CSIS Global Health Policy Center has published a new report on the role of the Department of Defense in three global health areas: (1) global pandemic preparedness, (2) military-to-military health cooperation, and (3) protecting and rebuilding civilian health systems in conflict environments. While the report contains solid points throughout, I was most impressed with its argument regarding civilian health systems. In the report, Eugene Bonventre, James B. Peake, and Elizabeth Morehouse argue that the DoD’s approach to civilian health systems in conflict has so far been ad hoc, despite the fact that effective health systems are often a core component of legitimacy-building in counterinsurgency operations:
“Preserving civilian health system capacity during conflict is not only an obligation of the military, but it actually helps the military achieve its own strategic objectives. The better the civilian health sector functions during a conflict, the fewer injured and sick civilians will require treatment in military field hospitals that are ill-equipped to address many of the needs of the women, children, and elderly who represent the demographic groups most affected by conflict. During a counterinsurgency, where a host nation’s legitimacy is tied to the population’s perception of its government as a reliable and equitable service provider, preserving civilian health capacity is also strategically important. The more effectively the government provides essential services (including public health services) to its population, the sooner a counterinsurgency can be won.” (Bonventre and Peake 2010, 24)
The authors propose a “A New Paradigm Of Preserving Civilian Health System Capacity” wherein war planners do more than simply not bomb health facilities:
“Current DOD policy mandates that its soldiers and contractors adhere to International Humanitarian Law (IHL) in all conflicts, regardless of the conflict’s context or character. IHL, which includes not only the four Geneva Conventions, but also treaties and customary law, requires that militaries minimize the impact of war on civilian public health and medical care. This responsibility is more complex than merely including hospitals on “do not target” lists. Minimizing the impact of conflict on civilian health requires optimizing efforts to preserve the integrity and capacity of the affected nation’s health system as a whole.” (Bonventre and Peake 2010, 23)
To develop this paradigm, the report offers five suggestions for the DOD regarding civilian health systems in conflict:
“Recommendation 1: The DOD should develop a civilian health theme for conflict and postconflict planning in close consultation with other relevant U.S. government and other agencies.” (Bonventre and Peake 2010, 26)
“Recommendation 2: DOD should support a civilian-led comprehensive strategy for assisting a conflict-affected nation to reconstruct essential health services.
“Recommendation 3: DOD should be prepared to play a major role in support of the reconstruction of the military health services of conflict-affected nations in close coordination with civilian health sector reconstruction.” (Bonventre and Peake 2010, 27)
“Recommendation 4: DOD should support a transition strategy that parallels and facilitates the transition from relief to development.” (Bonventre and Peake 2010, 27)
“Recommendation 5: All agencies including DOD should measure the impacts and outcomes that their conflict-related civilian health assistance programs have on health and on security and stability.” (Bonventre and Peake 2010, 28)
Recommendations 1 and 2 are dead on. For too long DoD war planners have considered civilian health systems the sole responsibility of the humanitarian space. Often, US military’s engagement of these systems is only slightly more than “don’t bomb hospitals”. However, foreign health systems are central to US interests. Health systems are fundamental bureaucracies of the state. They provide the most observable indicator of a government’s priority towards its citizens and its capacity to act on it. In all non-failed states, the political legitimacy of the government is inherently linked with the citizens’ perception of service delievery by the state. Weakened health systems reduce government legitimacy and open the door to illegal political challengers. Quite simply, health systems are central to national stability and security.
Christopher R. Albon is a political science Ph.D. specializing in armed conflict, public health, human security, and health diplomacy.