285. Memorandum From the Assistant to the President’s Special Assistant for Health Issues (Fill) to the Secretary of the Cabinet (Watson)1


  • Agency Comments on the Cabinet-Level Task Force on International Health Proposal

After reading the comments from AID, HEW, and OMB, I believe we are still on strong ground, and I disagree with Rick on not going to the President with this.2 OMB endorses a coordinating committee made up of all affected agencies, joining HEW in that regard.3 HEW also asks [Page 945] to be co-chairman of the Cabinet-level Task Force with State, if one is formed, thus reaffirming my own judgment concerning the lack of a lead agency in this field.4 AID is the more negative, but equally equivocal as the other agencies, and concedes the need for someone at the Executive Office level to pull together a “composite report” which is precisely what we suggest.5 We have no State comments. They may not have been consulted since Eizenstat’s request went to “State/AID” according to OMB, and there is no State response included in the Hutcheson package.

My assessment has not changed one iota on this classic case of Executive Branch turf protection. HEW sees itself grabbing the international health issue and has Kennedy’s backing to grow. AID sees its prerogatives jeopardized, recognizes the low (8–10 percent of total budget) priority given to health, but wants to make its own decisions. OMB sees its reorganization assignment being crowded by a mechanism which bridges both policy and functional reorganization, domestic and international programs, and the potential emergence of another mechanism within the Cabinet to do what it perceives itself as capable of accomplishing. The Domestic Council position is much less clear; however, it seems to me that there are two factors possibly disturbing them:

1. The Cabinet structure bridges domestic and international;

2. It offers the possibility that a planning and analysis mechanism may be created which is not subject to day-to-day legislative and managerial responsibilities.

This characteristic of institutional separateness from day-to-day responsibilities would be distinct from all the major Presidential advisory structures: CEA, OMB, NSC, and the Domestic Council. OMB, for example, had to establish new layers, essentially creating a new entity outside the day-to-day operations of OMB in order to fulfill their reorganization mandate. They also felt it necessary to hire new outside staff. Interestingly, Peter has not hired one international health person, [Page 946] borrowing five people not counting me, and if we can hold them together for 2 months, we will have a decision document ready. It has cost the government zero extra dollars and created no permanent new entity in EOP. Examples abound where domestic and international interests converge and compete, e.g., energy (at least 10 agencies), world food production and nutrition (26 agencies).

It is impossible to improve on Congressional committee fragmentation unless we establish a means to mediate competing interests and develop objective options for Presidential decision. A case could be made for a Cabinet mechanism which has a separate institutional base free from day-to-day responsibilities, is a renewable entity (e.g., staff temporarily borrowed from affected agencies and rotating EO assignments) and bridges domestic and international interests.

P.S.: Peter Bourne is in England for 2 weeks, and I am filling in.

  1. Source: Carter Library, Staff Office Files, Special Assistant for Health Issues—Peter Bourne Files, Subject Files, Box 34, International Health, 6/1/77–6/15/77. No classification marking. A copy was sent to Bourne and Parham. As Bourne’s assistant, Fill served as the Study Director of the White House International Health Assessment Staff.
  2. In an undated typed note to Watson, Hutcheson referenced OMB, AID, and HEW opposition to the Task Force, commenting “I suggest that you work with them further in developing this idea—I don’t think it’s ready to go to the President at this stage.” (Ibid.)
  3. Cutter, in a June 10 memorandum to Hutcheson, noted that OMB had reviewed the draft memorandum and, upon Eizenstat’s request, obtained the recommendations of the Departments of State and Health, Education and Welfare, and AID. Cutter underscored that the agencies and OMB believed that it “may be premature” to establish a Task Force, but, if the President approved the recommendation, the resultant Task Force should “serve primarily as a coordinating mechanism to assure a well executed study, with specific topics assigned to the responsible agencies for analysis and draft recommendations which would then be reviewed by the Task Force. If necessary, the Task Force could then make further recommendations to the President to insure an integrated U.S. international health policy.” (Ibid.)
  4. In a June 7 memorandum to Lance, Califano, in addition to proposing the coordinating committee, commented: “If and when a Cabinet-level task force is formed, I believe HEW should have a more central role within the executive overview committee than suggested in Jack’s memo. At a minimum, I would like to co-chair such a committee with Cy Vance.” (Ibid.)
  5. Gilligan, in a June 3 memorandum to Lance, proposed that each agency author drafts on the “parts of this exercise which fall within its own area of competence.” He added that completed drafts would be circulated to the other agencies for comment; Bourne and his staff “would then prepare a composite report to which each agency could react. The final report would then reflect agreement by all agencies, or where necessary, alternative agency views on specific points.” (Ibid.)