil - military cooperation improve global health? Gene Bonventre, M.D Consultant 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 Source: Oxfam America, Field report from Afghanistan Billions of 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

+ DefenseDiplomacy Development Missions and Objectives

+ U.S. Government Funding for Global Health The U.S. Government’s Global Health Policy Architecture. April 2009 Henry J. Kaiser Family Foundation

+ Department of Defense Health Programs Defense Health Program $46 billion plus, to keep soldiers, families, retirees healthy: Medical research: $900 million annually International Health: Defense HIV/AIDS Prevention Program $100 million annually to prevent HIV in foreign militaries Armed Forces Health Surveillance Center Surveillance/reporting of diseases/injuries in soldiers: Global Emerging Infections Surveillance and Response System: 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: 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

+ 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 Uniformed Services University reviewed 1000 after action reports and lessons learned, % 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

+ Discussion Gene Bonventre (202) 17

+ References 1. Title 10 US Code Section 2561 Humanitarian Assistance Title 10 Section 401 Humanitarian and Civic Assistance 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 Reaves EJ et al. Implementation of evidence-based humanitarian programs in military-led missions. Disaster Medicine & Public Health Preparedness 2008: 2(4); 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 Bonventre E, Hicks K & Okutani S. U.S. National Security and Global Health. Center for Strategic and International Studies, April 2009 on 8. Civilian-Military Relations: An LTL Strategies study group consensus report. July 2009, USAID and LTL Strategies on