Partnership for the Americas:
Western Hemisphere Strategy and U.S. Southern Command
By Admiral James G. Stavridis, USN
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CHAPTER 6
Health Engagement and Humanitarianism
Liberty is to the collective body, what health is to every individual body. Without health, no pleasure can be tasted by man; without liberty, no happiness can be enjoyed by society.
—Thomas Jefferson
This unfolding 21stcentury presents our entire national security structure in general, and U.S. Southern Command in particular, with an unprecedented opportunity to define and shape new means and capabilities that will best achieve U.S. national security objectives in an era of transnational and unconventional threats. We find ourselves at the dawn of new thinking about how we might overcome the inertia and restructure and reposition ourselves—to morph in ways that will improve our own interests as well as those of our partner nations to the south.
To accomplish this, we need a holistic approach to national and regional security—one that encompasses all facets of security, including: personal/physical; economic; political; intellectual; energy; environmental; financial; and health. Broadening the aperture in such a way is necessary to truly understand the different challenges we face and thus the different functions we may perform in confronting them. As such, this requires not only a cultural mind shift among assigned military personnel but also inclusion of new partners. Relationships are important, and such partnerships must be forged by building levels of trust in the ability of all to work together along traditionally unfamiliar, culturally distinct, but strategically important lines outside the Department of Defense.
We need to continue to recognize that the real thrust of 21st-century national security in this region is not vested in war, but in intelligent management of the conditions of peace in a volatile era. While we remain fully ready for combat operations, diplomacy dominates so much of what we do, and development is a mandatory requisite feature of true, long-term stability and prosperity. We need much greater engagement and resultant synchronization with the State Department and USAID throughout the enterprise. This is true in all aspects of security, but increasingly so in the realm of humanitarian assistance and disaster relief (HA/DR) and overall health security. We should undertake no task without first considering the valuable synergy provided when these and other entities work together— throughout the process—as a team.
While expanding our definition and understanding of "security," in addition to seeking greater unity of effort within and among the members of the interagency community, we have also sought to strengthen the bonds of mutual interest and cooperation with our partner nations in the region. Through a long history of training, communication, exercises, and liaison, we have built sturdy relationships that are now ready for expansion into a new realm of partnering arrangements. We have military liaison officers with partner nations now, but we might be even more effective in accomplishing the mission by offering liaison positions for civilian bureaucrats from agencies and cabinet bureaus from all the nations and territories throughout the region. So much of the power of the United States to create successful partnerships in our region is found in the private sector. For example, in May 2007 Microsoft announced a partnership with the Inter-American Development Bank to form a new Latin American Collaborative Research Federation that will create a "virtual research institute." Since then, Microsoft has committed $930,000 to finance the first 3 years of the project, enabling scientists at research institutions throughout Latin America to seek collaborative solutions to socioeconomic problems in areas such as agriculture, education, alternative energy, the environment, and health care.
Health security—the larger term that encompasses the spread of disease, lack of education and awareness of health threats, and equal access to health care, among others—is one key area where we at Southern Command must find ways to work with nongovernmental organizations, private charitable entities, international organizations, and the private sector, striving to become the partner of choice for those who wish to engage and better the region. We should look for ways to integrate this endeavor into key staff nodes. Such partnerships will better nurture common values and emphasize shared interests in expanding economic opportunity, promoting peaceful resolution of conflict, enhancing scientific collaboration, protecting the environment, fighting crime, and combating diseases that respect no border.
Security and stability throughout this region for the foreseeable future will depend upon the creation of a shared and cooperative hemisphere security environment that is inclusive and beneficial to all. We must find ways to focus the collective wisdom of all partners to defeat those groups and forces who want to keep us from reaching our goals. The threats and challenges in our hemisphere are not traditional military ones, and are often interrelated and involve both state and nonstate actors. Thus they require an international partnering and interagency community approach. This vision embodies our belief that our emerging and changing roles and missions require us to enable lasting and inclusive partnerships in order to work collectively to ensure a secure, stable, and ultimately prosperous home in the Americas.
The health of the people is really the foundation upon which all their happiness and all their powers as a state depend.
—Benjamin Disraeli
Health and Engagement
As previously mentioned, we foresee a regional strategic and operating environment in which the vast scale of challenges that will face the Nation will require the U.S. Government be able to attract people and other nations to support efforts toward shared desired endstates of enhanced cooperative security, sustained stability, and enduring prosperity throughout the Americas. Regional perceptions of the United States will increasingly be critical to our overall effectiveness in these pursuits, and as a result, we will increasingly need substantive, strategic public diplomacy assets with which we can effectively engage the region. In this context, we see a clear opportunity to leverage the Nation’s strength in public health to engage the region in a highly positive, concrete, and overt fashion. Health interventions are particularly valuable and visible to the recipients and can have extremely long-term positive effects—especially when delivered in a comprehensive, synchronized, and integrated fashion that ties together the partnership efforts of military and civilian, foreign and domestic, and public and private sectors. Harnessing the capability of multiple disciplines with a shared regional health mission will necessitate greater unity of effort and synergy between U.S. agencies and bodies, rather than perpetuate duplication of efforts. In short, we see much value in empowering a "whole-of-government"—truly, a whole-of-society and ideally a whole-ofmany-societies—approach to supporting efforts to increase the level of regional health security through fully recognizing and utilizing shared resources and fostering more effective public health diplomacy.
Global and regional health and its direct impact on national and regional security continue to assume a greater role in our nation’s foreign policy agenda, demanding greater insight, knowledge, and a more skilled diplomatic presence in the region. There is an important strategic opportunity for the U.S. Government to better leverage its substantial public health assets found throughout the interagency community to advance humanitarian leadership and protect ourselves and our neighbors from emerging global disease threats and other, broader, and more persistent population-based public health challenges to security. There is a continued need for us to collectively be able to wield this valuable portfolio of health assets in a variety of different circumstances in a more strategic, agile, and facile manner. This will require transcending traditional stovepiped responses to health-related crises and issues, sharpening the ability to identify and respond to key regional health concerns, prioritizing areas for U.S. Government action, and also identifying areas where the United States and its specific agencies will need to perform vital missions in support of another partner, foreign or domestic. Ultimately, our goal is a region whose population is educated in basic sanitation and preventive health strategies; one which has relatively easy access to health professionals; and one whose health professionals have an increased surveillance, predictive ability, and response capacity to confront or even prevent disease outbreaks.
Achieving this endstate first requires a broad, multidimensional definition of public health including, for example, the health-related aspects of agriculture, commerce, the environment, transportation, and the broad population-based benefits that biomedical research yields. Thus, it will require engaging not only agencies such as the Department of Health and Human Services (HHS), the State Department, and the U.S. Agency for International Development (USAID)—which have clear, well-established international health mandates—but also DOD, the Department of Agriculture, the Environmental Protection Agency (EPA), and other Federal Departments and agencies, plus forming and leveraging partnerships with key actors in the private sector and nongovernmental organizations (NGOs) whose programs can have a significant impact on global and regional health. For example, large-scale interagency and public-private sector efforts and ventures are already underway in water and sanitation, malaria, polio, regional disease detection, maternal and child health, refugee and environmental health, and other essential regional health domains.
Once again looking through the lens of U.S. Southern Command, we see we must continue to take a more proactive role in striving to raise the level of health security in the region. In the past, the interests of ensuring national security and the advancement of economic and political objectives consistently have been kept separate and distinct from seeking to achieve humanitarian goals or public health initiatives. Today, because we are more interconnected with our neighbors than at any other time in history, challenges to regional public health represent a growing threat to U.S. health security as well as the long-term stability of weak or developing states. One might even classify "health problems," particularly pandemics, as a growing transnational nonstate actor that has the potential to seriously destabilize Latin America and the Caribbean without a single shot being fired or illicit activity being performed.
For example, according to the 2009 Failed States Index by the Fund for Peace, one indicator of failed states is the progressive deterioration of public services, including health and sanitation.1 Though not the sole factor contributing to the decline of states, health concerns, if ignored, can become a serious threat on a local, regional, and even global scale. DOD will never be the lead agency in providing health security or increased access to health services—nor should we be. We do, however, recognize the growing threats to security posed by endemic health problems. We do understand that poor health conditions are a definite factor contributing to rising instability and eventual conflict, and thus we can and must do all that we can to help create and ensure the conditions of security so that NGOs and other U.S. and foreign agencies can do their jobs in a safe and permissive environment.
Our concepts of "security" and "health" have been viewed as separate focal areas—disconnected, and purposely so. "Security" connotes primarily political, military, and increasingly economic indicators of stability and success, whereas "health" has been relegated to a "merely" humanitarian concern. Health initiatives have focused on improving quality of life in underdeveloped nations, mainly using disease eradication and increased access to health care. Today, though improvement of public health continues to be largely a humanitarian concern, it has also taken on a necessarily more pressing security dimension. An inability to detect and treat an emerging disease, for example, can lead to both a decrease in economic productivity, as well as to an increased probability of exporting this disease and allowing it to transform into a pandemic, particularly in today’s increasingly interconnected world.2 Preventing the spread of infectious disease must be just one of our health priorities as we seek to educate, train, and engage with the military and security forces in the region. Furthermore, although continuing concerns about bioterrorism and pandemic disease tend to dominate discussions of health-related security threats, we also must address the security implications of the state of public health systems in our area of focus.
It may seem at first incongruous for a combatant command, even one which strives to be as interagency-oriented and forward-leaning as U.S. Southern Command, to be engaged in efforts to improve public health. And perhaps it is, particularly if that is how our engagement efforts are expressed or viewed. If, however, we restructure our strategic approach and message to convey that we subscribe to the understanding that "public health" plays a vitally important role in maintaining long-term stability, then we can restate our strategic objectives more along the lines of removing and/or reducing health issues as a potential factor to increased likelihood of conflict. Thus, our continuing commitment to engaging in what some have termed "medical diplomacy" becomes inherently synchronized with our previously stated strategic goals to promote security, enhance stability, and allow for economic prosperity.
And as we continue to emphasize expanding and understanding the definition of security, our roles and missions can and will include a growing list of support functions within the spectrum of public services and institutions. As we have seen, stability, prosperity, and lasting democratic institutions require state security. This, in turn, can be affected and influenced by a wide variety of factors—fed by the two most prevalent and dominant undercurrents and systemic causes of much of the misery and potential insecurity in our region: poverty and socioeconomic inequality. The relatively recent rapid urbanization of Latin America, with its accompanying crowded living conditions, air pollution, and inadequate sanitation, combined with the region’s social inequality and poverty, pose increasingly significant health threats. Thus the rate of growth outpaced the ability of society to keep up. These social challenges can also breed discontent as people recognize the tremendous disparity in access to health care and social services to which they should have equal opportunity access.3
A recent joint study by the Center for Strategic and International Studies and Massachusetts Institute of Technology showed that poor countries are more than twice as likely as wealthy countries to suffer a political crisis in the next 2 years.4 This study then correlated infant mortality rates with the degree of poverty in a nation: poor countries exhibited an infant mortality rate in the highest quartile of the global distribution, while wealthy countries possessed the lowest infant mortality rates. Despite few studies existing that directly relate health concerns and violence, reduced productivity stemming from poor health will further increase poverty, which has been linked conclusively to high rates of violent crime. Further, lack of access to health care is often related to high poverty rates, which predict crime.5 Correspondingly, income inequality is often considered as one of the main factors that increase the prevalence of crime and violence, including gang membership and illicit trafficking.6
An Inter-American Development Bank report calculates that violence can cost a staggering amount—up to 6 percent of GDP in some countries—when one accounts for the provision of services for the injured party, the infrastructure to support those services, and the lost productivity.7 Thus, increasing health security and improving the conditions that would lead to a sustained capability to provide these services for a populace, will have a direct and positive impact on reducing the rates of crime, thereby allowing for increased economic development. Preventing armed conflict is always preferable to fighting one; thus, the more ways we can proactively engage in and support efforts to mitigate the effects of poverty, the farther along we will be on our journey to long-term security and stability in the region.
Southern Command has and must continue to play a vital role as one member of a whole-of-government team carrying out a thoughtfully crafted and integrated health engagement strategy for this region. We must persist in striving to identify optimal ways to address the most pressing health security issues in the region. Our efforts must be handled in a multifaceted manner in order to facilitate a greater sense of "citizen security," which will lead, in turn, to greater national security and enduring stability. Our approach at Southern Command has been to focus on the operational elements of implementation, as well as supporting the development of a holistic strategy that incorporates our interagency, international, and nongovernmental partners. Engagement with the region must continue to occur, and it is imperative for a long-term coherent strategy to be anchored in clearly articulated vital national interests. As with many of the challenges that exist in our region that cannot be restrained by geographic or institutional borders and boundaries, achieving and enhancing health security are greater challenges than any one agency or nation can handle—we need to work in concert with our partner nations, other U.S. Government agencies, and NGOs to be most effective in allocating finite resources toward specific problems.
To this end, our approach at U.S. Southern Command has been to champion and support sustainable development of health resources and care in a context of positive, consistent, and enduring regional engagement. We in DOD possess certain and unique capabilities and the capacity to help partner nations improve their health care capability, especially if we leverage our relationships with NGOs, businesses, and U.S. agencies. Our goal is not to provide health care for the entire region, but rather to build our partners’ capability—and then strive to ensure a long-term capacity—for treating their own populations and for responding to health emergencies, both those arising from infectious diseases and those from humanitarian crises.
Our health engagement should be just one component of the over-arching integrated strategy for health security and stability as delineated by the State Department and other agencies and organizations. We must refrain from the temptation to "go it alone" or get impatient when the wheels of bureaucracy and diplomacy do not turn as rapidly as we would like. We cannot conduct these health security–related missions and exercises—to include HA/DR and medical and dental readiness training exercises (MEDRETEs and DENTRETEs, respectively)—in an ad hoc or poorly coordinated manner without consideration of other agencies’ stability operations. Enhanced and open interagency and partner cooperation is crucial to the success of future security and stability operations.
As previously mentioned, Southern Command’s participation in health engagement directly supports our primary focus of achieving and furthering national and regional security objectives. There are also numerous secondary benefits to such engagement—some of which are viewed as equally, if not more, important than health security. First, U.S. military presence that is associated with humanitarian missions, instead of offensive and intrusive military action, will show the United States cares about the region for more than just its own national security—for example, only engaging via counternarcotics or transnational terrorism threats. Such consistent and enduring engagement in the area of health security will show that we also truly care about the long-term security, stability, and ultimately shared prosperity full of hope and equal opportunity for all who call this region home. As shown by DOD’s experience in Indonesia after the 2004 tsunami, aid can produce a significant amount of sustained goodwill toward the United States, and particularly toward its military.8 Putting a face to the U.S. military, especially when the face is that of a doctor performing surgeries, or that of a SeaBees team building a medical center, can only be a force for improving international relations and creating a positive perception of the United States. We should also remember, however, that this strategy is not novel—Cuban doctors have been deploying throughout the region and across the globe for almost 50 years, and have had great success in garnering positive public opinion.9 We should provide a similar example to be able to display our product in this competitive marketplace of public opinion. We need to do a better job of taking some deserved credit for the countless hours of truly selfless dedication and altruistic pursuits that have an added benefit of helping to reduce security concerns, challenges, and threats to the residents of this hemisphere.
Still another benefit is that continued health care and health security engagements provide outstanding training opportunities for selected U.S. forces and personnel to deploy to a nonhostile area and practice the skills they will need on a battlefield or other high-intensity conflict situation. These skill sets range from logistics planning to construction in remote areas to providing initial medical care that transitions into longer-term sustained health care and rehabilitative efforts. Being able to train and work with the partner nation medical professionals, volunteers, and security personnel on these and other vitally important health-related missions provides a clear benefit to both sides and can be a cornerstone in forging and fostering long-term cooperative arrangements and enduring relationships based on the most human needs. Thus, health engagement in Latin America and the Caribbean provides a moral foundation upon which sovereign nations can build. As they see our lasting commitment to improving the lives of our neighbors and contributing to the betterment of our shared home, perhaps our friends and even competitors will be inspired to contribute in meaningful ways to humanitarian work that enhances regional security and stability, in addition to working to develop and maintain an internal capacity to sustain the skill sets being created through such endeavors.
Southern Command has taken great strides in forming new partnerships with NGOs and we seek to work ever more extensively to maximize the effect of HA/DR missions. NGOs are not necessarily constrained by U.S. Government statutory regulations, and thus their funding usually comes with fewer caveats and restrictions. By cooperating with them, we can learn from them and leverage their expertise and resources to improve our ability to effect improvements in the overall level of health security in an area. Forging trust, cooperation, and teamwork between two nontraditional and perhaps historically noncompatible entities like the military and certain humanitarian-focused NGOs is important as it allows us to present an entirely different image and convey a softer message of engagement instead of presence being construed as occupation or some other imperial pursuit. In return, we are able to offer the NGOs the ability to expand the scope of their endeavors and to conduct health-related missions that would normally be prohibitively expensive or impossible because their desired location for aid or engagement may be a nonpermissive environment because of threats to their personal security. Even by just providing transportation for their personnel and material on a space-available basis, we enable NGOs to devote more of their finite fiscal resources into much-needed supplies and other areas.
Often, opponents of the military’s involvement in development operations will argue that aid should only be administered by neutral groups because the military has some Machiavellian intent in conducting any such operation. They claim the military will always be seeking access to a region for its assets or basing rights or "hearts and minds," rather than for purely humanitarian reasons. This is an undeniable secondary benefit of conducting HA/DR and similarly focused missions, but this should not be the primary focus. The intent of providing training, education, and services to populations is not to precipitate a quid pro quo situation, but rather to increase health care quality, access, and capacity to facilitate security and stability within our shared home.
Return on Investment
In 2008, a group of experts composed of eight Nobel Prize laureates and renowned academicians met to set cost-effective priorities for increasing global welfare, particularly focusing on developing countries. Their conclusions, titled the Copenhagen Consensus, laid out 30 priorities, of which 12 addressed malnutrition and disease. The solution with the best cost-to-benefit ratio was providing micronutrient supplements for children, with other top solutions including expanded childhood immunization, de-worming and nutrition programs at school, and malaria prevention and treatment.10 While the panel’s findings were not exclusive to Southern Command’s region of focus, its recommendations should nonetheless be included in health engagement strategies because: 1) they have been deemed to be highly cost-effective in the prevention of conflict; and 2), the benefits to lives and economic potential far outweigh the required initial investment in care and education.
Further Copenhagen Consensus research assessed that addressing health security issues is not prohibitively expensive; modeling exercises have been done that show that training health care providers on specific protocols for diagnosing and treating common childhood diseases is extremely beneficial when initial quality is low and disease incidence is high—children’s lives can be saved for as little as $14 in preventive treatment.11 Certainly, this is a relatively cost-effective process. Still further, some studies show that 1 extra year of life expectancy gained for a country can produce a per capita GDP increase of 4 percent.12 This increase can be crucial to economic growth and development, as well as their associated positive effects. As we address health care and its role in health security, we can also look at integrating crime and violence prevention programs into our efforts at improving health education, especially in high-risk zones.
On the other side of the spectrum, other opponents will argue that military resources should not be wasted on missions that fall clearly into the operating lanes of other government agencies. The bottom line is that the military is primarily a war fighting organization; however, if we seek to ensure stability by improving the level of health security of the region, then there should be an undeniable role for the military in humanitarian and other medical and health security–related missions. While relatively expensive compared to other agencies’ operating budgets, the missions make up only a small fraction of the total DOD budget. Analysts estimate a recent $20 million humanitarian mission of the USS Pelileu to Southeast Asia to be equivalent to just 10 percent of U.S. daily operating costs in Iraq and Afghanistan.13
Not only with the military help that the United States has been offering, but the humanitarian assistance helps to reaffirm the special bond between the American and Colombian people.
—Juan Manuel Santos Calderon
Minister of Defense, Colombia,
on board USNS Comfort
This type of diplomacy really touched the heart and soul of the country and the region and is the most effective way to counter the false perception of what Cuban medical teams are doing in the region.
—Elias Antonio Saca Gonzalez
President of El Salvador,
on board USNS Comfort
We share a vital connection with the wonderful and diverse nations of the Americas. Today, more than ever, common interests interweave the fabric of this beautiful hemisphere. We share common challenges and opportunities; and our futures are inextricably linked. As such, we pursue a host of programs designed to foster security, stability, and goodwill in the region, with the ultimate goal of enabling the spread of true and lasting prosperity to the approximately 460 million people living in this part of the world.
At Southern Command, we are committed to being good partners— and to being the partner of choice throughout the region. Every day, year after year, we dedicate the majority of our resources toward building the security capabilities of our partners, while working to encourage an environment of cooperation among all of the nations in the region. This involves numerous training exercises, educational programs, technology-sharing, intelligence-sharing, security procurement assistance, humanitarian aid, and a myriad of other programs. We endeavor to improve our region’s ability to respond to today’s and tomorrow’s security challenges. Through a steady improvement in security, we can help create the conditions that will enable this region to counter the poverty and inequality that have gripped it for so long.
In terms of military-to-military contact, Latin America and the Caribbean represent many opportunities for U.S. engagement. Of the 31 countries and 10 protectorates in the region, only 2 are land-locked. Maritime engagement has a huge potential for positive effects, especially because the United States has already established a long history of maritime contact and cooperation with most of the region. As a result, we have witnessed numerous positive results from integrating many initiatives originating from nontraditional approaches to the nonconventional challenges we have alluded to thus far. These missions are relatively low visibility, but they can have a huge impact on U.S. military and partner nation military and security force readiness, particularly when they are done in a consistent and enduring manner. Exercises like UNITAS provide excellent forums for military-tomilitary relationship-building, as well as multilateral HA/DR training, and we have been involved with this wonderful event for 50 years, hosting the 50th Anniversary exercise and celebration in Jacksonville in 2009.
Building confidence, capability, and cooperation among partners is essential to confronting today’s security challenges. Our exercise Fuerzas Aliadas (Allied Forces) Panamax has matured over the last 7 years and has become one of our flagship programs. Panamax is a multinational and interagency exercise that focuses on defending the Panama Canal from traditional and nontraditional threats. The exercise began in 2003 as a limited naval exercise with just three participating nations. Due to past successes and efforts to expand partnerships, the exercise has grown to include a roster of more than 20 nations, several U.S. departments and agencies, international organizations, nongovernmental organizations, and multiple military branches of service.
Cosponsored by Panama, Chile, and the United States, this year’s exercise formed a truly integrated international force—Multinational Force– South. The force was led by Southern Command’s Army component, U.S. Army South, but the maritime components were headed by Admirals from Chile and Brazil. While the exercise scenarios focus on the security of the Panama Canal, this type of integrated multinational training certainly benefits any response to real-world threats in our region—conventional or unconventional. From responses to catastrophic disasters to United Nations– mandated multinational forces, this type of collaborative training has already proven to be indispensable. In addition to the security scenario focused on the Panama Canal, Panamax also included a multinational peacekeeping battalion training event, an interagency Proliferation Security Initiative training event focused on the shipment of weapons of mass destruction, and, what is arguably our most important and farthest reaching mission area, multinational humanitarian training and assistance/disaster-relief training. We integrated the health-security aspects of Panamax to assist the Government of Panama with synchronizing its interagency homeland security exercise, Panamax Alpha, with Panamax and facilitated for the first time the involvement and support of the Defense Threat Reduction Agency, the U.S. Coast Guard, and the Federal Emergency Management Agency.
Joint, international, interagency, and public-private involvement is the essence of Panamax. The collaborative integration of participants and helpful lessons learned this year were exceptional. The increased participation and scope of Panamax over the years underscore the significance the international community places on cooperative efforts and strong partnerships as pillars of worldwide security and stability.
Along these lines, one of our most visible and successful initiatives toward building partner capability and capacity in the health security arena has been Continuing Promise. In 2007, for the first time, we sent a hospital ship—the USNS Comfort—with its specifically tailored joint, interagency, international, and private sector crew—on a 4-month tour of Latin America and the Caribbean to bring modern medical care and conduct medical training in 12 countries. It was a tremendous success. Over 385,000 patient treatments were completed, along with 1,170 surgeries, more than 20 community-improvement projects, 17,700 livestock vaccinations, and more than 25,000 dental patients treated. Throughout the deployment, our personnel received vital training, and our message of positive commitment to the region and to its peoples penetrated deep and touched millions. This effort combined multiple military services, multinational integration, and medical professionals from the private sector.
The success of the mission, combined with uniquely integrated medical and construction training for our personnel, spurred the conception of Continuing Promise 2008. Since the Navy only has two dedicated hospital ships, the Navy sourced our request to repeat the Comfort mission in 2008 with two large amphibious ships. Building upon the lessons learned from the Comfort, we increased mission duration from 4 to 7 months, increased contact time in each port, and integrated more partners for the undertaking.
The two ships carried a mix of military, interagency, multinational, and even nongovernmental medical and health specialists. Along with this diverse medical team, we embarked military engineers, construction experts, Navy and Marine Corps helicopters and crews, and military training experts. This uniquely designed team was tailored to training and humanitarian missions, but had the flexibility to easily transition to disaster-relief efforts should the need arise—which it ultimately did.
One of the ships, the USS Boxer, completed the Pacific phase of Continuing Promise with superb results: over 65,000 total patient treatments, including 127 surgeries, 4,000 optometry patients treated, 14,000 dental procedures, medical and military training for thousands of host-nation students, and construction projects at almost a dozen sites. The second ship, the USS Kearsarge, completed the Atlantic phase in November, and its joint, international, and nongovernmental medical professionals worked alongside host nation officials to treat more than 145,000 patients in six countries. The crew also dispensed more than 81,000 prescriptions, provided veterinary care to nearly 5,600 animals, and completed various construction and renovation projects in each of the countries visited during the mission.
As an example of the flexibility of this type of venture deployed in our region, after Haiti was struck by successive tropical storms and Hurricane Ike in September, the Kearsarge diverted from its planned stop in Colombia to respond to this emergent humanitarian crisis. Supporting relief efforts led by the USAID’s Office of Foreign Disaster Assistance, the Kearsarge and its crew delivered 3.3 million pounds of food, water, and other relief supplies to Haitian communities devastated by the storms.
In 2009, USNS Comfort returned to our waters and again far exceeded everyone’s expectations in numbers of patients encountered and treated, numbers of relationships forged, and lasting impact on various host nation populations. With over 100,000 patients seen, 1,600 surgeries performed, 135,000 pharmacies dispensed, 13,000 animals treated, and 37,000 students trained, we were able to engage on a scale previously unimaginable just 4 years ago. But the impact on the host nations was more than just numbers—the types of procedures performed and training conducted spoke to the long-term positive effects on society and citizen security as our joint, combined, and integrated crews focused on hysterectomies, thyroids, cataract removals, and education on prevention.
On the engineering side, over 14,000 man-hours were worked by 21 Construction Battalion (SeaBees) personnel as they repaired and improved five hospitals and clinics; provided refurbishments to seven schools; and renovated one baseball field. In addition, in direct support of existing USAID projects, Comfort personnel assisted in a laboratory completion in the Dominican Republic and assisted in dock repairs in Panama that buttressed a USAID eco-tourism project. Perhaps even more impressive was the Sea-Bees showcase project at Exporcol School, where they built three classrooms, a kitchen, and a playground from the ground up for the neighborhood of Exporcol in Tumaco, Colombia. The community now has a functioning school which was nonexistent prior to the SeaBees’ arrival. As a result, the children of Tumaco will no longer have to attend school in shifts.
From a partnership perspective, during the 2009 deployment, 271 NGO representatives served on board and ashore, 60 partner nation personnel were embarked, and 84 medical essential billets were filled, which increased the overall surgical capacity on board Comfort by 30 percent. These invaluable medical professionals volunteered to fill critical roles as medical doctors and nurses, ophthalmologists, veterinarians, dentists, preventive medicine practitioners, plastic surgeons, anesthesiologists, and even a speech therapist. Our engagement and partnering with the private sector also yielded an overwhelming response in the form of donations, as the deployment received over 4 million dollars in contributions, including $1.4 million in high-nutrition meals, medicines and medical supplies, hospital beds and wheelchairs, school supplies, clothing, and first aid kits. Two specific recipients felt the greatest impact as both the Angel Missions and the Children’s International Lifeline received more food, medicine, and supplies during Comfort’s short visit than either would have received in 3 years of normal operations.
Through postdeployment polling completed by the Center for Naval Analyses, 62 percent of the host nation populations polled reported a significant and positive change in their opinion of the United States, citing the fact that most of the care was focused on previously marginalized neighborhoods and citizens and the personal interaction with and treatment from the medical providers. In addition to creating a lasting impression that the United States cares about the lives of our neighbors and that this type of engagement has continued for 3 consecutive years, other noted impacts of the visits included a demonstration of U.S. goodwill to new governments; a collaborative venue for host nation militaries and their governments; the generation of an interagency planning and execution opportunity for each host nation; and, finally, the definitive change in the attitude of Tumaco residents toward fixing their own community. Over the past 3 years, Continuing Promise has been an incredibly successful mission that further advanced our strategic messaging and built confidence, capability, and goodwill in numerous countries in the region serving as a visible and lasting counterweight to anti-U.S. messaging.
More than just a medical mission, these humanitarian service groups (HSGs) have provided dental care to about 50,000 patients, conducted medical training for almost 60,000 host nation students and medical providers, and sponsored over 40 construction and restoration projects at local schools and health care facilities. These visits also extended veterinarian services throughout their journeys, treating and vaccinating thousands of animals, which constitute the livelihood of many families. This shining example of enduring engagement for the greater health security of the region also has become a symbol of goodwill and has brought renewed hope to those who might have given up on a healthy future, as well as to those who might have previously been sympathetic to anti-U.S. rhetoric. Continuing Promise has directly changed the lives of many and indirectly touched the lives of several hundred thousand throughout our shared home.
While our programs and initiatives focus primarily on security— the absolute bedrock upon which the foundation for lasting stability and long-term prosperity is built—increasingly our approach has expanded and is just one effort that supports a broader national approach to true partnering and engagement in the Western Hemisphere. Access to health care is such a critical component of stability and the Comfort’s mission is only one of many medical outreach efforts. For example, Southern Command also sponsors MEDRETEs and DENTRETEs, consisting of military medical teams that treat over a quarter of a million patients annually in the region, focusing primarily on needy rural, isolated populations. These unique training exercises have had tremendous impact inland across the region at over 75 separate locations—changing lives, providing alternative perceptions, and spreading goodwill through quality donated medical assistance. Key to this success is a novel approach to partnering that combines the synergistic efforts of a diverse group of experts from U.S. and international militaries, nongovernmental organizations, and volunteers and donations from the U.S. private sector. This integrated approach highlights the power of creative public-private partnerships to show our true interest in, and eternal commitment to, the people of the Americas. As the new smile upon the visage of every child after facial reconstructive surgery will certainly attest, this is vitally important work and the positive effects can last a lifetime.
Besides medical programs, Southern Command sponsors numerous other humanitarian projects, ranging from planned events such as the construction of wells, community centers, and medical facilities to rapid response missions in the wake of disasters. We also conduct frequent military training exercises with our partners, send thousands of partner military and civilian experts to various leading academic institutions, and provide other critical security assistance to our friends in the region. Throughout the years, Southern Command’s Humanitarian Assistance Program has augmented traditional military-to-civilian engagement activities in order to increase our partner nations’ ability to respond independently to natural and man-made disasters. Our program helps local populations who could benefit from completed projects such as schools, clinics, community centers, orphanages, emergency operations centers, disaster response warehouses, wells, and potable water systems. In 2008 alone, we completed 49 construction projects and provided critical training programs for first responders, disaster managers, firefighters, and disaster warehouse managers.
A close corollary to the Humanitarian Assistance Program is the New Horizons series of joint and combined humanitarian assistance exercises that U.S. Southern Command conducts with Latin American and Caribbean nations. These exercises provide readiness training for U.S. Engineer, Medical, and Combat Service Support units, but also provide great benefit to the host nation. Each New Horizons exercise lasts several months and usually takes place in remote areas. U.S. Southern Command strives to combine these efforts with those of host nation doctors and civic personnel. In 2007, we conducted these exercises with four nations—Belize, Guatemala, Nicaragua, and Panama. We built on this in both 2008 and 2009, building relationships and capacity in six additional nations.
Also demonstrating U.S. goodwill, Southern Command directed military forces to provide disaster relief to six of our partner nations in times of dire need. These disaster relief operations, which were integrated with USAID-led efforts and those of the international community, helped alleviate the suffering of many and assisted affected regions in their recovery. Specifically, in one 8-month span in 2008, we provided much needed flood relief to Bolivia in March, quickly provided assistance to Peru following an earthquake in August, and aided Belize after the passage of Hurricane Dean. We were critical first-responders to a Nicaraguan request for relief following Hurricane Felix in September, arranged the procurement of firefighting equipment for Paraguay during a widespread wildfire also in September, and assisted the Dominican Republic after Tropical Storm Noel ravaged the island nation in October.
In almost every case, our Joint Task Force–Bravo (JTF–B), located in Soto Cano, Honduras, was a major contributor to the success of these disaster relief operations. Essentially a small, joint air wing comprised of 18 helicopters, JTF–B is our only permanently deployed contingency force in the region. JTF–B responds to crises as a first-responder and routinely participates in humanitarian assistance, disaster relief, search and rescue, personnel recovery, and noncombatant medical evacuations. JTF–B has a long history of answering the call for assistance and is a tremendously valuable asset to U.S. Southern Command’s partnership and goodwill efforts in the region.
In addition to conducting exercises that build understanding and multinational cooperation, U.S. Southern Command conducts a comprehensive Theater Security Cooperation program to develop the capability and capacity of our partners to respond to mutual security threats of many different forms, including those related to health security—either independently or with regional partners. The overarching maritime strategy that encompasses this approach is called Partnership of the Americas (POA), and for 3 straight years, Southern Command has conducted a maritime POA event in our region.
Evolving from the initial 1-month event in 2006, POA 2008 involved a 6-month Navy and Marine Corps mission throughout Latin America and the Caribbean that focused on enhancing relationships with regional partners and improving operational readiness and interoperability. During the most recent deployment, a four-ship multinational task force circumnavigated South America, participated in several multinational exercises sponsored by Southern Command, and conducted theater security cooperation and community relations events on shore. Our POA events serve as visible symbols of U.S. commitment to bilateral and multilateral military cooperation and have evolved into comprehensive engagement missions that maximize exposure to international partners and local communities.
Another multinational exercise—Tradewinds—focuses on transnational threats in the Caribbean Basin. This successful exercise brings together security forces and interagency personnel from 18 nations to practice coordinated first-responder, fire, police, and military responses to security threats. The exercise scenarios emphasize basic security operations, counterdrug activities, and disaster preparedness in a field environment with a focus on regional cooperation.
In addition, we sponsored the pilot deployment of a new U.S. Navy program called Global Fleet Station. This innovative new concept provides a modular platform for sustained engagement tailored to each unique region. This floating theater security cooperation platform hosted more than 5,000 military and civilian personnel and involved a joint, multinational, and interagency approach at each training site. Swift has also conducted community relations projects in each port to refurbish local schools and community centers and to deliver tons of donated goodwill materials. As with Comfort, this type of deployment represents the future of engagement—visible, persistent, scalable, and cooperative engagement that trains our personnel and demonstrates the goodwill of the United States while building partner nation security capabilities.
Our region is not all water, however. Thus, to complement our robust maritime programs, we are extremely excited about revamping land engagements with a young program called Beyond the Horizon. This program aims to maximize the impact of our land events by increasing the number of "microburst" engagements—engineer construction, small unit familiarization, subject matter exchanges, medical readiness training exercises—as well as establishing longer-term programs that integrate the efforts of other U.S. Federal agencies, host nations, and the private sector.
We have accomplished much with these exercises, operations, and training opportunities, but there is still much more work that remains. We will look to increase the duration and number of countries visited through Continuing Promise and other similar efforts as part of the Partnership for the Americas, which will build on the successful missions of the Comfort, Kearsarge, and Boxer. These deployments will highlight consistent and enduring engagement with innovative approaches and initiatives that build and leverage strong interagency, multinational, and public-private cooperation. In so doing, we will continue to track along our command heading: understanding the linkages the United States shares with the region; working together with partners to overcome shared challenges; and fulfilling the promise of a secure, cooperating, and prospering hemisphere through innovative and effective strategic initiatives.
It is a privilege for the second time to be on board this fabulous ship, the Comfort—messenger of peace, hope and alleviator of suffering. The ship is an alleviator of suffering and hope for the people, it is a messenger from the United States government for those who suffer from health problems regardless of their ideological or political affiliations but who share the common problem of extreme poverty.
—Jaime Morales
Vice President, Nicaragua
To continue to be this messenger, we need to communicate effectively that the United States cares about the people of the region—and that we will continue to do our part to help fulfill the promise of the Americas for the duration of the journey. We also need to demonstrate how we are engaged positively on security issues throughout the region. A good portion of our task might simply involve building a wider recognition of all that we currently do in the region—taking some deserved credit if you will—while also developing new ways of connecting with the people of this vibrant and dynamic region. Most importantly, all our endeavors need to harness and emphasize the natural alignments and shared interests between the nations of the Americas. Despite our differences, we continue to grow more economically and culturally interconnected and interdependent and our shared security challenges prove that we are all, in fact, on this journey together.
As we look to the future, we see the increasing importance of developing innovative subregional, regional, and hemispheric partnerships to combat transnational security threats. Our current and future security needs require a cooperation that goes beyond mere agreements on the desire to work together. This cooperation needs to be concrete and able to adapt as the willful threat adapts. It needs to combine a multiagency, multinational, and private sector approach to security. But several key prerequisites need to be met before this level of cooperation can take place.
First, we need to earn and maintain trust in order to keep the partners we have and to develop new ones. Our unified approach will require consistent and effective resources, cohesive strategic messaging, and innovative and earnest information-sharing across the board. Second, we need to reexamine the various exercises, programs, and partnerships we sponsor in the region and find innovative ways to make them more inclusive and more effective at communicating our connection to the peoples of the region. Paramount to this effort will be finding the right size and shape of participation with which each nation or agency is comfortable. Participation can range from international peacekeeping operations and humanitarian assistance to large multinational events like the UNITAS and Panamax exercises.
Last, but not least, we need to do a better job of relating and publicizing the efforts of all U.S. agencies and of our own private sector. There is a tremendous amount of good the United States does in the region—from billions of U.S. foreign direct investment, to millions of nongovernmental volunteer hours, to the quarter million medical patients Southern Command treats each year. But often we do not tell our story well, particularly in a way that can help us counter the image that the United States does not pay enough attention to the region. If we employ all of these methods, we will achieve more effective and stronger security partnerships. Coming together and forging lasting cooperative relationships centered on issues of health, humanitarian assistance, and disaster relief offer a framework and opportunity for engagement that exists outside the realm of contentious and highly politicized matters of foreign policy. We need to seize and take advantage of this fact.
U.S. Southern Command hopes to do its part to make these partnerships work. Our evolving engagement strategy commits us to build the security capability of our military counterparts and to expand the capacity for all of us to work together. One way we seek to foster such partnering is an initiative designed to harness the vast potential of public-private sector cooperative ventures in the region. We created a staff structure and engagement plan to tap into these private sector resources and combine their goodwill efforts to our outreach programs. As an example, we use the U.S. Navy’s global outreach program, Project Handclasp, to transport materials donated by the U.S. private sector—such as ambulances, school supplies, high-nutrition meals, and children’s bicycles—and distribute them as Navy ships pull into ports in our region.
In April of 2009, Project Handclasp, as part of its Million Meals Initiative and Clean Water Initiative, provided the following to hurricane-ravaged Haiti: 1,425,600 high-nutrition meals (which weighed over 217,000 pounds), water filter capability for 350 institutions/homes (each filtration system possesses a 10-year life span), pharmaceuticals valued at over $268,000, medical materials, hygienic supplies, wheelchairs, and stuffed animal toys for children. The expiration dates of pharmaceuticals ranged from more than 1 to more than 3 years from the date of presentation in Haiti.
The high-nutrition meals consisted of fortified soy rice casserole, a product formulated in consultation with Cargill, Pillsbury, General Mills, and Archer Daniels Midland to meet all nutritional requirements for physical health and mental capacity of severely malnourished children, as well as healthy adults. This protein and nutrient-rich formula is a comprehensive and easily digestible product for reversing the starvation process and restoring health and mental alertness. Project Handclasp obtained private sector donations to transport the meals to the ship at no cost. Project Handclasp provided 350 institutions/homes with water for drinking, washing, and bathing for up to 10 years. The filters are portable, easy to use, affordable, and don’t need electricity. An analysis of the point-of-use water technologies recognized by the World Health Organization ranked this as the top-rated technology.
Only through building new, capable relationships such as the shining example Project Handclasp embodies—inside and outside government, on both the domestic and international fronts—will we be able to match our strategic outlook to effective unified action, particularly when confronting threats and challenges that do not fall clearly into operating lanes typically reserved for DOD. Only through a robust commitment to partnering will we be able to gain and maintain the critical regional friendships we need for the security of our hemisphere. We truly are all in this together—collectively, the nations of the Americas are better poised to meet head-on whatever the future holds in order to bring about a stable, prosperous, and secure future in this special part of the world that we share.
It is difficult to assess precisely the overall impact of training missions with humanitarian benefits of this scale. But based upon the positive local and international press, the number of national leadership visits, and the vast number of people touched by the USNS Comfort missions and Kearsarge and Boxer deployments, we believe they were a significant success. Certainly, there are many lessons learned from these unique and paradigm-shifting deployments to Latin America and the Caribbean—and we will incorporate them into any future deployments—but the integrated and cooperative nature of this mission really serves as a model for the future of engagement and training: Joint, Combined, Interagency, International, and Public-Private. We plan to conduct similar missions on a regular basis as part of our continuing fulfillment of our partnership and cooperation with regional neighbors.
With the goal in mind of creating conditions for empowering the population, Southern Command will need to tailor its efforts to include the local health professionals in as many events and projects as possible. Current missions already make efforts to include local health care providers and administrators. Ideally, we envision partner nations’ health care professionals deploying on tours similar to Continuing Promise (CP) missions, either in a joint role with the United States, or even perhaps in a self-initiated, sustainable, multinational effort. Before that point, we need to continue building and fostering host nation commitment to the participation in and support of medical missions in the region, both to promote education and to ensure that the mission is seen by inhabitants of the region as a cooperative effort, not an imperial one. Host nation involvement in preparing their populations for U.S.-led missions can make a significant difference in the allocation of services to the right individuals. As seen in CP 2009, if the local ministry of health is engaged and cooperative, the mission’s efficacy will be maximized for the local populace.
In addition to recognizing and being pleased with short-term gains and advances in initial health care and security, as well as with local populations’ positive perceptions of the United States, we need to always remember to adjust our lens to a longer focal length and ensure we are devoting the proper amount of time, energy, and resources to the enduring strategic objectives. To that end, we can focus more on the education and sanitation components of health care and security. Though the statistics are more quotable when referencing numbers of immunizations given or surgeries performed, many of the Copenhagen Consensus solutions involve longer-term solutions to health security challenges. While the military may not necessarily be able to provide courses of vitamin A supplements (as the Consensus suggests) to every child under the age of five in the Americas— nor should we necessarily attempt to take on such an endeavor unilaterally—our presence in the region does give us many opportunities for interaction on a vast array of humanitarian issues.
One novel tactic was implemented during CP 2009 and can be duplicated on a bigger scale. A large fraction of the more than 100,000 patients who came in for a consult were much more interested in receiving a small supply of vitamins and Tylenol for themselves and their children than they were in addressing a serious and/or chronic medical concern. If those people could be identified in the first steps of screening the potential patients, they could be gathered into separate groups for instruction from a corpsman, nurse, or doctor to receive general health education and preventive medicine materials before they received their vitamin handout. Considering the mostly generic and nonemergent nature of the patients’ complaints, this process could serve to maximize the effective use of our health providers’ time and resources while in-country; more importantly, however, it would greatly assist in providing the benefits of long-term health education, basic sanitation principles, and health awareness.
Education can help to create the conditions for empowering local populations to improve their public health milieu. USAID provided $390 million last year to "invest in people and humanitarian assistance," an objective that includes increasing access to health care, basic education, and training. Southern Command should work with agencies like USAID to support their missions; they too have recognized that education and training are central to creating sustainable successes. To further elaborate on this, Ambassador Ivonne A-Baki, the 2007–2009 President of the Andean Parliament, believes that "It is common to view economic development and poverty reduction as two separate issues. Programs and policies for economic development should go hand in hand with programs to reduce poverty. In fact, reducing poverty by investing in education and health care is the best way of achieving economic development."14
Another way to assist in the long-term development and sustainment of the level of health care and security is to encourage local buy-in on programs. Continuing commitment to involve local leadership and organizations, especially local doctors, will be essential in promulgating our message and ensuring effective and accurate engagement. Subject Matter Expert Exchange (SMEE) is a program that exists to educate the host nation health care providers by having U.S. military and partner NGOs give instruction on public health, veterinarian services, and advanced lifesaving techniques. SMEE sessions, already implemented on the Continuing Promise missions, offer an opportunity for health engagement missions to continue to yield benefits long after the deployment ends. By doing focused local projects and by training the professional health care providers, we also strive to show to the local populations that they have the ability to take ownership and control over efforts to improve their own situation. A series of connected wins in the health care arena, whether they involve vaccinations, new disease control and surveillance methods, or enhancing local treatment capacity, are vital to demonstrating that the United States does care about the region in a proactive manner and that we will continue to care because we are just one inhabitant of a home we share together.
Finally, as within any home or family, sometimes conflicts can develop between the competing objectives. As alluded to at the beginning of this section, health care and humanitarian missions have traditionally been kept separate and omitted from any discussions involving national security strategy and policy. However, as we continue to have ongoing missions and endeavors like Continuing Promise and others that purposely combine "health" with "security," we are going to increasingly find objectives that seemingly are in direct opposition to each other. Humanitarian assistance and disaster relief (HA/DR) training, improving the health of the population, and public relations are frequently cited as major mission objectives. What matters are the order of importance of these goals and the desired endstate of the region receiving aid. If long-term stability of the region is the ultimate goal, then health awareness, health levels, and health security should be considered the primary focus areas. To that end, medical, dental, and public health professionals should optimize U.S. military medical missions to provide the services that will make the greatest difference for the greatest number of patients and will leave an improved health infrastructure. While there are differences of opinion on how to do this best, the missions must be designed primarily to improve the levels of health education, awareness, access, and overall security—only then can this mission area truly be an enabler toward long-term stability.
HA/DR training goals could complicate and conflict with long-term stability goals, at times. Whereas seeking long-term health stability requires extensive cooperation with the host nation to build capacity, HA/DR training limits operations to addressing only acute threats to health. Since HA/DR is not meant to build health care infrastructure per se, it may actually work against long-term health stability when used in nonemergency situations. It is important that the mission be planned carefully to "first, do no harm" to the existing health security capacity. HA/DR training need not conflict with long-term health security goals, but the offices leading the respective missions should be mindful of the potential for disagreement and working toward cross-purposes. The same can be said over the potential to focus on public relations events to the detriment of increasing patient encounters with those in dire need but perhaps of less "political value." Individual health, including a corresponding access to health care, is a cornerstone of citizen security, and this is and should remain true external to and irrespective of any political system or maneuverings. It is an issue that strikes at the most fundamental of our basic human needs. Thus, it is a perfect mission area to find common ground, come together, and forge lasting relationships toward a regionally shared endstate of security and stability. As Scottish philosopher and author Thomas Carlyle once commented, "Ill-health, of body or of mind, is defeat. Health alone is victory. Let all men, if they can manage it, contrive to be healthy!"
This mission represents not only the cooperation, but the dream, the willingness and the future between these countries that morally share a long history in the future of cooperating and looking for ways to bring people closer and improve the quality of life of the people of the Americas.
—Martín Torrijos
President, Panama
I expect to pass through the world but once. Any good therefore that I can do, or any kindness I can show to any creature, let me do it now. Let me not defer it, for I shall not pass this way again.
—Stephen Grellet (1773–1855)
French-American religious leader
Because of ever-increasing rates of regional and global travel and trade, environmental factors, and growing natural resource constraints, the intensity and regional scope of health challenges will continue to increase in the coming years. Health challenges will also progressively be interwoven with other issues, raising their potential significance for U.S. national security. Finally, we must always remember that for the focused regional public health efforts envisioned in this capability to be successful, they must consistently be planned and undertaken with close consideration of the broader development context of a given host nation or subregion. If this is not synchronized and integrated throughout every level of planning to execution, the tireless efforts amount to little more than episodic events and exercises that have a much shorter shelf-life.
In today’s complex global and regional environment, promoting human security, health, and development is the order of the day. Thus, U.S. Southern Command, in coordination with other U.S. Government (USG) agencies, seeks to evaluate its humanitarian assistance and disaster relief programs with the same diligence it gives to military campaigns. We are still in the nascent stages of Continuing Promise and our other health-security and humanitarian missions, but already we can see that improved mechanisms for USG interagency communication and coordination are required. Based upon feedback from each of the deployments and exercises, we learned that operators in the field are starving for information, but there is no consistent place to go to find out who is doing what. For example, teams might show up to build a flood control project in one country, only to find out later that another USG agency has just completed one on the same river, but farther upstream. Equally important is a consensus that monitoring and evaluation need to be implemented for all humanitarian and development assistance programs, using similar terms and techniques across USG agencies, based on international standards and best practices. When we build a clinic, how will we know if it was useful, how the host nation felt about it, or whether it was still functioning a year later?
We need to ensure that each word, thought, and deed is improving the overall well-being of the host nation and is in line with our and the host nation government’s overall objectives. As we strive to measure the impact of our health security and humanitarian missions and programs, it makes sense to leverage the lessons learned, best practices, and capabilities in the other agencies. This will undoubtedly enhance efficiency and continuity, and we will be one step closer to a true whole-of-government approach—ultimately, a whole-of-many-governments approach—on this important issue. Health engagement is an important strategic opportunity for Southern Command specifically, and for the U.S. Government as a whole. Regional health is a definitive indicator and factor in national and regional security. Being able to mobilize nontraditional, soft power elements and integrate them with more traditional resources and approaches in a strategic manner will be an invaluable asset to better addressing emerging/potential regional and global health threats, while also advancing our public diplomacy as a leader in humanitarian assistance and disaster relief.
Many people argue strongly for making public relations the top priority in our regional engagements, so as to maximize U.S.-oriented goodwill.15 The difference between aiming toward short-term goodwill or long-term health security may seem to be a false choice to many. "Won’t every humanitarian aid mission do both?" is the question frequently posed by those who believe that these missions are a win-win for both the goodwill and the stability goals. A small baggy of vitamins and a 10-day supply of Tylenol certainly curry goodwill, but do they constitute a gain in true health security or any sense of long-term stability? Public relations will be a part of every medical aid mission, but if goodwill supplants long-term security and stability as the ultimate objective, then the focus of the missions will inevitably start to shift from maximizing health gains to maximizing positive media exposure. The result will be seen in everything from the dosage sizes given by the pharmacy to the primacy of distinguished visitor visits over medical operations. During any mission, a vast number of "health encounters" can occur, but the question of efficacy looms large in every physician’s mind. Though surgeries, medical consults, and vitamins provide for targeted successes and photo opportunities, they do not constitute enduring, comprehensive solutions to the endemic problems of health care, awareness, and security in many of the countries in this region. This is not an argument against promoting goodwill through medical missions—rather, it is an argument for applying the proper emphasis in the planning phases to ensure the missions are designed to maximize both health gains of the region and increased goodwill or perception of the United States. Since one of the ways we seek shared regional security is through healthy populations, public relations should work with and throughout the core medical operations, not as a separate entity or isolated objective. By law, Title 10 of U.S. Code prohibits the use of military personnel for humanitarian missions that do not directly impact the security of either the United States or the host nation. Good press and positive attitudes about the United States, our intentions, and our commitment to the region will ultimately come as supplementary benefits.
One of the most difficult parts of the entire medical engagement enterprise lies in evaluating the effectiveness of the mission. This can be simple when missions are quantifiable: for example, the doctors on the USNS Comfort performed X surgeries or handed out Y pairs of eyeglasses to the local populations. Even days of training can be counted for the Sea-bees and MEDRETE/DENTRETE teams deployed to the region, or we can count qualifications earned by our personnel. Much more difficult to quantify, however, are the long-term effects of our efforts for the citizens of each nation visited. If our goal is not just regional presence, but rather instilling in the populace and governments that this is part of our constant commitment to enduring engagement, then we must not be dissuaded by a lack of short-term, quantifiable effects or results. Our commitment to a health security mission focused on education and prevention must be composed of a series of engagement events that are focused and synchronized to produce maximum effects. We must remember, however, that the effect may not be immediately visible; nevertheless, it needs to be clearly articulated from the outset and sustained throughout—hence the mandatory coupling of deeds to words in our strategic communication.
Ultimately, the measure of the success of our joint efforts will be the health of the populations in the regions we focus upon, though it will be very difficult to isolate the exact impact of DOD efforts in a sea of competing factors. We could measure changes in the number of doctors per population unit; these currently vary throughout the region from a low of 2.2 doctors per 10,000 people in Guyana, to a high of 38.7 in Uruguay.16 From a strategic standpoint, success comes in the pragmatic form of incremental gains over time, not dramatic shifts in the efficacy of national health care systems. Evaluation might also be possible through the use of polling in areas where U.S. military personnel have visited, to quantify reactions to our presence and, especially over time, what the impact has been, in terms of both U.S. image and medical care. In fact, polling has been performed after each year’s health engagement deployment throughout the region thus far, and we will continue to use this valuable source of feedback. Though it is far from a comprehensive system of indicators of success, increasing the availability of care in measurable ways can help us assess our long-term positive impact on the region.
Before we can assess effectiveness, or carry out missions designed to achieve long-term national and shared regional strategic objectives, however, we must first have that strategy. We need to sit down together, all of us who have a part to play in this vitally important mission area of health security—across the interagency community as well as private sector and NGOs—and create a single, comprehensive, integrated, and synchronized overarching health engagement and health security strategy for the U.S. Government. This strategy would be designed to build both the capability and capacity of our partner’s health care systems and accompanying infrastructure to provide lasting health security, as well as articulate and assign supported and supporting roles in executing this strategy. It would also need to clearly identify one single agency to coordinate the humanitarian assistance and disaster relief efforts and resources that come from the dozens of participating agencies and entities.
Until such a lead is designated within the existing framework—or a new office to lead such an effort is created—we at Southern Command must strive to integrate our current range of operations that tend to exist more toward the "hard" end of the smart power spectrum with our partner agencies, organizations, and nations who possess a broader skill set of soft power tools and approaches. We also need to ensure there are integration and synchronization to maximize effects and reduce duplication of efforts. Working with the State Department, we can help to coordinate efforts by USAID, HHS/CDC, NGOs, multinational organizations, and other bodies throughout the region so that we are most effective in delivering aid, providing education, participating in disaster relief, and starting to create a lasting health security capability and self-sustaining capacity. The more coordination that occurs between the participating players, the more likely it is, for example, that a MEDRETE deploys to the region and is timed to complement follow-up visits by AID teams or NGOs—quite a harmonious concert would result when all the instruments are playing off the same sheet of music under one masterful conductor!
The benefits of medical diplomacy are myriad, ranging from the simple fact that medical missions help increase the level of health security and positive U.S. perception, to the complex and interrelated positive effects that better health care, access, and security can have on national health indicators, economic performance, and eventual societal stability. As Southern Command seeks to engage our partners and neighbors in a sustained, positive manner, we need to work with all our partners—foreign and domestic, military and civilian, public and private—to synchronize efforts, focusing on efficiency and effectiveness, and on improving partner nation capability and capacity. Humanitarian aid and disaster relief missions also serve a diplomatic mission; administrations that are usually critical of U.S. operations in the region find it difficult to deny the nonthreatening and benevolent presence of scores of doctors and literally tons of medical supplies. Health engagement ultimately serves an undeniable security purpose—strengthening local disease surveillance and control systems can help to prevent pandemic disease; encouraging local health education and preventive care can increase the overall level of health and prosperity; and all these provide a cumulative effect to make a country or region less likely to be unstable or to develop into a security risk for any of the inhabitants of our shared home.
We have learned time and again that if we only build the capability of the operational forces—the health care responders and providers— without concurrently building and maturing the corresponding supporting institutional capacity, our partners will never be able to sustain these efforts on their own. As we equip our partner nations physically with supplies, tools, medications, knowledge, and even buildings, we must constantly ask ourselves if the host nations can sustain what we are giving them and what we are teaching them. Is this what they need? Does it make sense for the manner of security and the methods they use to provide it? Are we really enabling them to provide health security for their own people?
We must leave the people with an enduring capability and force generation capacity for health security, or they will eventually lose the means to overcome this challenge once we depart. In the end, it is not how well we can achieve health security in the short term (such as the number of vitamin packs, inoculations, and 10-day vitamin packets we provide); rather, it is how well the host nation government and society can provide and maintain health security in the long term—sustained capacity through stability and infrastructure—that will ultimately make the difference. To help accomplish this requires a bit of a paradigm shift on our part, namely, we should not focus as much on generating, giving, or providing a capability for them; instead, we should focus on developing their ability to generate, employ, and sustain this capacity for themselves. This is the modern day equivalent of the "Give the man a fish and he eats for a day . . . teach the man how to fish and he eats for the rest of his life" parable.
Fred Baker of the American Forces Press Service wrote a wonderful piece on the 2009 Comfort deployment in which he describes "teenagers and grandmothers work[ing] side by side with military members from around the world to provide care."17 This spirit of joint, interagency, international, civilian, and private sector diversity was absolutely critical to the mission, and we at Southern Command firmly believe this symbolizes the way ahead for U.S. efforts in the region.
"My sense is this is the future of operations," said CAPT Tom Negus, the mission commander on board Comfort. "If we as a nation are going to hope to have an effect, then we are going to operate in an arena like this, with [nongovernmental organizations] and partner nations . . . all collaborating, all focused on achieving a purpose, having that alignment, that unity of mission."18
The United States has established individual relationships with the countries of this region primarily through military-to-military contact. However, during the course of Continuing Promise deployments, we have benefited from working with a mix of agencies and nations—and learning to work through the bureaucracies of each. This unique aspect and resulting relationships will prove valuable in the event the ship is called upon for aid in times of crisis, since "We know firsthand who to call—the people who can make things happen," CAPT Negus said. "That capability makes all of us much more ready in the event of a disaster. But it also fundamentally strengthens the trust between our nations. And the more . . . that we understand each other on so many different levels, then the stronger our ties are with those nations."19
And should we get caught up in the typical rush to quantify our results and determine success or failure in terms of sheer countries visited, patients treated, dollars spent, or public relations photos snapped, Baker closes his article with an incredibly poignant image. He uses it to remind us that the true impact of the mission cannot effectively be measured in terms of gross numbers, but more so in the individual lives it changes. He writes about the experience of Peggy Goebel, a volunteer nurse working aboard the Comfort for her second voyage with Project Hope, one of the first groups to team up with the Navy for these types of missions. I have included the excerpt verbatim below:
"The difference can’t be measured in bottles of Tylenol passed out . . . that’s not it," she said. Goebel recalled a teenager she saw in a remote village in Nicaragua. She was 16, poor and hungry. Her baby was swaddled in rags, and at 2 months old, weighed less than a newborn. The young mother was trying to breastfeed, but hadn’t eaten enough to produce milk. The baby was starving, listless and covered in scabies, Goebel said.
A Navy physician at the site took money from his pocket, gave it to an interpreter to buy formula and diapers, and asked the mother to return the next day. When she did, both mother and baby were bathed and clothed. The doctor and Goebel taught her how to mix the formula. They cleaned her only bottle and fed the baby.
More importantly, Goebel made contact with a local Project Hope coordinator, who will follow up with the mother and child to ensure care. The formula the doctor bought was enough to last only a few days, but the follow-up care could mean the difference between life and death for the baby.
"That baby may not have lived a week. That was a life-changing experience," Goebel said. "We can’t help them all. We can’t do everything. But hopefully, we can plant a seed that we can make a difference."20
All of these engagement efforts gain significant power if the United States can achieve broad-spectrum message awareness and reception in the region. As U.S. Southern Command interacts with Latin America and the Caribbean, our message must reflect the promise of sustained commitment and enduring engagement with our neighbors toward shared humanitarian and health security objectives. Because we will continue to operate in a resource-constrained environment for the foreseeable future, effective strategic communication will exponentially increase the value of our engagement endeavors within and throughout the region. Southern Command or DOD will never be the lead agency in U.S. Government humanitarian activities—nor should we. However, we do have the potential to do great good as our units deploy throughout the region, and to capitalize on that good to enhance a positive U.S. image within our shared home. Additionally, our international, interagency, and NGO partnerships will give us a better range of possible support activities, and a bigger impact than if we were to attempt to accomplish these missions alone. In short, all of our efforts, combined with the tremendous involvement of other Federal agencies and the huge contribution of the U.S. private sector, show that we are engaging on a large scale with our friends and partners in Latin America and the Caribbean. And it will only get better. As our focus in Southern Command and other Federal agencies shifts from a somewhat unilateral viewpoint to an integrated, multiagency, public-private cooperative approach, we will better show how the United States has cared, and always will care, about this incredibly worthy region and its diverse and vibrant people.
Notes
1 The Fund for Peace, "Failed States Index 2009, " accessed July 26, 2009, at: < http://www.fundforpeace.org/web/index.php?option=com_content&task=view&id=99&Itemid=140>.
2NationalIntelligenceCouncil,"StrategicImplicationsof GlobalHealth,"ICA2008-10D,December 2008, available at: < http://www.dni.gov/nic/PDF_GIF_otherprod/ICA_Global_Health_2008.pdf>.
3 Laurie A. Garrett, HIV and National Security: Where Are the Links? A Council on Foreign Relations Report (New York: Council on Foreign Relations, July 18, 2005), 12.
4 Jack A. Gladstone and Jay Ulfelder, The Center for Strategic and International Studies and the Massachusetts Institute of Technology, "How to Construct Stable Democracies," Washington Quarterly 28, no. 1 (Winter 2004–2005).
5 Katherine E. Bliss, Health in Latin America and the Caribbean: Challenges and Opportunities for U.S. Engagement, A Report of the CSIS Global Health Policy Center (Washington, DC: Center for Strategic and International Studies, April 2009), 10.
6 Clare Ribando Seelke, Gangs in Central America, Congressional Research Service Report for Congress, October 17, 2008, 3.
7 Mayra Buvinic and Andrew Morrison, "Violence as an Obstacle to Development," Inter-American Development Bank, Sustainable Development Department, Technical Note 4, 2000, page 4. Available at: <http://www.iadb.org/sds/doc/SOCTechnicalNote4E.pdf>.
8 Tom McCawley, "US Tsunami Aid Still Reaps Goodwill," Christian Science Monitor, February 28, 2006, accessed July 4, 2009, at: <http://www.csmonitor.com/2006/0228/p12s01-woap.html>.
9 Michael Voss, "Cuba Pushes its ‘Medical Diplomacy,’" BBC News On-Line, May 20, 2009, accessed July 24, 2009, at: <http://news.bbc.co.uk/2/hi/americas/8059287.stm>.
10 Copenhagen Consensus Center, "Copenhagen Consensus 2008—Results," 2. Available at: < http://www.cpoenhagenconsensus.com/Home.aspx >.
11 Philip Musgrove, "Challenges and Solutions in Health in Latin America," Copenhagen Consensus Center and the Inter-American Development Bank, September 12, 2005, 44.
12 Dean T. Jamison, Prabhat Jha, and David Bloom, "Disease Control Executive Summary," Copenhagen Consensus 2008, 2.
13 Steven Liewer, "Warship Sets Sail from San Diego on Humanitarian Mission to Asia," San Diego Union Tribune, May 24, 2007.
14 Remarks at "Poverty in Latin America: Challenges, Opportunities and Innovations," hosted by the Millennium Challenge Corporation and Council of the Americas, August 13, 2009.
15 McCawley.
16 Pan American Health Organization, "Health Situation in the Americas: Basic Indicators 2008," Washington, DC, 2008. We do not include Cuba because its value, 62.7 doctors per 10,000 people, is artificially inflated by government policy; Cuba exports its doctors for foreign relations objectives.
17 Fred W. Baker III, American Forces Press Service, "Comfort Care Shapes Lives, Course for International Aid," accessed July 22, 2009, at: <http://www.defenselink.mil/news/newsarticle. aspx?id=55224>.
18 Ibid.
19 Ibid.
20 Ibid.