The Missing Link in Military Global Health Engagement.

Military missions are rightfully focused on the national security mandate given to the Defense Department by the President, the Congress, and the taxpayers. Reducing threats, teaching allies to take care of themselves, and performing in a cost-effective manner are all in the Department of Defense (DoD) portfolio. Military health care personnel have been reducing threats to soldiers and to the American homeland for generations. Some of DoD’s finest hours and best products came from this line of effort. Teaching is a newer aspect of global health engagement work. Performing in a cost-effective manner is the biggest challenge, in the authors’ opinion, and the one where DoD and its medical forces have fallen short of the mark too often. It is a key link in the chain of success, and it is often missing. The authors look at the world of global health engagement through experiences as military health care officers for a combined total of nearly six decades, and both of us treasure our time in uniform. Much of that time was spent in a simple, bipolar, Cold War paradigm. There was minimal incentive to assess “relative value” of missions, learn the mission outcome value for multiple stakeholders (including host nation), or determine long-term impact of different global health engagements. Throughout the two decades after the Berlin Wall came down, DoD initiated programs in all services that facilitated (directly or indirectly) health engagement (Special Forces, USA Civil Affairs, Foreign Area Specialists). In 2000, the International Health Specialist program stood up, and global health engagement evolved into a vital priority of all the regional Combatant Commands. Often, in the era of medical civic action programs, there were few identified medical consequences of DoD’s humanitarian work. Many in DoD were happy to take the simple road and measure patient count and sometimes attribute regional stability to health engagement activities. Measurement of public health progress, sustainable capacity built, or improvement in mutual security was not mandated. The U.S. Ambassador was pleased to get a positive photo op, and the 4-star thought that anything the medics do must be good. The medics did not educate either the Combatant Commander or the Ambassador, perhaps taking a shortcut, not challenging tradition, or sometimes just seeking to improve career opportunities. So tax dollars were wasted, year after year. Health program management and evaluation, especially in global health engagement, is among the most complex tasks known. “Global health is not rocket science. It is much harder,” is a tenet that is taught to students at the Uniformed Services University of Health Sciences on the same campus as the Walter Reed National Military Medical Center in Bethesda. Challenging but essential steps in monitoring and evaluation of responsible global engagement include planning with the end in mind, establishing accurate baseline metrics, assuring host nation ownership, monitoring the mission trajectory, measuring results that are attributable, and ultimately looking back months to years later for intended and unintended consequences. Unfortunately, essential steps are sometimes not attempted nor done satisfactorily. How can this happen, after decades of Government Accountability Office reports about mismanaged DoD Humanitarian Assistance programs? The short answer, as they say in the movies, is “follow the money.” Short assignment cycles and fiscal year spending limitations do not incentivize DoD’s leadership to critically measure outcomes of global health engagements. Better to be ignorant of a bad outcome, with plausible deniability, than to use lessons learned to improve subsequent cycle planning and execution. Some leaders judge it to be wasteful to spend mission funds on evaluation of mission outcomes. This judgment may seem cynical and harsh, but this behavior has a basis in fact. “Value” is a combination of price and quality. Many would say that quality is more difficult to evaluate, especially when considering global health engagements. Health quality is notoriously difficult to determine, as learned from Nobel Laureate economist Kenneth Arrow in 1963. Yet, DoD actors have had more trouble with the price parameter of this value equation. Short assignment cycles make it easy to be *Department of Preventive Medicine and Biometrics, Uniformed Services University, 4301 Jones Bridge Road, Bethesda MD 20814. †Department of Surgery, Uniformed Services University, 4301 Jones Bridge Road, Bethesda MD 20814. The views expressed are those of the authors and do not reflect the official policy or position of the Uniformed Services University of the Health Sciences, the U.S. Air Force, the Department of Defense, or the U. S. Government. doi: 10.7205/MILMED-D-15-00348