DoD and Global Health: Time for a Dose of Development Realism

I recently had the opportunity to participate on a panel hosted by the Kaiser Family Foundation on DoD’s role in global health—check out the webcast and their excellent report, which identifies three major categories of DOD’s work in global health: 1) force health protection and readiness, 2) medical stability operations and partnership engagement, and 3) threat reduction. While I find the first and third categories relatively straightforward and welcome the ancillary benefits for global public health of DoD’s own health-related work (e.g., infectious disease research or military to military HIV prevention programs), it is the second category which alarms me.

[caption]U.S. Army Sgt. Renisha Perry teaches tooth brushing in Djibouti. Photo Credit: U.S. Air Force [/caption]

Medical stability operations are generally the activities of the Geographic Combatant Commands to provide technical assistance and other health-related activities to build trust, prevent conflict, and increase the capacity of partner governments. DoD’s argument goes something like this: since health is part of a community’s overall well-being, improving local health services supports the extension of good governance while making extremist groups less attractive to citizens. Or stated even more broadly by Dr. Kathleen Hicks, principal deputy undersecretary of defense for policy, in her presentation at Kaiser, “The physical health of these poorer populations can have a profound impact on social and economic health. Expanding on this concept, actions to improve the health of a fragile state may prevent it from becoming a failed state."

Ever the skeptic about DoD’s value-added in development, I see six problems with medical stability operations:

1. Weak premise. There is no empirical evidence to suggest that improvement of local public health or delivery of health services to marginalized communities is relevant to preventing fragile states from becoming failed states or communities from providing support to violent extremist groups. Yes, effective governments are more legitimate in the eyes of their citizens, but the link between improving this one aspect of social service delivery and preventing states from failing is tenuous at best. Experience shows that improving citizen security, justice, and jobs are far more important to breaking cycles of violence. Engaging youth, reforming education, mitigating conflict, and countering extremist ideology are far more relevant to countering violent extremism [PDF].

2. Mismatched timelines. Effective development cooperation is a long-term proposition requiring local ownership, sustained engagement, and mutual accountability. DoD humanitarian activities—health or otherwise—are typically one-off, short-term, drop-ins of cash, technical assistance, or direct service delivery, resulting in fleeting improvements at best, inadvertent  harm at worst. Development aid provided in accordance with internationally-accepted principles can produce results, even in unstable and insecure environments like Afghanistan. Aid projects to meet short-term security goals are much less likely to succeed in delivering either development or stabilization objectives, as my colleagues at CGD have documented.

3. Development naiveté. Even with its corps of highly trained medical specialists, the US military is not equipped to build indigenous institutional capacity to deliver services effectively, no matter the desire to render the state more legitimate in the eyes of its citizens. Development is a complex process not largely influenced by exogenous forces, however well intended. While aid can play a supporting role, it is far more challenging than merely transferring knowledge, providing resources, or building infrastructure. National security objectives for public health administration may be very different than development objectives, e.g. prioritization of communities based on perceived support for insurgency versus prioritization based on needs.

4. Coordination challenges. The United States’ civilian foreign assistance agencies spend more on global health than nearly any other sector of foreign assistance, second only to peace and security. In FY 2012, this amounted to more than $9 billion in assistance. (Health typically accounts for 60-70 percent annually of USAID’s development programs in Africa, for instance.) DoD, by the Kaiser Family Foundation’s best estimate, spent at least $580 million on global health related activities in FY 2012, though it is impossible to know the actual total or what part of this went to medical stability operations. While improvements have been made in aid coordination between DoD, State, and USAID, significant challenges remain in coordinating programs and budgets.

5. Mixed messages. Delivery of health services to civilian populations is a civilian role, not a military one, even in poorly governed or otherwise insecure areas; only in grave emergencies for finite periods of time is it appropriate for the military to step in (e.g., immediately after a massive natural disaster). The provision of normal health services through the US military or counterpart military forces or even direct US military engagement with national ministries of health and local health officials may send mixed messages about the role of military in society. This is particularly important in many fragile African states where the balance between civilian and military roles is not clearly delineated. A perceived or actual failure on the part of the civilian authorities is not justification for the military to step in and assume the role. This is how coups happen.

6. Ulterior motives. Most problematic is that DoD’s engagement in medical stability operations, or building partner health capacity, is not really about improving public health in remote and needy places; it is about preventing or mitigating terror or insurgencies that cause instability and are perceived to threaten US national security. DoD is explicit that gaining access to (and influence over) relevant populations and building relationships that will lead to better intelligence on insurgent threats is the first priority. And ultimately, DoD’s war-fighting focus render its motives suspect, with or without active intelligence operations. This is where DoD efforts in global health are far more harmful than helpful, as its activities destroy the trust humanitarians and development professionals depend upon to vaccinate children, deliver food, assist with educational reform, support livelihoods, or help mitigate conflict. Not only are aid workers killed out of suspicion of collecting intelligence, vaccination campaigns and other life-saving assistance are also thwarted or denied. The chilling effects are far-reaching and very hard to reverse.

If providing humanitarian aid and promoting development is in the United States’ national interest, then it should be done by those best-suited to do the job—civilian development experts. DoD should instead focus on its value added to development: promoting physical security so that civilians can do their jobs.