Health Diplomacy

There are a number of older threads relating to this subject. Some excellent comments too. I was the 'Medical Director' for an NGO that sailed in the USNS COMFORT last summer/fall. There were about 400 medics, Navy, AF, Army, Canadian military, USPS and NGO. We did primary care and some surgery in 12 countries around latin America.
The previous year the USNS Mercy had conducted a similar mission to SE Asia. This year the 6th Fleet is using a couple of ships to undertake a similar mission along the coast of West Africa and the MERCY is off again in June to SE Asia.
The use of US military assets to undertake these sorts of missions, as distinct from and in addition too humanitarian relief missions such as the MERCY's involvement in the Tsunami, is a ramping up of DOD and State Depts efforts to use healthcare as a diplomatic tool, they call it Health Diplomacy.
Having been a player on the team, i have some strong opinions about what can and cannot be achieved using this approach. I also have some reservations about the interface between the military and NGOs and the advantages and disadvantages for each.
As this is now an official US Navy mission, included within the most recent Navy Concept of Operations, i think it needs some considerable thought and debate.
Would someone like to kick off?

So, Barnsley, you pull up to a nation, put your anchor down and wait for the diseased and debilitated to show up? Okay, I'm a bit cheeky here, but how does this work? Is this like Doctors w/out Ports?

The one i did was organized and run by SOUTHCOMM.
And advanced party had been to each of the host [target] countries months before and organized with the Mins of Hlth what they wanted and what we could provide.
We turned up on the day and did what we could for about a week at a time.
As you might guess it wasn't exactly satisfying for some of the recipients and for many of the care givers. it could have been though, it was a good idea badly executed and I am sure could be improved hugely and to the benefit of all.
There are a couple of pieces written on the COMFORT trip which might cast some light and expand the argument. One is here
www.usmedicine.com/column. cfm?columnID=251&issueID=103 - 21k -
I hope I have posted this properly and not invoked the wrath of Ted

Given your experience with NGOs, I'd like to hear your thoughts. Although I am not familiar with the new "health diplomacy" concept you refer to, I have often thought that we could use military assets to address some of the human security needs in ungoverned or loosely governed regions of the world.

I think this would serve a number of purposes. First and foremost, it would get health care and other necessary aid to people that need it. Second, it would provide valuable training for the military personnel involved. Third, it would send a positive message regarding the US and its military. Fourth, when partnered with appropriate local authorities, it could help establish the legitimacy of the local government thereby denying legitimacy to any terror/insurgent organizations that exist or could exist. I think it hard for people to want to assist the US in its notions of democracy when disease and starvation are killing their kids. Fifth, in some situations it could prevent an insurgency from occuring.

I have often heard that NGOs don't like working with the military, but the military is the best equipped organization to do this. Of course, the military may need to revamp its method of conducting business and may even need to cede some control to NGOs, but given the benefits, it might be worth it.

Your basic tenets. However, i think the most vital aspect of a Mil/NGO relationship is that of security. My experience is that it is impossible to provide humanitarian aid or even day-to-day healthcare in an insecure environment. You will hear and read much about how such self-promoting organizations as "Egos Without Borders" do to save the poor and down-trodden in war and peace, but most times they find it impossible to work in an insecure environment.
As an example: Over the past few years there has been a constant state of conflict between the NGOs working in the IDP camps of northern Uganda and the Ugandan Peoples Defence Force, the Army. The NGOs have blamed the UPDF, sometimes with good cause, for all kinds of awfulness but when the UPDF was not able to guarantee the NGOs security, they didn't venture out of their compounds. I have witnessed entire kid's vaccination programs fall apart because of lack of security.
That I think is the key role of a Mil/NGO cooperative program
Anyway, enough from me. I know at least one of the Council has practical experience of the same in Rwanda
I am searching for someone who might know how much NGOs spend on their own security ( as a % of thie budget)

Hey Bob !
This concept merits consideration, but I remain skeptical. Not because our governments couldn’t employ/enforce said, but the players are, shall we say… historically at odds and otherwise have quite different mindsets and missions.

At one point during the Rwandan refugee crisis, my boss was asked to immediately depart the AO when it was determined he was armed. I felt that was ignorant and naive of them considering the ever present machete attacks in the same camp.

Our 3rd member (of a 3-person team (note the PC)) was a former Peace Corps volunteer and later headed the DART program both in Goma, Zaire and Kigali, Rwanda. She never really understood the Colonel and I, but would later appreciate having us around. I honestly think she felt we were basically ‘disciplined armed thugs in uniform’. But, we were American thugs :D

The rather small contingent of US forces ensured security patrols maintained a safe environment for NGOs, but in all honesty, that was not why they were there. If it weren’t for my boss and the US military leadership, most of the NGOs would have fallen victim to typical Zairian 'Jungle Rules' :eek:

We did try connecting potential security elements in Kinshasa with folks in Goma, but it was a politically charged and sensitive issue that nobody seemed willing to engage in. Even with their Alphas on the line, they refused to take sound advice or employ adequate security.

Regards, Stan

In some situations, a military designed to address human security needs would need to go in heavy. Situations like Somalia and Iraq (immediately after the fall of Saddam) would need the ability to provide security for both the military itself and local civilians. Nothing says "check yourself" to the local troublemakers better than a battalion of Marines. I would envision the team setting up shop and then slowly spreading their influence and operations. Sort of like an ink-blot scenario.

Since NGOs typically have more experience at this stuff than us, it would be nice to coordinate the effort with them. Or perhaps we could simply contract out for an advisory team that could assist us in doing this the best way.

Barnsley, I would be interested in hearing your thoughts on what methods might be employed in your area.

After the earthquake in Azad Kasmir (Pakistani administered) now two years ago a number of NGOs, international military teams and locally based militants all took part in providing help. The Pakistani Army took longer to help and due to politics help from India was declined.

There are reports that the local Kashmiris were impressed by the help provided by the UK and USA, notably the helicopters - moving whole villages to lower ground and engineers. Interestingly the UK effort was influenced by NGO knowledge, mainly in provision of shelter for the coming winter, which double up as schools. Building up food supplies for the winter too.

Not heard of the impact now, although the region remains on the UK "radar", partly political and a recognition of the impact of events there as Kashmiris make up the largest group in the UK's Pakistani community.

davidbfpo

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We did try connecting potential security elements in Kinshasa with folks in Goma, but it was a politically charged and sensitive issue that nobody seemed willing to engage in. Even with their Alphas on the line, they refused to take sound advice or employ adequate security.

Regards, Stan

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Ultimately we succeeded for what it was worth, Stan. The CZSC was recruited directly from the DSP and it came with "advisors" at some of whom were Israeli.

I am fairly content that the CZSC helped keep the lid on security for the NGOs; I was and still am truly appalled angered that in the longer term, it's "success" was trumpeted by some as a working solution to the threat those camps represented.

Barnsley,

I don't have an average figure as I expect it varies from one extreme to the other. Abu Buckwheat on here has been an NGO security manager. I made it into Uganda a few times, twice on runs to Kamapala and a third to Queen E Park. And Stan and I made a loop through Kisoro counting Rwandan refugees while we were in Goma.

As for "Egos Without Borders," I know those guys quite well. They harshly criticize security forces until they themselves need them. Reminds one of Kipling's Tommy

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For it's Tommy this, an' Tommy that, an' "Chuck him out, the brute!"
But it's "Saviour of 'is country," when the guns begin to shoot;
An' it's Tommy this, an' Tommy that, an' anything you please;
But Tommy ain't a bloomin' fool - you bet that Tommy sees!

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Best

Tom

I am not a big proponent of the ink-blot theory. I have developed one of my own that I think is more practical and explains the spread f control much better - especially in areas of some countries that are ungoverned - or undergoverned so as not to offend!

I call it the spider web phenomenon. To keep in line with the "big stick" of a group of Marines, especially in an ungoverned area, think of the Marines or other appropriate security force as a spider. Initially, the spider simply builds the spokes of its web. It remains in the center, but can travel the spokes - the initial netowrk of security and influence (Lines of communication). As time passes, the spider is able to begin to lay the circles of the web starting from the center - where things are strongest (most secure). If an event happens, say a fly gets into the ointment (uprising or security situation), the spider can still travel the spokes, but areas between the spokes at this point are still being missed.

The spider continues to spread its web, laying more concentric circles. This is the security force gaining influence, building trust and partnerships in the areas surrounding its base of operations. The more concentric rings of web, the more things the spider/security force can respond to with greater speed and efficiency. This all serves to allow for the IOs/GOs/NGOs operating there a better security blanket in which to operate.

The goal is to have multiple spiders at critical locations (the most violent and unstable) and ultimately, through their work of building trust and partnerships in the areas in which they work, build their webs large enough and over enough time, to have the webs begin to overlap.

There will always be areas that the spiders simply can't build their web for whatever reasons, but at this point, the "flies" only have so many areas they can get through the webs without getting caught, and the aid workers have much greater freedom of movement.

Anyway, just the way i think we should be trying to do things. I haven't copyrighted it yet, but if I see it in someone else's book I am gonna be pissed!

HA HA

let me know what you think...I have my kevlar vest on for protection so fire away!

It's not a bad theory, but what happens when a spoke or two is removed. As you say, a spider runs several spokes out to various points and then begins connecting them into a web. If I come along early enough, I can simply remove two points of contact and the rest is swinging in the breeze. The spider has expended much energy with no results and now needs to begin again.

Move this into the COIN world and I see two or three lines of communication broken and instead of a web swinging in the breeze, there is a local population left hanging. While we established the "spoke" through their area, we established contact and perhaps instilled some hope. Once that spoke is broken, they've lost that hope. Have we then created more damage than waiting for an ink-blot?

I see the spoke as being potentially weak; perhaps too weak to defend against a serious effort. The ink-blot, however, spreads and has the ever increasing center to support the edges where the bad guys are. The spokes could be out there all alone.

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Originally Posted by LawVol

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I see the spoke as being potentially weak; perhaps too weak to defend against a serious effort. The ink-blot, however, spreads and has the ever increasing center to support the edges where the bad guys are. The spokes could be out there all alone.

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They will be -- build an MSR or a spoke and the goal of the bad guys will be to cut it. Again and again. Recall that they can adapt far faster than can we...

Similar to the ink blot though, the spokes gain strength as the center is solidified - the concentric web rings strengthen the spokes as they expand their area of influence outward from teh nexus of the web...

appreciate the comments, this helps!

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Originally Posted by Progressive Ranger

Similar to the ink blot though, the spokes gain strength as the center is solidified - the concentric web rings strengthen the spokes as they expand their area of influence outward from teh nexus of the web...

appreciate the comments, this helps!

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that regardless how thick or strong these spokes are they will always have a weak area which can be exloited and thus as stated before they will be targeted.

The key to ink blot or a more flexible liquid type change is that despite anything the enemy may affect that point is still surrounded by what has already changed and thus the liquid/ink will flow back in.

Just a thought...

Correct me if I'm way off here...

In the aftermath of the fall of Baghdad, we tried something pretty similar to the theory posed by PR. We set up huge bases and connected them with lines of communication/supply. These were the spokes and the various bases were the spiders. These spiders conducted roving, mounted patrols but were unable to establish security due to the dispersed attacks of AQI and other groups. In other words, we were swatting at flys rather than catching them because the web hadn't been built.

Fast forward to Patraeus and we see something akin to an ink-blot strategy. Our Soldiers and Marines moved into the various sections of Baghdad and other towns/villages and slowly expanded that presence, coverting former enemies as they went. Ultimately, AQI et al, were driven from placed like Al Anbar and Baghdad.

The people want security and stability. They want to be able to send their kids to school without having to worry whether they'll make it home alive. They want to be able to put food on the table and have a stable job. Spokes don't do that because they are too easily broken since presence is never more than temporary. However, with an ink-blot presence, either in the form of US troops or converted allies, is permanent.

It's a much slower process and our American penchant for quick solutions (we are indeed a very impatient people) is severely tested. Using spokes merely satisifies a short-term need (actually a political need) to demonstrate that we're doing something. However, the possibility of backlash is much higher with spokes than ink-blots. Although we can initially show some progress, if a spoke or two is cut, we're back on CNN and in Congress trying to justify our strategy and fending off those that seek to withdraw.

just my .02, I'm certainly no expert.

LawVol,

i am with you...but i see all those small COPs throughout B-dad as spiders in their own right, continually going out and returning to home base, ever expanding the surface area of the web.

i think the reason it has worked so well is that we now have enough spiders with enough web coverage that there are very little areas where there is no coverage.

i think everyone focused ont he spoke part of my theory...the spokes aren't what makes the web...the concentric rings of control/influence/stability are the key.

that is why a spide has so many spokes...for support - often times in parallel, sometimes on slight angles - but all for support...if one does break, which is inevitable, the spider can still get to anypoint ont he web to address problems/irritations, and has the ability to rapidly fix any part that breaks.

With the ink blot theory, if some of the ink runs off to one area in a long rivulet, it is surrounded on three sides, for a great distance by nothing...however in the web application, if you drop a spider, while it may be surrounded initially with full encirclement, it slowly and patiently expands its influence, builds more rings of support an dstability, strengthening its web, until its web overlaps with a brother spider.

Seems like we may keep going round and round on this, huh guys? In the end, I think we are all getting at the same thing...just a different analogy...

PR

Great Thread, wish I would have seen it when it started. I have a ton of thoughts, but also a lot of questions. I have been and will be blogging this subject a lot lately.

First let me say I see this type of humanitarian support to be a form of expeditionary warfare in the 21st century. Lets face it, the tools of war have changed, and I am excited to see the Navy take on the mission and do more with it. I explain my observations from the perspective of strategy here.

Second, this months issue of Proceedings is on Medicine, and a number of articles are related to this subject. You can check it out on the Naval Institute's website if you are a subscriber, although I will blog on the articles over the coming days if you are not a member and choose not to be.

Third, I have several questions. How do we measure effectiveness in humanitarian assistance ops? Statistics like number of shots, etc... aren't benchmarks. By the same token, how do we measure the effectiveness of regional partnerships that create the environment for health diplomacy? The Navy hasn't been in the business of programming humanitarian operations beyond the last few years, and the DoD less so. How should it be resourced?

Sorry to join this one so late - have been swamped with work and travel, and haven't gotten up on line much.

I will probably repeat stuff I've written before here, so apologies. Externally delivered assistance such as the ship medical missions, or traditional MEDCAPs, deliver some short-term health diplomacy, but fail to address the fundamental needs in these places.

I was listening to some right wing radio knucklehead last night while driving home from the train station, and he was ranting on about "give a man a fish, feed him for a day. Teach a man to fish, and feed him for life." He was directing this lecture toward the NGO community. Despite the obvious contradictions (some organizations aren't particularly motivated to work themselves out of jobs, which is what our work should really be all about), most major, successful NGOs these days figured out the capacity building deal quite some time ago, and the rant is about ten years out of date. However, these MEDCAPs are often the "give a man a fish" element of the cliche.

There have been recent exmples of which I am personnaly aware of the military and/or the USG parachuting clinics and hospitals into Afghanistan and HOA without a lot of consideration of existing public health capacities, gaps, and plans already underway (usually a race to see who can get a facility up and running and "branded" with the appropriate flag/logo). And this, despite having true public health specialists involved in the process who advised differing, more appropriate applications of resources. The incidents I've observed have pretty much been "so-and-so up the chain wants this to happen, and you need to MAKE IT HAPPEN!" So, someone gets a nice writeup on his/her OER Support Form, but little, if any consideration has been given to the sustainability of the facility created, and the anger that's going to develop as local residents see a dilapidated facility that was gifted to them not-too-long ago, and now of little use.

Perhaps some of this is a misapplication of approach? A tendancy to deliver shorter-term support, such as MEDCAPs or other emergency/relief-style services to places that would be better served with a longer term (and less sexy, less OER Support Form filling) introduction of public health capacity building programs. Capacity development is always a hell of a lot harder to quantify for bean counters thousands of miles away than is the number of bandaids delivered to a site.

Cheers,

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Originally Posted by Barnsley

I am searching for someone who might know how much NGOs spend on their own security ( as a % of thie budget)

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I don't know how much other NGOs spend on their security - for the larger organizations, this is more a country-by-country issue, dependent upon a very wide range of insecurity levels. An organization might be in 20 countries, but only have major security expenditures in four or five of them, or even fewer.

From my perspective of running an NGO and having to bring in the projects and funding, our donors, whether they be USG, other international governments, or United Nations, are quite tolerant and supportive when it comes to our security needs in the field. In Iraq at one point, we even had a United Nations agency insist that we somehow or another engage a PSC, though that was an exception.

Cheers,

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Originally Posted by LawVol

Since NGOs typically have more experience at this stuff than us, it would be nice to coordinate the effort with them. Or perhaps we could simply contract out for an advisory team that could assist us in doing this the best way.

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I've been attending CIV/MIL conferences with increasing frequency, and am a panelist at one next Monday for AFRICOM and State. Your quote above reinforces one of the major points I'm going to try and convey.

When military entities use the term "coordinate" with NGOs, UN, what-have-you, the humanitarians immediately run screaming from the room, and will continue to do so. The result of US military "coordinating" the efforts of international NGOs in places like Iraq and Afghanistan are that these NGOs become much higher profile "combatants" to some of the actual combatants. In conflict and post-conflict situations, this is not likely to change.

That being said, what is likely to be the most effective way to improve overall interoperability (I will be waterboarded by my community for using that term here!) of military and NGO elements in relief and development situations is to let the majority of the coordiantion/deconfliction reside where it should - with USAID and State.

A greater focus by DOD, State and USAID upon improving their own coordination and deconfliction mechanisms is probably the only way to substantively improve these efforts in conflict environments.

Cheers,

I agree that USAID and State are the best mechanisms for long term "teach a man to fish" projects, but what about the short-term in the immediate aftermath of combat ops or upon initial intervention for more permissive environments? Most of the time the military is the only presence and I would think that having the skill sets necessary to answer the mail from a humanitarian perspective is a crucial need. From what I'm seeing the military doesn't seem to want to put much resources into this aspect of small wars. Of course to do this, we'd need a new approach that values non-lethal power as much as lethal power and that just isn't as sexy as putting rounds down range.

If you can point me to any good website discussing approaches to distributing humanitarian aid (from food to schools to health care, etc.) especially those looking at military involvement, I'd certainly appreciate it.
-john

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Originally Posted by LawVol

From what I'm seeing the military doesn't seem to want to put much resources into this aspect of small wars. Of course to do this, we'd need a new approach that values non-lethal power as much as lethal power and that just isn't as sexy as putting rounds down range.

If you can point me to any good website discussing approaches to distributing humanitarian aid (from food to schools to health care, etc.) especially those looking at military involvement, I'd certainly appreciate it.
-john

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I don't think the military would need to value non-lethal power as much as lethal power - just value it more, as a contiguous part of overall military operations. Additionally, I think it would help if DOD accepted that the NGOs are never going to act the way that DOD seems to think they should/will. Accept the reality of the environment, and adapt accordingly (kind of like they should have done earlier in Iraq, at least at the senior levels).

There are a variety of good sources of relief and development thinking out there. You can check out the SPHERE standards (http://www.sphereproject.org/), they've been around for a while. InterAction (www.interaction.org) publishes its Monday Developments, which is both industry news/opportunities and more in-depth writing on program delivery and outcomes. There's also the European version of InterAction, the International Council of Voluntary Agencies (http://www.icva.ch/). I have found the Humanitarian Practice Network (http://www.odihpn.org/) to often contain a lot of useful information and articles - a lot of folks in our community seek to publish there. There are also many sector- or cluster-specific publications. The Humanitarian Mine Action (demining) community has the Journal of Mine Action published by James Madison University's Mine Action Information Center. The Journal of the American Medical Association (JAMA) regularly publishes results of public health surveys and other efforts from various crises. There's a periodical called Disasters out there, that we've even published in, but I can't find the link to it. Some of my guys feel its a pretty good publication.

Cheers,

I have been out of touch for a few weeks. I have just read up to date the comments on this whole health diplomacy issue and the civ/mil relationship quandry.
i am trying to write a paper on the subject right now. I am probably going to steal the best quote I have heard to date as the title, 'When Bloody Hands Meet Bleeding Hearts'
Thanks for the lead to Proceedings!
i will write longer later. This site is truly a great help in sorting out my often muddled thinking. Thank you all.

If you have a continuing interest in this subject, you might want to take a look at the following URL www.stabilisationunit.gov.uk/
It is the new Brit approach to civ/mil ops
The short speech by the boss has some good thoughts.

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Originally Posted by LawVol

I agree that USAID and State are the best mechanisms for long term "teach a man to fish" projects, but what about the short-term in the immediate aftermath of combat ops or upon initial intervention for more permissive environments? Most of the time the military is the only presence and I would think that having the skill sets necessary to answer the mail from a humanitarian perspective is a crucial need. From what I'm seeing the military doesn't seem to want to put much resources into this aspect of small wars. Of course to do this, we'd need a new approach that values non-lethal power as much as lethal power and that just isn't as sexy as putting rounds down range.

If you can point me to any good website discussing approaches to distributing humanitarian aid (from food to schools to health care, etc.) especially those looking at military involvement, I'd certainly appreciate it.
-john

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John
look for anything by Hugo Slim
Particularly a piece called 'The Stretcher and the Drum'

Forget teaching men to fish; repairing a man's hairlip, cleft palate or cogenital birth defect so that he can finally get a date is going to generate more soft power and long-lasting good will towards the United States than all the fish in the world.

NGOs, State Dept, and USAID are (as others have noted) often better-suited for long-term contributions, but for quick, short-term operations, the military possessess the logistical capabilities and manpower necessary to excel where others struggle. The US Navy can port at a remote Indonesian island, perform surgeries and provide medical examinations for local children, then depart entirely on their own power. An NGO seeking to do the same would have a nightmare trying to arrange transportation, secure lodging for the doctors, etc.