Wednesday, October 26, 2005

Follow-up on 'Strange Bedfellows' post

Tommy Thompson was the Secretary of Health and Human Services from February 2001 to January 2005, and is currently Chair of the Deloitte Center for Health Solutions in Washington, D.C. Someone working at Deloitte -- after reading the October 19th post on this blog -- sent the editor a link to an op-ed piece by Thompson recently published in the Boston Globe. There Thompson passionately and explicitly states the connections he sees between US national security and the improvement of health in the developing world. The more investment there is in the health care of developing countries, Thompson suggests, the safer from threats (i.e. terrorism) Americans and American interests will be. He even has a catchy concept for this alliance of foreign policy and foreign health development: ‘medical diplomacy.’

Medical diplomacy must be made a significantly larger part of our foreign and defense policy, as we clean up from costly and deadly wars in Afghanistan and Iraq. America has the best chance to win the war on terror and defeat the terrorists by enhancing our medical and humanitarian assistance to vulnerable countries. By delivering hope we will deliver freedom.

If Tommy Thompson (ex-Secretary HHS) and Andrew Natsios (current Administrator of USAID) are anything to go by, the concept of ‘medical diplomacy ‘ is all the rage in certain Washington circles. It is, at the very least, a clever attempt to siphon some of the obscenely large ‘anti-terrorism’ budget into foreign assistance coffers.

Still, bioethicists have the obligation to examine the assumptions of the medical diplomacy approach. For example, is terrorism rooted in poor health circumstances such that improving global health will necessarily undercut global terrorism? Are these defensible causal claims? On what evidence are they based?

There are possible counterexamples to the fundamental claims of medical diplomacy. The majority of the 9-11 hijackers came from Saudi Arabia, a country which made considerable investments in its own health care system (US$16.4 billion in the years 1985 to 1990). The recent London bombings were perpetrated by men who were born and/or raised in Britain, whose health system is comparable to the US and other developed nations. And conversely: some very poor nations with weak health care systems (such as Swaziland) are hardly havens for terrorists. Is it possible that the roots of terrorism are political, rather than medical in nature, and that they may have to do with the ‘less compassionate’ face of US foreign policy over the years?

Perhaps one should not look a gift horse in the mouth, and be glad investments are made in impoverished health systems, no matter what the underlying motives are. Lives can be saved by questionable intentions too. But if the assumptions behind ‘medical diplomacy’ turn out to be false, if hearts and minds are not necessarily won by new hospitals and antibiotics, then expect the global health cash flow to dry up quickly – along with talk of ‘loving your neighbor’.


Blogger Hatcher said...

While Saudi Arabia has indeed made huge investments in its health and medical systems, those investments have not been evenly distributed.

The 15 Saudi hijackers, for instance, came from the Asir region, in the southwest of the country. That region has notoriously been on the short end of the development stick--as has the Eastern Province.

Health care is generally excellent in urban areas of Saudi Arabia. It is of lesser quality and quantity in rural areas.

12:13 PM  
Blogger Stuart Rennie, Editor said...

Thanks for your remarks hatcher.

You are right to point out regional differences in Saudi Arabia. But even taking into account such differences, if you look at the overall country figures, I am still inclined to think that the poor health care/terrorism connection is still thin. Take for instance the figures from the 2004 Human Development Report on Saudi Arabia:

Population with sustainable access to an improved water source (%), 2000: 95%
Population with sustainable access to affordable essential drugs (%), 1999 95-100%
One-year-olds fully immunized against tuberculosis 2001: 94%
One-year-olds fully immunized against measles 2001: 94%
Oral rehydration therapy use rate, 1994-2000 .. n/a
Contraceptive prevalence rate (%), 1995-2001: 32%
Births attended by skilled health personnel, 1995-2001: 91
Physicians (per 100,000 people), 1990-2002: 153
Public health expenditure (as % of GDP), 2000: 3.5%
Private health expenditure (as % of GDP), 2000: 1.0%
Health expenditure per capita (PPP US$), 2000: $641

I agree that the health care in rural areas is of lesser quality than in urban ones, but I think that the case of Saudi Arabia is not a very strong one in support of the 'medical diplomacy' view stated by Tommy Thompson in the post.

9:29 PM  
Blogger Kevin T. Keith said...

The question about the empirical basis of claims that medical infrastructure investment will reduce terrorism is a good one. And certainly years of US aid in various forms have not necessarily built the global goodwill that would deflect terrorism. We know that all too well these days. But the link between the two may not be as direct as that ("build a hospital, dissuade a bomber").

There are two things to note about anti-Western Islamic terrorism: it has consistently been accompanied by quite explicit complaints about the Western behavior that prompted it, and it is often promulgated by organizations that simultaneously participate in infrastructure programs in their own societies. Regarding the former, the complaints have largely focused on religiously offensive behavior (which medical diplomacy would not cure), but also have included the economic exploitation of Middle Eastern lands and support for dictatorships that have neglected their people. This latter complaint, and the practice of local social programs by terrorist groups, suggests that development projects are a significant means of reducing the needs-fueled resentment of Middle Eastern populations. (And note that, outside the Middle East, the most-active campaigns of anti-US terrorism have been directed at oil and diamond extraction projects in South America and Africa - which again points to economic exploitation as a source of resentment.)

"Medical diplomacy" may be a source of stability in two ways: as one kind of infrastructure development and direct in-kind aid, it may help defuse the complaints of terrorist instigators in underdeveloped countries. And by making it easier for women to survive childbirth in good health, making it easier for women to control their fertility, reducing infant mortality, making inroads against HIV and other communicable diseases, and helping men stay healthy in order to hold jobs consistently, it may remove some sources of social disruption and low economic productivity, thus contributing to social stability and economic development that itself would reduce tensions and resentment.

It does not surprise me that there is little evidence of a simple inverse linear relationship between medical infrastructure invetment and terrorist activity; the situation is clearly far more complicated than that. But it also strikes me as intuitively reasonable that medical investment would be an important part of the overall social and infrastructure changes that would reduce global tensions and diminish the attractiveness of terrorism among local populations.

Thomas Friedman's thesis has been that "superempowered angry young men" become terrorists because, essentially, they have nothing else to live for. There is probably something to that. It makes sense that giving them something to live for - including life itself - would help turn that equation around.

3:49 PM  
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2:29 PM  

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