Monthly Archives: January 2018

Health / Medical Diplomacy and Navy Medicine

We are quite used to seeing big white ships festooned with large red crosses much in evidence after natural disasters. Our Navy’s hospital ships Comfort and Mercy, and the Chinese ship Peace Ark create very dramatic visual representations of their nations’ outreach to provide humanitarian assistance and to help build local medical infrastructure through advice and training.

Building international goodwill through medical assistance is a relatively new arrival in diplomacy, which started out as efforts to manage interdynastic or international communication. The earliest “diplomats” likely were relatives of monarchs sent to foreign capitals as hostages to assure honest fulfillment of treaty agreements. Because such hostages were of high social station, they likely had ready access to their “host”‘s leadership, and thus could report to the folks back home on a variety of matters of interest. From this simple expediency evolved the system of information gathering, representation and negotiation by state-designated agents (and non-state actors, too) that we call diplomacy today. There is evidence of such (City) State – to (City) State representation as early as the Sumerian civilization around 2400 BCE.

“Diplomacy” around health matters no doubt accompanied the health policies instituted by Mediterranean states in the 14th century, as commercial ships and their crews were held in quarantine, sometimes for weeks, without compensation. As international trade and travel increased, quarantine and other local policies failed to prevent the rapid spread of diseases. The mid-19th century saw the institution of a wave of international sanitary conferences that sought to create synchronized policies for the control of diseases like cholera, yellow fever and plague and to regulate trade and traffic in alcohol and drugs. These efforts were supplanted in the 20th century first by the League of Nations Health Office, and later by the World Health Organization. Other health-oriented organizations like the Pan American Health Organization also were created by governments to promote policy synchronization and technical interchange on a more regional basis.

The current status of health diplomacy is captured in this graphic from the National Defense University Press:

This document categorizes various types of “medical engagement” according to their benefit to local populations. In a tone of realpolitik, it also attempts to assess “U.S. Gains” from said engagements.

So, what are some examples of each “Mission Type”; and in particular, what roles has U.S. Navy medicine played?

As I mentioned at the top, very visible examples of Types I & 2 missions include big white ship (and other large naval unit) participation in efforts of humanitarian relief, training and technical exchanges. According to Navy publicity, the most recent international deployments of Mercy and Comfort, in Pacific Partnership and Continuing Promise operations respectively, saw visits throughout the Indo-Asia-Pacific and Central- & South-America and the Caribbean over the past several years. In 20 port visits the ships’ medical staffs cared for more than 140,000 patients and performed nearly 2000 surgical operations. Medical personnel of this joint operation also provided disaster relief trainings, and offered such technical assistance as monitoring for mosquito larvae near schools. The most recent purely international disaster response that I could find was the very visible attendance of Comfort to provide humanitarian relief after the devastating Haitian earthquake in 2010. Immediately upon arriving her medical staff of 300 began caring for the sickest and most severely injured earthquake victims.

According to a 20 November 2017 China Daily article, the People’s Liberation Army Navy’s sole purpose-built big white ship (and one only 4 or five hospital ships in the world), Peace Ark most recently participated in a multinational medical mission in Africa. The ship’s 115 medical workers, “mostly from the Naval Medical University” provided “carry out free medical services, humanitarian assistance, and conduct medical training to consolidate and promote friendly relations and deepen professional exchanges between China and (several nations on both coasts of the African continent).” Peace Ark carried out a similar mission in 2015.

Such short term endeavors seem to me to have great humanitarian merit, but as “diplomacy”, I think they miss the mark, because they by and large fail the definition of diplomacy I offered at the top: information gathering, representation and negotiation. Certainly, except for temporary “feel good” relationships, it’s hard to imagine many meaningful nation-to-nation policy changes emerging from Mission Types I & II. Think of it this way: do you remember the name of the doctor who set your child’s broken bone 20 years ago? Did you even remember that she broke her arm? Apply that thought to people who benefit from temporary humanitarian relief and one-week medical visits to rural communities.

The U.S. Navy has long been engaged in Type III missions. Navy medical historian André Sobocinski has pointed out that the Navy was fortunate to have a world class expert in tropical diseases – Edward Stitt, MD – in its ranks at the turn of the 19th to 20th centuries. His interest was piqued by the “new” medical problems he saw as a result of our Navy’s engagement during and after the Spanish American War (1898) and our resulting acquisition of tropical territories in the Pacific and Caribbean. Under the leadership of Stitt and others, Navy doctors, corpsmen and nurses soon were engaged in research, diagnosis, treatment and prevention of diseases exotic and common in those areas. Between 1911 and 1918 Navy nurses established schools in American Samoa, Guam and Haiti to teach basic health knowledge and skills to native women. Navy personnel vaccinated the people of American Samoa and Guam against the scourge of smallpox in the early years of the 20th century. In the 1940s, Navy experts stood up a series of Navy Medical Research Units in places like Addis Ababa, Ethiopia and Jakarta, Indonesia. Today, NAMRUs in Cairo, Egypt, Lima, Peru and Honolulu continue their missions of monitoring disease activity, performing ongoing research (with particular emphasis on infectious diseases), and – medical diplomacy.

in 2012, Public Health England, the UK’s public health agency responded to requests for assistance during a cholera outbreak in Sierra Leone by sending a microbiologist with special skills in identifying enteric pathogens to work with local personnel to set up a national enteric bacteria diagnostic and reference lab. While there, he trained four local staff members on cholera identification and on laboratory safety and quality assurance. This Type III Mission also has Type IV (see below) implications, as the laboratory was to become part of Sierra Leone’s national cholera control program.

As can be seen by these example, Type III medical missions add a new element to medical diplomatic missions, the element of time. U.S. NAMRUs have been deployed for decades, and in the British example, direct involvement lasted for several weeks. The time element offers opportunity for plenty of professional-to-professional interaction that provides for education, and conceivably over time, will have international policy impact. Certainly the longer term goodwill created by these interactions can have a salutary effect on nation-to-nation relations.

While the U.S. Navy created physical and human infrastructure (Type IV missions) in territories “adopted” after the Spanish American War and World War I, such efforts are quite limited today. Interestingly, Cuba has become a major force in this form of medical diplomacy – especially in developing human infrastructure throughout the developing world. Originally an initiative of Che Guevara, himself medically trained, Cuba has sent more that 130,000 medical personnel to the world’s poorest areas to treat the sick and educate local providers. Even in today’s economic hard times in Cuba, something like 37,000 Cubans provide care in rural Venezuela; in return, Venezuela sends oil to Cuba. That’s medical diplomacy with a nice quid pro quo.

China provides another example of long term medical commitment to care, training and infrastructure. She started sending medical missions overseas in the late 1960s. Since then, in Africa alone, she has established a long term medical presence in 25 nations. China has constructed more than 100 hospitals worldwide, 54 of which are in Africa. She runs or participates in several medical training programs. When I visited my son in Mozambique a couple of years ago, the lovely 1950s Portuguese-built Central Hospital Of Maputo was undergoing renovations sponsored by the Chinese (they are not just putting up new structures). And they’ve built pharmaceutical production facilities in 3 countries abroad.

With Type IV missions – infrastructure building – the longer term political and diplomatic benefits become more clearly discernible. There are two reasons for this. First, the longer term person-to-person relationships that develop can produce, as the people involved move up in their national medical establishments, meaningful impacts on nations’ health and international policies. Second, the infrastructures developed – both human and and especially physical (hospitals, clinics, labs, schools) – provide a continuing remainder of the medical missions for the citizens of recipient nations. Generation after generation of goodwill and support can result. Think of it this way: if you’ve developed a good relationship with your GP, or your therapist, now, 20 years on, office visits are more likely to be taken up with conversations about the now adult kids in your families, or about politics… Thus it might be with populations, and especially thought leaders who’ve developed long term relationships with medical workers from abroad.

The National Defense University source for this post’s graphic gives no specific examples of Type V medical diplomacy missions. Perhaps examples of this level of medical diplomacy would include G7 and G20 health ministers meetings and other minister-level interactions and engagements. Besides producing high-sounding declarations of principle, they must provide “top down” direction for ongoing international health policy cooperation and execution.

One final note. I did a word search (“medical” and “health”) in the new National Security Strategy document released by President Trump in December 2017. I found no instance where either term was conjoined with “diplomacy”, and but one instance where “health” was used in an international context: “REDUCE HUMAN SUFFERING: The United States will continue to lead the world in humanitarian assistance. Even as we expect others to share responsibility, the United States will continue to catalyze international responses to man-made and natural disasters and provide our expertise and capabilities to those in need. We will support food security and health [italics mine] programs that save lives and address the root cause of hunger and disease. We will support displaced people close to their homes to help meet their needs until they can safely and voluntarily return.” But American medical diplomacy is not quiescent. HHS announced in December (the document was signed by Ambassador Deborah L Birx, MD) [bolding mine] that PEPFAR (George W Bush’s “President’s Emergency Plan for AIDS Relief” has seen remarkable success in controlling that scourge in Africa. (During my Mozambique visit, mentioned above, I met a Maputo-based Brazilian infectious disease specialist at an American 4th of July party. He told me that when he first came to the country, he saw people dying in the streets of AIDS / complications. “Today,” he said, “I see none of that. PEPFAR is a miracle for these people. President Bush is a revered hero because of it.”) The HHS announcement stated that President Trump had committed his support of the program, “noting both its importance and it as an example of doing more each year by finding more efficiencies and ensuring we continue to drive forward with impact and clear value for each dollar invested.”


Here are the sources I used for this post (in no particular order). I accessed all of them during the period of preparation for this post: 11 – 16 January 2018. I did not write at the weekend.

https://www.scribd.com/document/125263073/Black-j-2010-a-History-of-Diplomacy

http://ndupress.ndu.edu/Media/News/Article/577539/medical-diplomacy-in-achieving-us-global-strategic-objectives/

https://thediplomat.com/2016/04/chinas-medical-diplomacy/

https://csis-prod.s3.amazonaws.com/s3fs-public/legacy_files/files/publication/111122_Freeman_ChinaEmergingGlobalHealth_Web.pdf

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5331141/#!po=4.16667 I didn’t actually use any material from this article, but it’s quirky comparison of doctors and diplomats is enlightening and informative.

http://summit.sfu.ca/system/files/iritems1/10865/ghg-ghd-lee-smith-12-07-11.pdf

http://navymedicine.navylive.dodlive.mil/archives/3881

http://www.who.int/bulletin/archives/79(9)842.pdf

https://pdfs.semanticscholar.org/96a9/2f8d24383480e0a1f90842a4734972c0a535.pdf

https://health.mil/News/Articles/2018/01/11/Joint-efforts-in-search-of-a-cure-for-tropical-diseases

http://www.paho.org/hq/index.php?option=com_content&view=article&id=91

https://www.navy.com/about/equipment/vessels/hospital-ships.html

http://navylive.dodlive.mil/2015/10/01/by-the-numbers-pacific-partnership-and-continuing-promise/

http://www.chinadaily.com.cn/world/2017-11/20/content_34757172.htm

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/354156/Global_Health_Strategy_final_version_for_publication_12_09_14.pdf

http://www.coha.org/cuban-medical-diplomacy-a-developmental-paradox/

https://www.ft.com/content/debaad0c-5d6e-11df-8373-00144feab49a

https://www.scribd.com/document/8057665/Medical-Diplomacy-a-Brief-Outline “Medical Diplomacy – A Brief Outline” from Aesisgroup.com was a late find. It offers a different “system” for considering this topic, and carefully differentiates between “medical diplomacy” (by which medical resources are used to encourage positive relations between nations and / or to exchange specific benefits between nations) and “health diplomacy” (diplomatic efforts to enact international health measures). Aesis is a “network for advancing and evaluating the societal impact of science” – http://aesisnet.com/

http://www.g7italy.it/sites/default/files/documents/FINAL_G7_Health_Communiqu%C3%A8_Milan_2017_0.pdf Eric Hargan took office as Acting Secretary of Health and Human Services on 10 October 2017. I could not identify his face in the photo of ministers attending this November 2017 meeting. The HHS website is similarly unrevealing.

https://www.bundesgesundheitsministerium.de/fileadmin/Dateien/3_Downloads/G/G20-Gesundheitsministertreffen/G20_Health_Ministers_Declaration_engl.pdf I think I can identify then-HHS Secretary Tom Price at this May 2017 meeting.

https://www.whitehouse.gov/wp-content/uploads/2017/12/NSS-Final-12-18-2017-0905-2.pdf

https://www.whitehouse.gov/articles/american-leadership-brink-controlling-aids/

(c)2018 Thomas L Snyder

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Happy New Year!

To my readers, I know there’s been a drought of my scribblings over the past some time. But now I’ve passed most of my Naval Order responsibilities off to an energetic and capable successor, and already this ancient brain is beginning to swirl with ideas for new posts. Let’s hope some mental alchemy yields nuggets of gold from the lead that’s been mouldering in the depths and is just now getting some agitation!

My older son James gave me as a holiday gift Admiral Jim Stavridis’s 2017 book, Sea Power (New York, Penguin Press). In what I see as the Admiral’s combination memoir and strategic reflection, I encountered (for the first time in my consciousness) the term “medical diplomacy”.

Bingo! The subject of my next post – in a few days.

For now, my standard New Years mantra: may 2018 meet or exceed your expectations!