1. + Searching for Synergy: The Military Role in Global Health Gene Bonventre, M.D. USAID Global Health Mini-University October 8, 2010

2. + Overview Defense - Diplomacy - Development: the 3 Ds Magnitude of the Department of Defense’s (DoD) role in global health Impact of military activities on global health Health assistance and counterinsurgency operations Entry Points to DoD Potential roles of academia in civil-military dialogue

3. + DefenseDiplomacy Development U.S. National Security Strategy

4. + D D D Defense - Diplomacy - Development 4 D D

5. + USAID/DoD Spending in Afghanistan Source: Oxfam America, 2009 www.oxfamamerica.orgwww.oxfamamerica.org Field report from Afghanistan Billions of U.S. $

6. In Washington 91 Staff Positions In Africa 2,042 Staff Positions 23 Bilateral Missions 3 Regional Offices USAID Africa Bureau But USAID is the Bigger Player in Africa

7. State-USAID Funding for Sub- Saharan Africa FY 2008 Final 653(a) (in 000s) (* does not include $111 mil in Supplemental Funding ) USAIDDevelopment Assistance$674,156 Child Survival and Health Funds$739,330 International Disaster and Famine Assistance (actual)$295,403 Transition InitiativesTBD P.L. 480 Food Assistance (actual)$1,773,965 Millennium Challenge Account Threshold Program (actual)$47,797 USAID and StateEconomic Support Funds$183,249 Global HIV/AIDS Initiative$3,196,615 StatePeacekeeping Operations$130,222 Foreign Military Finance$6,457 International Military Education and Training$13,004 Nonproliferation, Anti-Terrorism, Demining$24,471 International Narcotics Control and Law Enforcement$21,642 TOTAL$7,106,311 USAID administers approximately 78% of the total

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

9. + DoD Health Programs Defense Health Program $46 billion plus, to keep soldiers, families, retirees healthy: www.health.milwww.health.mil 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.milhttp://afhsc.army.mil Global Emerging Infections Surveillance and Response System Overseas research labs in Cairo, Jakarta, Nairobi, Lima and Bangkok Hospital Ship Visits > $20 million per mission: www.mercy.navy.mil, www.comfort.navy.milwww.mercy.navy.milwww.comfort.navy.mil U.S. National Security and Global Health, April 2009 From Conflict to Pandemics, May 2010 Center for Strategic and International Studies www.csis.org

10. + DoD Programs that impact Global Health Commander’s Emergency Response Program (CERP) Primary purpose: urgent relief & reconstruction - $1.5 billion Iraq example: $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 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

11. + Quantifying DoD’s Impact on Global Health Uniformed Services University reviewed 1000 after action reports and lessons learned, 1996-2007 0.7% mention impact, assessment or measures of effectiveness Attempts to create Monitoring and Evaluation methodologies by RAND, Secretary of Defense’s Policy Office, and the Navy Bureau for Medicine and Surgery, among others Without attempts to determine outcomes and impacts, DoD is practicing anecdotal medicine

12. + DoD’s Policy on Global Health

13. + Counterinsurgency (COIN): A Secondary Mission for Military Medics? Counterinsurgency (COIN) mission Enhance perceived legitimacy of government Marginalize insurgents Assumption: DoD’s health projects win hearts and minds, which in turn increases stability & security, and undermines drivers of extremism Little evidence to support or refute

14. + DoD is not of one mind on COIN “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

15. + Opportunities to Influence DoD 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 Share Monitoring & Evaluation expertise Tandem field visits (assessments) USAID review of DoD policy and doctrine Humanitarian assistance guidance message Joint doctrine, service doctrine

16. + Entry Points to DoD Inside the beltway Office of the Assistant Secretary of Defense for Health Affairs Office of the Under Secretary of Defense for Policy International Security Affairs Special Operations/Low Intensity Conflict and Interdependent Capabilities 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 Command Surgeons Humanitarian Assistance program managers USAID Senior Development Advisors USAID Regional Bureaus Country level Office of Defense Cooperation Security Assistance Office Civil Affairs liaison officers

17. + Obstacles to Synergy…. 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 http://www.usaid.gov/km/seminars/2009/index.htmlhttp://www.usaid.gov/km/seminars/2009/index.html

18. + Potential Role for Academia Research Does military health assistance impact security & stability? What activities have the greatest impact, and in what circumstances? What are the risks, and how can they be mitigated? How can the U.S. government incentivize civil-military and interagency coordination? Operational How can DoD track the magnitude of its global health activities? How should the military measure impacts and outcomes? Both on health and on DoD’s security mission What options does DoD have to implement its new policy on medical stability operations?

19. + Discussion Gene Bonventre bonventre@yahoo.combonventre@yahoo.com 19

20. + References 1. Fischer J, Lief E, Seegobin V, Kates J. Mapping the United States Government Engagement in Global Health. Kaiser Family Foundation, August 2009 on http://www.kff.org/globalhealth/upload/7958.pdf http://www.kff.org/globalhealth/upload/7958.pdf 2. Reaves, E, Schor K, Burkle F. Implementation of Evidence-based humanitarian programs in military-le missions: Part 1. Disaster Medicine & Publicn Health Preparedness, 2008; 2(4);230-236. 3. 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 http://csis.org/publication/us-national-security-and-global-health 4. Bonventre, E & Peake J. From Conflict to Pandemics: Three papers from the CSIS Global Health and Security Working Group, May 2010 on http://csis.org/publication/conflict-pandemics http://csis.org/publication/conflict-pandemics 5. Bourdeaux M, Lawry L, Bonventre E, Burkle F. Involvement of the U.S. Department of Defense in Civilian Assistance. Disaster Medicine & Public Health Preparedness 2010; 4(1):66-73.

21. + References (con’t) 6. Bonventre EV. Monitoring and Evaluation of DoD Humanitarian Assistance Programs. Military Review, Jan-Feb 2008, P.68-72 7. Civilian-Military Relations: An LTL Strategies study group consensus report. July 2009, USAID and LTL Strategies on http://www.usaid.gov/km/seminars/2009/index.html http://www.usaid.gov/km/seminars/2009/index.html