Global health as a bridge to security
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Global health as a bridge to security



Health and security are no longer separate domains for policymakers. They interact with each other. Military leaders who once viewed the world through a narrow security lens have become accustomed to ...

Health and security are no longer separate domains for policymakers. They interact with each other. Military leaders who once viewed the world through a narrow security lens have become accustomed to building health plans and programs into their decisionmaking. Health professionals appreciate that their engagement can help enhance the security and the well-being of the communities with whom they interact.



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Global health as a bridge to security Global health as a bridge to security Presentation Transcript

  • a report of the csis global health policy center Global Health as a Bridge to Security interviews with u.s. leaders1800 K Street, NW  |  Washington, DC 20006Tel: (202) 887-0200  |  Fax: (202) 775-3199E-mail:  |  Web: Editor Richard Downie September 2012 ISBN 978-0-89206-750-3 Ë|xHSKITCy067503zv*:+:!:+:! CHARTING our future
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  • a report of the csis global health policy centerGlobal Health as a Bridgeto Securityinterviews with u.s. leadersEditor September 2012Richard Downie CHARTING our future
  • About CSIS—50th Anniversary YearFor 50 years, the Center for Strategic and International Studies (CSIS) has developed practicalsolutions to the world’s greatest challenges. As we celebrate this milestone, CSIS scholars continueto provide strategic insights and bipartisan policy solutions to help decisionmakers chart a coursetoward a better world. CSIS is a bipartisan, nonprofit organization headquartered in Washington, D.C. The Center’s220 full-time staff and large network of affiliated scholars conduct research and analysis and de-velop policy initiatives that look into the future and anticipate change. Since 1962, CSIS has been dedicated to finding ways to sustain American prominence andprosperity as a force for good in the world. After 50 years, CSIS has become one of the world’s pre-eminent international policy institutions focused on defense and security; regional stability; andtransnational challenges ranging from energy and climate to global development and economicintegration. Former U.S. senator Sam Nunn has chaired the CSIS Board of Trustees since 1999. John J.Hamre became the Center’s president and chief executive officer in 2000. CSIS was founded byDavid M. Abshire and Admiral Arleigh Burke. CSIS does not take specific policy positions; accordingly, all views expressed herein should beunderstood to be solely those of the author(s).Cover photo: A U.S. Marine hands a local Afghan boy a bottle of water at the bazaar in Nawa,Helmand Province. The U.S. Marines along with the ANA and ANP provide security in thearea to allow the local infastructure to grow. Photo by isafmedia,© 2012 by the Center for Strategic and International Studies. All rights reserved.ISBN 978-0-89206-750-3Center for Strategic and International Studies1800 K Street, NW, Washington, DC 20006Tel: (202) 887-0200Fax: (202) 775-3199Web: 2
  • contentsAcknowledgments  ivIntroduction by Admiral William J. Fallon   v1. Admiral Thomas B. Fargo   12. Ambassador Cameron R. Hume   53. Rear Admiral Thomas R. Cullison   114. Ambassador John E. Lange   165. Ellen Embrey  226. Ambassador Donald Steinberg   277. General Peter Pace   308. Ambassador Jendayi E. Frazer   359. General James E. Cartwright   3910. Ambassador Linda Thomas-Greenfield   4211. Dr. S. Ward Casscells   4612. Admiral William J. Fallon   5113. Dr. Connie Mariano  56  About the Editor   60 |  iii
  • acknowledgmentsWe are indebted to the 13 leaders who took time out of their busy schedules to be interviewed forthis project and who followed up to offer feedback and edits to the draft report. In particular, weare grateful for the contribution of Admiral William Fallon, who provided leadership and direc-tion to the project, suggested potential interview subjects, contributed his own interview, andwrote the introduction to this volume. Special thanks are due to Lindsey Hammergren, program manager and research assistant atthe CSIS Global Health Policy Center, who managed the project and helped edit the draft reports.J. Stephen Morrison, senior vice president and director of the Global Health Policy Center, guidedthe project from its inception, shaping the research agenda and providing critical insights, sugges-tions, and feedback. We are grateful to Julia Nagel, Web and social media assistant in the GlobalHealth Policy Center, who filmed the interviews and produced a video to accompany this publi-cation. Thanks are also due to Alisha Kramer, program coordinator and research assistant at theGlobal Health Policy Center. We are very grateful to our CSIS publications team of James Dunton, Donna Spitler, and DivinaJocson, who met a demanding schedule to bring this volume to fruition. Vinca LaFleur, partner atWest Wing Writers, made an invaluable contribution in shaping the initial draft chapters. ■iv  |
  • introductionAdmiral William J. FallonOur understanding of global health and its reason, I welcome this effort by the Globalrelationship to national security, the safety of Health Policy Center at CSIS and have beenour citizens, and the well-being of the wider glad to contribute toward community has grown and evolved The approach CSIS took was simple: toover time. It is now widely accepted that na- explore the nexus between health and se-tions with healthy populations are more likely curity by collecting the personal stories of ato be productive, prosperous, and peaceful. selection of our nation’s leading military andThis matters to the United States because global health professionals. We approachedpeaceful nations generally make good neigh- some of the men and women whose decisionsbors. Conversely, poor health indicators are have helped shape our thinking on healthusually a sign that something is not right and security during the past decade or so andin a society. Nations with high numbers of asked them to reflect on their experiences.unhealthy citizens are more likely to be poor, In particular, we asked them to consider thebadly governed, weak, and prone to instability moments in their career when health andor even conflict. One need only take a sample security-related considerations came togetherof countries that fall into this category—So- or collided with each other. How did theymalia, Afghanistan, North Korea—to under- reach their decisions? What was the outcome?stand the potential threat they pose to the What did they learn from their experiences?United States. The interviews we conducted form the basis of For these reasons, health and security are each of the narratives that follow in this shortno longer separate domains for policymakers. volume. Each individual approached the sub-They interact with each other. Military leaders ject in his or her own unique way, but despitewho once viewed the world through a nar- their varied experiences and backgrounds—row security lens have become accustomed to whether in the military, diplomatic, or medi-building health plans and programs into their cal fields—a number of common themes anddecisionmaking. Health professionals appreci- messages emerged.ate that their engagement can help enhance The contributors acknowledge that theirthe security and the well-being of the commu- thinking on the relationship between healthnities with whom they interact. and security has evolved throughout the The men and women who have grappled course of their career. As the accepted defini-with health and security issues in their profes- tion of security has broadened out to includesional lives have built up a considerable body human or individual security, as well asof experience in this field. But to date, there national security, health considerations havehas not been a consistent effort to document begun to play a more central role in policytheir activities, analyze their policies, and calculations and activities.draw lessons from their experiences. For that |  v
  • The world has changed beyond recogni- been an uptick in both the frequency and thetion since World War II, the era when many of severity of natural disasters. In scale, the 2004our interviewees were born and grew up. An Asian tsunami was an almost unprecedentedera of total war and of mass destruction, it was disaster in the modern era, claiming thea time when militaries made the first, uncer- lives of around a quarter of a million peopletain steps toward dealing with the health needs across six countries and prompting a complexof the populations with whom they came into emergency response effort coordinated by thecontact. The years of the Cold War were when United States. The threat of global pandemicsmany of our interviewees “cut their teeth,” so has risen as globalization gathers momentum,to speak, crafted their worldview, and made with passenger aircraft providing an easy de-their first forays into public service. It was a livery mechanism for the spread of potentiallytime when national security considerations lethal strains of influenza. The events of 9/11were paramount, but it was also a time when prompted urgent efforts to assess the threat ofthe battle for hearts and minds meant making biological terrorism and devise strategies toappeals to citizens of nonaligned nations by prevent it.showing concern for their health and well- The experiences of the past 10 years havebeing. As the Berlin Wall came down, our placed extraordinary demands on peopleinterview subjects were assuming leadership working in the arena of health and securitypositions. They had to contend with a new in- and forced them to work more closely together.ternational arena in which positive trends such By doing so, they have come up with someas globalization and democratization rubbed innovative solutions. The narratives that followup against less positives ones like state failure, highlight some of the medical, logistical, andwhich challenged long-held assumptions about technological advances made by our militarythe Westphalian system of states, with its edict in preserving the lives of our servicemen andagainst external intervention, even in the face women and treating the wounds, both physi-of massive humanitarian abuses and genocide. cal and mental, they have suffered in combat.As the new century dawned and the 9/11 at- These advances were spurred on by the urgen-tacks punctured the hopes that came with it, cy of having to fight two wars. Disasters likeour leaders focused on a new set of complex the Asian tsunami and the 2010 earthquakesecurity threats posed by nonstate actors— in Haiti have encouraged our military andthose who actively sought to target civilians civilian personnel to come up with creativewith their bombs and bullets. Our interview- solutions for maximizing their joint assets toees’ views of how health fits into this picture deliver speed and efficiency to their emer-have evolved to keep pace with the changing gency response efforts. The emerging threatsecurity outlook. of pandemic flu has focused the minds of our Several trends over the past decade or so diplomats and health experts on leading globalhave prompted a further shift in thinking and efforts to build a network of disease surveil-helped reinforce the links between health and lance and response. The scourge of diseasessecurity. Two long, bloody wars in Iraq and like HIV/AIDS has prompted an outpouringAfghanistan have caused enormous civil- of U.S. assistance and expertise to global healthian suffering and placed huge physical and initiatives such as the President’s Emergencypsychological burdens on U.S. servicemen Plan for AIDS Relief (PEPFAR).and women. They have also led to postcon- At the same time, the demands of the pastflict reconstruction programs that have often decade have highlighted a number of gaps incontained a health component and involved our thinking and exposed shortcomings inboth civilian and military personnel. There hasvi | global health as a bridge to security
  • our ability to act in coordinated, preemptiveways to tackle issues concerning health andsecurity. The absence of an overall strategy fortackling global health issues has led to haphaz-ard and ill-planned initiatives. Opportunitieshave been missed to link up with partners bothinside and outside government. The failure toadequately join up institutions within our gov-ernment and military has frustrated efforts todeploy our resources to their maximum effectto deliver health care and security. Our over-seas engagement has often been fitful and shortterm in nature, making it difficult to achievethe kind of sustained improvements in pub-lic health we desire. The lack of a deployablecivilian capacity within our government hasmeant that military personnel have ended upperforming health roles by default in conflict-afflicted or postconflict environments—notbecause they are the best equipped to do sobut because they are the only people on theground. When dealing with health issues incombat environments or disaster zones, wehave found it difficult to define exactly wherethe responsibilities of the military end andthose of civilians begin. Institutional cultureshave made working relationships problematic. Although missteps have been made alongthe way, overall the picture is one of progress.More often than not, positive outcomes havebeen the result of individual initiative ratherthan the strength and flexibility of our gov-ernment institutions. We have done an admi-rable job in meeting the challenges of the pastdecade and learned a lot of lessons along theway, but more must be done in the future toenable us to remain the true leader on globalhealth. Our health assets are one of our corestrengths as a nation. We should actively seeknew opportunities to use them in the pursuitof our security interests, to build friendships,and to improve the health of people around theworld. ■ richard downie  | vii
  • 1admiral thomas b. fargoDuring a naval career spanning more than 30 years,Admiral Thomas B. Fargo (USN, ret.) held fivecommands in the Middle East, Indian Ocean, EastAsia, and Pacific Ocean. They included commanderNaval Central Command/commander Fifth Fleet,commander in chief of the Pacific Fleet, and, finally,from 2002 to 2005, commander of the U.S. PacificCommand (PACOM), where he was responsible forjoint operations of the U.S. Army, U.S. Navy, U.S.Marine Corps, and U.S. Air Force across PACOM’s100-million-mile area of responsibility. He iscurrently chairman of Huntington Ingalls Industries,the nation’s largest shipbuilder, and holds theShalikashvili Chair in National Security Studies atthe National Bureau of Asian Research.O ur definition of security has widened As commander of PACOM, I was typically tremendously from when I was a involved with two kinds of health-related young officer on a submarine right programs. The first involved building healthin the middle of the Cold War. As well as the programs and outreach into my securitymilitary component, there are also economic, cooperation plan, which helped build andenergy, and health components. Health and se- maintain relationships and establish process.curity are very closely tied together. On a very The second was disaster response. The twobasic level, we recognize that the health of a efforts are linked because if you’ve built a solidcountry is closely linked to its people’s prosper- foundation with the first set of programs, it’sity, productivity, and economic well-being. All much easier to move into action quickly tothese things are critical to a country’s stability. deal with a calamity.On a second, even more direct level, are the Part of any commander’s engagement plankinds of health emergencies that I had to deal is to be able to move medical forces into thewith when I was Pacific commander—things area of responsibility to do medical-capacity orlike SARS (severe acute respiratory syndrome) dental-capacity exercises. These exercises takeand bird flu—which can have a dramatic effect our professionals and put them in the field tonot only on the security of a country but also deal with very specific problems that a countryon that of an entire region. might have. The emphasis is on providing a |  1
  • form of training to people on the ground so by individual people, but it also establishesthat what they learn can be passed on from relationships and builds trust and confidencetown to town and professional to professional. that are important to the United States and allThese efforts included conferences where we of our regional allies.would bring medical military professionals For some time now, we’ve been buildingtogether to try to share best practices and humanitarian assistance and disaster relieffundamentally lift the health of the entire preparations into our large exercises. A multi-Pacific region by its bootstraps. national exercise like Cobra Gold in Thailand The Philippines offers a good example includes 10 plus players and observers andof this type of programming. It’s a place that provides an opportunity to build standardhas always been beset by natural disasters operating procedures and also strengthen rela-and where poverty is high. In addition, tions with the nongovernmental organizationsin Mindanao, and specifically the Sulu (NGOs) that have a great deal of expertise toArchipelago, there was a serious Islamist bring to these problems. What you find is thatinsurgency. PACOM put a plan together to if you exercise regularly and improve yoursupport the government of the Philippines. capacity for response, when a very seriousThis plan included what you would call soft disaster strikes, your ability to react quicklypower to make sure that we had the support of and effectively rises dramatically.the indigenous people. We brought engineers At the time of the 2004 Boxing Dayto Basilan Island, for example, where they tsunami, I had been back in the Pacific forrepaired the basic road that ran around the over five years, so I knew the leadership in theisland, dug wells, and worked with the local region. These relationships proved to be verycommunity to repair the schools. important. After the initial news report of the These activities had very practical out- tsunami, the first call I got was from Generalcomes. Better roads meant you could more Peter Cosgrove, Australia’s chief of defense.easily get to the people who were causing That call gave us an immediate opportunityproblems for the local communities. The wells to put in place initial coordination, and fromimproved the quality of the water, which meant there we made a clear decision about whichhealth improved dramatically throughout the other leaders in the region we were going toisland. These efforts helped gain the support call and get involved.of the people, improve their feelings toward But I want to underscore that thethe government, and set the insurgency back Indonesian government was in charge ofon its heels. The thing about insurgencies is this relief effort, not the United States andthat when the people trust the government the multinational force. We coordinatedmore than they fear the insurgents, then you’ve immediately with my Indonesian coun-reached a tipping point that increases your terpart and Indonesian president Susilochances of success. Bambang Yudhoyono to make sure it was ab- To illustrate this point, I recall that we sent solutely clear that they were in charge and thata medical group of young navy corpsmen to we were in a supporting role. They understoodprovide basic medical care to a small village. that we’d provide all the help, expertise, andUpon arrival, they were greeted by local advice they wanted but that fundamentally, asveterans from World War II, who had come the host nation, they were in charge.into town just to provide security for this team. I was able to call my counterparts inThere’s a clear message here: not only is this Malaysia, Thailand, and Singapore not only totype of assistance tremendously appreciated2 | global health as a bridge to security
  • provide coordination but also to discuss access One of the assets that we had availableto the worst-hit areas. We needed to be able immediately and that I could deploy under myto get into Aceh, right on the very northern own authority was the aircraft carrier grouppoint of Indonesia, where there isn’t a lot of led by USS Abraham Lincoln, which was atbase support. The infrastructure in Aceh had port in Hong Kong. We immediately orderedbeen fundamentally destroyed; everything the battle group to head to the Malacca Straitfrom the coastline to two miles inland was because we knew it had the capacity to help incompletely knocked down and devastated. Of a very substantial way. We also had an am-course, the world was energized by wanting to phibious ready group, which included anotherhelp, to move food and relief supplies into the large-deck ship, and of course all these assetsarea, but because there was only one relatively bring a lot of capacity.modest landing strip in Aceh, coordinating They bring helicopters, for example, whichhow to move supplies into the area was a key are lift assets, enabling us to move into rela-challenge. We established a forward operating tively remote areas where the support structurebase in Butterworth in Malaysia, which was had been devastated. With the helicopters, weimmediately adjacent across the Malacca Strait could put our personnel on land to work onfrom Aceh. This allowed us to move critical the disaster response effort during the day andpeople and supplies into the area. bring them back to the ships at night. That was We built a multinational joint force and very helpful because we didn’t have to build aheadquartered it in U-Tapao, a Royal Thai huge infrastructure within the country just toNavy airfield very close to Bangkok. We support our people. The large-deck amphibi-used the same structure that we actually had ous ships also bring very significant medicalfor Cobra Gold. With liaison officers from capabilities. In some cases, they are big enoughAustralia, Singapore, Japan, Malaysia, and to accommodate a 600-bed hospital. On topThailand, we had a cohesive group that could of that, you have the talent that doctors anddeal with the magnitude of the crisis. And medical professionals bring that can aid in thebecause we knew that a very large portion of initial response and move supplies into thethe disaster relief effort was going to be done devastated NGOs and UN organizations, we brought In addition to the military assets, wethem into the fold quickly. deployed the hospital ship, USNS Mercy, right The scale of the disaster was incredible. away, but I recognized it was going to takeIn some areas, the wall of water leveled about three weeks to arrive from its base ineverything in its path. Approximately 250,000 San Diego. Because of that delay, there was apeople died, and many were displaced. When handoff that occurred at about the one-monthI flew over the area, I could see that not only point of the operation where the militaryhad the houses been knocked down but also vessels left the area and the hospital ship, withthat they’d been dragged out to sea. All I was its very sizable capability, continued to providelooking at were the cement foundations. The the support necessary for a fairly significantability to shelter people, make an immediate period of time.assessment of their medical condition, and, The military’s role in these situations isof course, to get fresh water in were therefore to provide the initial disaster response, andvitally important. If you don’t have water for of course we have a lot of communications,the people, then you have the potential for logistics, command-and-control capabilitiesoutbreaks of disease that could be even more and other resources that allow us to be verytragic than the initial disaster. richard downie  | 3
  • effective. But it’s important to remember that as all the nonprofit organizations, that pro-there’s huge capacity in the international com- vided assistance. The world really stepped up.munity. The UN has a number of organizations This leads me to my final point. The funda-that specialize in this work. In addition, the mental lesson you learn from disaster responsehost nation is going to get back up on its feet is that no one country, no single organization,pretty quickly. The military in my view ought has the capacity to deal with these problems onto do everything it can to get in at the outset, its own—they’re just too large. Faced with a di-stabilize the situation, stop the loss of life, saster on the scale of the Boxing Day tsunami,and make sure the basics are covered so that you’re going to need to have a broad range ofthe situation isn’t going to get any worse; and players, both inside and outside government,then it should provide, as early as possible, a coordinating together to provide the supporthandoff to organizations that are designed and necessary to relieve the suffering.equipped to do this on an international basis. Anything you can do in advance of the Our relationship with Indonesia was calamity really helps. I have seen organiza-transformed by our response to the tsunami. tions that didn’t previously cooperate on aIt built a lot of trust. If you looked at data regular basis but that now are getting togetherfrom a survey conducted afterward by the Pew frequently to talk through plans and workResearch Center, the standing of the United together to solve problems. Those mechanismsStates in Indonesia had doubled in its approval are in place, and they’re improving everyrating. But the crucial thing to remember is day. The dialogue is more sophisticated, andthat relationship building is not a one-time certainly the willingness to come together hasevent. After the tsunami, we continued to de- never been higher. ■ploy the hospital ship under an exercise calledPacific Partnership, where we moved aroundthe archipelago and the whole of SoutheastAsia to provide support, training, and medicalassistance. I think that consistency of supportis important. We applied lessons learned from theAceh tsunami to the 2011 tsunami in Japan.In addition, our very strong, ongoing alliancewith Japan played a big role in the response.We have exercised together over the yearsto the point where we are very comfortablecoordinating in the most difficult situations.Often, these very strong relationships tend tofall below the radar screen, but it’s importantto nurture them because they will be neededat some point in time. Certainly that’s what wesaw in the Japanese tsunami: it really was anincredible effort to deal with three crises—anearthquake, a tsunami, and a nuclear inci-dent—simultaneously. You have to be proud ofall the people from both governments, as well4 | global health as a bridge to security
  • 2ambassador cameron r. humeA career diplomat, Ambassador Cameron R. Humerepresented the United States in a range of positionsat the United Nations and in Europe, Africa, Asia,and the Middle East. He served as U.S. ambassadorto Algeria (1997–2000) and South Africa (2001–2004), as chargé d’affaires to Sudan (2005–2007),and as ambassador to Indonesia (2007–2010).I f you go back 40 or 50 years, the concept There are two reasons why this matters to of foreign policy was more Westphalian. the United States. One is the role of the United There was a sense that issues could be dealt States as a superpower or trustee of the inter-with by states within their sovereign limits and national system. It is in our interests to workthat the international system consisted mostly for structures of cooperation between states toof regulating those relations. Today there’s a limit the damage, not only to ourselves but alsomuch greater appreciation that the interstate to others. The other reason is that the spreadsystem is not an adequate prism for under- of infectious disease affects our own citizens.standing the impacts that people in one area Both of these interests are rising in importancehave on people in another area. Global warm- because increased travel means that the risk ofing and the depletion of maritime resources spreading disease is far higher than it was.are two examples; another is infectious disease. Health care and foreign policy intersectedDiseases don’t know when they cross a state most closely in two of the places I served. Theborder. They don’t know the citizenship of the first was South Africa. I was there from 2001 toperson they infect. Thus you have an awkward 2004. Thabo Mbeki was the president. A highmatch between state action and germ action percentage of the world’s HIV-positive peoplethat affects human security and, potentially, lived in South Africa, and the rate of infectionstate security. was very high. At the time, the government |  5
  • in South Africa did not feel there was a policy After President Bush’s visit, I calledsolution out there that was adequate to con- together the people on the “embassy team.”front the scale of the problem. We had people from the Centers for Disease Control and Prevention, the U.S. Agency for Before I went to South Africa, I spoke International Development (USAID), the Stateto several people I knew who gave me some Department, and the military, all of whomadvice. One was Dick Holbrooke, who at the owned some aspect of the issue. We talkedtime was head of the Global Business Coalition about what we imagined would be required toto Fight HIV/AIDS. In his characteristically stand up a program in South Africa and howdirect manner, he told me there was absolutely we would go about it.nothing more important for me to do than toget the South African government to change its At the end of the meeting, I asked howpolicy on HIV/AIDS. long it would take between the adoption of the law, the signing into law of the program, The second person was then-Secretary and the first grant in South Africa. One of theGeneral of the United Nations Kofi Annan, people, I think from USAID, looked at mewho shared my concern over the health situa- and said, “Ambassador: 10 months.” I was ation in South Africa but cautioned me that as little surprised; I thought this was a matter ofa white man I should never raise the question urgency. I said, “Well, OK, but since we don’twith Thabo Mbeki. have the law in place, why don’t we start work- As a result, I had an unclear path ahead ing today on the critical paths? Maybe that wayas I set off to South Africa. What I found was we’ll take a month or two off of that estimate.that it was possible to talk with Thabo Mbeki Every month or two we take off, we may saveabout HIV/AIDS but in a particular way; that some human lives, so why not try it?”is, it was possible, if it was not the main subject We had very good people, and they didof the meeting, to brief him at the end of the work together as a team—even though whenmeeting on what the United States was doing you come back to Washington, agencies oftenabout HIV/AIDS, maybe to leave a memo with seem to be on opposing teams. They camehim, but not to be under the illusion that I was up with a structure to go out and solicit bidsgoing to be so persuasive that I would change or proposals; they set up a panel to reviewhis deeply held views. My goal was simply that the bids that came in. We posted online ourhe should understand that it was a subject that solicitation explaining that if PEPFAR wasn’twas always on the mind of the United States. passed into law, there would be no money but This was a time when U.S. policy toward people who wanted to take a chance on gettingHIV/AIDS was evolving, with the introduction an early grant were welcome to apply.of the President’s Emergency Plan for AIDS I went out with junior Foreign ServiceRelief (PEPFAR). I think this was due in large officers to find groups the embassy had neverpart to the personal influence of President dealt with before, and we discovered a lot ofBush, who cared deeply about it. He visited very creative people doing good things. AndSouth Africa in the summer of 2003, at the five months later, at the end of the year, Itime the legislation was pending in Congress. went to another working group meeting andSecretary of State Colin Powell, like Dick said, “Congress hasn’t passed the legislationHolbrooke, told me there was nothing more yet; what are we looking at here?” They said,important for me to work on than HIV/AIDS “Sir, we’ve made some progress. We’ve gottenand said I should be ready to help implement through the initial reviews of the proposals.the PEPFAR policy in South Africa. But we have a lot of work left to do. It prob-6 | global health as a bridge to security
  • ably will be another two months.” I said, important things: how people in an African“Well, that’s great!” And we went off for our environment were responding to the differentChristmas holidays. cocktails of drugs and whether or not people would be compliant with the treatment regime. At the end of January, we had anothersuch meeting. And I consider it a highlight of With NIH, we structured a series of meet-my career that when I asked the same ques- ings and conferences with people from all overtion about how much more time we needed, the world to come up with a plan for clinicalan argument broke out between those who trials with the military hospitals. These groupsthought it would take one week and those who are not used to working together, and I thinkthought it would take two weeks. I said, “Don’t it was very difficult; but NIH had the guts toworry; you started with an estimate of 10 reach out and begin the implementation of themonths; now we’re down to one or two weeks! program before we actually had signed docu-And you’ve got there in six months.” Two or ments. The military saw it as a way of gettingthree weeks later, the PEPFAR legislation was treatment, and the bet we made was that thesigned into law, and within 24 hours we’d given more people we got on treatment, the more thethe first grants. South African government would be morally bound to permit the program to continue. By Our strategy on PEPFAR was to simplify, the time there were 600 or 700 people on treat-get to the goal line, find good programs, have ment, we were able to get the signatures. Thegood input; be legitimate, open, transpar- then-health minister couldn’t stop it becauseent; and—critically—use one process for all she couldn’t tell the military, “Go commitagencies of government. I don’t know how we suicide.” And President Mbeki wasn’t going togot away with that because at the time there tell the military to go commit suicide.was a form of warfare between the Departmentof Health and Human Services and USAID. Thus we were able to begin treatmentBut because we were able to agree at post, in South Africa—in South African militaryWashington let us go ahead. We had the most hospitals, training the staff doing the treat-creative and dynamic launch of the PEPFAR ment—three years before the change in Southprogram of any place in the world, and we African government policy. And this enableddeveloped our approach before the legisla- the development of actual knowledge, clini-tion was adopted. I would say, then, simplify, cal knowledge, about how the South Africanand keep your eye on the distant target. That population responded to the drugs that wereworked for the PEPFAR program. on offer and to help design the best treatment regimen. That meant that when the govern- I spent a great deal of my time on a pro- ment changed its policy, it wasn’t stumblinggram with the South African military, between around saying, “How do we do this?” Thethe South African military medical system and pioneers already knew how to do it.the U.S. National Institutes of Health (NIH).The military, given its demographics, has a My view was that the health challenge washigh percentage of people who are HIV posi- the greatest security challenge South Africative, about 20–30 percent of its forces, includ- faced. And my hope was that South Africansing senior officers. Critically, the South African wouldn’t wonder who we were as a people;military hospitals keep records. NIH—which, they would understand that in their momentI think, played an absolutely critical role in of need, facing a new challenge for the twenty-all the struggles against HIV/AIDS—saw that first century, the United States was there andif it was able to work with the South African helped. We were helping the South Africanmilitary, it could get more information on two military deal with illness among its own people richard downie  | 7
  • at a time when its own government wouldn’t in infectious diseases. Given its location, ithelp. That’s pretty powerful. And because we was particularly interested in flu. Why? Aboutdidn’t talk about it and try to draw political 40,000 Americans die each year from seasonalgain from it, we had the traction to go ahead. I influenza. Where does seasonal influenza comethink it was a unique set of circumstances that from? It comes from Southeast Asia.allowed us to do that. But often, if you look Indonesia is home to 43 percent of thehard, you’ll find the key that fits the lock. people of Southeast Asia. Because it’s the place I think the program between NIH and the where you have the best opportunity to collectSouth African military potentially laid a basis flu samples in order to develop the vaccinesboth for better clinical knowledge and better re- that are used in the Northern Hemispherelations with the security services. And, along the during the flu season nine months later,way, we established great relations with a broad there’s a direct impact on U.S. health from thisnetwork of researchers, activists, and people in research. I’d point out that people in Indonesiagovernment, including future President Jacob don’t die from seasonal flu; it’s a mild infectionZuma, who encouraged this work to go ahead that becomes more virulent in the Northerneven though he knew it wasn’t a government Hemisphere. But when I went to Indonesia,policy. I think we got a lot done. there had been outbreaks of bird flu, and bird flu is pretty lethal; it has about a 50–60 percent When I went to Indonesia, I had to deal mortality rate for people who are infected.with a different set of health challenges. Therewere two things going on: first, Indonesia was Half of all bird flu infections have occurredthe epicenter of the bird flu outbreak; and, in Indonesia, and more than a third of all birdsecond, the future of the U.S. Department of flu deaths in the world occurred in a townshipDefense overseas medical research labora- called Tangerang, outside Jakarta, which is atory in Jakarta, called NAMRU, was under city of 12 million people. Tangerang is wherenegotiation. the international airport is. At the time, there was a great fear—there’s still some fear—that Some may have the impression that the bird flu might become contagious. And it’speople in our military labs spend their days important to understand that influenza usuallyimagining how to deal with mustard gas vectors when people are still healthy; you’re noattacks. It’s not that at all. It’s very practical. longer contagious by the time you get sick. TheHow do you help your troops survive in the fear was that someone would get on a plane inmost extreme circumstances? And by exten- Tangerang and go to, say, Frankfurt. And he’dsion, how do you help others living in extreme be sneezing in Frankfurt. People in Frankfurtcircumstances, who tend to be poor people in would get on planes, and it wouldn’t take twopoor countries? or three days before there were people who To give an example, the use of little saline had the pathogen in almost every country inpackages for rehydration treatment wasn’t the world.developed by the Red Cross or the World To prepare for the eventuality of human-Health Organization; it was developed by an to-human transmission, we had to be able toAmerican scientist working in one of these study samples of the flu with a possible view tomilitary laboratories in the Philippines, seeing developing a prototype for a vaccine. I thoughthow to help people who were suffering from this issue was critical. Indonesia had previ-severe dehydration, particularly caused by di- ously shared flu samples—not necessarily witharrhea. I think that the scientist in that labora- NAMRU, the military lab, but often through ittory has saved hundreds of thousands of lives. to CDC. But at this point, Indonesia had cutThe laboratory in Jakarta was mostly interested8 | global health as a bridge to security
  • off sharing these flu samples. The Indonesians I think that most of the people in thewere concerned that, by handing over samples, Indonesian government understood thevaccines would be developed by rich countries lab’s value, but it was an issue on whichand they would be the last in line to receive none of them would take on the populistthem. They therefore refused to share them, voices. Certainly President Susilo Bambangclaiming “viral sovereignty.” Yudhoyono encouraged me directly to go ahead with the negotiations, but in the end At the same time that the bird flu crisis he wasn’t about to instruct his health ministerwas playing out, we were negotiating the future what to do. And when we saw that, my judg-of the NAMRU lab. The lab had been set up ment was, “OK, let’s not have a constant argu-with the approval of President Suharto 40 years ment; close the laboratory and in the morningago. There had been, off and on, for different we’ll get up and we’ll rebuild the healthreasons, mythic charges about what was going relationship with Indonesia.” And I think that’son in that laboratory. What evil doctor is in what’s happening. The interests between thethere cooking up pathogens to kill the world? two sides are strong and we’re back to cooper-Is this a germ warfare laboratory? The discus- ating, but, unfortunately, not with the NAMRUsion had become politicized. Eventually, the laboratory. One of the scientists there went onlease, or the agreement, had to be renewed. to another of our labs in San Diego, where heAnd we tried to get it renewed so that there’d correctly typed and identified the subsequentbe a clear future ahead. outbreak of swine flu in Mexico. The previous Our own military was superb. I explained year he’d been working in Indonesia, but thatthe political context to them and said I thought was an asset that was lost and sent elsewhere.the one chance we were going to have to What’s lost as well is that we weren’t able to usestraighten this out would be if we were able to the lab renewal as a pivotal point to contributehave the lab run as a binational laboratory in to a strengthening of relations between thewhich Americans would be doing the actual United States and Indonesia, the third- andmanagement of the laboratory but where there fourth-largest countries in the world. I thinkwould be a binational oversight board and it health care will come back and be part ofwould no longer be a closed military environ- that; I think education has to be a part of that;ment. We would have to have scientists work security obviously has to be a part of that. Butthere who were appointed by the Indonesian because of the loss of NAMRU, I think we lostgovernment. Amazingly, our military agreed. It 10 years on the health care component.was very open. It said, “This is only about sci- As for bird flu, I think it was containedence. We have to be careful about management simply by fate. But it’s not gone away. It’s justfor use of U.S. Government resources, but we not shown the capacity to mutate into some-are glad to open the doors to the Ministry of thing that’s contagious between two humanHealth.” beings. When I reflect on the negotiations With that, we went back and had a po- with the Indonesians over bird flu samples, mytentially fruitful negotiation articulating how view is that if people cooperate you can comea new arrangement would be structured. But to agreements. It comes back to what I said atin the end it didn’t work. And it didn’t work, I the beginning about states and sovereignty.think, because the then-health minister had a What happens if an American is in Indonesiaslightly different agenda. She didn’t want to be and gets bird flu, gets on the plane and comesthe one who signed the document. Although home, gives a flu sample, and some Americana doctor, she wasn’t really a clinical researcher. company makes a vaccine—who owns that?This wasn’t her thing. The Indonesian is going to tell me, “No, that richard downie  | 9
  • was an Indonesian virus that jumped into that the United States benefits enormouslya person. It happened on our territory.” It from people admiring us for our restlessbecomes silly. I think it’s better to address determination to conquer disease. That’s partthese issues and discuss them. If we’d reached of what makes an American an American. Ifa cooperative agreement in Indonesia, the we have a legitimate claim to leadership in theinvestment in their health infrastructures world, part of that should be sharing our abilitywould be increasing, and it would result in and determination to confront humanitarianbetter health care for Indonesians, too. challenges. I think health care is a strong point in our engagement with the world. We ought to What do I take away from these experi- make more of an effort to facilitate it. ■ences, working on health and security? First,I’d underscore the importance of establishingpersonal relationships with the health expertsin our own government and understand-ing what they’re about. In the U.S. federalgovernment, health is the responsibility of theDepartment of Health and Human Services,and it has a number of really wonderfulinstitutions, particularly NIH. When I wentup to visit NIH before going to South Africa,it was seen as very unusual; I would bet todayit’s still unusual. Most Foreign Service officers,most ambassadors, wonder why they need totalk to these people. I tried to get the AfricaBureau of the State Department to invite NIHto its weekly staff meeting and failed. But itwas people from NIH who had the couragein our government to make a bet on changein South Africa and to leverage the influenceof the South African military as the one placein the South African government that couldmake a decision independent of the healthminister. I think we should be more open tothose kinds of collaborations and more willingto deal directly with the actual players; and inthe case of NAMRU, that meant dealing withthe military. Remember, we’re structuring a foreignpolicy for this century, not for the last century,not for the nineteenth century. We’re not send-ing the Great White Fleet around the world.What are we sending instead? People look at the United States, and theyhave one impression of us from our use ofdrones; they have another impression of usfrom the excellence of our health care. I think10 | global health as a bridge to security
  • 3rear admiral thomas r. cullisonRear Admiral Thomas R. Cullison (USN, ret.) cappeda 42-year naval career by serving as deputy surgeongeneral for the U.S. Navy and vice chief of theBureau of Medicine and Surgery from 2007 to 2010.Following his retirement from the navy, he was thechief operating officer of the Center for Excellence inDisaster Management and Humanitarian Assistance,in Honolulu, Hawaii, from 2010 to 2012.S ome may ask why health outreach is to those who would like to see countries stay important. Why is it important for the unstable; they will help develop close relation- United States to spend its treasure on ships—both military and civilian—betweensomebody else’s health care, to put it bluntly? countries and the United States; and they willLook at the relationship between the United create friends out of what could potentiallyStates and Vietnam, for example, which has have become enemies.evolved in my lifetime from active combat to The navy has a long history of healthvery good relations; much of that improved engagement. Navies tend to be far flung acrossrelationship was developed through health the world, and part of their job is to developcare. Look at the relationship between the friendly relationships with whatever countryUnited States and Thailand. Look at the many they happen to visit. Health outreach iscountries that right now don’t have a very good certainly a way to do that.relationship with us but with whom we cantalk about nonthreatening topics, such as basic When I was in Guantanamo Bay in thehealth, HIV/AIDS, and noncommunicable dis- early 1990s, there was a mass migration out ofeases. These are the reasons we should support nearby Haiti. We were taking care of people’sthe use of both uniformed and nonuniformed medical problems in the displaced persons’U.S. capabilities to help countries develop their camp. I treated an HIV-positive boy whohealth systems. These efforts will deny a base was probably 12 or 13 years old. He’d broken |  11
  • his shin bone when he was young, and it disaster response and humanitarian assistancehad never been properly treated; he had this as a core concept, a core duty that the seachronic, seeping wound—an infection that services will be required to provide.had been there for years. We took him to the Everyone views the 2004 tsunami in Acehoperating room and dealt with the problem in Province of Indonesia as a turning point. A lotabout 15 minutes by scooping out the infected of things came together during that disaster:bone and treating him with antibiotics. As far a vast international response, a large I know, he recovered well. And I thought, military response, and an indigenous response“By gosh, we’ve just done in a few minutes in a province of Indonesia that at the timesomething that will probably benefit this was experiencing an insurrection against theperson for the rest of his life.” And I tucked this government. Everybody knows that the rebelobservation away as an example of how small movement signed a peace deal after this hugeinterventions can really help the United States disaster hit. I think the international responsegain friends. and the way it was received by Indonesians Using medicine to build friendships helped strengthen the idea that “soft power,”goes beyond the individual level. I began or the ability to work on the human level,my career back in 1972 as a line officer and can have a longer-lasting effect than kinetica diver, serving in Vietnam during the war. interventions.In the early 2000s, when I was at U.S. Pacific The first thing one must realize whenCommand, we had the opportunity to engage disasters occur is that the primary responsibil-with the Vietnamese once again. I took the ity for response lies with the host country. TheVietnamese surgeon general on board a navy U.S. military will not be involved without aship in Hawaii. We subsequently visited him in formal request from the country. That requestHanoi—a place that in 1972 I never thought I comes through our embassy, is relayed to thewould see—where I met with the Vietnamese Department of Defense, and is then transmit-Army medical department and arranged for a ted to a U.S. military organization to respond.follow-on visit to engage its military on HIV/ If a country’s own capability is overwhelmed,AIDS prevention. and if there is no international capability that Working with our former enemies on a can quickly and effectively respond, the U.S.topic that was of concern to both countries military can be brought in to do those thingswas, I think, very helpful in developing a that nobody else can do, for a very shortrelationship. It seemed to me that health period of time.could be a building block, a common issue for That was the case during the Haiti earth-discussion among military people that was quake in 2010, where the government itself wasnonthreatening to either side. It offered us a largely destroyed. My involvement was to deployway forward with Vietnam at that point, and our hospital ship, the USNS Comfort, with theour relationship has now matured into one that right specialists and supplies on board and to getis much more diverse. it to Haiti. The Comfort is berthed in Baltimore, Disaster response is another way of build- and it takes about five days to get from Baltimoreing relationships. The navy knows it will be to Haiti. A lot is going to happen in the first fivecalled on in that regard, and we really practice days following a disaster of that size. The hardfor such emergencies. The most recent strategic part for us was to predict what type of medicaldocument that the commandant of the Marine response would have occurred during that period,Corps, the chief of naval operations, and the what would be needed when we arrived, and howcommandant of the coast guard signed treats we would best fit with the ongoing response.12 | global health as a bridge to security
  • The response to a major disaster is just the time. The capability that we bring with oursame as response to a war: the information that ships is something that nobody else has. Forcomes out initially is often incorrect, it’s often surgeons, this is a good place to work. I alsoeither understated or overstated, and the situ- think it’s quite good for the United States to beation becomes clearer as you go along. What able to show other countries that when we allwe did was to get the ship moving with a base put on scrubs and go to the operating room, itmedical capability on board—about two-thirds doesn’t really matter who is the military doctorof the medical staff that we knew we would and who is the civilian doctor: what mattersneed. Meanwhile, we sent additional staff is who’s the best surgeon to take care of theto Guantanamo Bay, from where they could problem. And that’s the person who operates.join the ship when it arrived in Haiti. This We had a very close relationship with theapproach gave us an opportunity to choose Orthopedic Trauma Association, which towardthe staff whose skills best matched the needs the end of the Haitian earthquake sent many ofon the ground. Even though we were fighting the country’s finest orthopedic surgeons downa war in Iraq, we had people in Afghanistan, to the Comfort to deal with some of the mostand we had other deployments going on, difficult trauma problems they’d ever seen.staffing the ship wasn’t a problem. A day and That was a great example of private-militarya half after the disaster, we had roughly 500 partnership.people ready to go when the ship went. As When you look at the areas of responsibil-the situation evolved, we worked with many ity of the different parts of the U.S. govern-nongovernmental organizations (NGOs), ment, what are the borders of humanitarianincluding Project Hope and Operation Smile, assistance and health outreach? Where doeswhich came to assist on the ship. Because we the military stop, where do others take over,had already worked with these organizations who should be where, and when? I think weduring peacetime hospital ship deployments all need to remember that it’s the United Statessince the 2004 tsunami and had become very that we’re representing. We need to workcomfortable with each other, in this time of together to both define and blur those bordersturmoil it was easier to take a civilian organiza- as much as we can. When a hospital ship turnstion and incorporate it into a navy ship. up, it’s usually a big media event and there’s The relationship between the NGOs and a lot of interest paid; it can be a great time tothe military has been developing over the past drive other goals and work together on specificdecade or so. Some NGOs feel threatened if capabilities that a country might need.they’re anywhere close to anyone in military But the military realizes that its approachuniform because they may suffer the conse- is episodic. Except in very specific situations,quences of being perceived as being on one the military is unlikely to be in one place for aside or the other. We respect that, and we want very long time. For many events, our hospitalto maintain a distance when required. Other ships have gone out to a country and stayedNGOs want to work with us because they for a couple of weeks. Working with the hostsee the synergy of the military and civilians country, they can do a lot of things in thoseworking together. two-week periods, but it will be two years When you’re on a hospital ship, you’re on before they come back. Other U.S. governmentone of the largest trauma centers in the world. agencies, the U.S. Agency for InternationalThe navy’s two hospital ships, the Comfort Development, for example, will be in-countryand the Mercy, both have 12 operating rooms long term, supporting domestic organizations.and can take care of 500–1,000 patients at a richard downie  | 13
  • If we in the United States are going to pro- ever. Another is the development of a traumavide humanitarian assistance successfully, the system that allows us to deliver more capablefirst thing that needs to be developed is a good surgery, farther forward than ever. Our abilitygame plan so that we know what assistance will to do aeromedical evacuation of patients frombe helpful and what won’t. Much humanitarian both Iraq and Afghanistan to the U.S. militaryassistance has been provided in a piecemeal hospital in Landstuhl, Germany, and back tofashion, based on the capability and interest of the United States, has evolved through the pastthe organization that’s doing it and what the 10 years into a worldwide trauma system that’sreceiving country or organization says it would saved lives. The army’s Institute of Surgicallike to have, which is sometimes driven by Research, based in San Antonio, has studiedpolitical decisions. We need to come up with all aspects of trauma care, from the momentan objective way to figure out what will benefit of injury, to care in the field, to care at thethe host organization, community, province, or initial hospitals, to what goes on during thecountry. Everybody could then contribute the air evacuation, to what happens in Landstuhl,particular piece of the development process to care for our patients when they come backor the engagement process that will ultimately to the United States. We’ve been able to makebenefit the recipient most. stepwise advances that have made an excellent system even better. Turning from health outreach to lookingafter our own servicemen and women, which One thing that is critical for a surgeon orwas my primary duty as deputy surgeon a physician to have is information about thegeneral for the navy, I look at the wars we patient, preferably before he or she arrives. Inhave been fighting for roughly 10 years now, an ideal world, we would be able to plan theirin two locations; the interesting thing from a treatment in advance, making only minormedical standpoint is that we truly rose to the modifications to take account of what’s hap-occasion. If you look at health outcomes, two pened to the patient in transit. In the military,things stand out. One is that in World War II we require people to move about a lot. Weand in other wars prior to that, the likelihood might need to transfer a patient from Baghdadof becoming incapacitated from illness was to San Antonio; from Kandahar to Bethesda,actually higher than the chances of being killed Maryland, all within three days, without losingin combat. In these latest wars, that’s not been any information about them.the case. This improvement can be attributed The only real way to do this is electroni-to superb leadership and excellent preventive cally, both to transmit images and to transmitmedicine: finding out what’s there, what we are electronic medical records. There’s been a lotlikely to get sick from, and where we should of angst over the past several years about thebuild our bases to avoid exposure to dangerous development of an electronic health record.elements. There have been many proponents and many The other incredible thing that has come naysayers. From personal experience, havingout of these wars has been that even though been treated in at least five different militarywe’ve had many small unit actions in many facilities from the East Coast to Hawaii, it’sdiverse places, the number of people who really refreshing to come in and find my entireactually die from combat has been the lowest record for the past 10 years available to which-of any previous warfare. ever physicians are treating me, to have it there sequentially, and to have them make a decision There are several reasons for this. One based on the data rather than send me to theis that the body armor and the vehicles we lab for my nineteenth blood test that day.have today provide better protection than14 | global health as a bridge to security
  • The key is making the electronic healthrecords user friendly for the provider and alsohaving them available so that the patient getsthe undivided attention of the provider. We’renot quite there yet, but we’re getting closer. ■ richard downie  | 15
  • 4ambassador john e. langeAmbassador John E. Lange (ret.) spent much of thelatter half of his career working on global health andhealth diplomacy issues, including serving as the spe-cial representative on avian and pandemic influenzain the U.S. State Department (2006–2009) and asdeputy global AIDS coordinator for the President’sEmergency Plan for AIDS Relief (2003–2004). Heserved from 1999 to 2002 as U.S. ambassador toBotswana, where HIV/AIDS was his signature issue.He was deputy chief of mission at the U.S. embassyin Dar es Salaam, Tanzania, from 1997 to 1999, andheaded the embassy as chargé d’affaires from Januaryto September 1998. Ambassador Lange currentlyworks for the Bill and Melinda Gates Foundation assenior program officer for Africa in its global policyand advocacy program.I didn’t make the connection between immediate action—whether one-fourth of health and security until I was nominated the adults in a country are HIV positive or by President Bill Clinton to be the U.S. whether one-third of the adults are HIV posi-ambassador to Botswana. When you’re the tive: it’s a disaster in either case. Here was oneU.S. ambassador, you look at the entire range of sub-Saharan Africa’s true success stories,of U.S. interests in the country. Botswana and yet, as one book on the AIDS epidemic inhad many positive things going for it: it was a Botswana put it, “Saturday is for funerals.”1long-standing democracy, it had a free market This was 1999, before the advent of af-orientation, it had a relatively free press, it had fordable, accessible antiretroviral therapy. Thea good military that was clearly under civilian cost for this treatment was some $10,000 percontrol, and it had low levels of corruption. person, per year, which was out of reach forBut when I went there, it was estimated that the vast majority of Batswana. Moreover, at the38 percent of adults aged 15–49 were HIV time, to learn if you were HIV positive, yourpositive. doctor had to send a blood sample to a labora- Subsequent estimates indicate that the tory in South Africa. When I looked at thefigure of 38 percent could have been high.But other than how it affects the individual, 1. Unity Dow and Max Essex, Saturday Is forit doesn’t really matter—for the need to take Funerals (Cambridge: Harvard University Press, 2010).16  |
  • panoply of U.S. interests in Botswana, many would be overwhelmed, and huge resourcesthings were going well, but I thought I needed would be needed to provide medical care toto focus on HIV/AIDS. people as they developed AIDS and eventually died. With that kind of socioeconomic crisis, I didn’t want to be known as the HIV/ more and more young people would becomeAIDS ambassador and have some audiences unhappy—and radicalized—because their livesignore my message. But I ensured that in every weren’t improving while their governmentspeech, no matter the context, I wove in the devoted more and more resources to healthneed for HIV prevention, urging people not to care. An unchecked AIDS epidemic was atake risks and to protect themselves from HIV recipe for political instability.infection. We produced a pamphlet entitled,“The Partnership: Botswana and the United I remember talking to officials of aStates against HIV and AIDS.” We made HIV/ company in one of the worst-affected cities inAIDS a significant focus of every U.S. agency Botswana; they thought they normally neededthat was based in Botswana. One of the great 500 employees but were planning to have 600programs, which predated my arrival, was the on their rolls because they had to take intoBOTUSA partnership involving the Centers account frequent absences of those who werefor Disease Control and Prevention (CDC) suffering from AIDS or had family membersand the Botswana health ministry that focused suffering from AIDS who needed care at home.on prevention, care, treatment, and research Fortunately for Botswana, the president aton HIV, AIDS, and tuberculosis. the time was Festus Mogae, who later received I worked the same way with all seven U.S. global recognition for his leadership on HIV/government agencies on the embassy’s country AIDS. He talked publicly about the threat ofteam. For example, while I was there, the “blank extinction” of the Batswana people.International Law Enforcement Academy was And the minister of health at the time, Joyestablished to train middle-management law Phumaphi, was very energetic and committedenforcement professionals from sub-Saharan to saving the populace. She gave very emo-Africa on a campus just outside Botswana’s tional speeches urging people not to take riskscapital, Gaborone. Working with the program that could result in an HIV infection. Thisdirector, we ensured that the multiweek study leadership was critical for Botswana and, at thecourse included a two-hour program about time, set it apart from some of its neighbors.HIV/AIDS. Some police officers from one During this period, on the world scene,country with a very high HIV infection rate Richard Holbrooke, then the U.S. ambassadortook part and said, “What do we need this for? to the United Nations, organized a historicHIV/AIDS doesn’t affect us.” But it did affect UN Security Council meeting on the impactthem. of AIDS on peace and security in Africa. The In my mind, the connection to secu- January 2000 session was the first councilrity was the destabilizing effects that a large meeting ever devoted to a health issue, and itnumber of deaths could have on a country. made clear the connection between AIDS andThe effects would be much slower moving security and stability.than, for example, a coup d’état. But life I remember in early 2002, the then sec-expectancy could decline, and some people retary of health and human services Tommyin high positions in government would die Thompson brought a delegation of about 50prematurely from AIDS. Tens of thousands, people to Africa to look at the HIV/AIDSeven hundreds of thousands, of children would situation. They came to Botswana from Southgrow up as AIDS orphans. Health services Africa, and it was interesting to hear them richard downie  | 17
  • talk about the contrast. That was a time when measurable objectives that were monitoredkey leaders in South Africa were questioning and evaluated and that required new countrywhether HIV even caused AIDS, and the operational plans and reporting requirements.delegation had left that country dispirited. This effort initially placed an additionalIn Botswana, right across the border, the burden on USAID and CDC staff stationed inargument about whether HIV caused AIDS the PEPFAR focus countries. There was thenever really resonated. It was very clear that usual friction among U.S. government agen-President Mogae and the minister of health cies as the bureaucratic layers tried to workwere deeply engaged, and their leadership together in a way they had not done before.made a major difference in how the country Still, PEPFAR was put together quite quickly.dealt with its AIDS epidemic. I think everyone was well meaning, because— for those who cared about HIV/AIDS—there It was also clear that the U.S. government was a clear realization that this was a historiccared about Botswana’s single-biggest issue opportunity to make an enormous differenceand was a key partner in helping the country in an emergency situation.confront the epidemic. As a result, our supportin combating HIV/AIDS was a major factor in Many actors are working on health issues,expanding the good relations between the U.S. the most important of which are the govern-government and Botswana. ment, private sector, civil society organizations and others in each affected country. Globally, Many other U.S.-based entities helped numerous international and regional organiza-Botswana deal with its terrible HIV situa- tions, governments working multilaterally andtion: the Harvard AIDS Institute, the Bill bilaterally, nongovernmental organizations,and Melinda Gates Foundation, the Merck private foundations, and others are involvedCompany Foundation, the Baylor International in this effort. The U.S. government is withoutPediatric AIDS Initiative, and others. Civil doubt a global leader. The creation of PEPFAR,society’s engagement, coupled with the leader- and the extraordinary amount of moneyship of Botswana’s government, made a huge that came with it, was the major factor backdifference. in 2003. Since that time, other major U.S. About a year after my time in Botswana, programs on health—such as the President’sI was asked to help the U.S. global AIDS Malaria Initiative, coupled with the integrated,coordinator set up the new PEPFAR office in coordinated, and results-driven approachthe State Department. I stayed on as one of two of President Barack Obama’s Global Healthdeputies during the program’s start-up year. I Initiative—have kept the United States in thehad been deeply engaged on this critical health forefront of those caring about improving theissue during my three years in Botswana, and I health of people in developing countries. Thisbrought that concern to the program. undertaking has not only benefited many of It was clear that the United States was the poorest people in the world but has alsoserious about confronting the threat of HIV/ brought great benefit and real political capitalAIDS. PEPFAR was a huge, historic commit- to the U.S. government. That said, I’m not surement to combatting a single disease. While the that the United States is getting all the credit itprogram was based in the U.S. Department deserves for saving as many lives as it has andof State, it was implemented primarily by the for its continued, generous health programsU.S. Agency for International Development delivered on behalf of the American people.(USAID) and the U.S. Department of Health Regarding PEPFAR, the program needs toand Human Services through the CDC. The continue, in part for fundamental humanitar-focus was on having strategic, clear, and ian reasons. We can’t put people on antiretro-18 | global health as a bridge to security
  • viral therapy and then take them off it without produced the National Strategy for Pandemicserious potential medical consequences. More Influenza Implementation Plan. It served inbroadly, however, this program has dramatical- many respects as a blueprint for how to bringly changed countries with high HIV infection the national security interests of the Unitedrates, particularly in southern Africa. In 2010, States into the health field, because it showedI met with the current president of Botswana, how a catastrophic pandemic would affect theIan Khama, and he recalled the days, 10 years entire fabric of American society.earlier, when one would see motorcade after Pandemic preparedness and responsemotorcade of cars going off to rural areas on needed to involve other governments. In thethe weekends to attend funerals. That’s no Department of State, I led a task force calledlonger the case. the Avian Influenza Action Group that sought PEPFAR is saving lives and helping these to work with other countries and internationalcountries get back to normal so that they can and regional organizations in preventing andevelop economically and socially. With the influenza pandemic and in preparing for one ifwidespread use of antiretroviral therapy now we could not prevent it.provided by PEPFAR, as well as by the Global In the United States, every agency in theFund to Fight AIDS, Tuberculosis, and Malaria U.S. government had a role, including theand other organizations, the security threat has Department of Defense, the Departmentgreatly diminished. Countries are now very of Homeland Security, and, of course, theunlikely to suffer from political instability due Department of Health and Human large numbers of HIV/AIDS deaths and the Issues involved vaccine manufacturers, borderdiversion of massive government resources to officials, and even the financial services indus-those suffering from AIDS. Substantial credit try. State and local governments, the privatefor this change goes to PEPFAR. sector, and civil society also had critical roles. The last three years of my Foreign Service The federal government estimated that,career, prior to retirement in 2009, were spent at the peak of a severe pandemic, perhaps 40working on the threat of pandemic influenza. percent of the workforce would be absent.In 2005, President George W. Bush became People could be afraid to leave their homes,very concerned about the threat posed by they could be caring for sick loved ones, theythe H5N1 virus. It was spreading among could be sick themselves, or they could havechickens and other fowl, in Asia in particular, died. And if 40 percent of the workforce isand experts were greatly concerned that it missing at a nuclear power plant, for example,could mutate and become a human influenza that’s a national security concern.pandemic. If we look back on the history ofpandemics, perhaps 40 million people died At the time, many of us looking at thefrom the influenza outbreak of 1918–1919. The spread of H5N1 saw Indonesia as the epicenter.United States therefore considered the pan- It had the largest number of cases of H5N1demic threat to be a matter of national security, among birds, as well as among people. Thebecause literally millions of Americans could CDC needed to be able to monitor the virusdie in a severe outbreak. that was in Indonesia to determine if there were any mutations or changes that would But we couldn’t fight the pandemic threat bring it closer to possibly starting a humanalone; we needed to work globally. Within pandemic (which experts defined as sustainedthe U.S. government, pandemic influenza and efficient human-to-human transmission).policy was driven by what was then called the For that, CDC needed virus samples. But theHomeland Security Council, which in 2006 Indonesian health minister at the time, Siti richard downie  | 19
  • Fadillah Supari, was concerned that if samples advance warning, the delay in preparationswere given to CDC and other laboratories and could have been catastrophic and resulted inthen a pandemic occurred, Indonesia would many needless deaths. In November 2007,not receive lifesaving vaccines until after Minister Supari and I, along with two col-everyone in the United States and other rich leagues, held a one-hour negotiating session incountries had received them—even though the United Nations Office in Geneva. I consid-the vaccines may have been created using ered our discussion to be a frank and candidviruses originally supplied by Indonesia. The exchange of views; she later described it as theU.S. government’s position was that Indonesia most violent argument she ever had.could not claim ownership of a virus, which While these negotiations were goingwas a pathogen. on, the world experienced an influenza This dispute raised a fundamental point pandemic caused by the H1N1 outbreak inabout the difference between looking at an 2009. In a sense, we all dodged a bullet withissue in terms of global health and looking at H1N1 because it turned out to be a moderateit through a national security lens. In global pandemic. In some respects, you could arguehealth, we try to work for the benefit of all. that the delegations negotiating the pandemicFor decades, the World Health Organization’s influenza preparedness framework didn’t getGlobal Influenza Surveillance Network had the message—that pandemics occur, there wasreceived influenza virus samples from all over a real threat out there, and that we urgentlythe world in order to monitor changes that needed to solve this. The negotiations draggedcould affect global health. That network, which on, almost divorced from that reality.included the CDC, needed the free flow of vi- Finally, in May 2011, four years afterrus samples—including those from Indonesia, negotiations began and two years after thewhich were particularly worrisome—for the H1N1 epidemic, the World Health Assemblybenefit of the world. adopted a pandemic influenza preparedness By looking at this question through its framework that put the sharing of influenzaown national security lens, however, Indonesia samples on an equal footing with benefitswas disrupting the institutional order and the derived from those samples. Now a structurelong-standing precedent of unencumbered is in place whereby the companies that benefitvirus sharing. In May 2007, the Indonesian from receiving virus samples, such as vaccinedelegation brought the issue before the World manufacturers, will pay a certain amount toHealth Assembly. I was on the U.S. delegation, help the Global Influenza Surveillance andand we negotiated for long hours. In the end, Response System defray its expenses. They canthe best we could accomplish was unanimous contribute in a variety of ways, but the ideapassage of a resolution that created a negotiat- is that developing countries will derive someing process. Indonesia’s concern about being benefits from sharing samples of influenzarequired to share virus samples without receiv- viruses with pandemic guaranteed benefits in return resonated When we look at this issue from thewith a group of developing countries. perspective of global health diplomacy, we can Subsequent diplomatic negotiations were see the distinction between meeting immediatedifficult but dealt with an issue of paramount health needs and participating in cumbersome,concern. If the H5N1 virus mutated in multilateral negotiating processes that canIndonesia to the point where a pandemic take years to conclude because of the manyactually began, and if Indonesia had not been vested interests and legal, foreign policy, andsharing those virus samples to give the world health issues to be resolved. It was almost as if20 | global health as a bridge to security
  • the reality on the ground was irrelevant to thenegotiations. As we look at some of today’s pressingglobal health issues—including the spreadof HIV/AIDS, the continuing threat frompandemic influenza, the millions who diefrom diseases that are easily preventable byvaccines, the opportunities to eradicate polioand other diseases, and the need to improvethe health of women and children to save livesand to enhance productivity and social andeconomic participation—we see that healthis critical to a country’s development and, inparticular cases, has a definite, direct impacton a country’s security and stability. And that,in turn, can have a significant impact on U.S.national security. For many reasons relatedto its national interests, including the funda-mental humanitarian goal of helping those inneed, the U.S. government has responded to amultitude of global health challenges. Millionsof people are alive today as a direct result ofthat response. ■ richard downie  | 21
  • 5ellen embreyEllen Embrey spent 35 years in the federal govern-ment, serving in a variety of positions straddling thefields of national security and public health. She wasacting assistant secretary of defense for health affairsat the U.S. Department of Defense from 2009 to2010; deputy assistant secretary of defense for forcehealth protection and readiness from 2002 to 2010;and deputy assistant secretary of defense for militaryassistance to civil authorities from 1998 to 2001.Currently, Ms. Embrey is a counselor at the CohenGroup and president and chief executive officer ofStratitia, a management consulting firm she startedup after leaving government service.H ealth and national security clearly more engagement with these colleagues, I intersected in my various positions at appreciated the need to invest in the research the Department of Defense (DOD)— necessary to protect not only U.S. citizens butfirst in my work on disaster and emergency also any citizen against these kinds of weapons.response policy and, second, in ensuring the As a result, I started getting more and morehealth and medical readiness of our troops and involved.the medical forces that support them. I changed jobs after September 11, 2001, The links became clear to me in 1993 and began working on Department of Defenseafter the first World Trade Center bombing, force health protection issues, where I focusedwhich killed six people. The attack prompted on understanding and protecting against thea considerable effort in trying to understand health threats to our military personnel, par-emerging threats to our country. I knew noth- ticularly when they were deployed around theing about health at the time; I was working world. Because part of this effort meant tryingin disaster response policy and coordination. to understand emerging infectious diseases, IBut I got to talk to experts on bioterrorism, got involved in global health surveillance andwho had concerns about the threat of infec- in understanding ways to collect and monitortious diseases being used as weapons. They information about diseases and examining thewere saying that our nation had no ability to potential impact they might have.protect its citizens against these threats. After22  |
  • Soon after 9/11, the issue of biological that emerged. We undertook a different, but noweapons came up in Iraq. Did Iraq have these less significant, effort to protect our deployingweapons, and if we went there, how would forces against anthrax attacks, which we saw aswe protect our forces? My very first task in the most likely potential biological threat theyDOD force health protection was to work might face in Iraq and Afghanistan.with the Food and Drug Administration, the Together, the ongoing operations in IraqDepartment of Health and Human Services, and Afghanistan represent the U.S. military’sand Wyeth Laboratories, the company that longest continuous conflict. We’ve had tomanufactured the smallpox vaccine, to bring adapt to a series of health challenges for forceit back to life so that we could administer it protection, and I think we’ve improved the wayto our troops. It had been more than 20 years we operate as a result.since the vaccine had been used.1 The effortto ensure that the old vaccine was safe and The size of our military hasn’t grown thateffective and to build a reliable and effective much, despite the burden of these conflicts.screening, education, and vaccine administra- Over the past 10 years, many servicemen andtion capability for deploying troops was a huge women have deployed at least three timesundertaking, and it had to be done in less than either directly in theater or in supportingsix months. combat operations. You can see the effects in some people, with higher rates of depression At the time, it was considered to be a risky and of anxiety and sleep disorders than beforevaccine because there was a fairly high rate of the wars. These problems are also symptoms ofassociated morbidity, particularly triggering traumatic brain injury (TBI), which some haveneurological and cardiac complications in characterized as the signature wound of thiscertain high-risk people. war. Certainly, TBI is closely linked to what I We had to come up with a very strong would say is the signature weapon of the war,screening process to ensure we didn’t vac- improvised explosive devices. The cumulativecinate people at risk of complications from the effects of exposure to these explosions on thevaccine, as well as to check that the vaccine head, brain, inner ear, balance, and cognitionactually offered protection. The screening can affect soldiers’ ability to perform, evenprocess involved taking comprehensive though they might not realize histories, excluding those at risk of Mild TBI may be far more prevalent thanexperiencing complications from the vaccine, posttraumatic stress disorder (PTSD)—a veryand holding an educational session where we acute and then potentially chronic problemdescribed how to protect and prevent spread of usually related to a specific incident of trauma.the live virus while the vaccination site healed But it has very similar symptoms; soldiers findand produced the signature smallpox scar. We they get anxious, irritable, can’t sleep very well,aggressively monitored the daily health status and can’t focus or concentrate. Although DODof every person for 10 days after vaccination invested significantly in research to betterand set up an elaborate adverse reporting understand how to identify, diagnose, treat,system to make sure we understood and and recover from TBI, as yet we don’t havereacted in a timely way to any new health risks the sophisticated diagnostic tools in place to definitively distinguish a mild-to-moderate 1. The United States stopped childhood vac-cinations in 1977, and in 1980 the World Health TBI diagnosis from a PTSD or severe depres-Organization declared that smallpox had been sion diagnosis. The diagnosis is complicated byeradicated from the globe. the fact that because blasts usually have trauma richard downie  | 23
  • associated with them, it is not infeasible that The conflicts of the past decade or so haveour warriors are legitimately suffering symp- also spurred improvements to our militarytoms from both at the same time. health system. Before the wars, we used a fleet of dedicated aircraft just for medical purposes. Understanding brain injury has been But because they had become very old andthis war’s biggest health challenge, but it has expensive to operate, we made a decision inalso been the one that’s yielded the greatest the year before we actually went into Iraq tohope, not only for the U.S. military but also use opportunistic airlift, so that when someonefor civilians as well, who have benefited from was wounded, any aircraft in the area couldthe research. DOD has partnered with the pick him or her up.National Football League and hockey leagues,for example, to do extensive research on how We put portable, certified airworthybrain injuries occur and how to improve our “stabilization and care suites” into our aircraft,knowledge of what it takes to help the injured with a common set of medical supplies andperson recover. helped streamline patient movement protocols across the armed services. We also improved Congress has given us millions of dollars our medical supply chain management fromto research the problem, including fund- garrison to theater. The daytime heat ining the Defense Centers of Excellence for Afghanistan and Iraq meant we had to comePsychological Health and Traumatic Brain up with more effective ways to acquire, collect,Injury. The Department of Veterans Affairs store, transfer, track, and use blood and otherand DOD collaborate through the center to cold chain medical supplies.better understand TBI and PTSD. They’veworked with the national governing body We created what we call the joint theaterthat creates diagnosis codes to include the trauma system to improve the evacuationkinds of brain injuries we’re seeing from Iraq of injured personnel from the battlefield byand Afghanistan. Now physicians have more ensuring they were taken not necessarily todiscrete ways to characterize and evaluate the nearest facility but to the place where theirthe extent to which TBI is affecting a person’s requirements could best be met, even if it was acognitive function. two-hour flight away. We have reached a point where less than 72 hours passes from the point New technologies at various stages of of injury to life-saving surgery and stabiliza-clinical trials will help determine the brain’s tion in theater and then to the United Statesperformance, and a significant amount of work for critical care, rehabilitation, and recovery.has been done to collect baseline information That’s pretty amazing, and it’s due to theabout cognitive function prior to troop deploy- commitment and dedication of all the talentedment, so that we can understand people’s people involved.brain function before they are sent into awar environment. If servicemen or women We have also made big advances in opera-are exposed to anything during their deploy- tional medicine. We’ve learned how to management that could affect the brain, we have new bleeding through new technologies and bypolicies in place to respond. Instead of saying, issuing easy to use, self-apply tourniquets to“Shake it off, keep going,” they must now be our soldiers. I would say that thousands of livesadministered a test and the results must be were saved as a result. We’ve also learned thatcompared to those of the baseline test before in trauma situations, controlling the tempera-they first deployed. ture and the hydration of the patient has made24 | global health as a bridge to security
  • a big difference in survival rates. That realiza- varying treatment, from isolation to coddlingtion has fundamentally changed emergency to being sent home to being forced to “shake itmedicine, even in the United States. off and move on.” On top of that, we’ve also made significant At every site, we provided oral feedback toprogress, in collaboration with the Department the commanders so that they understood theof Veterans Affairs, in producing much more areas they needed to pay attention to. A lot ofsophisticated prosthetics and have added to different issues came up, including the needour knowledge of restorative care and recovery for better training and awareness, a consistentfor post-amputation. Among other advances, policy, a better understanding of how victimswe now have prosthetic knees that bend so that should be treated, and the kinds of counsel-the person can walk up and down stairs more ing and support that should be offered. Ournaturally. The list is too long to detail, but the report resulted in the creation of a programemphasis on helping to restore capability for that implemented virtually every one of ourour wounded and injured warriors has led to recommendations.some pretty amazing developments that will There are a small number of sexual preda-have significant implications for the civilian tors in the military just as there are on themedical world. civilian side. We are a reflection of the popula- The conflicts in Iraq and Afghanistan tion from which we draw. And the predatorsalso exposed other, very different, challenges are very good at hiding their behavior andrelated to the health and security of our forces. their actions. They are the people that ourRelatively early in the conflict, there were programs were primarily organized to detect.reports of an increasing number of sexual While I think very good structures are in placeassaults committed in theater by U.S. military right now, the military still doesn’t have a goodpersonnel on their colleagues. Defense handle on alcohol abuse and binge drinking,Secretary Donald Rumsfeld thought this was which are prime contributors to these kinds ofa command issue and ordered a quick DOD- incidents.wide assessment of the processes then in effect The wars in Iraq and Afghanistan havefor reporting assaults, the services available to also taught us lessons about how the militaryindividuals who had been raped or sexually can best use its assets to promote public healthassaulted, the repercussions for individuals among the people with whom we interact.that reported abuse, how the guilty were held Undoubtedly, health leads to stability, andaccountable, and the quality of the care that stability leads to security. It’s a very clear,was offered. repeated, proven path. I was asked to lead that taskforce. We During peacetime, the military cancarried out a 90-day assessment of the system, leverage its relatively large footprint overseasand we went to several U.S. bases and every to help arrest instability and economic declinemajor base in Iraq and Afghanistan. We talked by working with military or civilian partnersto commanders, victims, law enforcement offi- to build infrastructure and capability aroundcials, counselors, and the medical community. public health. When disasters strike, we co-We found that the rate of reported instances ordinate through our embassy on the groundof sexual assault in the military was actually to lend assistance. When we’re in conflict,lower than in the private sector; however, the wearing the uniform becomes a challenge forreason for this was that people were afraid the U.S. military because we carry guns and yetto report and it was difficult to report. When at the same time we’re trying to protect peoplepeople did report abuse, they got widely and sustain their health. That’s something of richard downie  | 25
  • a contradiction to people, and even our own and as a result we’re more willing to work withgovernment recognizes this. I think the State nongovernmental organizations and others toDepartment is less enthusiastic about the make sure that when we go into countries werole of the military in providing global health give them the kind of support that allows themsupport during times of war. to succeed on their own in the long run. ■ In my view, what the military does best iscreate the conditions for stability in nationsthrough building infrastructure—lighting,roads, water facilities—and then helping thosenations preserve that capability so that it canlead to more permanent stability and security.I think the U.S. coalition in Afghanistan,which included both civilian and militaryassets, learned that it shouldn’t immediatelybuild sophisticated modern medical facilitiesand equipment for a country that has limitedpotable water, weak electrical power grids, andlimited medical training. We later refocusedour efforts on introducing basic infrastructure,meeting basic public health needs, and provid-ing training programs that allow people tooperate in ways consistent with their cultureand beliefs, not ours. We learned to be moresensitive to capabilities, resources, and basicneeds when we make our plans to provideglobal health assistance and to communicateand collaborate in a much more culturallyappropriate way. When we first went into Afghanistan,children were not being vaccinated againstchildhood diseases, and few if any womengot regular health care. The mortality rate forpregnant women and babies was incrediblyhigh. Together with the State Department, weintroduced vaccination programs and prenatalcare, but I wouldn’t say our effort was a totalsuccess because there were cultural issues wedidn’t think enough about. I think the United States has probablylearned these lessons before, but I’m not surethat we’ve applied them, and that has held usback from effectively planning and providingearly, meaningful, and useful assistance that’swell received. I think U.S. global health pro-grams are slowly realizing this shortcoming,26 | global health as a bridge to security
  • 6ambassador donald steinbergDonald Steinberg is deputy administrator at the U.S.Agency for International Development. Previously, hewas deputy president for policy at the InternationalCrisis Group. During a three-decade-long career inthe U.S. government, Ambassador Steinberg servedin a variety of positions, including director of theState Department’s Joint Policy Council, deputyWhite House press secretary, senior director forAfrican affairs at the National Security Council, U.S.ambassador to Angola from 1995 to 1998, specialrepresentative of the president for humanitariande-mining, and officer-in-charge at the U.S. Embassyin South Africa during the transition from apartheidto nonracial democracy.T here is a direct link between health and Later, when I served as U.S. ambassador to security in several key areas. When Angola, one of my key roles was to support a you are involved in peace processes peace process designed to end 25 years of civiland trying to bring warring parties together, war. Because the government and oppositionfor instance, health is often a “soft” issue that UNITA forces frequently refused to come tocan be used to draw people together and seek the table to discuss substantive peace processconsensus. issues, we used a nationwide polio eradication effort as a unifying factor. We got both sides When I served at the U.S. Embassy in to set up vaccination programs throughoutSouth Africa during that country’s transition the country, which helped extend nationalfrom apartheid to nonracial democracy, for ex- administrative control throughout the entireample, we would draw together the apartheid territory, opening up areas of Angola that hadgovernment, the African National Congress, previously been either completely governmentother political parties, and civil society groups controlled or completely rebel discuss HIV/AIDS. It was essential forthese groups to remember that the political Equally important, the effort reminded thenegotiations and interracial machinations were armed forces on both sides that larger issuestaking place against the backdrop of an AIDS were at play: Angola was losing as many peopleepidemic that could potentially sweep away all to diseases, whether malaria or HIV/AIDS orthe progress that could be achieved. polio, as it was to the conflict itself. |  27
  • There is no stronger signal that a peace restoring a strong and accountable police orprocess is working than improvement in health military force. To have meaning, peace must beconditions or, conversely, that a peace process reflected in improved socioeconomic condi-is failing than a deterioration in those condi- tions and an end to other forms of violence intions. In modern conflict, it is civilians who society. Unless you do a peace process prop-suffer the most, about 90 percent of the deaths erly, the end of conflict on the battlefield canthat occur. Further, the death and suffering simply lead to a different kind of violence inthat result from poor health conditions, poor society. If you demobilize soldiers, you need toeducational conditions, sexual and gender- provide them with skills, psychosocial support,based violence, and other socioeconomic and resources; otherwise, they find themselvesconditions swamp the impact of the conflict alienated and disempowered when they goitself. back to the communities they left and find that their wives and families have moved on. If that In Angola, our peace commission worked happens, there is a rash of domestic violence,not only on issues related to disarmament, rape, alcoholism, drug abuse, and divorce. It’ssecurity sector reform, and forming a unity as if the end of the formal conflict is simply thegovernment but also on mother-child health beginning of a new and more pernicious formcare, psychosocial programs for the victims of violence, usually against women.of violence during the conflict, assisting thesurvivors of land-mine accidents, and so on. Indeed, women must be factored into peace processes more directly and from the Regarding land mines, at the time the outset. Yet, in the initial stages of negotiations,peace agreement was signed, about 4 million the mediator and armed combatants almostAngolans were displaced out of a population of always fail to incorporate key socioeconomicabout 12 million people, and about 1 million and accountability issues into the mines had been planted throughout the The process usually addresses formation ofcountry. We wanted to get people home as a national unity government, disarming andquickly as possible so that they could get their demobilizing soldiers, and putting into placelives going again. We de-mined the major commissions to extend government controlroads, but mines were everywhere; they af- of the national territory. Civil society gets thefected the ability of people to farm their fields, message: the peace process is designed for thereach water sources, and collect firewood. The men with the guns, not for them.return of people to their homes without theclearance of these mines led to a massive flood In postconflict situations, you need toof land-mine accidents. Even where land-mine build popular support for peace and security asaccidents didn’t occur, they stopped life from a way of life. You need to bring in civil societygetting back to normal. On top of that, about as planners and implementers of all programs25,000 land-mine survivors injured during the and demonstrate the real benefits that theconflict itself were in desperate need of health population is getting from the peace This was one of the biggest challenges That can be through expanded education forwe faced, and it remains so today, just as it their kids and better infrastructure for thedoes in Vietnam, Laos, Cambodia, Iraq, and country—lights, electricity, and water—butAfghanistan. a key element is restoring health systems. In Iraq, for example, the hospitals stopped The United States is coming to accept running in the immediate postconflict period.the whole concept of human security: that People knew that; they viewed it as a sign thatis, the idea that when you’re trying to bring their lives had gotten worse, and it added toan end to conflict, security doesn’t mean just the instability.28 | global health as a bridge to security
  • The challenges of engaging in health to build institutions, whether it’s governmentin postconflict and emergency situations health ministries or whether it’s civil societyabroad have brought about changes in the institutions, that can then deliver a moreway we do business as a government. The fundamental form of health in a postconflictvarious agencies that are involved in global issues—the principal three being the South Sudan is a perfect example. We’vePresident’s Emergency Plan for AIDS Relief been working very diligently to build up(PEPFAR), the Centers for Disease Control health systems there, and the improvementsand Prevention (CDC), and USAID—have in maternal mortality, child mortality, andcome together with a whole-of-government nutrition have been impressive over the periodapproach. since the North-South peace agreement was Haiti provides a good example. In the signed. Yet, the recent austerity and insecurityperiod after the 2010 earthquake, PEPFAR, have produced food shortages, disease out-CDC, and USAID came together in response breaks, and population displacement that haveto the destruction of Haiti’s health system forced us to divert our resources for long-termto define what our specific roles were and to development assistance to immediate needs.make sure we weren’t stepping on each other’s As we look ahead, we recognize thattoes. But beyond that, there was a synergy poverty, malnutrition, and instability abroadamong our activities. When, eight months after are among the greatest national security threatsthe earthquake, a devastating cholera epidemic the United States faces. We need to rememberbroke out, we were able to use HIV/AIDS that countries that are healthy, prosperous, andplatforms that PEPFAR had set up to distribute secure don’t tend to traffic in drugs, people,Ringer’s Lactate (a fluid replenishment solution and weapons; they don’t send off huge num-administered intravenously), clean water, and bers of refugees across borders and oceans;oral rehydration therapy. they don’t transmit pandemic diseases; they Haiti’s cholera epidemic fundamentally don’t house pirates or terrorists; and they don’tundercut the reconstruction effort. We re- require American troops on the ground. Thesponded well as an international community, nexus between our own national security andand, fortunately, that response helped build well-fed, healthy populations abroad is clear.up systems that will address broader public It’s also important for health issues to behealth throughout Haiti. But there was clearly viewed in the context of American interestsa trade-off. We had to move a lot of resources and influence abroad. Health issues are ainto the purchase of basic commodities that means for the United States to build up creditswould otherwise have been available for more in the “soft power” account. To the extentbasic health system strengthening. that you’re demonstrating your interest in In such situations, you’re always torn the well-being of Angolans or South Africansbetween addressing the crisis right in front or host-country citizens, such credits giveof your eyes and building systems that will you access and help soften the edges of otherexpand public health in the longer run. If you actions you have to take as the representativedo it right, you can build systems that both of a superpower. ■respond to the immediate crisis and addresslong-term development, but it’s difficult.When one of these crises hits, you are flushwith resources that you will not have later. Youtherefore have to use those resources effectively richard downie  | 29
  • 7general peter paceGeneral Peter Pace (USMC, ret.) served as the six-teenth chairman of the Joint Chiefs of Staff from 2005to 2007. He was the first marine to hold the nation’smost senior military position. His other four-starassignments included a term as vice chairman of theJoint Chiefs from 2001 to 2005 and as commanderin chief of the U.S. Southern Command from 2000 to2001.M y thinking about health and secu- the capital, Mogadishu, and the country, in rity went through an interesting December 1992. The second time was after the transition during the 40 years of my United Nations had taken control, after Blackmilitary career. As a young lieutenant, a rifle Hawk Down; because of the realization thatplatoon leader in combat in Vietnam, I was things were not going well, we went back in forconcerned about the health and well-being an additional six months. The living conditionsof my troops but not overly concerned about in Mogadishu were horrendous. When youthe civilian population in my area because we drive through a city and you see kids pickingwere transiting all the time and didn’t have through a trash dump, looking for food, youresponsibility for one specific place. If we saw know you’re in a situation where the healthsomebody we could help, we did, but it wasn’t needs of the population are enormous. It waspart of my day-to-day process to think who we during this second tour that I began to thinkcould help today. more about what we might use, other than force, to gain the influence we wanted to have. It was in Somalia, where I spent a total ofnine months in the 1990s, that the possibility When I was commander in chief of theof strategic medical impact first crystallized in U.S. Southern Command, all our engage-my mind. I went in as a deputy commander ment in South and Central America and theof the marine force whose mission was to take Caribbean centered on doing good works.30  |
  • Many of the things that I asked for were both of those questions is yes, then you are infocused on medical teams. I was delighted good shape. Folks who answer yes and yes arewhen I was allocated the USNS Comfort, the not going to be revolutionaries. If the answernavy medical ship, to take a swing around all to one of those questions is no, then you haveof South America, because that meant that we got to ask yourself what the problem is here.were going to do a lot of good and also gener- We gained enormous credibility withate a lot of good feeling for the United States. many people in Pakistan, for example, when When I was vice chairman and then we responded to the earthquake and resultingchairman of the Joint Chiefs, it seemed clear flooding that occurred in 2005. We did theto me that as you try to persuade people in right thing for the right reason, and the peoplethe countries you’re involved in that your way appreciated that. That goodwill has dissipatedof life is better than the way of life they have over time because of the kinetic action thatbeen living, you should focus on things that followed; militarily, we had to go get Osamahave immediate impact for them. Medical bin Laden, which was also the right thing forassistance plays a big part. To the extent that the right reason, and that upset the do medical activities for a population, you But even in a country that, arguably, is halfincrease the probability of making friends, and for and half against the United States, you canyou decrease the probability of having to get see that when you go in with no prejudgmentinto a gunfight with them. other than responding to a disaster, that help is very much appreciated. I am proud that I was a proponent ofstanding up the U.S. Africa Command. We In the planning to go into Afghanistanspecifically set it up as a joint interagency and later into Iraq, a great deal of thoughtcommand, not just U.S. military. The proposal was given to medical issues. First, for ourwas to have, in addition to a military com- own medical needs, you want to make suremander and a military deputy, a second deputy that when you send Private First Class Pacewho would be an ambassador in the State into battle, you’re prepared to take care of hisDepartment and then senior leadership from wounds and any other health issues he has. ButUSAID. In other words, all the elements of U.S. in the formative stages before the battle begins,national power were represented. This entity there’s also a great deal of preparation for help-would prevent conflict on the continent by ing the civilian population. Then, everybodygetting in early, by affecting people’s lives early, goes into his or her lane. As a senior officer,so that when al Qaeda came along and said, I’m relying on my medical officer to help me“What have these guys done for you lately?” understand whether or not the plan we havepeople would say, “Wait a minute—these folks is working and what else we might do for ourare here. They’re helping us build schools. own troops, the civilian population, and—byThey’re doing all the things, other than shoot- the way—the enemy wounded who come intoing, that help change a nation.” our hands. I’m a huge proponent of that. Let’s get Once you’ve completed the militarythe population to the point where they are operation and you’ve secured Baghdad, forconfident that their government is working for example, then you start refocusing. You ask,them and they believe that tomorrow is going How do we consolidate what we’ve done? Howto be better than today. If you can walk up do we start fixing things that we’ve destroyed?to someone in any country and ask them, “Is How do we get the population’s support? Andtoday better than yesterday? Is tomorrow going the more you think about the impact of whatto be better than today?” and the answer to you’ve done and the need to have the local richard downie  | 31
  • population be supportive, the more that things Pace in a town in Afghanistan or Iraq, tryinglike medical outreach come to the fore. to run the water works, trying to run the medical facilities, because he’s the guy on the You learn as you go. One thing we learned ground. We’ve recognized that problem, butwas that we needed to have smaller teams we have yet to respond to it as a nation. Youavailable in more places to find out what have your military medical teams that you canpeople needed. Those teams included medical deploy all over the world, but there’s so muchfolks who could assess the health of the local more in a nation’s capacity that’s not “deploy-population and make some determinations able.” I felt we were lacking the whole civilianabout what could be done right now. For piece during the six years that I was part of theexample, would a dentist visit here for a day leadership responsible for the conduct of themake a huge difference? And in most places war in Afghanistan and Iraq, and I still feelthe answer was yes, it would. like that today. We’re using the wrong tools in The nature of warfare has changed. We’ve many cases.moved from an approach of complete devasta- If we really believe that our medicaltion—destroying another country, its cities capability—as one example—is a true differen-and crops—to an understanding that what tiator and a strategic asset, then why wouldn’tyou’re trying to do is influence populations. In we have more than just the U.S. militaryWorld War II, because there were no precision configured to be able to deploy? Why doesn’tweapons, you laid down as many bombs as you the nation have a system like the Nationalcould, as close to the target as you could, in Guard whereby in the event of humanitarianthe hope that you’d also get the target. During need, disaster relief, or postwar reconstruction,World War II, to take out a bridge, you’d need doctors and nurses go overseas for six months3,000 bombs, on average. In this war and or a year to apply their skills and talents? Ofthe next war, it’s one bomb, one bridge. The course, if you’re going to put people in harm’samount of destruction is very much dimin- way, you’ve got to train them in how to dealished, which allows you to spend fewer of your with that. But if you’re serious about both theresources rebuilding a country’s infrastructure human value of doing the right thing and theand more of your resources, more quickly, on impact value of doing the right thing, then youthings like medical engagement. ought to get more people involved than just the I think there’s been a positive evolution, U.S. military.not only in the way that force is applied but When I consider the health impact on ouralso in our understanding of the other ele- own military personnel of the wars of the pastments of national power, like our medical decade or more, there’s a fundamental reasonassets. We’re one of the very few nations on why I think the strain on the force has beenthe planet that has that capability. I’m proud bearable. When I came back from Vietnam,that when disasters happen around the world, those fellow citizens who thought we wereit’s not long before a U.S. aircraft carrier or an doing the right thing were very warm towardamphibious ship or the USNS Comfort shows me, appreciated me, and said thank you. Thoseup and we start helping as best we can. who thought we were doing the wrong thing The problem from my perspective, as a were hostile and were willing to accost me inmilitary guy, is that often it’s only the U.S. public. What has happened in the subsequentmilitary on the ground. Only the U.S. military 40 years is that the population has matured,has the capacity to order people overseas as has the military. Nowadays, when peoplequickly to do things. You end up with Major don’t agree with what we’re doing, they will32 | global health as a bridge to security
  • say so, but they’ll also say that they appreciate would be hugely valuable to me. I would thenour willingness to do it. Today, the members know that after three deployments, you stop.of the U.S. military feel very much appreciated I could use that data to better protect my menby their fellow citizens, and that’s critical to the and of the force. Another problem is that the macho part Since 2001, less than 1 percent of the na- of what we do gets in the way of taking care oftion has been defending the 99 percent. They our troops’ medical needs. In my own experi-have done so as volunteers. You have a need ence, I know that marines are proud of the factfor forces overseas, which until recently was that we don’t lose. We’re going to do whateverprobably close to 400,000 when you add up it takes to win. I love that attitude; I’ve livedall the deployments around the world. It’s not it for 40 plus years. The problem is that now,like World War II where you could conscript when Sergeant Pace comes home and is a littlepeople, send them to war, and then bring them bit sideways emotionally, he thinks it’s nothome when it was over. We’re in year 11 of this warrior-like to look for help. We spent a lot ofwar, and our enemy has told us they have a leadership time in the last part of my tenure100-year plan. We can have arguments all day trying to identify and help soldiers and ma-about the rights and wrongs of going into Iraq rines understand that it’s OK to get help. Theyand Afghanistan, but the fact is, until we defeat may not have suffered a wound that bleeds, butal Qaeda and its philosophy, we’re going to be it’s a wound all the this war, which means we’re going to have to I think we’ve done a much better job ofkeep up this kind of tempo. knowing what to look for in our predeploy- Since 2001, we’ve had great young ment briefings to the troops themselves andAmericans who’ve been on five, six, even eight to their families. I think we’ve done a reallydeployments. It takes a toll when they’re there, good job of postdeployment briefings andand it takes a toll when they come home. And checkups. But if it’s a journey of 100 miles, Ifor kids born during the past 10 years whose would guess we’ve probably gone the first or dad or both are in the military, they’ve You can understand that Sergeant Pace, who’sseen nothing but mom or dad or both home looking to get home, probably isn’t going to sayfor a year, gone for a year, home for a year, anything that’s going to delay his departure. Ifgone for a year. That does a lot of damage, yet you say to him, just as he’s getting on the planeto be totally understood. to go home, “Hey, how are you doing today?” he’s not going to tell you that he needs some We have no clue about the psychological medical help. He’s going to tell you, “Great!”impact of this many deployments, not only so that he can get on that plane, get home, andon the troops themselves but also on their hug his wife and kids. That’s why the follow-upfamilies. I am working with a company that is so important—the one-month, two-month,crunches data in unique ways, and I’ve asked three-month, six-month rechecks with thethem to take a look at this issue. Take all families and with the troops themselvesthe data we have about posttraumatic stress after they’ve had a chance to get home anddisorder, for example, and crunch it to see decompress.whether there is a common denominator. Forexample, if you could tell me that somewhere The families are important because they’reafter the third deployment and before the the glue that holds everything together. Youfifth deployment, the probability dramatically recruit individuals, but you retain families.increases that Sergeant Pace will come home Guys like me deploy and come back, deploywith emotional problems, that information and come back, but our families have more richard downie  | 33
  • strain. If I’m gone, I know when I’m in trouble. combat, and then you’ve got the destructionAnd I know as a marine that if I’m going to and the population to deal in trouble, there’s no place else I’d rather be My bottom line is that we’ve identifiedthan with a bunch of other marines. My family medical opportunities in these countries. Takehas no clue when I’m in trouble, and every day any mother, any father. First of all, they wantI’m away, they’re thinking the worst. Then, their kids to be healthy. You look at your baby,when you come home, you have to go through you look at your daughter, you look at youra process of reassimilation. I don’t care how son, and if they’ve got medical problems andmuch people love each other; you know that you can’t do anything about it, you feel despair.when you’ve been gone for a year, there are Folks coming in from the outside promisinglumps and bumps in relationships that have to you a better life start to resonate with smoothed out. Medical outreach is the right thing to do as a When I was chairman of the Joint Chiefs, fellow human being. The outcome is that fami-stress on the force and stress on the family lies will have the ability to answer yes and yesplayed a major part in discussions about troop to those two questions about whether thingsdeployments. When we debriefed President are better today and will be better tomorrow.Bush on how we could do a surge in Iraq, We’re a great nation that truly does care.we told him that it would mean extending Now we need to figure out how to take thedeployments from 12 months to 15 months lessons we’ve identified from the recent conflictand that would affect the guys on the ground and translate them into policies and processesas well as all those families who thought their that allow us to more quickly make a positiveloved ones were coming home in January but impact on people’s health. ■now wouldn’t see them until April. That wasvery much part of the dialogue, which is why,when President Bush made his decision, healso increased the size of the army and theMarine Corps, to get the deployments back to12 months as quickly as possible. Obviously when you talk about the warsin Iraq and Afghanistan, you can have lots andlots of arguments on both sides of that issue.But once our nation’s leaders had made thedecision that it was important for us to go in,the question became, What’s our goal? What’s clear is that whether you start outusing military force or you start out usinghumanitarian assistance, at the end of the day,you end up doing humanitarian assistance.And that’s why our medical personnel are al-ways important. Sometimes they’re importantfrom the get-go, because USNS Comfort showsup and you go in and it’s all about disaster re-lief or tsunami relief, for example. Sometimesyou go into a country like Afghanistan, there’s34 | global health as a bridge to security
  • 8ambassador jendayi e. frazerJendayi E. Frazer is Distinguished Public ServiceProfessor at Carnegie Mellon University in the H.John Heinz III College’s School of Public Policy andManagement. Ambassador Frazer spent a decade ina variety of senior government positions related toAfrica, including serving as special assistant to thepresident and senior director of African affairs at theNational Security Council from 2001 to 2004, U.S.ambassador to South Africa from 2004 to 2005, andassistant secretary of state for African affairs from2005 to 2009. She was instrumental in establishingsome of the Bush administration’s flagship initiativesin Africa, including the President’s Emergency Planfor AIDS Relief (PEPFAR) and the MillenniumChallenge Account.H ealth is absolutely critical to the caused by the health impact these conflicts stability of societies in Africa. A had on societies. Populations were on the decade or so ago, huge numbers of move constantly. Because people were living inpeople were dying from HIV/AIDS. We were unsanitary conditions, without access to healthseeing the entire middle class of some coun- care or adequate nutrition, they were moretries wiped out. How could there be a stable vulnerable to diseases. The high morbiditysociety, a prosperous society, a secure society, rates in the DRC were the outcome of this lackif all the professionals, the teachers, the nurses, of stability.were dying of AIDS? Children were being left I think all these considerations have led toas orphans; grandparents were raising little health becoming an integral component of It was a tremendous crisis that required a national security policy and national securityglobal response. interests. We obviously understand that, In addition, we had the health impact of because diseases don’t respect borders, a globalcivil wars and guerrilla struggles, such as those approach to public health is required. I thinkin the Democratic Republic of Congo (DRC). the United States has become more aware ofMost of the deaths that happened in the Congo and responsive to the issues.during the two wars of the 1990s and early Security and health came together for me2000s were not caused by bullets; they were when I was at the National Security Council |  35
  • during the Clinton administration. At the time, to keep the White House Office of Nationalthere was a lot of discussion about trying to AIDS Policy, and I think that was very helpful.raise the profile of HIV and AIDS internation- In addition, some of us in the administra-ally; the Clinton administration declared a tion wanted to do far more in Africa, given“war on AIDS” as a means of conveying a sense the emergency nature of the crisis there. Inof urgency. One of the ways of framing the May 2001, a team of us accompanied Secretaryissue that came up when Richard Holbrooke Powell to Africa. We went to Kenya, Mali, andwas the U.S. ambassador to the United Nations South Africa, where we saw people who didn’twas to link HIV/AIDS with peacekeeping. have access to antiretroviral drugs dying ofThe administration had already conducted a AIDS. When we returned, with the support ofnational security estimate about the impact of National Security Adviser Condoleezza Rice,AIDS on global security and stability, and the we were able to push the issue fairly high uplogic was to point to the problem of HIV/AIDS the agenda, to the point where the presidentamong peacekeepers and how it affected their picked it up as well; it was then decided in theability to serve in UN missions such as the one White House early on to do something big onin the Congo. HIV/AIDS. We were all in. Later on, when I served as U.S. ambas- The first G-8 meeting took place in Julysador to South Africa, we had Project Phidisa, 2001, and one of the big announcements waswhich was an HIV/AIDS intervention research that the United States was going to put anotherprogram that was done in conjunction with $200 million toward tackling AIDS. Anotherthe South African National Defense Force $200 million followed shortly after, and from(SANDF) and its medical health services. there we just kept on going. Kofi Annan wasIt specifically linked HIV/AIDS to military calling for an international fund on AIDS.preparedness issues. We gave out antiretroviral We took the lead in mobilizing internationaldrugs to uniformed military personnel as well resources and then standing up the new Globalas their dependents. This program had a huge Fund to fight AIDS, Tuberculosis, and Malaria.impact and was very positively received by the Tommy Thompson, secretary of health and hu-government as well as the SANDF. man services, became the fund’s first chairman. Project Phidisa involved giving out We played a huge role in the design, and weantiretroviral drugs before the Mbeki govern- were very insistent that scientists and doctorsment did it on a national level, and I think should be the ones to vet grant proposals toit led the way. It certainly helped military the fund and decide who would get money. Wepreparedness, because the SANDF was one of really wanted it to be accountable, which wasthe major contributors of peacekeepers across very much President Bush’s approach.Africa. Its military preparedness affected not In that period, a lot of things were com-only its national interests but also U.S. national ing together to make it more feasible to getsecurity interests in Africa. antiretroviral drugs into the field. The National During the George W. Bush administra- Institutes of Health were coming up withtion, the focus on HIV/AIDS was there from innovative ways to get drugs out to the popula-the start. I have to give Secretary of State Colin tion, using motorcycles and bicycles in Haiti,Powell a lot of credit. Within the first week of for example. The prices of drugs were comingthe administration, he put to the White House down; the whole issue of intellectual propertythe notion of having a cabinet council on HIV/ rights was being worked through at the WorldAIDS. Some people were opposed, but the Trade Organization.ones in favor prevailed. A decision was made36 | global health as a bridge to security
  • And at the same time, a drug called ing PEPFAR wasn’t framed in security terms,Nevirapine was discovered, which reduced at least explicitly. The focus was more on whatmother-to-child transmission of HIV. This we could do and whether it would be effective.drug provided us with a compelling argument, The impact of AIDS on society and on securitybecause who can argue against saving a baby’s was known Getting Nevirapine out into the field When the $15 billion PEPFAR announce-through USAID and the Centers for Disease ment was made, African leaders were quiteControl became the next U.S. program, and stunned. The scale of the commitment createdour success built confidence that we could a “wow factor.” But after the president madeactually do drug therapy in poor, hard-to- the announcement, we had to fight a battle inreach places. Congress to get it funded. We mobilized the President Bush always wanted to do African Ambassador Corps to be advocates onsomething big in addressing the global AIDS the Hill, explaining to congressmen and sena-challenge. We would hold seminars on the tors the impact that AIDS was having on theirissue, experts would come in and brief him societies. They played a very important role.beforehand, and he would always ask, “Where PEPFAR gave us tremendous credibilityare we on the cure?” He was very engaged in our diplomacy, and we saw this expressedwith African leaders on the issue and was very when President Bush went to Africa in 2003taken with what Presidents Festus Mogae and and 2008 and the reception he receivedYoweri Museveni were doing in Botswana from governments there. This response wasand Uganda to educate citizens about the a reflection not only of PEPFAR but of theillness and speak in public about the threat way the president had been engaging Africanit posed. All of these shared experiences and leaders on the issue during their many visits toconfidence-building measures are really what the White House and at all the meetings at theled to PEPFAR. UN General Assembly and the G-8 summits. But there was a fight in the administration They built a foundation for good relations andover the allocation of funding. Some people strong diplomacy.were saying the money was better spent Another factor was President Bush’s cred-domestically, on education, for example. ibility. When he was sitting in the Oval Office The argument pitched those who favored and talking to leaders, he’d always say, “I’m notdoing something big on public health, who going to just sit here and tell you somethingsaid we had a responsibility and a means that you want to hear. I am going to tell you if Iof doing it, against those who said, “We are can do it; I am going to tell you if I can’t do it.”fighting a war in Afghanistan; we have a global I think that approach helped build credibility,war on terror. You’ve got all this international and the PEPFAR program was evidence ofspending and now you’re talking about doing that.another billion-dollar program on top of all of When I became ambassador to Souththat?” The argument was really framed as one Africa in 2004, President Thabo Mbeki wasof domestic versus international spending. fairly shut down on the issue of AIDS. He Condoleezza Rice became the true cham- wasn’t speaking about the challenges hispion of PEPFAR; she took the brunt of the country was facing on AIDS because he hadbattle. Her perspective was, “I didn’t start the come out wrong on the issue earlier, by sayingwar on terror. HIV/AIDS is a national security it was really about economic development andchallenge for our country, and we have no that nutrition was key rather than antiretro-choice but to respond.” The rationale for creat- virals. He wasn’t wrong entirely, but he didn’t richard downie  | 37
  • show the type of clear leadership that was more money. I think some of that is happeningdesirable for his own population as well as for right now. We are in a much tighter budgetthe international community. cycle and are having to prioritize. In addition, he had a health minister, Unfortunately, one of the things that weMantombazana Tshabalala-Msimang, who are not prioritizing is global health. I thinkwas far more extreme about the problems of that omission will fundamentally undermineantiretroviral drugs. In a well-known episode, our role in national security in the long term.she suggested that people with AIDS should Of course, a country like South Africa shoulddrink beet juice. When I became ambassador, show a commitment to make HIV/AIDS aI was determined not to antagonize her but top priority, and if it can increase its fund-rather to try to co-opt her. In some of our first ing capabilities, programming, and nationalmeetings, I said to her, “You’re absolutely right; infrastructure, it should do so. That said, wenutrition is critical. I am going to support you have to remember that it is still a developingon nutrition. But you have to understand that country with multiple have to use pharmaceuticals as well.” Keeping people alive on antiretroviral With President Mbeki, my approach drugs for longer periods of time is a key factorwas to try to get him to speak out, because in the stability of these societies. It keepsPresident Bush truly believed that national families alive and productive, enabling themleadership was necessary. There had even been to bring up their young people and keep themsome questioning of how big South Africa’s out of the hands of social services. If we startPEPFAR program should be, given that we cutting back on programs like PEPFAR fordidn’t have the perception, and frankly the re- budgetary purposes, we put long-term stabilityality, of presidential leadership. But fortunately, at risk. We could face reversals that get us rightSouth Africa had capable cabinet ministers; the back to where we were a couple of decades ago,deputy minister of health was fantastic. And when vast numbers of people were dying andindeed, the South African government did destabilizing society, which has a direct impactquietly allow antiretrovirals to come into our on the United States.program and did not stand in our way. As a We have to be careful. Public healthresult, we were able to do a lot. investments are for all of us: they are worthy Nowadays, the global landscape on AIDS investments and we should continue to makehas changed significantly; antiretroviral drugs them. ■have been pretty much universally introduced,prices for those drugs have gone down, andaccess has improved. With PEPFAR, of course,there is a certain bureaucratic inertia, whichhappens whenever a major agency is created.But PEPFAR continues to do good. My viewis that the United States should continue toprovide significant resources in this area. Of course, national governments haveto take greater responsibility for providingfor their populations; this can’t be the U.S.role forever. But we shouldn’t use talk aboutnational responsibility as an excuse to coverthe fact that we aren’t prepared to provide38 | global health as a bridge to security
  • 9general james e. cartwrightFrom 2007 to 2011, General James E. Cartwright(USMC, ret.) served as vice chairman of the JointChiefs of Staff, the nation’s second most senior mili-tary position. Previously, he was commander of theU.S. Strategic Command, which oversees U.S. nuclearforces; among his other assignments, he served asdirector for force structure, resources, and assessment,J8, providing analysis and advice to the Joint Chiefsof Staff, and he was commanding general of the FirstMarine Aircraft Wing. In 2011, General Cartwrightwas appointed the Harold Brown Chair in DefensePolicy Studies at CSIS.I n my opinion, what will come out of the were properly integrated and had an element wars we’ve been involved in since 2001 is of military health innovation in their charter. the rise of machines and machine learn- An analysis of data from our medical institu-ing and the need to understand the correct tions yielded correlations suggesting that wheninterface between the machine and the person. a university, a military hospital, and assisted-The scientific breakthroughs that lie in front of living facilities are located close to each otherus are likely to present us with moral dilem- and working collaboratively, the growth ofmas but will also present us with significant medical technology will be superior to that ofand unprecedented opportunities. We will the best stand-alone research hospital. Whenhave to work our way through those ethical we inserted multidisciplinary researchers intodilemmas and decide which discoveries we’re those organizations, we could see the benefitswilling to accept and which ones we are going of cross-pollination. For example, in ourto outlaw—but at the same time recognize that work on prostheses, we put together softwareeven if we outlaw them, the discoveries are still engineers, chip development engineers, andgoing to be out there. prosthetics experts, and these teams made significant advances. I spent a substantial amount of my timein the vice chairman and J8 roles, ensuring Meanwhile, universities appreciated work-that our research labs, such as the Defense ing with the military because it enabled themAdvanced Research Projects Agency (DARPA), to make technological leaps in the quantity |  39
  • and scale of procedures that they wouldn’t that science can turn that mapping into anotherwise have been able to afford. understanding of how to stimulate the brain in the absence of normal stimulus—for example, Growth in computational power has been when a patient has lost a limb or suffered nerveone key to breakthroughs, as researchers damage. Researchers have found they canmapped the human genome and expanded that interpret and translate certain “thoughts” fromresearch to map larger populations. Another a patient into electromechanical actions.area of concentration has been on man-machine interfaces: in other words, seeking Researchers are also investigating what hasthe optimum working relationship between been termed “phantom pain”—the patient’shuman and computer. sensation of pain in a missing limb. When the brain is stimulated to operate an artificial limb, The 1997 experiment that saw the the feedback loops to the brain seem to reducecomputer, Deep Blue, take on the world or eliminate phantom pain.chess champion, Garry Kasparov, is generallybelieved to be the moment when the com- These and other breakthroughs are aputational power of the computer exceeded by-product of the wars in Afghanistan andthe capacity of the human mind. The chess Iraq—health care advances that are likely toexercise was particularly interesting because yield significant benefits in prognosis andwhen the computer made a mistake, it was so diagnosis for individuals and eventuallydrastically wrong and so nonsensically wrong populations, at what I believe will be a signifi-that it defied explanation. However, when a cantly reduced cost. But when peace breaksperson was teamed up with the computer, the out, the imperative to put the resources behindtwo together were better than either alone, and these breakthroughs, to follow them throughthe chess master would be the first to tell you from development to introduction, is going tothat he improved. In other words, there was a be a challenge. We know that unless there is ansynergy between man and machine. imperative to develop these resources, health costs will continue to escalate. We have an ag- What are the implications as we go ing population, and as a result of the wars, weforward for man-machine interfaces and for have large numbers of injured former soldiersmachine learning? Where do machines belong who are going to be very expensive to care forand where do people belong? And how do we 30 years from now.start to apply this research to conflicts in waysthat might make a significant difference to our The issue of man-machine interfaces is nothealth and our ways of doing business? The only recasting medical boundaries, but it’s alsogovernment is now working on these questions changing the way we think about war and thethrough DARPA, along with universities and way we fight it. People talk about unmannedmedical labs. The belief is that as our compu- aerial vehicles, or drones, and say that peopletational power increases over the next two or can now be pulled out of warfare and thatthree years, we’ll soon have the capacity to map casualties will be reduced. It’s not as simple aseveryone’s genomic information and build on that.the advances of machine learning, along with From my perspective, the main challengeman-machine interfaces only dreamed of a few of this conflict, and most likely the mainyears ago. These advances could fundamentally challenge going forward, is where to put thechange medicine. person in the fight. At Gettysburg, opposing For example, one endeavor has been the forces were merely a few feet apart; they coulddetailed mapping of the brain. The hope is have been sitting across a table from each40 | global health as a bridge to security
  • other. By the time of Vietnam, the distance had have him speak the right language, know theincreased. We thought that the bomber pilots right gestures, know how to stay alive?really weren’t in the war. They flew overhead To help us answer these questions, we’veat 30,000 feet, dropped their bombs, and went conducted a series of experiments to under-back home for happy hour. The guys fighting stand the different cognitive levels of humanon the ground felt as if the aviators didn’t really processing. The first level of processing isdeserve to be treated like war fighters because iconic; it allows us to identify the images inthey weren’t getting muddy. front of us. The next levels involve putting the In today’s conflicts, the same argument pieces together and understanding how theyis used relative to the people controlling the relate. Iconic processing is easy for a computerdrones. People say to them, “Because you to do; it’s pure computation. The second levelslive in Las Vegas, for example, and go to your are a little harder, but we’re aiming to get thereoffice nearby every day, you’re not really in the through better computational power.fight.” Outsiders tend to dismiss the trauma, In one of our experiments, we tookthe stress, the sleep deprivation, and all the away the radios of a ground unit heading toissues that are actually the reality for the drone Afghanistan and gave them commercial cellpilots—no days off, no leave, and the tours that phones and pads instead. They had customdon’t end after a year, 15 months, or even 18 apps on their phones, which provided battle-months. The trauma is very real, and we don’t field maps and global positioning system soft-understand the health implications of what ware, so they could see the locations of theirdrone pilots have been through. comrades and enemies. They could gather What we do understand is that through real-time information about the operationa drone, pilots can be on the other side of and swap photos and intelligence with otherthe world, prosecuting a fight that no human soldiers. And time and again, we heard frombeing is capable of fighting. In other words, the soldiers, “After a week with this technology,that man-machine interface is doing what no I’d just as soon leave the barracks without myperson can do, doing it for 24 hours at a time, rifle than leave without this stuff. I know what’swith high precision, high awareness, and lower going on around me, I can stay out of trouble,casualty and collateral damage rates than any I can get help if I need it, it always works, andcomparable man-machine combination has I didn’t have to go through any training to usedone in the past. It’s not hard to imagine a fu- it.” I see real potential for engineering moreture in which the man is part of a chain that is tools that can augment human capabilitiesdirectly linked to the movements of the drone. with significant computational power, whetherWhat will that mean for warfare? There will be it’s through their communications systems ornumerous ethical, cultural, and moral issues to the weapons they use. ■be worked out. But unmanned warfare is notgoing away. It’s too late for that. The questionis, What is the correct balance between manand machine, so that we get the best out of theman and the best out of the machine? How dowe use computational power to give soldiersan advantage on the battlefield that they wouldnot have by themselves? How do we put a19-year-old soldier in an unfamiliar place and richard downie  | 41
  • 10ambassador linda thomas-greenfieldAmbassador Linda Thomas-Greenfield is directorgeneral of the Foreign Service and director of humanresources at the U.S. Department of State. She hasbeen a career member of the Foreign Service for30 years and served as U.S. ambassador to Liberiafrom 2008 to 2012. From 2006 to 2008, she wasprincipal deputy assistant secretary in the Bureauof African Affairs. She served as deputy assistantsecretary in the Bureau of Population, Refugees, andMigration from 2004 to 2006. She has also served inJamaica, Nigeria, the Gambia, Kenya, Pakistan, andSwitzerland.W hen I arrived in Liberia as U.S. had suffered terribly in the process. Women ambassador in 2008, the country were the biggest victims of the war in Liberia. was in transition. From 2003, Not only during the conflict, when they had towhen the second civil war ended, through take on sole responsibility for their children,2007, Liberia faced a humanitarian emergency. but after the war as well, when they wereOur government’s support and approach were victims of violence committed by men whoprimarily humanitarian, as opposed to provid- had themselves known only violence in theiring development and reconstruction. By the lives.time I got there, we were shifting to a develop- On the other side were the combatants: thement approach, and the infrastructure require- young boys and sometimes young girls, whoments and the technical support requirements in my view were victims as well but who hadwere much more defined by that point. We perpetrated violence against the population.were ready to start helping Liberia rebuild for They did not feel that they had a stake in peace.the future. They were terrorizing people on the street Two sides of the security problem in through begging and intimidation. One day ILiberia were linked to health. On the one side met a young man at a university who stood upwere the obvious victims: the women and and proudly introduced himself as an ex-com-children who may have survived the war but batant. I looked at him and asked, “What are42  |
  • you now?” He replied, “I’m a student.” I said, at a time, not knowing whether their family“In the future, introduce yourself as a student. members were dead or alive.You cannot wear the status of ex-combatant as As U.S. embassy officials in a postconflicta badge of honor.” Yet, people were doing that environment, we needed to be very consciousbecause they felt they needed to use intimida- that while we may have moved on, the localtion to get their point across. population has not. When I first arrived in I constantly reminded my colleagues that Liberia, everybody seemed angry to me. I feltthese young men were very much victims they were looking back at what they’d lost,of the war as well, despite the fact that they still mourning the deaths of relatives, the losshad carried out many of the killings and of property, the loss of a generation’s worth ofperpetrated much of the destruction that took education for their children. All those thingsplace. They had done so at such a young age had a profound effect on Liberians’ mentalthat you could not hold them accountable or health. Inside the embassy, we constantlyresponsible. You had to be conscious of the focused on trying to help our staff deal withhealth needs that arose as a result of their the issues that affected them. By the time I leftparticipation in the war. in 2012, that look of anger on people’s faces had dissipated somewhat because Liberians In 2008, as today, Liberians were still deal- were beginning to feel the benefits of with the psychological impact of the war. They had begun looking to the future ratherI think that was one of the most significant than looking back at the problems we dealt with. We could seethe people who had bullet wounds or whose Outside the embassy, I don’t think welimbs had been hacked off. We knew the dealt with mental health consistently. If youpeople who had been killed. But the psycho- have a limited budget and someone is dyinglogical impact of the conflict was not always of malaria, you’re going to cure the malaria;obvious. Frankly, I can’t say we’ve focused but the needs of the person with mental healthenough attention on mental health, because problems may not be as obvious. We are realiz-it is not always visible. You only start to see ing that this is something we need to focus onit when it starts affecting security or people’s because until we start addressing mental healthability to do their jobs. needs, people will continue to have difficulty adjusting to Liberia at peace. Within the context of the embassy inLiberia, we had employees who had serious On another note, I would like to mentionproblems with stress-related illnesses: high that during my time in Liberia, we workedblood pressure, diabetes, high cholesterol. very closely with the Ministry of Health andMany of these illnesses were related to the Social Welfare. Liberia had the good fortunestress of trying to survive in a postwar situa- of having an outstanding health minister,tion. Many of my American colleagues at the Dr. Walter Gwenigale, who had a vision andembassy had not experienced Liberia at war, who knew where he wanted to take the healthbut our Liberian staff had gone through those sector and what the requirements were forhorrors. Many of them had lived in camps training, capacity building, and infrastructure.for internally displaced people and had been He took the lead in setting the agenda, andseparated from their families for long periods. over a period of four years, we started to seeWhen the fighting in the embassy neighbor- the capacity of the ministry grow. By the timehood was at its most intense, some of our staff I left Liberia, we needed fewer outside expertswere forced to stay in the embassy for weeks because Liberia had begun to produce experts internally. richard downie  | 43
  • The minister called me at one point, very were very few trained nurses, doctors, andearly in my tenure, to say he was not prepared health workers in Liberia after the war, one ofto meet with a group of American aid rep- our priorities became building a program thatresentatives until he was sure that they were fo- trained the first cohort of nurses to graduatecusing on the priorities that he had established from the University of Liberia.for the Liberian government. I supported As U.S. ambassador, I saw an importanthim 100 percent on that. I think part of our part of my role as trying to determine the topsuccess was due to the fact that we allowed the priorities among many priorities. On any givenLiberian government to set the priorities and day, the priority could be energy, which is im-we worked with the government to fulfill them. portant for health. If you don’t have electricityDoing things that way sometimes required and you don’t have clean, running water, youpatience. When there are huge capacity gaps, cannot run a well-functioning health facility.the easiest thing is to go in and do the job The next day, our focus might be on trainingyourself. Sometimes it’s hard to stand back and health workers. Another day we might bewatch while mistakes are made. But that is part working with traditional leaders to help us getof building capacity. And now the Ministry the message out about HIV, family planning,of Health has reached a point where we have or whatever the top health issue might be. Thisenough confidence in its management capacity didn’t mean that we were not working on alland accountability systems to give it direct of the issues on a daily basis, but the issues webudget support. That’s something we have not highlighted on any given day might change.done in many places and certainly nowhereelse in Liberia. Our embassy did lots of great work in the health sector, but I can’t say that my primary Looking back, I think the main asset the focus as ambassador was health; my primaryUnited States had to offer was experience. We focus was stability. It’s important to recognizehad a number of very well qualified health that stability is about much more than security.professionals from USAID and the Centers Yes, we worked very hard to help Liberiansfor Disease Control and Prevention who rebuild their army and police force, but itworked closely with the Liberians as part of was equally important that we help buildour embassy team. Because I’m not a health the Liberian government’s ability to provideprofessional, I depended on their advice and essential services for its people. I always toldthe ministry’s leadership to determine where my staff that our key objective every singlewe should focus our attention. For example, day was to help the people of Liberia succeed,we knew that mother-child health was a key whether that was in the health sector, in educa-to success, including ensuring that mothers tion, in infrastructure, or in democracy anddidn’t transmit HIV to their children. Malaria governance. For example, the 2011 electionswas another key problem; we were finding that became a key focus for us. If you don’t have amore children were dying of malaria than from peaceful, stable government elected in a freeany other disease. Those became important and fair democratic process, then you’re notfocuses for our health program. going to have a health system that functions. In addition, we recognized that the focus All of these issues are interconnected.should not just be on building infrastructure— Looking at the challenges facing the healththings like hospitals and clinics. The Chinese sector in Liberia, I think capacity continues tohad built a very large hospital up country, but be a problem. There are still very few trainedthat kind of facility is of no use if you don’t doctors. The University of Liberia’s medicalhave the capacity to run it. Given that there school graduated its first cohort of doctors44 | global health as a bridge to security
  • last year, but that’s just a drop in the bucket in that is a place where they can build a future formeeting the population’s health needs. their children. A second challenge is getting health care I think health is critical to the overallout of the urban areas and into the rural areas. picture. The job won’t be finished until healthIf you don’t provide health care in the coun- care is available to everyone in the society.tryside, people will keep coming to the urban We’re still working on that, but health will becenters. key to Liberia’s success. ■ One-third of the entire country of Liberialives in the capital, Monrovia. It was initiallyconstructed for about 50,000 people, but nowyou have about 1.4 million people jammed intothe city, looking for jobs, looking for healthcare, looking for education, and looking forthe comforts of life because few of those thingsexist outside of Monrovia. Trying to establishhealth care outside the capital city is impor-tant. That means focusing on infrastructure,on getting roads and health clinics into ruralareas, but it also means trying to convincehealth workers to go there as providers. Theydon’t want to go, because there’s no housingfor them, they can’t pick up their salaries, andthere’s no education for their children. Manycomponents go into getting a solid health caresystem up and running, issues that go beyondsimply training health care providers. Let me close by making two final points.We in the United States want to see countriessucceed; and when they don’t succeed, wewant to help. We don’t want to see disastersdestroy countries. Looking at this from aself-interested point of view, we recognize thatfunding a humanitarian crisis response costsmuch more than helping a country build itscapacity to grow and become stable. In the particular case of Liberia, werecognize that our country has a long historicalconnection with Liberia, going back many gen-erations. We have tried to honor that relation-ship. And we want to help the president ofLiberia—Africa’s first woman president, EllenJohnson Sirleaf—succeed. My goal every dayas the U.S. ambassador to Liberia was to showthe people of Liberia that they can live in acountry that is peaceful, that can prosper, and richard downie  | 45
  • 11dr. s. ward casscellsS. Ward Casscells is Tyson Distinguished Professorof Medicine and Public Health at the Universityof Texas School of Public Health. A cardiologist bytraining, Dr. Casscells joined the U.S. Army as areservist in 2005; he helped devise the army’s avianflu preparedness plan and went on to serve in Iraq.Dr. Casscells was assistant secretary of defense forhealth affairs from 2007 to 2009, taking on respon-sibility for the nation’s military health system in thewake of newspaper revelations about substandardconditions for wounded servicemen and women atthe Walter Reed Army Medical Center.I first got interested in the intersection of center in 2001. We learned a lot from that health and security while at the University dreadful experience. By the time 9/11 came of Texas, from the standpoint of improv- around, we had amassed quite a bit of experi-ing the care of patients who’d suffered heart ence in responding to industrial disasters andattacks. Fifteen years ago, telecommunications natural disasters like floods, hurricanes, andbetween the emergency medical services and earthquakes. It was natural that we would tryhospitals were almost nonexistent. We began to put some of the expertise of the Universityto put wireless video communications in am- of Texas at the military’s disposal.bulances so that we could get the right patients The more time I spent with the military,to the right facilities faster. The army took an the more interested I got in what they wereinterest in our attempts to make better use of doing and the more admiration I gained fortelecommunications, gave us some grants to them. And then one morning, my younger soncontinue our work, and later adopted quite a Henry, who was just a little boy at the time,bit of what we learned to the situations in Iraq asked me if my father, who had been in Worldand Afghanistan. War II, had seen active combat. In fact, he had; Soon afterward, I got interested in disaster in North Africa, Italy, and German-occupiedresponse after a terrible flood and storm in France. I showed Henry my father’s tatteredHouston destroyed much of our huge medical uniform, that of an army medical captain, and46  |
  • he looked at it with awe. Then he gave me a wreck, thinking, “What in the world did Ilook. I said, “Off you go to school.” And as I get myself into?” I had pre-traumatic stresswalked past the bedroom, I said to my wife, disorder.“Roxanne, I’m going to join the Army Reserve My mission was to try to help Iraqis—if they’ll have me.” I was 52. She said, “When particularly civilians—figure out how to takepigs fly,” and rolled over and went back to better care of themselves. We were not receivedsleep. very favorably, except by the Iraqi military, I did try to join, but they turned me down with whom we developed very close bonds andbecause I’d had bad cancer, which hadn’t who proved to be a very positive influence.stabilized yet. But eventually we got the cancer On the civilian side, the Ministry of Healthunder control, and the army took me on a was under the thumb of Muqtada al-Sadr, thewaiver. My first deployment was very quick; Shi’a cleric and political leader. He not onlywithin a couple of days of being sworn in, I controlled militias but also controlled a lot ofgot a call from the army surgeon general, who popular opinion and made it very difficult forsaid, “I’m looking over the list of new medical the Ministry of Health to do anything useful.officers and I see you have been publishing In fact, he basically used the ministry as hisabout influenza.” I said, “Yes, sir, we found it piggy bank. We made almost no progress. Weis a trigger of heart attack and stroke,” and I had Iraqis help build clinics, but most of thestarted to go on and on. And he said, “Well, money was wasted or stolen. When a cliniccut it off right there. I need you up here in 72 was finished, it was often bombed and thehours to help me formulate a policy, because people we had trained disappeared. It was veryI gather you have a paper that says influenza disappointing and discouraging.might be used as a biological weapon.” Interestingly, I kept hearing about an The research we conducted for the army Englishwoman, Emma Nicholson, who wasconcluded that the threat of the H5N1 strain having extraordinary success in restoringof influenza being used as a biological weapon health and education services with her char-was quite significant. We found that influenza ity, the AMAR Foundation. Her clinics werewas so easy to mutate in the wild that one built on time, under budget. They were staffedcould, with very little technology, develop a by Iraqis. They were not bombed. They weremalicious strain and send it in the mail. Our simple clinics, but they were very followed the 2001 anthrax attacks in I studied her, and I was deeply impressedWashington, at a time when there was a lot because she was doing with pennies what weof concern about respiratory threats from were failing to do with dollars. She believed inbiological weapons. her mission, and she made it clear that she was going to be in Iraq for the long term. I think We published the policy, and at the end that was an important point. She also insistedof my mobilization, as I was getting ready that Iraqis contribute to her project in someto come back home to Houston, the army way, in labor, money, or something else, tosurgeon general decided to give me a medal. ensure buy-in.He called in all of the officers and, in front ofmy wife and kids, said, “Well, I bet you’d love In most postconflict countries whereto go to Iraq, wouldn’t you?” What could I say? the United States operates, a lot of our State“Yes, sir!” Department funds for renovation, rehabilita- tion, education, and so forth are run through But this was in January of 2006, during nongovernmental organizations (NGOs). Butthe worst of phase of the war. I was a nervous in Iraq, the military got into the habit of doing richard downie  | 47
  • civilian projects on its own, because so many Then she said to the guy operating onplaces were just too dangerous for most NGOs. my arm, “Major, get that Colonel out of here;The military’s tendency is to say, “No, we’ll do he’s not injured in any significant way.” I gotit; stand aside. Once the local people see what a big laugh out of this. But there was a lessonwe can do, they’ll trust us.” But I believe there here, too. Here was an army nurse, triaging,are reasons to do more through the NGOs. freeing up the emergency room, not based on nationality or rank, just on how critically Frequently, for example, a captain gets sent injured these Iraqis were. I thought that wasto a country like Afghanistan and basically a wonderful lesson, and I hope that the Iraqishas to learn everything on his own. There are who were in there picked up on it. I don’t knowmanuals out there, but he’s deployed suddenly if they were soldiers or civilians, but they wereand may not have time to read them. When he going to get care, and the U.S. Army colonelgets there, he finds there’s not enough time to was going to be in the hall.learn how to really relate to the Afghan elders.The captain has to struggle to learn lessons that While I was in Iraq, I got a call from themany of the NGOs know by heart. White House saying, “We have several posi- tions we are looking to fill; we are going to fly I agree with the new presidential policy you back.” Eventually, I was offered the posi-that deemphasizes counterinsurgency in favor tion of assistant secretary of defense for health,of counterterrorism; it puts less emphasis on and I jumped on that. Suddenly I had gonewinning hearts and minds because there aren’t from being a professor to being an army officerthe funds for the military to do it. Such funds to being a government health policy person.that are available perhaps would be better I had responsibility for a $50 billion budget,spent in partnership with NGOs. People in the 140,000 employees all over the world, and 100host country believe that the better NGOs are hospitals and clinics.offering a long-term commitment. As assistant secretary of defense for health All that said, I do believe the military affairs, my primary job was to improve combatcares deeply about doing right by civilians. To and convalescent care for our own troops. Weillustrate that with a story, while I was in Iraq, had many challenges. Information technologyI got a minor elbow injury in a humvee, and it was balkanized, staff weren’t communicatinggot infected. I knew it needed to be drained. well with each other, and there were contro-So I went to the combat hospital and found a versies about how we could better screen andmajor there who was an orthopedist, a reserve monitor people who’d suffered combat from Seattle. He said, “Colonel, you On top of that, the problems at Walter Reeddon’t need any anesthesia for this, do you?” Army Hospital had just received a lot of atten-And I replied, “No, no need,” and he began to tion in the newspapers—problems related toscrape it all very thoroughly. It was tender as prolonged outpatient rehabilitation that was incould be. many cases bureaucratic, frustrating, cold, and I was face down on the gurney, my head ineffective. We had a lot to do to improve ourin a pillow, when I heard a nurse come in. She TLC of injured, and particularly psychologi-had a voice like a foghorn, and she bellowed, cally injured, service members.“I’ve got two choppers coming in with Iraqi We introduced simple things, like makingIED victims. I’ll need all available stretchers sure that a soldier’s or marine’s room at theand gurneys, and anyone who hasn’t given hospital had a foldout sofa for a family mem-blood in the last six weeks, prepare to give ber to spend the night or a battle buddy toblood.”48 | global health as a bridge to security
  • come visit them. We eliminated visitor hours, pelvis, for example—someplace where it’s hardso that kids could visit, because people don’t to compress the bleeding—taking aspirin is awant to be alone in the hospital. We provided very dangerous thing.a counselor who could cut through the maze We were able to clear all of the aspirinof the many, many advocacy options that these from our stores and throughout all of ourinjured soldiers have. We provided entertain- theaters of operation and get all of our soldiersment and other activities to help people get warned before they deployed that even onethrough a long, stressful rehabilitation. aspirin a week before combat can increase For years, the military’s modus operandi their risk of bleeding. I was very proud of that.was to patch people up and get them back on At the time I was assistant secretary of de-the battlefield or, if they couldn’t return, retire fense for Health affairs, another issue we werethem. Nowadays, people so badly want to stay thinking a lot about was how you could usewith their unit. For some of the wounded, we health care to win hearts and minds. Does itknow that it may take 6 or even 18 months of win people over when you vaccinate their kidsrehabilitation before they can go back to their or their cattle, or pull their bad teeth, or buildunit or at least stay in the military in a desk clinics, or teach them barefoot doctoring? I gotjob. But we now offer that opportunity. very involved with that set of issues. We can’t In our combat theater care, my most prove that health has been an effective bridgeembarrassing day in the Pentagon was when to peace, and there are critics who say that inDefense Secretary Robert Gates revealed Iraq today, the Iranians have more influencesome data that I didn’t have: that we were not than the United States does. But those of usreaching the majority of our Afghan casualties who have been involved in health care feel itwithin 60 minutes. That was the only time I has a positive impact.felt that we hadn’t done absolutely everything To give one small example, in 2007 I was inpossible to get the best outcomes. Ecuador on the USNS Mercy, one of the navy’s The survival rates of those we reached at medical ships. When there was an earthquake75 minutes were very nearly as good as the in Pisco, Peru, the joint staff surgeon, Rearones who got in at 45 minutes. Nevertheless, Admiral David Smith, and I got on a plane andwe changed things to have more medical headed to Peru. We got there so quickly—onlyevacuation helicopters, so that we could get 49 hours after the earthquake—that the Redeveryone within an hour. In fact, the data Cross from Ecuador, where we had been, wasshow that we have the best survival outcomes just arriving on the same plane. This timingnot only in battlefield injuries but also in made a huge impact on the president of Peru,disease and nonbattlefield injuries. Our service Alan García, when he came to meet us at themembers are more safety and health conscious. earthquake site. He said he couldn’t believeAnd through many advances, we’ve improved that an assistant secretary and a navy two starcombat care, particularly self-care, for ex- were supervising aid to help poor families inample, in the use of self-applied tourniquets. Pisco. On top of this have been medical advances We were, of course, delighted to meet thesuch as understanding how best to delay or president of Peru, because he had been alignedprevent bleeding. One of the simplest improve- with the Chavez and Castro camp against thements that I was credited for was abolishing United States. The next day the Americanaspirin in theater. Aspirin prevents clotting; Ambassador Michael McKinley phonedin fact, it promotes bleeding. If one has had a President Bush during a National Securitybad bump in the head or in the chest or in the Council meeting and said, “You won’t believe richard downie  | 49
  • this, but the President of Peru called me totell me that the high-level medical delegationyou sent is the first time that America has everdone anything useful in Peru.” Of course, it’s not true—the U.S. govern-ment had done a lot for Peru—but this helpwas visible. Senior-level officials were on theground making sure that people got pulledfrom the rubble and got first aid, blankets,food, and shelter. Obviously, President Bushwas thrilled that Peru was now leaning awayfrom Chavez and Castro. And how, after all,did Castro get that influence in the first place?By sending a great many doctors to Peru overthe years. Health assistance speaks to people. ■50 | global health as a bridge to security
  • 12admiral william j. fallonAdmiral William J. Fallon (USN, ret.) served morethan four decades in the U.S. Navy. From 2007 to2008 he was commander, U.S. Central Command—the first navy officer to hold that position. His otherfour-star assignments were commander, U.S. PacificCommand (2005–2007); commander, U.S. FleetForces Command (2003–2005); and vice chief ofnaval operations (2000–2003). Shortly after hisretirement, Admiral Fallon cochaired the CSISCommission on Smart Global Health Policy, whichcompleted its work in 2010.M y view on the role of health has challenges only by looking at the political and changed during my more than military side, we miss many opportunities. Not four decades of service, in tandem only that, we misunderstand where individualwith the evolution that has taken place in my priorities lie. It is in our interest to have betterunderstanding of security. When I began my public health because it enhances securitycareer, we tended to view security in terms of and stability. People are less susceptible tostate actors and state security. Certainly that being lured away by extremists when they feelwas the case during the Cold War, when it was healthy and secure.“us versus them,” with each country siding This realization has several implicationswith one of the two great powers and some for us as a nation and as a military. On thenations, in places like Africa, going back and positive side, it helps that people are funda-forth. mentally the same. They may come from many But as I gained more experience, it became different backgrounds with differing ethnicity,obvious that for individuals in this world, religion, politics, language, and culture, but insecurity is much closer to home. It begins with the vast majority of cases, people are lookingtheir own personal security and that of their for the same basic needs to be in other words, hearth, health, and The downside is that the local and indi-home. And if we attempt to work on security vidual factors combine to make our operating |  51
  • environment much more complicated. As a Opportunities arose for the U.S. militaryresult, we need to approach security issues to get involved in helping build trust andfrom two directions: bottom-up as well as confidence with other nations and thereby totop-down. We need leadership at the top; we prevent conflict. We engaged with leaders inneed governments and states that have the other countries—in many cases for the firstpower to bring resources to bear. But at the time, such as those in Central Asia—whereend of the day, we depend on individuals, and we found people eager to learn more aboutit is essential to work from the bottom-up to us and about how we could help them helpachieve effective results. The U.S. military is themselves. We began to look at how we couldattempting to adapt to this evolving worldview, combine our experience with that of othersbut big institutions are difficult to change. who were trying to make things better in different countries and with that of U.S. and The most significant experience in my foreign government organizations that werelifetime was probably World War II, when we of the same general mindset, as well as withwere forced to do virtually everything from A nongovernmental organizations. We had ato Z in the course of projecting power around significant opportunity and began to devotethe world. We got involved not only in combat more resources to our health engagement, but,operations but also in the care and feeding of unfortunately, after 9/11 the focus shifted toour people and the indigenous people with dealing with the terrorist challenge. Since then,whom we interacted. Our experience in World we’ve had a decade of conflict in the MiddleWar II taught us that we needed to have a East and southwest Asia.broad range of national capabilities to dealwith security challenges. The demand for resources, particularly personnel resources, has been significant, Some of that legacy carried forward to and we never had quite enough to do all wethe present. For example, the U.S. military wanted. There were specific, dedicated effortsmade it a priority to pay close attention to on health within Afghanistan and Iraq; but as aemerging public health challenges around the regional geographic commander, I was focusedworld, such as tropical diseases. We established beyond those areas. While the conflicts wereDepartment of Defense research laboratories, raging in the Central Command area, I wasincluding in Egypt and Indonesia, focused on trying to scrape together enough resourcesstudying regional health challenges. We have to bring them to bear in other countries andlearned a lot, thanks to the networks they have other parts of the world.formed and the interactions they have had. For example, the U.S. Navy has a couple In the beginning of the Cold War, as our of wonderful hospital ships—one berthed oncountry grew in power and wealth, we put a lot each coast. A number of us thought it couldof resources into helping ravaged areas of the be really useful to take the ships to other partsworld recover from World War II and learned of the world, to do a little bit to help people.a great deal in the process. The Cold War’s end, Manning the ships was challenging becausewhich allowed us to breathe a sigh of relief and the medical personnel we needed already havethink that maybe we would not have to worry full-time jobs, typically in U.S. medical centers,about nuclear exchanges for a while, enabled treating our citizens, including those woundedus to focus on a broader set of security issues. in combat. Getting personnel to commit to anIt also gave countries in the so-called third extended period of time at Pacific Commandworld the opportunity to focus less on picking or in Africa was hard, but it actually workedsides with East or West and more on the task out pretty well because we invited civilianof doing things for their own people.52 | global health as a bridge to security
  • organizations to augment the force by placing if we could figure out a way to leverage theirsome of their doctors and medical people on activities with some bigger “muscle movers,”board. perhaps link them up on an episodic basis, for a specific problem, with a visit by the U.S. The only challenge I had was that every- military?body on the receiving end wanted a lot morethan we had resources to provide. Every U.S. Take for instance diarrhea-related illness,ambassador in the region wanted a visit, but most of which is caused by contaminated waterthe ship can only be in one place at one time. supplies. The military could help by doing things like well drilling. We have significant As the ship visits unfolded, it struck me engineering capability that we could share,that however good these one-time shots may perhaps for a few weeks or a month. This effortbe, the real need is to figure out ways to sustain could have a lasting effect, if we could link upthem and to transfer capability to the indig- with people on the ground who could keep theenous populations so that they can continue to pumps running after we have left and educatetake care of their people. Of course, it is great them to carry on the work. I think there areto go in and immunize kids, check them for many opportunities for people to orchestratetooth decay, and treat them for chronic illness. these types of activities.The military can get a lot done very quicklyand have a near-term effect on a particularly The final challenge is to tie all our develop-critical pop-up situation. But the long-term ment activities together: those of the U.S. gov-improvement of public health requires some- ernment, which has invested over $60 billionthing else. An infrastructure and a network of in global health over a five-year period, withsupport within the country of interest must be other major international donors and philan-built, and technology must be transferred into thropic organizations like the Bill and Melindapeople’s hands in an affordable and sustainable Gates Foundation. That requires a lot of effort.way. That is the real challenge. It has several At the country level, our foreign engagementcomponents. is organized around our ambassadors, who are critical. But at the international level, we need First, if the U.S. government is going to a strategy and clear policy direction. What docontinue to devote substantial resources to we want to go after, what are our key objec-global health, the U.S. Congress will demand tives, how do we define success, and then howresults. American taxpayers will want to see do we propose to get there?convincing metrics that their tax dollars arebeing invested wisely. But measuring health To take an example, most of the moneyimprovement is difficult, particularly over the our government spends on global health isshort term, and we can end up demanding a being put into HIV/AIDS and malaria preven-lot of time and resources from host countries tion. On HIV/AIDS, big progress is beingto document results—so much so that they made in working on the problem, makingsometimes begin to wonder if this assistance is people feel better through treatment, andreally worth the effort required. extending their lives. But there is still a long way to go; who knows how much research is The next challenge is how to take ad- necessary to come up with a medical solution?vantage of the surprisingly large number of Malaria, however, is something we know howpeople who are willing to invest their time and to deal with. We have experience, we have aresources to go to distant lands, put themselves grip on it in many places in the world, and,on the ground, identify a need, and try to in my opinion, it would not be so difficult towork on that need. Wouldn’t it be wonderful richard downie  | 53
  • get to the point where it becomes almost a are, they get a powerful message that we dononissue. But it requires an orchestration of really care.resources and effort to make it happen. Based on my experience, many countries Here we have two different diseases that are willing to have the military come in to un-are tying up the bulk of our financial resources dertake health missions or engineering-relatedin public health, requiring different solutions. health missions—but not all of them. When IIn one case, we can almost solve the problem; was at Pacific Command, we were able to getin the other, we have work to do. What we the Vietnamese government to agree to allowneed is a strategy, a set of policy goals that can us to put a clinic in place in central Vietnam,be reviewed periodically. Let’s lay it out, try to but they did little or nothing to publicize that itget the major actors to agree to it, and then see was a U.S.-initiated and supported operation,what can be done. and they made sure the clinic was located off the beaten track, in the middle of the jungle. Of course, we need partners on the host Still, people eventually figured out where it wascountry side as well if we want to make lasting and found it was something that could addressimprovements to public health. Relationships their needs. The important thing was that itdiffer from country to country. Things are was a start, and we hope it is something wemuch easier if there is a history of trust and can build upon to improve people’s health anda record of positive activity. If a government distrustful of us and our motives or if themedical bureaucracies are not particularly well Across the border in Laos, the relationshiptrained or have other agendas, then it is much was even colder and more challenging. In theharder. only real interaction with the government at that time, it agreed, in return for substantial Some governments want help only on remuneration, to allow us to try to locate andtheir own terms. They do not want to feel that excavate remains of our soldiers who werethey are being talked down to, and they may missing in action from the Vietnam War. Iwonder whether we are just trying to make spent several days working to convince thethem feel good so that we can “end-run” them government leaders that it was really in theirwith something else. interest to expand our relationship, that there Another big issue is corruption. No matter were many things we could do to help themhow good our engagement may be, if the coun- and their people, and that health was one oftry’s leadership is skimming off the resources them. Progress in that country has been slowwe give, it presents a real challenge for us. Not in coming but is improving.only does it make us inefficient, but it also The 2004 tsunami in Indonesia was a greatraises suspicions among the citizens of the host example of how a terrible disaster can havecountry, particularly if they are well aware of surprising consequences—even providingtheir own so-called leaders’ corruption. If they opportunities to reshape relations and endfind us dealing with those same leaders, they conflict. The United States was very quick tomay start to wonder if we are just the same and respond to the disaster by getting relief andwhether they should trust any of us. medical supplies to Aceh Province, the worst Again, this is an area where grassroots affected area. Meanwhile, the Indonesianengagement from individuals can make a government, which had a major militarydifference. When local people see an American contingent in Aceh, had a tough decision tofar from home, living and working and swat- make. It was facing an insurgency and wasting mosquitoes in the same conditions as they under constant attack by the rebels. To his54 | global health as a bridge to security
  • credit, Indonesian president Susilo Bambang the Chinese foreign minister the day afterYudhoyono directed the military to focus on Hurricane Katrina, and he was pleased to tellhelping the recovery effort. me that his country had loaded a jumbo jet of relief supplies and dispatched it to the United The rebels made many threats, both to the States to help out.Indonesian government and to us. But theremust have been a couple of enlightened heads As for our own military, emergencyamong them who concluded that while they response is our forte. We have extensivemight be able to get some short-term military logistics capability, we have accumulated medi-gain out of the disaster, in the long term, cal capability, and we can move quickly. Themaybe it was not such a smart approach to long-term sustainment piece is a little moretake. And they backed off. challenging, both in terms of our ability to do it well and from an interest standpoint: the U.S. As a result, people focused on attending to military has other priorities, and global healththe civilian population’s needs. After a couple is not at the top of the list.of months, the fact that the government hadtold its troops to forget about shooting and We need to think more about how wefocus on the people instead had begun to can link up the episodic use of our healthhave an effect. The European Union and the capabilities with other actors, in concert withMalaysians stepped up and said, “Maybe we a well-thought-out regional plan. This is wherecan help broker a settlement.” Lo and behold, our geographic combatant commanders comediscussions began, and within several months in: they are engaged, and they certainly want toan agreement was reached. The government help. ■withdrew a large military force, the rebels putdown their guns, and they began addressingthe real needs of the indigenous population.The combination of U.S. assistance, medicaland other disaster recovery efforts, helpedfacilitate that outcome. Another interesting result of the tsunamiwas the demonstration effect our recoveryeffort had on China. China, a huge countrywith a tremendously large population, has todeal with disasters all the time. It has a well-developed cadre of health expertise that haslearned from the rest of the world. But becauseit has not really figured out how to apply thisexpertise outside its borders, it is pretty slow incontributing to the kinds of relief efforts thatwe and other Western countries do as a matterof routine. When the tsunami struck in December2004, the Chinese were way behind the restof the world in delivering anything to theIndonesians, and I think they took a fairamount of criticism. But they are learning.I happened to have had a meeting with richard downie  | 55
  • 13dr. connie marianoEleanor Concepcion “Connie” Mariano is a Filipino-American physician and former flag officer inthe U.S. Navy. She became the navy doctor to theWhite House in 1992 and in 1994 was appointeddirector of the White House Medical Unit, the firstwoman to hold the position. In that role, she servedas physician to President Bill Clinton. After retire-ment in 2001, Dr. Mariano went on to found theCenter for Executive Medicine, based in Scottsdale,Arizona.O ver the course of my nine years at the to us: physician to the president. His policy White House, I followed the presi- was that we didn’t need to have 24-hour dent of the United States, the vice medical care at the White House; he felt thepresident, and their families around the world, president was healthy and that when he wasproviding service and care. Being health care in for the night, we could all go home and theprovider to three presidents—George H.W. Secret Service could handle any emergency.Bush, Bill Clinton, and George W. Bush—gave That bothered me. When I came on board,me a unique perspective. I got to observe their I spoke to the Secret Service and heard fromattitudes toward health and security based on them that they weren’t comfortable withhow they looked after their own health, their that policy either. Their job is to protect theoutlook toward care, their experiences with president; they’re not trained to administerother people’s health issues, including other medicines. I said, “If I ever run the Whiteleaders’ health issues, and their impressions of House Medical Unit, I’ll bring in 24-hour care,”health in general. because if something happens to the president When I came to the White House in 1992, in the middle of the night, it’s not enough toI was assigned to serve as the navy doctor. assume you can throw him in an ambulanceThere was also an army doctor, an air force and go down to the hospital. What if thedoctor, and another physician who was senior president had to be evacuated in the middle of56  |
  • the night to go someplace else, by helicopter? In 1994, Vice President Al Gore was hospital-Where are your medical people then? ized with an Achilles tendon rupture. I was the first White House Medical Unit Then, in 1997, when President Clintondirector to stay overnight at the White House. was on one of his many trips, he was going toWe instituted an agreement between the White spend the night at the Florida home of GregHouse Medical Unit and the Secret Service Norman, the golfer, but as he was walkingto provide round-the-clock, on-site medical down the steps of the house, his leg, and it’s been carried forward ever since. He had ripped the quadriceps tendon in hisAfter all, whenever we left the White House thigh muscle.compound and traveled, we were always beside This happened after hours; the Whitethe president. It makes sense for the most House press corps were already asleep in theirpowerful leader in the world to have a medical hotel rooms. The duty physician quickly wentprofessional “a few heartbeats away” who could out, assessed the president’s condition, andresuscitate him or her in case of an emergency, said, “We have to bring him to the emergencysomebody who could render medical care any room.” They loaded the president in an ambu-time of day. lance, and I met them at the hospital in West But whenever you make a change like that Palm Beach, where it was determined thatin an organization, there are repercussions. he needed surgery. Rather than have surgeryI think the most resistance I got was from there, we elected to fly back to Washington andsome of the doctors and nurses who said, “I perform it at Bethesda Naval Hospital, becausedon’t want to sleep at the White House.” I said, that’s our secure hospital. President Clinton“Well, explain your reasoning to me; you don’t said, “I don’t want general anesthesia; I want tomind sleeping down the hall in the president’s stay in charge.”hotel when he’s visiting Paris, but you don’t Whenever the president undergoes anywant to sleep in the White House shelter? kind of procedure, as White House physicians,Come on, how does that look?” we have to make decisions based on what’s best From my observation of the presidency, for our patient and what’s best for the country.I believe that if the president is not well, or is What’s important for the country is the 25thnot feeling well, it’s felt throughout the govern- Amendment, which was instituted in 1967 andment, throughout the country. People wonder, deals with presidential succession. The most“Is everything going to be OK for us? What’s important section concerns presidential dis-our future going to be like? Do we feel secure?” ability. If the president should become disabledOther countries see illness as being weak; they in any manner preventing him from perform-think that if the president is going to be preoc- ing his job, then a decision needs to be madecupied with his health, his surgery, or whatever to invoke this amendment, which transfers theissues he has, he’s not going to be able to focus powers of the presidency to the vice president.on the security of our country. When George The president can voluntarily do so; orH.W. Bush had his atrial fibrillation (irregular if he refuses, there’s the very painful task ofheart beat) and had to be hospitalized, that was taking the powers away from him, whicha scary time. Suddenly we were wondering, “Is fortunately has never happened. But in the caseour president healthy enough?” of President Clinton, he said, “Listen, can you Fortunately, during the eight years of the do this with a spinal anesthesia?” I said, “WeClinton administration, which covered most of can, absolutely.” They did, and he did fine. Hemy time at the White House, we had only two spoke throughout it, and afterward he spokemajor medical issues requiring hospitalization. to the press by telephone, saying, “My surgery richard downie  | 57
  • was OK; everything’s OK,” because the country White House team that goes out to the countryneeds a lot of reassurance in these situations. a year to six months in advance of the visit. They would look at all the potential health When he got back from his surgery, he hazards such as temperature, climate, and thewanted to go to Helsinki within five days to presence of endemic diseases, so that we couldmeet with Russian president Boris Yeltsin. I ensure that the president as well as the travel-said, “That’s not a good idea.” He said, “I know; ing party was immunized. They would look atjust make it happen.” We brought one of the sites to see whether there were places such assurgeons, a physical therapist, and a whole cobblestone streets where the president couldteam of people with us to keep an eye on him, potentially make sure he didn’t fall or trip. We would work closely with the Secret We also had to work out how to move him Service and then educate the president. Weabout. Because he didn’t really like to be in a would say, “This is a country where you’re go-wheelchair meeting another leader—it made ing to need all these shots, so we’ll immunizehim look weak—we got him some crutches, you. You’re going to need malaria pills; this iswhich looked like the ones Franklin Roosevelt what we’ll give you.” We’d caution him abouthad used. But still he wanted to stand. And we healthy food, healthy water. Fortunately, thesaid, “You cannot stand on that leg, you cannot president travels with a team of food serviceweight-bear, you will rip the muscle.” There officers who make sure he’s not given taintedwere a lot of arguments. That’s when you really food and water. But once in a while he wouldhave to be determined and frank, saying, “Mr. get sick, and we were prepared to take care ofPresident, you need to listen here.” One of the that as well.secrets of the White House doctor is that if thepresident doesn’t want to listen, you go to the The most frightening trip for us was tofirst lady: you appeal to a higher authority. I Morocco, where President Clinton attendeddid that several times during my career. the funeral of King Hassan II in 1999. There was a huge state funeral in Rabat; thousands of Naturally, the president, vice president, people were in the streets. There was very littleand first lady have a strong sense of need- security, and the crowds were lunging at theing to maintain their mission. Their health motorcade. After President Clinton went in tounfortunately takes second place because they pay his respects to the late king’s family, he waswant to project that they’re strong, they’re fit, going to go over to the mosque for the funeraland they’re able to continue their job. They service. But as President Clinton walked out oftravel nonstop, they suffer from jet lag, they the palace with the new king, rather than getdon’t sleep, and they have lots of occupational into the limousine, he decided to walk withinjuries like back pain from standing up for the king behind the casket, in the streets oflong periods of time; they get respiratory Morocco.infections from all the people with whom theycome into contact. My job as a doctor is to We were terrified. He was now an openmake sure they are healthy enough to maintain target, walking in the middle of the street. Ittheir mission. But it’s a struggle. If they’d been was a hot, humid day; the crowds were wild;regular citizens, in some instances they would there were people on the rooftops. The securityhave been in the hospital. hazard was huge. The Secret Service was very uptight; this was the only time I saw them Overseas travel presents a different set of nervous.risks. Before the president traveled, we wouldsend a medical representative, usually a physi- I got into the president’s limo, and wecian or one of our senior nurse staff, with the followed him through the streets. We finally58 | global health as a bridge to security
  • got to the mosque, and he went inside. About there to remind him to take his medications, toan hour later, I was called over the radio; they watch his diet and activity, and to be close bysaid, “Eagle”—the president—“needs you.” I should he have another cardiac problem.entered the mosque, and it was wall to wall Now we are in a presidential campaignhuman bodies. I couldn’t even get to him; I year. Barack Obama and Mitt Romney are bothhad to kick and push my way through all these young men, who by history are healthy. But thepeople. issue of medical records always comes up dur- One of the agents finally found me, ing a campaign. Knowing their health recordsgrabbed me, and pulled me through. I went and health issues are under scrutiny, willover to the president’s side; he was sweating, he candidates want to hide things? I look at howwas tired, and he looked a little disoriented. I the candidates are holding up to the gruelingthink the jet lag, the fatigue, and the dehydra- campaign schedule to see whether there couldtion had caught up with him. I said, “Let’s give be a problem down the line. Are they ablethe president some water,” and I asked him, to maintain their stamina, their endurance“Do you know where you are?” And he said, during those long hours of answering all those“Yeah, I know. I’m just tired.” I took his pulse; questions?it was a little fast but not bad. I said, “Let’s go.” It’s amazing how important a role the We got him out of there, again pushing health of our leader plays in delivering aand kicking our way through. But there were positive image to the world. The image weno magnetometers; anybody could have gotten want to portray is of a president who is stronghim. In these situations, you’re in fear; you and robust, a president whose health does nothope and pray nothing bad happens. And even affect his soundness of mind and his ability towhen you have a plan, when the president make quick decisions.decides to do something else, you can’t force If a leader is suffering, that suffering affectshim; you just have to respond. people’s vision of what’s going on in a country, Since 9/11, I think security has gotten the kind of challenges a country is facing. Iftighter. Presidents don’t stay overseas as long you have a healthy leader, you’re way they used to. They have their meetings, If you’ve got one who’s vulnerable and ill andand they get out. I think we’re as good as we struggling with physical or mental healthcan be, but nothing is 100 percent ironclad issues, then you’ve got a big problem that hassafe. We can’t put the president in a protec- an impact around the world. ■tive bubble. There’s this constant tugging andpulling between the need to keep the presidentsafe and the need not to isolate him from hispeople and from the job he needs to do. As for the White House Medical Unit,I’m proud to say not much has changed sincemy time there because we fine-tuned it to thepoint where it was very efficient in recognizinghealth hazards and in knowing what to do. Thebiggest change was 24/7 care, which we alsoinstituted for the vice president. Dick Cheneyhad that advantage when he was in office, andI think in a lot of ways we may have helpedextend his life because we were constantly richard downie  | 59
  • about the editorRichard Downie is deputy director and fellow with the CSIS Africa Program, based inWashington, D.C. In this role, he analyzes emerging political, economic, social, and securitytrends in sub-Saharan Africa with the aim of informing U.S. policymakers, the U.S. military, andmembers of Congress. Downie recently codirected a major project commissioned by the U.S.Africa Command that “stress-tested” African states, identifying possible sources of instability in10 countries during the next decade. He authored the Sudan country report in this series. He alsocompleted a project looking at the challenge of police reform in sub-Saharan Africa. Downie joined CSIS following a decade-long career in journalism. He was a reporter forseveral newspapers in the United Kingdom before joining the British Broadcasting Corporation(BBC), where he worked as a senior broadcast journalist covering the leading international storiesof the day for radio and television. Since then, he has conducted research and completed writingprojects on Africa for the Council on Foreign Relations and the U.S. Institute of Peace. He is acontributor to the Africa section of Freedom House’s annual report, Freedom in the World. He isa frequent commentator on African issues for the BBC, Al Jazeera, CNN, and other internationalmedia. He teaches seminars on U.S. foreign policy in Africa at the Africa Center for StrategicStudies, part of the National Defense University, and at the State Department’s Foreign ServiceInstitute. Downie holds a master’s degree in international public policy from the Johns HopkinsSchool of Advanced International Studies and a B.A. in modern history from Oxford University. ■60  |
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  • a report of the csis global health policy center Global Health as a Bridge to Security interviews with u.s. leaders1800 K Street, NW  |  Washington, DC 20006Tel: (202) 887-0200  |  Fax: (202) 775-3199E-mail:  |  Web: Editor Richard Downie September 2012 ISBN 978-0-89206-750-3 Ë|xHSKITCy067503zv*:+:!:+:! CHARTING our future