Medical diplomacy: a short history
Regarding your post on national security and global health, I happened to be a fly-on-the-wall when decisions were made to publicly promote American interest in global HIV/AIDS as an issue of national security. HIV/AIDS was the first health issue to be considered a national security threat by the US administration.
The Presidential Advisory Council on HIV/AIDS (PACHA) was established in 1995 by Executive Order to advice the President, Secretary of Health and Human Services, and the Administration regarding HIV/AIDS policies and programs. Its final report to President Clinton in September 2000 (AIDS: No Time to Spare, available through this site) explicitly acknowledged a "shift to a 'global' perspective" (p. 11) on HIV/AIDS and necessity for coordinated, sustained action. My job was to facilitate the process that led to the report.
Four of the six underlying themes of the report underscored the global nature of HIV/AIDS, including this one: "HIV threatens national and global security. The United Nations Security Council has recently characterized the global pandemic as a threat to security and stability, because HIV/AIDS has undermined the economic and political systems of many countries. Vice President Gore, speaking before the first-ever session of that body devoted to a health issue, stated, 'No one can doubt the havoc wreaked and the toll exacted by HIV/AIDS do threaten our security. The heart of the security agenda is protecting lives -- and we now know that the number of people who will die of AIDS in the first decade fo the 21st Century will rival the number that died in all the wars in all the decades of the 20th Century." Echoing that concern, U.S. Ambassador to the United Nations Richard Holbrook stated, '[AIDS] is the toughest and biggest of all issues, not just in Africa. Africa is just the epicenter... if you ask what is the number one problem in the world today, I would say it is AIDS.'" (p. 12)
During the deliberations for this report, then-AIDS Czar Sandy Thurman discussed the impetus of Administration thinking around HIV/AIDS and national security. This part of the summary particularly struck me: "The Department of Defense has allocated $10 million for military-to-military training, which has been hard won, although the military has been disproportionately affected by HIV/AIDS in Africa and elsewhere. In Congolese armies, infection rates run from approximately 40 percent among Angolans to more than 80 percent in Zimbabwe's army, for all ground personnel.This is particularly sobering when considering that the military constitutes the backbone of burgeoning democracies throughout Africa and maintains stability in the region. The best-educated professionals often advance through the military into positions of political power and are disproportionately infected. This has implications in terms of military engagement across national boundaries, in which, like other migrant activity, sexual conduct and the spread of the disease results."
On the May 2, 2000 McNeil-Lehrer News Report, then-National Security Advisor Sandy Berger provided an example of how HIV/AIDS destabilizes governments: "Well, the countries, for example, that have had enjoyed solid growth in Africa now are beginning to see that growth erode because its work force is not able anymore to function in the economy and the cost of the disease to the government is becoming overwhelming. What happens? Those countries begin to unravel. They are unstable. They're more likely to engage in conflict with their neighbors. And before long, we have something, a situation which is really tumultuous. And so the most important thing we can do is first of all, work with other countries to try to apply collective resources; two, work with the leaders of these countries to try to change the dynamic."
I also remember newspaper accounts of then-Joint Chiefs of Staff Chairman Colin Powell making similar remarks around this time. Interesting that HIV/AIDS is seen as an impediment to "stability" and not poverty (an underlying cause), for example, though that may be changing. I think that's one reason why framing global health as a national security issue is disconcerting to me. The real consequences for HIV/AIDS and other health issues on other countries' spending priorities, GDP, and military readiness are important, but should not be the primary reason to become involved. The alleviation of human suffering should be paramount. (A bit naive and idealistic, yes.)
On the other hand, I do think that a prioritization process for government spending and intervention should include consideration of broader non-health impacts. All of this is especially interesting given President Bush's call for $7 billion to prepare for the avian flu pandemic and previous talk of the military as first responder in such a scenario. But that's a post for another day.