Commentary
The United States Role in Global Health Diplomacy
Dennis E. Amundson, D.O.


Keywords: global health; health diplomacy; strategic engagement; military

Published: 16 August 2012
Cite as: Amundson DE. The United States Role in Global Health Diplomacy.
Bull Health L Policy. 2012;1(1): e4.

“War is nothing more but the continuation of politics by other means”

-Carl Von Clausewitz1

Introduction

It is very clear that the United States has engaged the World at new political levels, and that evolving policies and strategies have conspired to change the landscape in how the United States interfaces with the International Community. Moreover, the United States of America has recently discovered, and is attempting to capitalize on, the power of the healthcare system to potentially develop or improve tenuous international relationships. This strategy has been especially evident in the poor, underserved, and developing regions of the world.

In this time of increasing international chaos, mass migrations, civil strife, significant security concerns, and increasing anti-American sentiment, an effective bridge to peace and world harmony is sorely needed. This form of diplomacy may also serve as a
risk management strategy to proactively avoid conflict by providing benefits through the health care system, which may portray this country, or any of its components, in a positive light.

One means by which to do this, involves “Health Diplomacy.” This strategy may be beneficial to both public entities, such as governments, but also may be useful to private entities as they seek important goals in challenging international forums.

Health Diplomacy


Under the overarching tier of “International Policy,” and as part of the U.S. strategy for “Public Diplomacy,” the term “Health Diplomacy” has been applied to the U.S. Government’s international application of the American health sector. Health diplomacy represents an attempt to positively influence fledgling nation-states and developing countries.

The United States Department of Defense (DOD) has been increasingly called upon to help provide that health service to the world. Beyond its traditional role of country protection and armed response using its “Hard Power,” this new role in the DOD’s application of “Soft Power” has lead to dramatic changes in strategic DOD thinking and influences the potential use and allocation of DOD medical assets and human resources for the near future.

There are 4 current general strategies in the application of such Health Diplomacy. These include:

  • Disaster Response Actions;

  • Humanitarian Assistance Missions;

  • Health Reconstruction/Stabilization Programs;

  • Health Assistance in Nation-Building.

These are actually comprehensive strategies that include components of medical education, technology building, economics, infrastructure development, public health and provision of direct medical care (such as basic health services). Such comprehensive assistance systems can provide direct benefits of health care knowledge and technology to international forums that that currently display a wide array of public opinion (pro and con). Such influence using the healthcare sector to include involvement at the grassroots level will be expected to change public opinion up to the decision making entities. This strategy also allows important insights into cultural, social perspectives, and societal needs that allow greater understanding of host country challenges and that influence the perceptions of U.S. and other stakeholder entities.

Provisional Reconstruction Teams


In line with this Health Diplomacy, a new type of “assistance” program has been recently developed by the U.S. government. This new program is called the “Provisional Reconstruction Team” (PRT). The importance of the PRT is that its participatory scope goes beyond the military. This organizational unit
currently combines DOD and Department of State (DOS) assets. In the future, international and civilian aide organizations could potentially be incorporated into the PRT structure.

Importantly, PRT’s create a lasting presence through personal relationships. PRT’s rely on close personal mentoring and direct assistance to local leadership. The PRT’s were first fielded in Afghanistan in 2002 and have been operationalized in Iraq since late 2005.2 Described as a civilian/military aide organization, a PRT has 50-100 members that work closely with the local and regional government and local tribal and community leaders. This approach creates valuable opportunities for military and non-military personnel to interact with local groups to create mutually rewarding relationships and understanding that may be beneficial in ensuring at least on-going dialogue that may potentially avoid crises.

The scope of current PRTs is limited. Focusing on “quick fix” remediation with an emphasis on leadership, stability, and Democratic fundamentals, currently health is only a small component of these PRT’s. However the PRT’s global concept is expanding. Lessons-learned are helping to shape PRT actions and health is increasingly seen as a vital component. Problems do exist; individual team makeup, training, experience, and a 2-tiered (DOD and DOS) organizational provide challenges. However, until we can find better metrics and monitoring strategies, PRT organizations will continue to be a part of U.S. policy and hopefully will improve our global standing.

Results and Challenges


As noted, increasingly the United States military has become an instrument of Health Diplomacy. More specifically, the DOD has been directed to train and prepare for a variety of healthcare missions abroad. This Directive is commensurate with the National Security Initiative, Title 10 of the U.S. Code. In this light, and signaling the importance of this risk management approach, the DOD has issued general guidance on this peace-time mission and has elevated health care outreach to that of “war-fighting” status via a DOD Directive.3

Since this Directive was published in November 2005, there have been several military healthcare missions to underserved populations with many more planned. However, the effect on international public sentiment and the international perception of these missions has been mixed in terms of “hearts and minds” and in the long-term democratic benefits reaped.

The current DOD humanitarian missions have
not shown the change in public perceptive expected.4 Further, the results from stability/operation and nation-building programs are too early and rudimentary for reliable conclusions to be made on their effectiveness.

What has been learned is that these Health Diplomacy projects are costly and draw on increasingly stretched military and state department manpower pools. Although expected to be effective if properly applied, historically the international acceptance of military aide has been lacking or accepted reluctantly. This has limited DOD’s ability to provide disaster response assistance. This is the exact kind of assistance that has clearly been shown to improve the US global image. As these efforts go forward, the programs will require much more scrutiny, self-reflection and perhaps reprogramming before the United States can continue to effectively expand its role in global relationships using healthcare delivery/assistance.

Future Efforts

Note, however, that development of the Health Diplomacy concept may provide significant assistance in achieving the goals of global dialogue and better relations with foreign governments and their people. From the experience gained in Health Diplomacy, a promising avenue is to design a national program and effective policy through establishment of an independent, “Agency of International Aid.” This agency would use selective components of the State Department, civilian aide organizations and DOD. Such an agency would be able to develop a multidisciplinary approach providing programs, which may be more effective and more acceptable to the global community. Additionally, attention to reliable metrics to follow the impact of such programs needs to be integral to any national aid development program and will be essential to a robust and viable International U.S. presence.

Conclusion

Significant security risks to the U.S. exist today on the global front. Our relationships with other host-nations will either exacerbate or mitigate these risks. Health diplomacy efforts have real promise in increasing dialogue, understanding, cultural competency, and beneficial relationships worldwide. Using and learning from these approaches may provide benefits for all stakeholders to create mutually beneficial relationships that can effectively and efficiently promote global health.


Competing Interests: None reported
Acknowledgments: None reported

Author(s)
Dennis E. Amundson, MS, DO, is Adjunct Professor of Public Health, San Diego State University, Graduate School of Public Health, San Diego, CA. Dr. Amundson is formally Captain (ret.), U.S. Navy, Program Director for Pulmonary/Critical Care, San Diego Naval Medical Center, and has had extensive deployment experience with the Seabees, the Marines, and with special operations forces in the Global War on terrorism.

Correspondence:
Dennis E. Amundson, MS, DO, Adjunct Professor of Public Health, San Diego State University, Graduate School of Public Health, 320 Santa Fe Drive, Encinitas, CA 92024
Email: deamundson@gmail.com.

References (Blue Book)

1. W. Vanderwagen, Health diplomacy: Winning hearts and minds through the use of Health Intervention, 171 Mil. Med. 3 (2006).
2. United States Institute of Peace,
The U.S. experiences with Provincial Reconstruction team in Iraq and Afghanistan. (Oct. 2007), http://www.usip.org/publications/us-experience-provincial-reconstruction-teams-iraq-and-afghanistan (last visited Aug. 23, 2012).
3. D. Licina, Developing a monitoring and evaluating capability for the U.S. Department of Defense. Humanitarian Assistance Program, 172 Mil. Med. 172 (2007).
4. Seth G. Jones et al. Rand Center for Domestic and International Health Security, Health System Reconstruction and Nation-Building (2007).


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