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Boots and Birkenstocks: Can civil - military cooperation improve global health?. Gene Bonventre, M.D Consultant Global Health Mini-University – October 9, 2009. Overview. Defense - Diplomacy - Development: the 3 Ds Global health in the 3 Ds Department of Defense health programs

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boots and birkenstocks can civil military cooperation improve global health

Boots and Birkenstocks:Can civil - military cooperation improve global health?

Gene Bonventre, M.D


Global Health Mini-University – October 9, 2009


Defense - Diplomacy - Development: the 3 Ds

Global health in the 3 Ds

Department of Defense health programs

Impact on global health

Opportunities to coordinate with the military

Obstacles to coordination and potential solutions

usaid dod spending in afghanistan
USAID/DoD Spending in Afghanistan

Billionsof U.S. $

Source: Oxfam America, 2009 Field report from Afghanistan

us foreign assistance framework
US Foreign Assistance Framework

Prevent or mitigate state failure and violent conflict

Encourage reduced need for future assistance by introducing prevention and mitigation strategies


Stable environment for good governance

Increased availability of essential social services

Progress in developing policies and institutions that promote economic growth and poverty reduction




Missions and Objectives



u s government funding for global health
U.S. Government Funding for Global Health

The U.S. Government’s Global Health Policy Architecture. April 2009

Henry J. Kaiser Family Foundation

department of defense health programs
Department of Defense Health Programs

Defense Health Program

$46 billion plus, to keep soldiers, families, retirees healthy:

Medical research: $900 million annually

International Health:

Defense HIV/AIDS Prevention Program

$100 million annually to prevent HIV in foreign militaries

Armed Forces Health Surveillance Center

Surveillance/reporting of diseases/injuries in soldiers:

Global Emerging Infections Surveillance and Response System:

Surveillance/response in US military & foreign civilian populations

Overseas research labs in Cairo, Jakarta, Nairobi, Lima and Bangkok

Hospital Ship Visits

$10-20 million per mission:,

Expanding to warships

department of defense programs that impact global health
Department of Defense Programs that impact Global Health

Commander’s Emergency Response Program (CERP)

Primary purpose: urgent relief & reconstruction - $1.5 billion

BUT: Iraq: $523 million total spent on 1800 health projects

378 primary health care centers, 138 hospital projects

Overseas, Humanitarian, Disaster and Civic Aid (OHDACA) program

Primary purpose: access, influence & building capacity for disaster response

$83 million annually, plus supplementals for major disaster response

BUT: 54% of projects - Clinic/hospital reconstruction, water/sanitation, disaster medicine training, healthcare training, direct medical services to civilians

Humanitarian and Civic Assistance Program

Primary purpose: training of military medical personnel

$9-11 million annual average, but no set limit,

quantifying dod s impact on global health
Quantifying DoD’s Impact on Global Health

For humanitarian missions, DoD must report to Congress

Total number of funds obligated

Number of completed transportation missions

Description of transfer of non-lethal supplies

For medical training missions DoD must report to Congress

Amount of money expended

List of countries where training takes place

Short description of activities

Uniformed Services University reviewed 1000 after action reports and lessons learned, 1996-2007

0.7% mention impact, assessment or measures of effectiveness

military motivations for global health activities
Military Motivations for Global Health Activities

Access to strategically important areas

Influence in strategically important populations


“Health diplomacy”

Reduce vulnerability to extremism

“Get between the population and the bad guys”

“Deliver assistance before the Wahabbists do”

“Eyes on the bad guys”


Recruiting incentive

Ultimate goal: security and stability


dod is not of one mind on this
DoD is not of one mind on this

“Counterinsurgency operations can be characterized as armed social work.”

U.S. Army Field Manual 3-24, Counterinsurgency, December 2006

“The U.S. military should never be mistaken for a Peace Corps with guns.”

Secretary of Defense Robert Gates


USAID review of humanitarian projects

Primary objective: ensure short-term DoD projects do not undermine long-term development

Secondary objective: identify synergies where DoD can fill gaps

Logistics, transportation, access

Share Monitoring & Evaluation expertise

Tandem field visits

USAID review of DoD policy and doctrine

Humanitarian assistance guidance message

Joint doctrine, service doctrine

entry points
Entry Points

Inside the beltway

Office of the Assistant Secretary of Defense for Health Affairs

Office of Partnership Strategy and Stability Operations (Policy)

Civil-Military Initiative

Civil-Military sub-Interagency Policy Committee

Operational issues & access to combatant commands: Joint Staff J-5

Doctrine: Joint Staff J-7, Joint Forces Command J-7 (Norfolk, VA)

USAID Office of Military Affairs

Regional level

Geographic Combatant Commands

Senior Development Advisors

Command Surgeons

Humanitarian Assistance program managers

Country level

Office of Defense Cooperation

Security Assistance Office

Civil Affairs liaison officers

obstacles and potential solutions
Obstacles….and Potential Solutions

Coordination is an unnatural act between non-consenting adults

Must be value-added to both agencies

USAID lack of resources

Use new mission requirements to justify manpower increases

USAID must lead US government development activities

Proactive choice of activities beneficial to USAID, rather than reactive to DoD requests

USAID (and DoD) lack of civil-military training

Use Office of Military Affairs expertise

Leverage common training venues, especially for new accessions

Career incentives for liaison positions

DoD lack of Monitoring & Evaluation

Pilot project in non-controversial area to demonstrate benefit

Contract out a common USAID-DoD assessment, but start during mission planning

Civilian-Military Relations, July 2009 on


Gene Bonventre (202) 248-2173



Title 10 US Code Section 2561 Humanitarian Assistance

Title 10 Section 401 Humanitarian and Civic Assistance

Bourdeaux M et al. The Department of Defense’s Involvement in Civilian Assistance, Part I: A quantitative description of the projects funded by the U.S. Department of Defense’s Overseas Humanitarian, Disaster and Civic Aid program. Disaster Medicine and Public Health Preparedness, in press.

Bonventre EV. Monitoring and Evaluation of DoD Humanitarian Assistance Programs. Military Review, Jan-Feb 2008, P.68-72

Reaves EJ et al. Implementation of evidence-based humanitarian programs in military-led missions. Disaster Medicine & Public Health Preparedness 2008: 2(4); 230-236

Kates J, Fischer J & Lief E. The U.S. government’s global health policy architecture: Structure, programs and funding. Henry J Kaiser Family Foundation, April 2009 on

Bonventre E, Hicks K & Okutani S. U.S. National Security and Global Health. Center for Strategic and International Studies, April 2009 on

Civilian-Military Relations: An LTL Strategies study group consensus report. July 2009, USAID and LTL Strategies on