294. Memorandum From the President’s Special Assistant for Health Issues (Bourne) to His Assistant (Fill)1


  • Health Policy Review

The commitment to address global human needs has become a fundamental theme of the Carter Foreign Policy. International Health is a key element in that policy. In part, because the United States has exceptional technical capability and expertise in this area to offer the rest of the world, but also because even among the range of issues relating to human needs, health is the area that is the least controversial and the most free from broader political concerns. Our study should be aimed at determining how the resources of the federal government and of the United States in general could be mobilized most effectively to make this aspect of the President’s foreign policy a reality.

Specifically, our goal should be to (1) inventory the resources of the federal government in the international health area, (2) to look for a mechanism to integrate international health concerns into the foreign policy making process, (3) to coordinate the resources of the federal government in such a way that we maximize our effectiveness and minimize duplication and overlap, (4) to establish a broad blueprint as to what the role of the United States should be in the world in carrying its share of the total effort to alleviate suffering through a coordinated global health strategy, (5) to carefully examine various new initiatives which we might be able to start that would highlight the concern that the President has in this area and also be a major new contribution on [Page 974] the part of the United States to dealing with this problem, and (6) to examine ways in which our contribution to the global health effort can be fully integrated with the activities of other nations and of multinational bodies particularly the United Nations Organizations.

The fundamental philosophical concept that we are attempting to communicate which differs somewhat from that of other studies going on with regard to international assistance is that we should define the international health area as a global problem and not a problem exclusively of the developing nations. This will allow us to get away from the traditional dichotomy that has plagued us in the past of donor and recipient nations, in which, the United States was in the posture of giving to other countries in need without a sense of shared responsibility for dealing with the suffering of their people. Even the concept of a North-South dialogue maintains the notion of donor and recipient, the only difference being that the United States has broadened the responsibility to include other industrialized nations. But it is still a question of charity, in which the wealthier nations have some obligation to the poorer nations. We hopefully will get beyond this, and conceive of health as being something which is a responsibility of all the people of the world regardless of where they live or what diseases they are locally afflicted by. In many respects the success in dealing with the problem of smallpox is a model which exemplifies this concept. There was a joint commitment by the countries throughout the world and by the World Health Organization that together the problem of smallpox would be attacked and defeated using a model that was quite different from our traditional foreign aid effort. And on this basis the problem has largely been virtually eliminated.

Specifically our project should be aimed at the following goals:

(1) Inventory all health resources within the federal government, in detail both in terms of personnel, budget and programs, so that it is possible to rapidly assess the extent of the federal resources in terms of the effort going into a given country or diseases entity or major programs area such as research or manpower training.

(2) We should examine the organizational structure of the federal government in order to determine the manner in which the international health issue can best be incorporated into the development of foreign policy. Military power has traditionally been the key ancillary component of our foreign policy. Over the years international economic policy has been incorporated as an important consideration in foreign policy development and has been placed managerially within the State Department structure. Even though President Carter has made clear that concern with basic human needs is a fundamental element in his overall foreign policy there is currently no single mechanism within the State Department to allow for the effective incorpora[Page 975]tion of this issue in the development of overall policy. This is in striking contrast to the manner in which other countries have successfully integrated concern for human needs into their foreign policy strategy. Only in the limited role of foreign aid to developing nations has concern for human needs any real role in the conduct of our own foreign policy. Our recommendations as a result may involve organizational changes within certain departments, particularly the Department of State.

(3) We should examine various alternatives that would allow for the centralized coordination of international health policy. This might take the form of a cabinet level coordinating committee, the development of a lead agency responsibility, or a focus in the White House. Coordination of sub-functions such as research, manpower, and the relationship with the private sector needs to be considered.

(4) To establish basic health goals for the next four, ten and perhaps twenty-five years with a clear cut plan as to how the United States would contribute to the achievement of those goals. It is clear that the development of such goals would have to be closely correlated with those established already by the World Health Organization. This is a function which we would not necessarily perform at this stage, but should be clearly an anticipated responsibility which the ongoing mechanism we set up would carry out in coordination with the Institute of Medicine and other groups.

(5) Having established the basic blueprint for America’s role in international health we should examine the specific ways in which each agency would play a role in the overall game plan. As clearly as possible we should define the role and mandate of each Department and Agency. At the same time we would also examine the manner in which the private sector and multilateral organizations would interface with the efforts of the federal government towards the achievement of those common goals.

In the long run I anticipate that we would end up with a global health plan with clear objectives and specific plans for reaching those objectives. As a derivative of that global plan we would have regional plans and specific goals and timetables for Africa, Latin America, Asia and other regions of the world, and at a third level specific goals for individual countries. These countries goals obviously would be the result of a carefully coordinated consensus between the global and regional goals which we had established and the goals which health planners in each nation had themselves established. I anticipate that in the long run the inter-agency coordinating mechanism that we recommend would then on a regular basis review our global strategy, our strategy for each region and our strategy in each individual country to insure that they were consistent with an overall plan. At those meetings the participants should have the capacity to present the entire federal effort going into a [Page 976] country or a region, and the policy basis on which the decisions were made to commit resources from each individual agency. After reviewing the commitments ongoing from the various agencies in a country this would be compared with the long-range objectives and should there be deficiencies plans would then be made jointly between the agencies to enhance or modify our efforts in that country to better achieve the agreed upon goals.

I believe also that we should be able to carry out a similar periodic review focusing on individual disease entities and that we should set in conjunction with WHO specific goals for the eradication and control of the remaining major cripplers and killers in the world. At a third level we should examine the major generic causes of ill health, namely lack of potable water, lack of adequate shelter, inadequate family planning and should establish for those generic areas similar goals that could be reviewed on a periodic basis by a single coordinating entity.

  1. Source: Carter Library, Staff Office Files, Special Assistant for Health Issues—Peter Bourne Files, Subject Files, Box 34, International Health, 8/1/77–8/31/77. No classification marking.