EDITORIAL

MILITARY MEDICINE, 177, 7:763, 2012

Bilateral Institutional Relationships: A New Mission for U.S. DoD Medical Capabilities in Support of Health Diplomacy
Maj Bradley J. Boetig, USAF MC
U.S. medical assets from all three Services are routinely applied in support of force health protection, garrison health care, and stability operations. With rare exception, those three pillars encompass the entire doctrinal application of Department of Defense (DoD) medical resources. This article recommends establishment of an additional doctrinal role for DoD assets in support of Health Diplomacy and Building Partnership Capacity initiatives. More specically, the establishment of enduring, bilateral relationships between U.S. and host-nation medical institutions should be routinely pursued as a means to accomplish mutual security objectives. BACKGROUND Although partnerships with friends and allies have always played a prominent role in security strategy, Secretary Gates Building Partnership Capacity (BPC) initiative in 2010 has made actually building the capacity of partners a top priority. Recognizing that the effectiveness and credibility of the United States will only be as good as the effectiveness, credibility, and sustainability of its local partners,1 Gates guidance to build partner capacity sent every organization within the department scrambling to gure out how to actually do such a thing. For example, The U.S. Army has established specialized Advisory and Assistance Brigades . . . and is adjusting its promotion and assignment procedures to account for the importance of this mission; the U.S. Air Force is elding a eet of light ghter jets and transport aircraft optimized to train and assist local partners, and it recently opened a school to train U.S. airmen to advise other nations air forces; and the U.S. Navy is working with African countries to improve their ability to combat smuggling, piracy, and other threats to maritime security. But what about the Military Health System (MHS)? The health sector is arguably the most challenging area in which to actually build capacity, and valiant efforts have been made by Defense Institute for Medical Operations, Combined Security Transition CommandAfghanistan, and others to do just that. The most notable example of successful military-to-military capacity building in the health sector is probably the Combat
Uniformed Services University of the Health Sciences, Bethesda, MD.

Casualty Care Course taught by the U.S. Southern Command to the Chilean Armed Forces; years after the training the Chileans and their regional partners successfully applied the concepts taught in response to a series of natural disasters in each of their countries.2 However, although the MHS has had a few successes in building partner-nation capacity, the majority of efforts have been more limited in focuslimited to building partnership, as opposed to building partnership capacity. Prominent MHS missions ranging from hospital ship cruises to the Pacic Angel operations establish access, foster individual relationships, and engender goodwill. But they do not do much to build capacity; and although it is unclear how long the goodwill might endure, the relationships are very shortlived. Those missions are also very expensive. BILATERAL INSTITUTIONAL RELATIONSHIPS A new focus on institutionalas opposed to individual relationships would be a far more effective model to build partner capacity in the health sector. Institutional partnerships would cultivate relationships that endure beyond the length of the individual assignment cycle. They would provide access, goodwill, and inuence beyond that which is achieved by the short-term missions all too common today. And institutional relationships would yield benets for a whole new realm of stakeholders including interagency partners, nongovernmental organizations, the service members themselves, and academic and training institutions. Consider an example of a hypothetical institutional relationship. If Naval Hospital Pensacola were to pair with the National Military Hospital in El Salvador (or any country where we have a strategic interest), there would be mutual benets for both parties, as well as for a wide assortment of stakeholders. According to Title 10 of the U.S. Code, the ofcial purpose of Medical Readiness Training Exercises (MEDRETEs) is to train U.S. service personnel; but the education and training value would be far greater within the construct of a bilateral relationship that incorporates, for example, the Family Practice Residency Training Program already functioning at a place like Naval Hospital Pensacola.
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Bilateral Institutional Relationships

Residents could share clinical cases with their counterparts in El Salvador, discuss grand rounds, learn about the different disease burdens in their respective populations, and truly acquire the much-hyped cultural competency skills that have to be earned by actually cultivating a partnership that endures beyond a 2-week MEDRETE. Beyond primary care, Riviello and colleagues prole six surgical training programs where institutional relationships with international partners enhance the quality of each of their programs.3 And even the biomedical engineers could consult with each other on how to maintain donated hospital equipment in working orderan all too familiar challenge for U.S. health interventions overseas. The mil-to-mil training value of this relationship from the perspective of both host-nation and U.S. physicians is also maximized within this proposed model. The host-nation hospitals reputation among its population and its regional peers will likely be enhanced by an established collaboration with a U.S.-based health institution. And the MHS will be better able to retain and train top specialists in elds such as tropical medicine, infectious disease, and Global Health if it has working overseas partnerships that provide opportunities for research and international collaborations. DoD struggles with the challenge of trying to maintain the clinical skills of its medical subspecialists; and there is no better way to maintain their skills than to provide our specialists with the opportunity to consult routinely on the more challenging cases that arise at partner military hospitals overseas. Even the Uniformed Services University, the nations only federal health university, would benet greatly from this new construct. The unpredictability and random nature of MEDRETEs does not harmonize well with global health and development theories taught in institutions of higher education, where evidence-based practices are taught and sustainable outcomes are given a high priority. But sustained institutional partnerships based on shared objectives would be mutually benecial. The value of institutional partnerships is so great, for example, the internationally recognized academic organizations such as the Consortium for Universities of Global Health actually require enduring partnerships with institutions in developing countries as a prerequisite for membership. And if the MHS could pivot away a little bit from short-term, uncoordinated missions to a construct based on bilateral institutional partnerships, it would lend a sense of academic legitimacy to all the hard work and effort that service members are already putting in around the world. Most important to DoD strategists, a model based on institutional relationships would better support the Combatant Commanders intermediate and theater objectives. Since MEDRETEs are not well suited to build capacity, members often resort to advertising their value in terms of the number of relationships that were established. Those relationships are almost always eeting, however, as individuals move in and out of units quite frequently; and rarely do units let alone individuals return repeatedly to the same location.
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It is easy to see how relationships are better fostered within an institutional partnership: the institution provides the continuity that sustains the relationship beyond the assignment cycle of the individual. And these institutional relationships are far more formalized and stable which, from the Line perspective, affords a greater degree of reliability and predictability with respect to access and inuence. Also, the Guard and Reserve units that actually conduct many of the ad hoc MEDRETEs today could more easily plug into an established institutional relationship. Much of the funds currently expended on site visits and other planning necessities could be redirected. Members would feel a higher level of satisfaction as their efforts would have a reasonable chance at actually improving the lives of the people in the host nationa quality that is directly linked to successful recruitment and retention.4 And military residency programs would benet greatly from the cachet that these relationships would bring to their programs as student interest in Global Health has surged remarkably over the past decade.5,6 Bilateral institutional relationships represent a unique opportunity to link the strategic interests of the DoD with the academic objectives of its own institutions to the personal and professional goals of its members. The civilian interagency is already moving full-steamahead in implementing a whole-of-government approach to Global Health Diplomacy. The Department of State is leading the charge within the U.S. Governments Global Health Initiative, USAID has been greatly expanding its efforts in global health and even branching out into the health-security realm,7 and even the Department of Health and Human Services has elevated Global Health Diplomacy as a priority agenda item, focusing on sustained partnerships and capacity building.8 It is the DoD, unfortunately, that is still conducting the majority of its health engagement activities under the same MEDCAP model that was unsuccessful in Vietnam.9 Secretary Gates clearly articulated this need to transition from short-term eld work to institutional partnership when he wrote that The United States has made great strides in building up the operational capacity of its partners by training and equipping troops and mentoring them in the eld. But there has not been enough attention paid to building the institutional capacity or the human capital needed to sustain security over the long term. We should work to apply this guidance to our operations in the health sector. Cynics will lament that they do not believe it to be the role of DoD to build capacity or to even do anything that ventures beyond strict security cooperation, access, and inuence. And in a sense, the cynics are correctit is not the role of DoD to build health capacity overseas. But this proposal illustrates that sometimes the best way to do security cooperation and actually sustain access and have true inuence is to build capacity. While it is not prudent for DoD to attempt to tackle full-spectrum development head-on, this niche of institutional relationships specifically within the health sector offers an opportunity for DoD to contribute to development efforts in a cost-effective and
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Bilateral Institutional Relationships

mutually benecial manner. And as Brigadier General (sel) Sean Murphy explained, our health efforts Should be an ongoing partnership that combines interpersonal relationships with a cooperative educational process designed to promote trust between populaces and professionals.2 The importance and urgency of this BPC initiative is amplied by the budgetary concerns hovering over the entire national security apparatus. Most programs and ideas that are said to enhance national security cost more money than what is currently being spent. But this is no longer acceptable. As stated in the January 2012 DoD Strategy Document signed by President Obama and Secretary Panetta, A reduction in resources will require innovative and creative solutions to maintain our support for allied and partner interoperability and building partner capacity.10 The driving force behind BPC is the need to accomplish our security objectives with fewer resources and enable our partners to take a larger role in our common defense. Institutional relationships are an innovative answer to the challenges posed by this new, limited-resource environment. We should begin building these institutional relationships now. They are a model that would better meet our training, educational, recruiting, diplomatic, theater-operational, and national security objectives far better than our current MEDRETE model. They emphasize nonmilitary means and military-to-military cooperation to address instability and reduce demand for signicant U.S. force commitments to stability operations. And they will better enable DoD to contribute to whole-of-government efforts in global health and facilitate true partnerships with nongovernmental organization and international partners. MEDRETEs have produced underwhelming impact; and doing nothing is not a viable option because, as Gates emphasized, Helping other countries better provide for their

own security will be a key and enduring test of U.S. global leadership and a critical part of protecting U.S. security. Improving the way the U.S. government executes this vital mission must be an important national priority. REFERENCES
1. Gates RM: Helping Others Defend Themselves. Foreign Affairs. 1 May 2010. Available at http://www.foreignaffairs.com/articles/66224/robertm-gates/helping-others-defend-themselves; accessed March 19, 2012. 2. Agner D, Murphy S: Cooperative health engagement in stability operations and expanding partner capability and capacity. Mil Med 2009; 174 (8): iiivii. 3. Riviello R, Ozgediz D, Hsia RY, Azzie G, Newton M, Tarpley J: Role of collaborative academic partnerships in surgical training, education, and provision. World J Surg 2010; 34: 45965. 4. Drifmeyer JE, Llewellyn CH: Humanitarian Service: Recruitment and Retention Effects Among Uniformed Services Military Personnel. Bethesda, MD, CDHAM Publication 02-08, 2002. 5. Kanter SL: Global health is more important in a smaller world. Acad Med 2008; 83(2): 115 6. 6. Drain PK, Primack A, Hunt D, Fawzi W, Holmes K, Gardner P: Global health in medical education: a call for more training and opportunities. Acad Med 2007; 82(3); 226 30. 7. USAID Policy. The development response to violent extremism and insurgency. USAID Policy. September 2011. Available at http://www.usaid .gov/our_work/policy_planning_and_learning/documents/VEI_Policy_ Final.pdf; accessed March 19, 2012. 8. U.S. Department of Health and Human Services. Global Health Strategy 20102015. Available at http://globalhealth.gov/pdfs/GlobalHealthSecretary .pdf; accessed March 19, 2012. 9. Wilensky RJ: Military Medicine to Win Hearts and Minds: Aid to Civilians in the Vietnam War. Lubbock,TX, Texas Tech University Press, 2004. 10. Department of Defense. Sustaining U.S. Global Leadership: Priorities for 21st Century Defense. U.S. Department of Defense Strategy Document. January 2012. Available at http://www.defense.gov/news/Defense_ Strategic_Guidance.pdf; accessed March 19, 2012.

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