Global Health and Foreign Policy Blog

For militaries, health has always meant the preservation of the health of armed forces. This is with good reason. Throughout history disease has decimated militaries, altered or cancelled military operations, and (particularly before the 1930’s) caused more deaths in wartime than combat. Zinnser writing in the 1930s went so far as to argue that “Soldiers have rarely won wars. They more often mop up after the barrage of epidemics.” So it is not surprising that a huge part of the Department of Defense’s (DoD) interest in health is in maintaining the health of its forces and their dependents during peacetime, predicting and preventing illness during deployment, and in combat care during war. (For a recent high tech example, see the Defense Advanced Research Projects Agency’s research into predicting illness in U.S. forces before symptoms are apparent. The rational is of course to minimize or even eliminate the impact of disease on U.S. military operations.)

DoD is also interested in the health of foreign militaries. You might think this would be because DoD wants to know if a threatening military may be weakened by disease, but more often it is to ensure that foreign militaries do not collapse due to HIV/AIDS. Since 2001, the Department of Defense HIV/AIDS Prevention Program (DHAPP) has been training foreign militaries, starting in Sub-Saharan Africa but now in 70 countries, to prevent, treat and cope with the impact of HIV/AIDS. DHAPP does this to 1) prevent HIV/AIDS from causing instability in foreign militaries that could lead to state instability and calls for U.S. military or humanitarian intervention; 2) ensure that foreign militaries can continue to contribute troops to peacekeeping operations and therefore eliminate the need for U.S. participation in peacekeeping; 3) build relationships through cooperation on HIV/AIDS that enables greater cooperation with the U.S. in the long war on terrorism. These programs are in DoD’s enlightened self-interest to pursue.

DoD’s third interest in health is in using health as a tool to pursue U.S. strategic goals. The rationale for this is competitive. The example I hear repeatedly is the case of Hezbollah running hospitals, and providing public health and social services, then going on to win significant representation in Lebanese elections. The Cuban training and exporting of medical personnel across Latin America since 1960 is another often cited example. As one Air Force Colonel at DoD says; “the competition uses health diplomacy.”

Unfortunately, DoD’s efforts to use health diplomacy seem neither as well targeted as Hezbollah’s nor as long-term as Cuba’s. One example is the recent 4 month, 12 nation USS Comfort mission to Latin America to counter Castro’s long-standing health diplomacy program. Supporters argue that the Comfort is on a “voyage of healing” that will win hearts and minds across the region. Detractors point out that the Comfort screens patients because they only treat problems they can fix within their 72 hour docking time, that the supertanker-based ship can only dock at 30% of the world’s ports, and that there is no telling when or if the Comfort will ever return. This hardly demonstrates a long-term commitment to health and development, and will likely only win a few hearts and minds for the $18 million dollar cost.

Another example is the use of medical civil-assistance programs (MEDCAPs) in Iraq, which are essentially temporary health clinics set up to treat as many patients as possible in a few hours before closing down. Supporters argue that a few hours of world class medical care can help win support of local populations, gather intelligence, and reward communities for cooperation with the U.S. Describing MEDCAPs as “tailgate medicine,” Major Jay Baker argues that MEDCAPs actually undermine local health systems while failing to build Iraqi health capacity. In the end he argues, they weaken the ability of the Iraqi government to provide health services and therefore undermine U.S. strategic goals. It seems that DoD still has a lot to learn about basic global health principles such as sustainability, building capacity, and low-tech interventions that save the most lives including clean water and maternal healthcare.

A final uncomfortable note for those in global health is provided by David Kilcullen, currently advising General Petraeus in Iraq, in his fascinating Twenty-Eight Articles of conducting counterinsurgency. Those in global health who hope to use health as a bridge between fighting populations to create peace, take note: “There is no such thing as impartial humanitarian assistance or civil affairs in counterinsurgency. Every time you help someone, you hurt someone else - not least the insurgents.”