Global health as a bridge to security

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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

  1. 1. 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: books@csis.org  |  Web: www.csis.org Editor Richard Downie September 2012 ISBN 978-0-89206-750-3 Ë|xHSKITCy067503zv*:+:!:+:! CHARTING our future
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  3. 3. a report of the csis global health policy centerGlobal Health as a Bridgeto Securityinterviews with u.s. leadersEditor September 2012Richard Downie CHARTING our future
  4. 4. 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, http://www.flickr.com/photos/isafmedia/5284101291/.© 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: www.csis.org 2
  5. 5. 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
  6. 6. 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  |
  7. 7. 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 it.global 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
  8. 8. 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
  9. 9. 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
  10. 10. 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
  11. 11. 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
  12. 12. 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 regions.by 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
  13. 13. 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
  14. 14. 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
  15. 15. 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
  16. 16. 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
  17. 17. 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
  18. 18. 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
  19. 19. 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
  20. 20. 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
  21. 21. 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 U.S.as 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
  22. 22. 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
  23. 23. 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
  24. 24. 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
  25. 25. 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  |
  26. 26. 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
  27. 27. 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
  28. 28. 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 Services.to 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

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