Conflict, war and medicine (catch all).

[ganulv]

The most well thought out strategy in the world will still fail if it is not properly executed at the regional/local level. […] The solutions to many or most of these problems are at the micro, not macro level.

With the sad reversal of the effective eradication of cholera in Haiti we can see that, yes, you have to get things right at the lower levels if you want a regional or national public health initiative to succeed. But the notion that many or most public health issues is a micro issue is just incorrect. For example, what can be done about MDR–TB at the local level besides treat and isolate infected individuals?

The idea that a Western power can come into a developing world state or region and implement a "grand strategy" that will fix their problems for them is, to borrow a phrase, a fatal conceit.

I don’t disagree, but I nowhere said that the West had to be involved at all.

Few states have the resources, never mind the national will, to devote to that kind of work. None that I have seen have shown any particular talent for it in any case.

The Musevini-lead anti-HIV/AIDS campaign in Uganda is an example of success at that kind of work, and one which the West (unless you count Cuba, whose role was minor in any case, as the West) did little to formulate or execute.

[Uboat509]

With the sad reversal of the effective eradication of cholera in Haiti we can see that, yes, you have to get things right at the lower levels if you want a regional or national public health initiative to succeed. But the notion that many or most public health issues is a micro issue is just incorrect. For example, what can be done about MDR–TB at the local level besides treat and isolate infected individuals?

The government can provide the drugs or the vaccines or the treated insect nets but it is up to the local providers to implement protocols, treat patients and distribute medical supplies. Dayuhan's vignette is a perfect example of that. If the local provider is simply selling the supplies and equipment that the government provides then the plan fails. Please do not misunderstand me. I am not saying that these problems are only at the micro level. I am simply saying that you cannot ignore the micro level.

I don’t disagree, but I nowhere said that the West had to be involved at all.

Sorry. That was not aimed at you. I was speaking generally because there are a lot of people who do make that complaint. I did not mean to imply that you had.

[ganulv]

The government can provide the drugs or the vaccines or the treated insect nets but it is up to the local providers to implement protocols, treat patients and distribute medical supplies.

True, and though increased oversight is no magic bullet (I say that mostly because I do not believe in magic bullets) you (by which I mean “me”) have to wonder if the government isn’t somehow willfully part of the fraud if no reasonable effort in the area of oversight is being made.

I would feel remiss if I did not mention that this sort of thing comes in an American flavor that most of us are unaware of.

[Uboat509]

True, and though increased oversight is no magic bullet (I say that mostly because I do not believe in magic bullets) you (by which I mean “me”) have to wonder if the government isn’t somehow willfully part of the fraud if no reasonable effort in the area of oversight is being made.

It is never out of the realm of possibility but Ken White has a great quote that I cannot find now that says something to the effect of "Never attribute to malice what can be easily attributed to incompetence." Lack of oversight can be caused by a number of different things. It can be a regulator who is complicit with illegal activities at the local level. It can be a lazy and/or overworked regulator. It can be a regulator that lacks an effective regulatory mandate to actually be effective. It can also be an incompetent regulator. It can also be a lack of funding to have enough regulators to cover all the locations. It can also be a combination of several of these things together.

I would feel remiss if I did not mention that this sort of thing comes in an American flavor that most of us are unaware of.

There is absolutely no doubt that our bloated social programs have problems.

[ganulv]

It is never out of the realm of possibility but Ken White has a great quote that I cannot find now that says something to the effect of "Never attribute to malice what can be easily attributed to incompetence."

I don’t know about malicious, but when your job is to stem fraud and the best you (as an institution, and the higher-ups within it) can do is throw up your hands and say, “What else can we do?!?” I kind of think you yourself are acting fraudulently. But that’s a discussion for a dedicated Ethics thread.

[Ken White]

I would feel remiss if I did not mention that this sort of thing comes in an American flavor that most of us are unaware of.

Only to have the Health Insurance bureaucracy come down on me like a ton of bricks, in essence telling me to sue, bring criminal charges or shut up in order for them to justify their over priced premiums...

Calling the Guvmint's Fraud Waste and Abuse hotline resulted in more of the same. No one flat said "we know and we like it that way..." but it was rather apparent that was the attitude.

One complaint was over an orthotic brace for my wife, an item that can be purchased for about $50.00 in most Medical Supply Stores or on the internet-- we paid about $85, the insurance company over $300...

Hanlon's razor, "Never attribute to malice that which is adequately explained by stupidity" doesn't apply -- the health care industry isn't stupid and, while not truly malicious, they sure aren't straight arrows...

[davidbfpo]

Medicine is not a speciality I am familiar with, but reading this thread and mindful of the history that supplying medical care in COIN is often described as a "win, win" option two thoughts came to mind:

a) traditionally IIRC medical care was given on an individual basis, with the host community being aware of what that meant and with very rarely was care given beyond the "village" or local community

b) today there is an emphasis on public health, e.g. clean water and on somewhat sophisticated medical care, way beyond local comprehension, local affordability and out of community sight, e.g. helicopter evacuation to Camp bastion's hospital for an IED injured child

It seems to me that in 'stability operations' we have adapted the traditional approach, which was kept small and in view, added the far more effective public health option - which may not be locally seen as benign and offered medical care that is simply too much.

This issue also appears in civil / NGO provision in medical emergencies, notably after disasters and natural failures, drought comes to mind.

Now back to my "armchair".

[ganulv]

Leaving aside for a moment the relationship to counterinsurgency and allowing me to oversimplify a bit: with public health-related projects greater avoided costs over the long term are associated with greater upfront costs. Rational planning of a public health-related project should begin by asking whether avoiding cost over time is the raison d'être. If the answer is “yes,” the next question should be whether meeting the upfront costs is feasible (not a purely financial matter, as there are political and social realities to take into consideration).

Returning to the issue of counterinsurgency, is there real evidence that providing healthcare is a successful means of winning hearts and minds?* I’m not trying to be a troll here but rather am seriously asking whether the concept can truly be said to rise above the level of assertion.

*Note that my question is not whether providing access to healthcare improves quality of life. I am taking that for granted.

[davidbfpo]

Ganulv posted:

Returning to the issue of counterinsurgency, is there real evidence that providing healthcare is a successful means of winning hearts and minds?* I’m not trying to be a troll here but rather am seriously asking whether the concept can truly be said to rise above the level of assertion.

Certainly in my reading on the campaign in Malaya and especially Oman there are references to the impact of providing basic medical aid in locations that had none.

My impression is that basic medical aid - in Oman - helped secure the loyalty of local people as proof the new Sultan cared before more extensive and expensive options arrived, such as building roads.