304. Letter From the Under Secretary of State for Security Assistance, Science, and Technology (Benson) to the President’s Special Assistant for Health Issues (Bourne)1

Dear Peter:

Since your November 9 draft of the Presidential decision document on international health2 grows out of the draft Report on which we have already commented, the remarks in my letter of November 143 apply equally to the proposed decision memorandum.

The State Department believes that the memo to the President needs substantial revision. The memorandum will be most helpful to all of us if it asks for the charge to explore and appraise the possibilities instead of asking for a mandate to establish programs and institutions. Those of us in State concerned with health will have to negotiate carefully with our internal management offices, with AID, HEW, EPA, and other programmatic bureaus, and with the OMB. This will be true for any of the major decisions. Further, these plans cannot be made outside of the much larger contexts of the long-term planning for AID, our State Department review of the technical attachés’ program, and so on.

State Department role (initiative 2, page 6). The Department, as I have assured you, is firmly committed to sharpening its attention to health and related issues. Our intention is to establish a clear focal point for health in the Department, to become staffed and able to identify and seize upon opportunities as they arise, to represent the internationalist cause to the domestic agencies, and to “broker” interests in this area effectively. For the State Department to become able to do these things would constitute a major improvement.

But the leadership must be shared with HEW and the other departments and agencies. Initiatives are not likely to enjoy long-term success unless the agencies that carry the required resources and technical competence are deeply involved in their development. The State Department is evolving to take on a larger role in space policy, energy policy, environment policy, oceans and Antarctica policy, technical-development policy, and communications policy—as well as health policy. Considerations of both interdepartmental relations and internal [Page 1001] bureaucratic limitations dictate that we keep our expectations realistic. We will work closely with HEW, AID, and others to improve coordination, and we will urge those agencies to upgrade their international offices.

Health initiatives as a primary element of foreign policy (pages 1 and 2). A better statement of what can realistically be expected, given all the political, military, economic, and other issues that have to be attended to, is that the United States should seek to give greater emphasis to international health issues and to better integrate health considerations with those of development assistance, cooperative research and the like. To overstate will serve no purpose.

Global Health Cadres (page 5). Although there doesn’t seem to be much initial enthusiasm for this proposal in State, AID, or HEW, the decision memo might call for consideration of the idea by these departments. The State Department is currently engaged in a review of the technical attachés’ program (science counselors, and energy, minerals, fisheries, and other attachés) and the question of how adequate the technical representation in our embassies is. We will certainly examine the desirability of health attachés as well.

Interagency committees (implementation Task Force, page 5; Interagency Strategic Coordinating Committee, page 6; and Executive Policy Group, page 6). It is just too early to consider establishment of all these committees until our objectives become clear. Whatever group turns out to be necessary should probably be set up either within the NSC Domestic Council or other well-established structures.

Major conclusions (page 3). These are poorly worded. For instance, the first “conclusion” is of little guidance as it stands: “A new ethic is required—one of global collaboration among all nations based on humanitarian not ideological themes, asking what we can do together not how much we can or ought to do for another.”

The second “conclusion” is also diffuse, and it says that “[The President’s] basic human rights policy is an ideal framework for global health collaboration”; this should be clarified either to discuss the human rights approach to health issues (which the Report did not address very fully) or the basic human needs strategy.

The third “conclusion”—that “the full U.S. scientific and technical potential is not directed to help meet basic human needs worldwide. Significant changes are required to do so”—deserves amplification. Specifically what changes are needed? Again, perhaps the memo could elicit directions to HEW, OSTP, NSF, and others to review the long-term health-related R&D agenda.

Priorities. The Report neither lays down priorities nor sets forth criteria to be used in generating priorities. If in the revision process these could be accomplished, considerable guidance to the U.S. government [Page 1002] and health communities will have been provided. The biggest problem in this entire sector is to chose efficaciously among the many possible activities. For example, should we attack tropical diseases, or maternal and infant malnutrition, or what? If tropical diseases, which one? And by eradication of vectors, or by development of vaccines? Bilaterally, or through multilateral efforts? The Report gives little guidance. What the memo could do is call for the departments and agencies to establish and adopt explicit priorities for their international health endeavors (for example, to emphasize prenatal and infant health, or to target particular infectious diseases). Beyond that, of course, these priorities should eventually be reflected in budgets.

Congressional relations. The document, like the Report, needs to give much more attention to the need to work closely with the Congress, to consult early, and to design initiatives within the limits of Congressional tolerance.

Overall tone of the memorandum. Reference to “prevailing passivity and skepticism” pages 2 and 4) are inaccurate and gratuitous and will serve no constructive purpose. Also, the description of the failures of the “trickle down” approach to development assistance (page 2), though correct in its general criticism, does not give fair recognition to the efforts and potential of the Peace Corps and other such activities. These problems can be taken care of by editing.

Encouraging private sector involvement (page 5, item B). The ma-jor study of incentives of private sector involvement might be conducted better by a nongovernmental institution than by the federal government.

Proposed Presidential Initiative (page 5, first paragraph of item C): “The proposals which follow build on existing programs or create new ones; they would specifically place your Administration’s stamp on basic human needs in a comprehensive way which Senator Humphrey, President Roosevelt and President Truman, for example, have been trying to do since the 1940’s.” This paragraph is both surprising and unnecessary.

AID program (page 3). The recommendation that any increases in health, population, and nutrition in the AID budget be made proportional to any increase in the FY 79 budget needs examination. The figures may even need to be increased above that level, but such a decision should be taken as part of an overall review of health and other priorities relating to basic human needs. There is no reference to the various AID reorganization studies. Organizational decisions should not be made independently of an integrated view of AID’s future.

Other proposals: research and training centers (page 6); global health consortia (page 7); Fogarty Institute (page 8); Presidential Scholars (page 8); National Endowment for International Health Assistance (page 10). None of [Page 1003] these receives much support from our bureaus. These proposals don’t address the larger problems, they risk seeming gimmicky, and the budgets proposed are in any event far too small to make much impact.

The above statements reflect views held throughout the State Department. If these concerns are accommodated in the revised decision memorandum, international health and the Administration will be better served.

We continue to offer our assistance, and we look forward to seeing the next drafts of the memo and the Report.

My best regards.

Sincerely yours,

Lucy Wilson Benson4
  1. Source: National Archives, RG 59, Policy and Planning Staff—Office of the Director, Records of Anthony Lake, 1977–1981, Lot 82D298, Box 1, Envelope 5: “Eyes Only—Tony Lake From Henry Blaney 11/29/77.” No classification marking. All brackets in the original.
  2. See footnote 2, Document 301.
  3. See footnote 7, Document 302.
  4. Benson signed “Lucy” above her typed signature.