299. Memorandum From Harry Blaney of the Policy Planning Staff to the Special Assistant to the Under Secretary of State for Security Assistance, Science, and Technology (Lowrance)1


  • Review of International Health Policy Draft

I. Summary

Overall the report is far too long, lacks focus, consistency and an adequate analytical framework and its recommendations are often too general or unrealistic.2 Thus, I believe, the report requires a serious and thorough redrafting. I recommend the present report remain in draft form and neither be published nor go forward for detailed review by Departmental principals or by the President until it has been edited, redrafted in parts, and reviewed by staff. Specific suggested changes in the draft are contained in the attached copy along with some minor or other comments.

II. Specific Comments

There are a number of inappropriate or incorrect statements about US “diplomatic health interests” and our developmental assistance policies which need either correction or some modification. For example, in some places we imply that we have specific “commercial interests” in our health diplomacy which gives the impression that the chief benefit of some of our humanitarian assistance is to advance our commercial interests. I believe these statements are both inappropriate and incorrect.

In addition to inaccuracies in the characterization of US policy, the report does not examine or make recommendations with respect to important international health issues which need both examination and correction. For example, improving the structure and programs of the World Health Organization3 is entirely missing. This organization is a major component of any international health strategy and nowhere are [Page 988] there recommendations about how to increase the effectiveness of its programs.

Likewise, there is almost a total absence of priority setting4 with respect to international health problems, particularly in our assistance programs.

The relationship of the health sector to our entire development assistance strategy5 seems to lack definition and analysis with respect to the interaction between various sectors. There is no real understanding expressed in the report of how, for example, health problems relate to food and nutrition and even, more importantly, to tough questions such as provision of community water services, education, and urbanization. The assumption seems to be that health is somehow over-arching many of these sectors and basically subservient to them. This perspective is in part reflected by one of the recommendations in putting environment and population under a Bureau of International Health. It seems to me this is a mistaken approach since it does not give adequate acknowledgement of the variety of forces at work in the development process or indeed of the problem of political and social environmental change which is fundamental to any development strategy. Clearly, health is vital to any development strategy but it is not the sole basis for either a human needs or a human rights policy.

In this same way, there is no recognition of limits to resources and personnel that6 might be available to the health sector. In a period of personnel and budgetary constraint within the USG it seems to me the process of priority setting is all the more urgent but there is little recognition of that reality. Further, there is no examination of appropriate funding levels for our bilateral and multilateral assistance programs.7 This, together with any substantive priorities in terms of international health problems (tropical diseases, cancer, toxic substances, air pollution, etc.), makes for a very serious deficiency in the policy usefulness of the report.

The characterization of the relationship between “health criteria” and human rights8 in evaluating the establishment and nature of rela[Page 989]tions with other countries needs reexamination and does not appear consistent with actual policy or practice. (See page 300.) Further, the broad characterization of the relationship between international health and human needs while fundamentally correct does not help us go very far in relating international health to other important human needs sectors such as the provision of food, shelter, family planning services, etc. There is no acknowledgement of how these different sectors can interrelate with one another or the emphasis that should be placed on one or another in our actual programming. In the harsh world of governmental decision-making it is just these trade-offs which must be taken into consideration when budgetary decisions are made. Some policy guidance in this area seems useful but certainly is not contained in the present paper.

An additional problem with this particular report is the request for additional studies such as those contemplated on pages 298–299. There are a number of other requests for reports to the President, reports to Congress, new studies, etc. It seems to me that this examination was largely meant to raise those issues, pose options and obtain decisions. I can see the usefulness of specific studies, or better specific issue papers with recommendations for action, but general calls for additional broad-gauged studies seems to me to be a waste of bureaucratic resources if they end with the same kinds of generalities and conclusions that this report presently contains.

We have to be very careful about how we characterize human rights and the provision of development assistance. In some cases we will want to relate economic and social needs with human rights while in other cases the connection may not be all that evident. For example, there are many countries where political rights and social rights are comparatively upheld by the government but what with the extreme poverty there is little delivery of health and other services. We certainly would not want to get into the position of characterizing these countries for denying basic human needs or rights to their people. In some cases almost every country could be criticized including ourselves about provision of services to our poorer people.

In addition, I think we need to examine the recommendations with respect to the role of DOD and specifically the flow [role?] of military programs in the health sector. The report recommends that military programs in the international health area be “significantly expanded”.9 This issue probably needs closer examination and discussion in a some[Page 990]what wider forum. There is already a debate about the use of military sources for “civic action” type programs, now euphemistically called “nation building.” Some of these policy issues, in fact, may adversely affect what we are trying to do in many of these countries in the human rights field. There appears to be no acknowledgement of that harsh reality in the report. In addition, there are important implications for AID (let alone for our DOD budget) in some of the proposals for significant increases in military assistance and increased personnel for this sector. (See pages 306–307.)

With respect to international organizations, as noted above, the report does not really examine how the WHO and other related organizations can be improved. While the report quite correctly raises the issue of the limit of US funding for international organizations at the 25% level, it does not specify what levels would be appropriate and how they might be directed for high priority programs. The report does not raise any of the more serious and important questions with respect to our relationship to WHO and other health related organizations. For example, it does not raise the issue of what relationship WHO should have with UNDP and UNICEF.

The report rightly raises the question of the impact of health on “global systems issues”10 but it does not go beyond mentioning this harsh reality and relate health specifically to how these global systems issues might be resolved by specific health related programs. For example, there is no analysis of the relationship between health services, population growth and food availability. (While it mentions OSTP’s role in such global systems issues it should also include CEQ which is now coordinating a Presidential study on population and environment.

Turning to the specific recommendations of the report, the following appear to be the appropriate State responses:

The establishment of a Bureau of International Health: We would best note that this is an almost impossible bureaucratic and resource task and would probably be counter-productive since it would isolate health from a number of other issues. It would also create a difficult bureaucratic situation among the nonhealth constituencies that would not look with favor on placing such items as nutrition and population under health. Rather, we should support the establishment of an Office of International Health in OES and under the Deputy Assistant Secretary for Environment and Population.11 In this way environmental and population health matters can be integrated at that level and related also to the entire spectrum of our foreign policy concerns.

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Interdepartmental Policy Panel and the establishment of an Inter-Agency Committee to Coordinate International Health Activities: My basic feeling would be that we should not establish these organizations in quite the form recommended by the report. Better options are available including: in place of abolishing the NSC Ad Hoc Committee on Population Affairs we might consider giving to that committee responsibility for population, health and nutrition which would parallel our recent policy emphasis in trying to integrate these sectors in our assistance programs.12 Another alternative would be to establish a separate NSC Ad Hoc Committee dealing with health issues chaired by the Assistant or Deputy Assistant Secretary in OES. Finally, the last alternative could have a White House chaired committee on international health perhaps run by OSTP or Peter Bourne with the State Health Office acting as Executive Secretary.

New International Health Attache Program: I believe we should oppose the creation of this corps. We are already under-going an examination of our Science Attache program and perhaps we might look at how science attaches can increase their responsibilities in the health sector. But unless we wish to have every U.S. Government agency send attaches to every Embassy, in effect duplicating the entire U.S. bureaucracy in each capital abroad, we need to find better alternatives to the suggestion in the report rather than accept such a proliferation. We might alternatively recommend that Foreign Service personnel be trained and involved in international health policy issues in their regular assignments abroad to a greater extent than has been the case heretofore. AID itself would probably be opposed to this idea since it would duplicate their health program officials that exist in many AID recipient posts.

Annual Report on International Health: It seems to me not an unreasonable requirement, but the difficulties are that such a report could become merely an exercise in description and not a mechanism for improvement of programs. Far better would be policy papers with recommendations on specific issues rather than a pro forma report.

III. General State Position and Response to White House

Finally, I believe the report should be considerably shortened and more focussed in its recommendations. At the very least pros and cons should be set forth for various controversial recommendations or alternatives offered. A sense of realism must be incorporated with respect to resources which might be available in this area.

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In our approach to the meeting with Dr. Peter Bourne and other agencies, I believe we should take the following basic tack:13

—The present report is too lengthy and diffuse14 and needs considerable reworking before it is officially reviewed or further disseminated within the United States Government.

—We make this recommendation because we strongly support a sensitive and integrated international health policy and the expansion of our efforts in this field. We fear, however, that the present report may harm rather than help this process.

—We are prepared to provide detailed comments and if appropriate a new draft of the Chapter V section: in any case it should be reviewed again by staff and then by the involved principals.

—The Department of State itself intends to upgrade our health capability but this must be from within the context of the whole range of foreign affairs issues and responsibilities, including such issues as environment, non-proliferation, population, energy, etc. We will establish a new health office in OES but a bureau is unrealistic.

—We have some serious problems with a number of the recommendations and would like to provide alternative solutions to the problems they attempt to address.

—Finally, we should look at this report in the context of the action memorandum to the President and ensure that both cover the priority issues and will reflect fully the views of the participating agencies. These documents should be reviewed together.

  1. Source: National Archives, RG 59, Office of the Under Secretary of State for Security Assistance, Science, and Technology, Lot 80D72, Box 1, HEALTH—Peter Bourne. Limited Official Use. Copies were sent to Lake, Kreisberg, Garten, and Brizill.
  2. Reference is to the 570-page draft report “Foundations for a New U.S. International Health Policy: Assessment of Problems, Programs, Resources, and Opportunities,” which Bourne had circulated for agency comment.
  3. An unknown hand placed a check mark in the margin next to “World Health Organization.”
  4. An unknown hand underlined the phrase “priority setting.”
  5. An unknown hand underlined the portion of the sentence beginning with the word “relationship” and ending with the word “strategy.”
  6. An unknown hand underlined the portion of the sentence beginning with the word “to” and ending with the word “that.”
  7. An unknown hand underlined the portion of the sentence beginning with the word “no” and ending with the word “programs.”
  8. An unknown hand underlined the portion of the sentence beginning with the phrase “‘health criteria’” and ending with the word “rights.”
  9. An unknown hand underlined the portion of the sentence beginning with the word “military” and ending with the word “expanded.”
  10. An unknown hand underlined the phrase “‘global systems issues’.”
  11. An unknown hand placed a tick-mark in the margin next to this sentence.
  12. An unknown hand placed a check mark in the margin next to this sentence.
  13. Presumable reference to a November 16 White House meeting chaired by Bourne and attended by representatives from the Departments of State, HEW, and Treasury and AID. Lowrance summarized the outcome of the meeting in a November 16 memorandum to Brizill, Todd Minnies (E), Patrick Kennedy (M), Blaney, Lindsey Grant, Andrew, Palmer, Joseph Montville (NEA), McNutt, Pat Hughes (EUR), Judy Kaufman (EUR), Phyllis Oakley, and Kathy Smith (AF). (National Archives, RG 59, Office of the Under Secretary of State for Security Assistance, Science, and Technology, Lot 80D72, Box 1, HEALTH—Peter Bourne)
  14. An unknown hand underlined the portion of the sentence beginning with “is” and ending with “diffuse.”