Applying Smart Power via Global Health Engagement

The U.S. military is entering a period of dramatic redirection and restructuring at a time of broader international upheaval, from Ukraine to Syria.1 The past decade of global conflict has emphasized the predominant hard power focus of the Armed Forces, often with limited success. The emergence of a new mission—smart power—offers opportunities to shift toward innovative forms of international intervention and conflict resolution by the U.S. military through coordination with national security strategies such as global health diplomacy (GHD).2 Recently articulated doubts over the wisdom of supplying health, development, and other forms of economic support to those countries that support Islamic fundamentalism highlight an increasing need for the United States and other world powers to harmonize and align development, altruistic, and security initiatives.3

U.S. Navy Hospital Corpsman talks with students from Andalas Primary School during subject matter expert exchange held at Andalas Social Health Clinic, during Pacific Partnership 2016, August 26, 2016 (Royal Australian Air Force/David Cotton)

Military forces could be deployed and used to contribute to foreign policy, global health, and the strengthening of key local actors in related sectors.4 Doing so could maintain strategic regional and international goals and advance international stability and development through strategies such as global health engagement (GHE). GHE is defined as “health activities which the DOD [Department of Defense] conducts in support of the national security policy and military strategy of the United States.”5 While a range of tensions exists around expanded military engagement in humanitarianism, we can attempt to guide this process toward a mutually acceptable engagement on both altruistic and strategic levels via the GHD paradigm.

Considerable damage to the international prestige of the armed forces of the United States and United Kingdom has resulted from the Iraq and Afghanistan wars and associated events.6 Combined with questions of strategic gains, cost-effectiveness (consideration of the “opportunity costs” of the combat and postcombat periods, including care of returning veterans), long-term regional stability, and lack of global social, political, and cultural acceptability, there is increasing speculation regarding the use of combined military, health, and development initiatives as some of the possible effective substitutes for, or complements to, hard power interventions. For example, strengthening host-nation healthcare systems is one path to achieving strategic goals, through accessing and stabilizing regimes opposed to extremism.7

Opponents of smart power strategies point to the fact that there is no proven correlation between international development programs and the capacity of donors to positively influence geostrategic or geopolitical events, yet medical initiatives are increasingly recognized as an effective and efficient method of supporting the global community’s dual-health and non-health priorities in tandem.8 These include threat reduction from epidemics, enhanced security (including health security), and political and diplomatic alliances—pursued in concert with each other, rather than in isolation, via DOD initiatives such as medical stability operations and partner engagement and force health protection and readiness.9 Thus GHE is specifically designed to support both national security and international engagement.10

The modern international security environment has undergone significant changes since the end of the Cold War. One significant driver of this change is the failed state, an environment that provides little hope for a better future among young populations and is “susceptible to exploitation by terrorists, tyrants, and international criminals.”11 Concurrently, the nature of the physical battlefield has changed via an increasing number of tribal and ethnic clashes that involve nonstate, guerrilla, or other irregular players rather than uniformed forces.12 This evolution of the conflict environment has had a corresponding impact on approaches used by security instruments to implement and influence foreign policy objectives.

The U.S. Marine Corps first identified related models in the latter half of the 1990s, describing its vision of future warfare in this context as the “Three Block War” under which hypothesis individual soldiers are required to simultaneously conduct military, peacekeeping, and aid operations in combination with, and in close geographical proximity to, each other.13 The essence of this innovative concept is that modern militaries, to be effective, must be trained to operate in all three operating environments simultaneously—and that to do so, leadership training in related noncombat skills, including health care and diplomacy, must be conducted at all levels of command.

Military technology has advanced significantly in recent years, including remote imaging that can be leveraged to gain immediate information regarding needs on the ground through overflight by satellites and unmanned aerial vehicles (UAVs). This ascendancy of technological warfare has led to a reevaluation of the role of traditional or conventional armed forces as ground troops.14 Apart from growing public intolerance of military and civilian “body counts” associated with the pre-UAV era, the increased range of options offered by related technological advances has meant that the threat neutralization roles formerly the responsibility of the foot soldier are increasingly delegated to unmanned interventions.15 As described in the Three Block War paradigm, the role of individual soldiers is evolving beyond mere combatants. To adapt to these new and diverse roles, as well as proving purposeful activity for the residual manpower surplus associated with technological warfare, the Armed Forces require increased training in, and awareness of, their role as international representatives, global health workers, and diplomats, as well as their traditional battlefield roles.

Soldiers will continue to function according to the rules of engagement and take orders and procedures from their officers, while demonstrating an explicit awareness and recognition of their implicit role as benign liberators and agents of international relations and development that stands to significantly enhance their prestige, value, functionality, and self-esteem. Such aspirations mirror the North Atlantic Treaty Organization’s longstanding Peace Support Operations doctrine, which includes the provision of humanitarian assistance to civilian populations as one of its six guiding principles.16

Since the end of the Cold War, international economic crises and domestic budgetary pressures have generated tremendous pressure on Western military establishments to adapt and streamline operations via a diversification of roles and responsibilities. Military and political leaders’ recognition of international health emergencies and climate change as threats to national security is notable.17 The Policy Guidance for DOD Global Health Engagement, released in May 2013, made important first steps in related diversification processes.18 All of these vectors have come to be important elements in the strategies and tactics used by the military in current and recent conflicts—as well as in the context of the debate about the appropriate role, structure, and composition of the U.S. military. These broader global developments have contributed in a critical way to a rapidly evolving conflict environment in which traditional interventions have struggled to achieve success.

People’s Liberation Army Navy hospital ship Peace Ark Senior Captain Sun Tao shares medical experiences during group activity during Fundamentals of Global Health Engagement Course at Makalapa Clinic as part of Rim of the Pacific 2016, Joint Base Pearl Harbor–Hickam, July 11, 2016 (U.S. Navy/Katarzyna Kobiljak)

GHD as a Strategic Military Tool

The discussion thus far suggests that the increased use of tools such as GHE by the Armed Forces should be examined more closely in the diplomatic context as well as in its primary health security role (for example, the 2014 response to West Africa’s Ebola outbreak) of protecting vital national health security interests.19 This is particularly relevant in the context of DOD guidance that promulgates the use of global health programs to achieve strategic endstates or to support other national and international objectives. Global health, in this context, is defined as the alleviation of those health challenges that affect the world’s poorest and most marginalized populations, with an emphasis on communicable diseases such as HIV/AIDS, tuberculosis, and malaria, as well as specific reference to health concerns that require global cooperation due to transcendence of territorial boundaries.20 GHD in this context is therefore best described as a foreign policy tool that blurs the line between altruism and enlightened self-interest. It leverages military and political assets in response to both human or natural disaster emergencies and longer term nation-building and stabilization through infectious diseases control and support in order to achieve specific goals for the global community.21

Western military forces hold a distinguished tradition of providing emergency health and aid assistance to civilian populations overwhelmed by natural disasters or civil strife.22 The military is unique in providing immediate response using transportation assets, surveillance, monitoring and evaluation, and other intelligence tools—particularly important in both epidemiological and security contexts.23 The Armed Forces also have a built-in logistics supply system that can put relief anywhere in the world in a short time. This represents a unique set of capabilities that often make the military the best “first responder” for GHE.24 Opportunities for those fields of endeavor related to GHE (for example, emergency medical care, provision of drugs or treatments, rapid mobilization of people or resources) and those generally associated with GHD (polio eradication, HIV/AIDS prevention or treatment, and anti-malarial campaigns) are increasingly evident.

Medical “hearts and minds” operations were also initially highly successful as an alternative to military force during the Vietnam War, and it remains a regret of the conflict’s high-level planners that such approaches were not maintained and employed more extensively.25 Modern GHE doctrine, encompassing longer term global health interventions, appears to have assimilated related lessons on the need for different configurations, supplies, and training for appropriate, sustainable, and effective responses, in both medical and strategic contexts. For example, after more than 13 years of operations according to traditional military roles, U.S. involvements and interventions in Southeast Asia are now increasingly characterized as soft power missions, while DOD policy guidance for GHE stipulates parameters to “ensure legality, appropriateness, and effectiveness” as well as building the trust and confidence of partner nations and communities.26 The United States is not alone in pursuing such innovative strategies; other international actors such as Venezuela and Cuba, through sustainable initiatives such as community based clinics and hospitals that provide long-term and affordable health care to recipient populations, have been “particularly adept at parlaying provision of medical services to nationals of other countries into support in international forums” as well as advancing strategic donor self-interest.27

The military has proved its nascent capacity in settings such as Iraq and Afghanistan to provide longer term GHE support operations. This is evident in programs that mitigate infectious diseases such as HIV/AIDS, tuberculosis and malaria, as well as making healthcare systems stronger.28 There has been no evidence to date of the maintenance of these activities after military withdrawal, while related GHE initiatives have both demonstrated the potential capacity of the military in this regard and produced significant yet unmeasured strategic gains that were potentially as effective in achieving strategic goals as combat and ballistic efforts.29 While combined tactical and altruistic successes have occurred throughout military history, no formal framework and set of standards for their delivery, along with a set of operational principles governing such engagements that optimize smart power effectiveness, have been developed and applied.

Issues of Primacy, Alignment, and Harmonization

In a recent editorial, The Lancet examines the risks and benefits of the inevitable augmentation of the military’s role in global health in the 21st century.30 We must ask to what extent GHE and other altruistic endeavors could be used by the United States and others as a convenient rationale for expanding international military presence—arguments that Russia has employed to justify its occupation of eastern parts of Ukraine.31 Interagency coordination and governance of combined GHE and GHD activities as well as public and media transparency are therefore key concerns.32

Enhanced alignment between DOD and the U.S. Agency for International Development (USAID), for example, inevitably raises questions around alignment between civilian and military doctrines. Would DOD, in a joint GHD/GHE operation scenario, subordinate itself to the governing principles and authority of USAID? Or, under a GHD paradigm, would USAID become increasingly aware of strategic considerations, with specific regard to settings in which conflict is currently taking place or recipient populations that pose a proven threat to donor security? DOD is at present subordinated to USAID through its Office of Foreign Disaster Assistance in every foreign disaster response that DOD is asked to support. For nondisaster engagements, such as partner-nation capacity-building, while not subordinate to USAID, DOD policy guidance directs that “GHE activities should be consistent with the relevant U.S. Embassy’s integrated country strategy and complementary to USAID’s country development cooperation strategy” to avoid redundancy—or even conflict—between individual agency efforts.33 The development of coherent, consistent, and broadly applicable GHE approaches may be informed, enhanced, and made practicable by reference to relevant criteria, standards, and guidelines for smart global health.34

Developing a Frame of Reference

If the U.S. military chooses to devote greater levels of resources and effort to GHE in order to achieve joint strategic and altruistic ends under a GHD paradigm, adherence to appropriate program and intervention design, delivery, and selection criteria will be of critical importance. As a recent RAND report notes, “A focus on the higher-order objective of enhancing legitimacy of local leaders would cause planners to carry out global health programs in a different way.”35 This demonstrates the importance of adapting focus to optimize multilevel gains. Equally important, interventions should not threaten the structure or integrity of local healthcare systems by significantly exceeding local standards of care.36 Smart intervention categories in this regard, and as described in recent DOD guidance, also include educational and training exercises. These are endeavors to which, for example, the plans, operations, and military intelligence division of organizations such as the U.S. Navy and Naval Reserve might meaningfully contribute.

Civil affairs units of the United States and other militaries traditionally conduct civil-military operations, including initiatives such as Civil Information Management, Foreign Humanitarian Assistance, and Nation Assistance. The remit of such units also extends to the preservation and restoration of protected targets such as healthcare facilities in war zones, facilitating links between military commanders and civil society. Civil affairs personnel have become increasingly integral to U.S. (and United Nations) peacekeeping operations in Iraq, Afghanistan, Somalia, and the former Yugoslavia, while also contributing via short- and long-term aid efforts in countries such as Cambodia and Honduras.37 Civil affairs units do not focus primarily on health issues, but, via the GHE paradigm, the U.S. military continues to develop international health and global health capacity in this context.

The development of systems by which the military can operate in closer cohesion with global health initiatives is central to the success of smart power strategies. These include consideration of the delivery of health assistance programs under military umbrellas, defined (in this context) as military support, advisement, protection, and coordination for health, development, and foreign assistance activities in unstable or insecure environments. While successful strategic outcomes may have been at least partially achieved in recent conflicts through global health roles in “armed social work,” the dangers posed to non-military international development and diplomatic representatives have never been greater.38 These include the increased incidence of violent deaths, abductions, and hostage situations involving formally and informally deployed personnel in regions as diverse as Sudan, Somalia, and Syria. To counter this threat, military intelligence, surveillance, and communications can provide support to assist a humanitarian response, allowing, for example, transportation and logistics to be fine-tuned for maximum impact and staff security. Careful and detailed advance liaison with local stakeholders, including health, military, and political representatives, can also help to ensure both health and strategic successes via a “hand off” to local personnel or organizations as the military departs.39

DOD policy guidance suggests that GHE initiatives should target activities on locations or regions “where there is humanitarian need balanced with operational and strategic significance.”40 Accessing unstable or ungoverned areas is a critical aspect of 21st-century U.S. military and diplomatic policy.41 Two of the major smart power questions—“What are the positions and preferences of the targets to be influenced?” and “What forms of power behavior are most likely to succeed?”—are linked to the objective of enhanced geographical influence and coverage by international actors.42 Access to and development of an international presence in otherwise non-permissive areas provide opportunities for communications and education to populations whose only other alternative is often exposure to extremist propaganda, doctrine, and inculcation. Appropriately designed, selected, and adapted global health initiatives, operating in concert with the military umbrellas to provide protection and support, have been demonstrated in such circumstances to enhance both international influence and relations in remote geographical regions of countries such as Afghanistan and Iraq.43

International development and health programs have traditionally assisted with or been employed as tools of international lines of strategic intelligence and communication.44 The recent outcry over the use of vaccination programs as a cover for intelligence-gathering activities in Pakistan elicited a range of dissociating responses from medical leaders, the White House, and other key actors at the State Department.45 Arguments that objectives such as international security transcend those of international development suggest that such condemnations should be tempered by broader historical and contextual considerations.46 The use of GHE surveillance from both the national and health security perspectives forms an explicit element of related DOD policy guidance.47 The access granted to global health and development programs in insecure environments cannot be systematically leveraged or exploited in this ad hoc manner, both risking safety and security of program staff and jeopardizing future target population approval of any forms of international involvement. Rather, a compelling case for structures governing the use of strategic communications and observations, in either an explicit or an implicit manner, is made based on the tragic lessons learned from such experiences.48

Training

GHD in the context of military personnel training will include the development of enhanced diplomatic and humanitarian skill sets, with a specific focus on improving strategic capacity within GHE staff and improving diplomatic and humanitarian capacity within combat staff. The Three Block War paradigm illustrates the complex spectrum of challenges and responsibilities likely to be faced during deployment or on the modern battlefield, including stability operations. The essence of such approaches is that both military and foreign assistance personnel must be trained to operate coherently in diplomatic, humanitarian, and combat capacities simultaneously rather than in a stovepiped fashion. Adaptations to the related “strategic corporal” approach build on the increasingly global consensus that leadership in complex, rapidly evolving, and potentially hostile health and security environments requires a much broader range of skills and training than previously considered necessary.

To achieve joint strategic and altruistic goals, the U.S. military may wish to invest further in the application of smart power and GHD contributions to GHE. This would include enhancing specialist diplomatic input on the choice of GHE interventions, the manner in which they are delivered, as well as their duration, sustainability, and alignment between medical and strategic considerations. These are of critical importance to “the evaluation of DOD GHE projects as a means to determine whether strategic theater objectives are satisfied,” with particular reference to unexpected health or non-health outcomes and consequences.49 To date, in the United States and elsewhere, diplomatic, development, and military forces, when acting independently of each other, “may lack either the appropriate authority or resources to employ smart power,” risking “tense and confusing dualities” between agency agendas.50 Such increased levels of interdepartmental cooperation are desirable yet have been exceedingly difficult to accomplish in practice.51 The use of GHD specialists, building on the development of GHE coordinators at DOD, will help to ensure the greatest possible strategic impact and alignment. Complementary inputs include advising on host-nation capacity for GHE project appropriateness and country ownership.52

Co-founder and CEO of Seed Global Health speaks on “Improving Developing Country Health Systems Through the Spirit of Volunteerism,” part of Secretary’s Office of Global Health Diplomacy Speaker Series, at State Department, April 22, 2014 (State Department)

Conclusions

What do these recommendations imply for the future acceptability, prestige, and success of international interventions by the U.S. military and its allies? As the 21st century progresses, DOD is presented with a unique opportunity to establish itself not only as eminently capable of power projection but also as an altruistic and humanitarian organization. To achieve these noble goals, which echo the national and international respect and admiration for the Armed Forces in the immediate aftermath of World War II as exemplified by the Marshall Plan, decisionmakers may choose to support strategic plans using GHE as a key role for the Armed Forces, addressing contemporary “asymmetries of perception” surrounding the military’s role in international affairs.53 It may be unrealistic to propose that significantly expanding the scope of GHE informed by GHD operating principles would single-handedly counter the doubts that have been generated by more recent armed conflicts in which the United States has engaged.

It is nonetheless hoped that such an enhanced role in both diplomatic and medical endeavors would augment the successful and simultaneous pursuit of development and strategic goals. Related initiatives such as Operation United Assistance have cast the U.S. military in a new light—as a highly responsive, effective, rapid response organization that has the capacity to contribute to national and also global health and non-health security.

A range of concerns and critiques related to U.S. military involvement in global health and broader international development programs deserves recognition. For example, the visible role that the military has played in recent disaster relief efforts from Haiti to Monrovia to Fukushima, and, most recently, the response to the Ebola epidemic in West Africa, has elicited an abundance of commentary both supportive and questioning of the military’s role. The latter has been driven by events such as attacks on healthcare workers in Pakistan as a result of associations with security activities in pursuit of Osama bin Laden and more general concerns around the implications of military GHE “occupations.”54 Such agendas, though potentially justifiable on the international and health security levels, cast doubt upon the viability of expanded collaborations between global health and geopolitical or geostrategic concerns.55 Until these ambiguities are resolved, DOD GHE efforts will continue to be critiqued for “an ad hoc, short-term focus, poor appreciation of local cultural norms, inadequate high-level involvement, and a failure to properly assess effectiveness.”56

Issues of political and social legitimacy surrounding armed interventions are at least partially addressed through the integration of hard and soft power operations, helping to rebuild American military preeminence as an agent of good.57 As a counterpoint, the pursuit of armed interventions that either ignore the health and well-being of civilian and other populations is increasingly unacceptable on social, political, and legislative bases—as well as being fraught with negative strategic consequences.58 Global public opinion appears united in believing that the reported 100,000 civilian deaths during the Iraq conflict should never be allowed to happen again.59 To limit the extent of such casualties and to improve military legitimacy, smart power efforts require critical funding decisions related to the military-industrial complex, including, where feasible and appropriate, advocacy for GHE in lieu of or complementary to ballistic alternatives. The past 3 to 5 years have already seen a dramatic evolution of the way GHE is designed, planned, and executed in many combatant commands. We advocate for the continuation, diplomatization, and acceleration of this process.

Former Chairman of the Joint Chiefs of Staff Admiral Mike Mullen has stated that “we have been leading with the military for far too long. We need to get diplomacy, development, fiscal, economic, financial, and educational tools out in front. We cannot kill our way to victory. It’s not going to work.”60 The limited effectiveness of the Transformational Diplomacy Doctrine under the George W. Bush administration is in direct contrast to the role of military GHE under a smart power system proposed in this article.61 As the United States faces expansionism from a more aggressive China, a newly emboldened Russia, and the dangerous Islamic State of Iraq and the Levant, the pressure to maintain and develop international stability and balance of power has never been greater. The declining social, cultural, economic, and political thresholds of public tolerance for violently contested international conflicts that do not relate directly to national security indicate that with each passing decade, the U.S. military is becoming more wary of becoming embroiled in less-than-vital engagements.62

Given the rapidly changing and increasingly non-human or technological nature of combat, serving Soldiers, Marines, Sailors, and Airmen need to be gainfully occupied in meaningful ways during both peace and war. An enhanced role for GHD-based GHE would address this issue in an enlightened and also a self-interested fashion. Otherwise, as Sun Tzu teaches us, an unoccupied army quickly becomes restless—and may, ultimately, end up provoking the very conflicts it seeks to resolve. JFQ

Notes

1 Frederick M. Burkle, Jr., “Throwing the Baby Out with the Bathwater,” Prehospital and Disaster Medicine 28, no. 3 (June 2013), available at <http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=8921591>.

2 CSIS Commission on Smart Power: A Smarter, More Secure America (Washington, DC: Center for Strategic and International Studies [CSIS], 2007), available at <http://csis.org/files/media/csis/pubs/071106_csissmartpowerreport.pdf>; Ronald Labonté and Michelle L. Gagnon, “Framing Health and Foreign Policy: Lessons for Global Health Diplomacy,” Globalization and Health 6, no. 14 (August 2010), 65–76, available at <www.globalizationandhealth.com/content/6/1/14>.

3 Matthew Levitt, Better Late than Never: Keeping USAID Funds Out of Terrorist Hands, PolicyWatch 1277 (Washington, DC: The Washington Institute, August 2007), available at <www.washingtoninstitute.org/policy-analysis/view/better-late-than-never-keeping-usaid-funds-out-of-terrorist-hands>.

4 Nathan Finney, “A Culture of Inclusion: Defense, Diplomacy, and Development as a Modern American Foreign Policy,” Small Wars Journal, September 26, 2010, available at <http://smallwarsjournal.com/blog/journal/docs-temp/553-finney.pdf>; J. Christopher Daniel with Kathleen H. Hicks, Global Health Engagement: Sharpening a Key Tool for the Department of Defense (Washington, DC: CSIS, October 2014), available at <http://csis.org/files/publication/140930_Daniel_DODGlobalHealth_Web.pdf>.

5 Office of the Assistant Secretary of Defense for Special Operations and Low-Intensity Conflict (OASD SO/LIC), Policy Guidance for DOD Global Health Engagement (Washington, DC: Office of the Secretary of Defense, May 15, 2013), available at <http://docz.io/doc/1738598/2013-policy-guidance-fo-dod-global-health-engagement>.

6 Phillip C. Saunders, “The United States and East Asia after Iraq,” Survival 49, no. 1 (Spring 2007), available at <www.cfr.org/content/meetings/Iraq-Impact/49-1_09_Saunders.pdf>.

7 Sebastian Kevany et al., “Global Health Diplomacy Investments in Afghanistan: Adaptations and Outcomes of Global Fund Malaria Programs,” Medicine, Conflict and Survival 30, no. 1 (January–March 2014), 37–55, available at <www.tandfonline.com/doi/pdf/10.1080/13623699.2014.874187>.

8 Ken Adelman, “‘Not-So-Smart’ Power: Go Ahead, Congress, Cut Away at U.S. Foreign Aid,” Foreign Policy, April 18, 2011, available at <www.foreignpolicy.com/articles/2011/04/18/not_so_smart_power>; Kellie Moss and Josh Michaud, The U.S. Department of Defense and Global Health: Infectious Disease Efforts (Washington, DC: The Henry J. Kaiser Family Foundation, October 2013), available at <http://kaiserfamilyfoundation.files.wordpress.com/2013/10/8504-the-u-s-department-of-defense-and-global-health-infectious-disease-efforts.pdf>.

9 Josh Michaud and Jennifer Kates, “Global Health Diplomacy: Advancing Foreign Policy and Global Health Interests,” Global Health: Science and Practice 1, no. 1 (March 2013), available at <www.ghspjournal.org/content/1/1/24.full>.

10 OASD SO/LIC.

11 Steward Patrick, “‘Failed States’ and Global Security: Empirical Questions and Policy Dilemmas,” International Studies Review 9, no. 4 (Winter 2007), 644–662.

12 James R. Clapper, Director of National Intelligence, Statement for the Record, Worldwide Threat Assessment of the U.S. Intelligence Community, Senate Select Committee on Intelligence, March 12, 2013.

13 James E. Szepesy, “The Strategic Corporal and the Emerging Battlefield: The Nexus Between the USMC’s Three Block War Concept and Network Centric Warfare” (MALD thesis, 2005); Charles Krulak, “The Strategic Corporal: Leadership in the Three Block War,” Marines Magazine, January 1999.

14 Sarah Kreps and Micah Zenko, “The Next Drone Wars: Preparing for Proliferation,” Foreign Affairs, March/April 2014, available at <www.foreignaffairs.com/articles/140746/sarah-kreps-and-micah-zenko/the-next-drone-wars>.

15 Moss and Michaud.

16 Allied Joint Publication–3.4.1, Peace Support Operations (Brussels: North Atlantic Treaty Organization, July 2001), available at <http://publicintelligence.net/nato-peace-support-operations-doctrine/>.

17 Harley Feldbaum, “Global Health and Foreign Policy,” Epidemiological Review 32, no. 1 (April 2010), 82–92, available at <www.epirev.oxfordjournals.org/content/32/1/82.full>.

18 OASD SO/LIC.

19 “National Armies for Global Health?” Editorial, The Lancet, October 25, 2014, 1477, available at <www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)61923-1/fulltext?rss=yes>.

20 OASD SO/LIC.

21 Thomas E. Novotny and Vincanne Adams, “Global Health Diplomacy: A Call for a New Field of Teaching and Research,” San Francisco Medicine 80, no. 3 (April 2007), 22–23.

22 Michaud and Kates.

23 Kevany et al., “Global Health Diplomacy Investments in Afghanistan.”

24 “National Armies for Global Health?”

25 Robert S. McNamara, In Retrospect: The Tragedy and Lessons of Vietnam (New York: Vintage Books, 1996).

26 Gary J. Schmitt, “A Hard Look at Soft Power in East Asia,” AEI Research (Washington, DC: American Enterprise Institute, June 19, 2014), available at <www.aei.org/publication/a-hard-look-at-soft-power-in-east-asia/>; OASD SO/LIC.

27 Robert Huish, “Why Does Cuba ‘Care’ So Much? Understanding the Epistemology of Solidarity in Global Health Outreach,” Public Health Ethics (October 2014), available at <http://phe.oxfordjournals.org/content/early/2014/10/15/phe.phu033.full>; “Stimulus to Aid Fogarty Grantees,” Global Health Matters 8, no. 1 (January/February 2009), available at <www.fic.nih.gov/News/GlobalHealthMatters/Documents/ghmjan-feb2009.pdf>.

28 Moss and Michaud.

29 Michael H. Basler, “Utility of the McNamara Fallacy,” British Medical Journal, vol. 339, b3141 (August 4, 2009), available at <www.bmj.com/content/339/bmj.b3141>.

30 “National Armies for Global Health?”

31 Ibid.; Uri Friedman, “Putin’s Playbook: The Strategy Behind Russia’s Takeover of Crimea,” The Atlantic, March 2, 2014, available at <www.theatlantic.com/international/archive/2014/03/putins-playbook-the-strategy-behind-russias-takeover-of-crimea/284154/>.

32 Burkle.

33 OASD SO/LIC.

34 Eugene V. Bonventre, “Monitoring and Evaluation of Department of Defense Humanitarian Assistance Programs,” Military Review (January–February 2008), 66–72; CSIS, “Final Report of the CSIS Commission on Smart Global Health Policy,” Washington, DC, March 2010, transcript available at <http://csis.org/event/rollout-final-report-csis-commission-smart-global-health-policy>.

35 Maria C. Haims et al., Developing a Prototype Handbook for Monitoring and Evaluating Department of Defense Humanitarian Assistance Projects (Santa Monica, CA: RAND, 2011), available at <www.rand.org/pubs/technical_reports/TR784.html>.

36 OASD SO/LIC.

37 M. Baker, “History-Making MEDCAP Mission to Cambodia,” Naval Reserve Association News 44, no. 9 (September 1997), 29.

38 Feldbaum; Burkle.

39 Sebastian Kevany et al., “Diplomatic and Operational Adaptations to Global Health Programs in Post-Conflict Settings: Contributions of Monitoring and Evaluation Systems to ‘Nation-Building’ in South Sudan,” Medicine, Conflict and Survival 28, no. 3 (July–September 2012), 247–262, available at <www.ncbi.nlm.nih.gov/pubmed/23189590>.

40 OASD SO/LIC.

41 Roberts.

42 Joseph S. Nye, Jr., “The Decline of America’s Soft Power,” Foreign Affairs, May/June 2004, available at <www.foreignaffairs.com/articles/59888/joseph-s-nye-jr/the-decline-of-americas-soft-power>.

43 Kevany et al., “Global Health Diplomacy Investments in Afghanistan”; Sebastian Kevany et al., “Global Health Diplomacy in Iraq: International Relations Outcomes of Multilateral Tuberculosis Programmes,” Medicine, Conflict and Survival 30, no. 2 (April–June 2014), available at <http://dx.doi.org/10.1080/13623699.2014.890827>.

44 National Intelligence Council, Strategic Implications of Global Health, ICA 2008-10D (Washington, DC: Department of State, December 2008), available at <www.state.gov/documents/organization/113592.pdf>.

45 Pierre M. Buekens et al., Medical School Deans’ Letter to President Barack Obama, January 6, 2013, available at <www.jhsph.edu/news/news-releases/2013/Klag%20letter%20to%20President%20Obama.pdf>.

46 W. Michael Reisman and James E. Baker, Regulating Covert Action: Practices, Contexts, and Policies of Covert Coercion Abroad in American Law (New Haven: Yale University Press, 2011).

47 OASD SO/LIC.

48 Frederick Burkle, Jr., and Richard Garfield, “Civilian Mortality after the 2003 Invasion of Iraq,” The Lancet, March 16, 2013, available at <www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)62196-5/fulltext?rss=yes>.

49 OASD SO/LIC.

50 Nye.

51 Joint Publication 3-08, Interorganizational Coordination During Joint Operations (Washington, DC: The Joint Staff, June 24, 2011), available at <www.dtic.mil/doctrine/new_pubs/jp3_08.pdf>.

52 OASD SO/LIC.

53 Steven Metz and Douglas V. Johnson II, “Asymmetry and U.S. Military Strategy: Definition, Background, and Strategic Concepts,” January 2001, available at <www.strategicstudiesinstitute.army.mil/pubs/summary.cfm?q=223>.

54 Daniel Tiefengraber, Non-State Actors & Global Health: Eradicating Polio in Pakistan, Case Study 15 (Barcelona: Barcelona Institute for Global Health, November 2013), available at <www.isglobal.org/documents/10179/25254/15.Eradicating+Polio+in+Pakistan.pdf/639c1179-2694-4e39-82ab-f978631141ea>.

55 Declan Walsh, “Polio Crisis Deepens in Pakistan, With New Cases and Killings,” New York Times, November 26, 2014.

56 “National Armies for Global Health?”

57 Jarat Chopra and Tanja Hohe, “Participatory Intervention,” Global Governance 10, no. 3 (July–September 2004), 289–305, available at <http://siteresources.worldbank.org/INTJUSFORPOOR/Resources/ParticipatoryIntervention.pdf>.

58 Burkle.

59 Burkle and Garfield.

60 U.S. Global Leadership Coalition, “Military Leaders,” available at <www.usglc.org/budget-center/on-the-record/military-leaders/#LetterM>.

61 Justin Vaïsse, “The Rise and Fall of the Bush Doctrine: The Impact on Transatlantic Relations,” presentation at the Institute of European Studies, University of California at Berkeley, April 6, 2006, available at <http://econpapers.repec.org/paper/cdlbineur/qt5qg2v2d8.htm>.

62 Andrew J. Bacevich, “A Less-than-Splendid Little War,” Wilson Quarterly 38, no. 1 (Winter 2014), 52–67, available at <http://wilsonquarterly.com/stories/a-less-than-splendid-little-war/>.