U.S.

GLOBAL HEALTH POLICY

T H E U . S . DEPARTMENT OF DEFENSE AND GLOBAL HEA LT H

S e p t e m b e r 2012
 U.S. GLOBAL HEALTH POLICY

T H E U . S . DEPARTMENT OF DEFENSE AND GLOBA L HEA LT H

S e p t e m b e r 20 12

Josh Michaud

Kellie Moss

Jen Kates

Acknowledgments: The authors would like to recognize the contributions of Rebecca Katz and
Derek Licina during the researching and drafting of this report. In addition, the authors thank all
of the interviewees who kindly shared their time and input.
Acknowledgments: The authors would like to recognize the contributions of Rebecca Katz and
Derek Licina during the researching and drafting of this report. In addition, the authors thank all
of the interviewees who kindly shared their time and input.
TABLE OF CONTENTS
Executive Summary .......................................................................................................................................................................... 1
Introduction ...................................................................................................................................................................................... 4
Methods............................................................................................................................................................................................ 4
History and Context .......................................................................................................................................................................... 5
Evolution of DoD’s Global Health-Related Activities .................................................................................................................... 6
Organizational Structure and Approach ........................................................................................................................................... 9
Leadership and Planning ............................................................................................................................................................ 11
Key Components ........................................................................................................................................................................ 11
Office of the Secretary of Defense ........................................................................................................................................ 12
Organization of the Joint Chiefs of Staff................................................................................................................................ 13
Combatant Commands ......................................................................................................................................................... 14
Military Departments ............................................................................................................................................................ 15
Coordination with USG Agencies and Other Partners ................................................................................................................ 19
USG Interagency Coordination .............................................................................................................................................. 19
Coordination with Other Organizations ................................................................................................................................ 21
DoD’s Global Health Focus Areas .................................................................................................................................................... 21
Force Health Protection and Readiness ..................................................................................................................................... 22
Medical Research and Development .................................................................................................................................... 22
Health Surveillance ............................................................................................................................................................... 23
FHP Education and Training for U.S. Personnel..................................................................................................................... 23
Medical Stability Operations and Partnership Engagement ...................................................................................................... 24
Medical Stability Operations ................................................................................................................................................. 24
Partnership Engagement ....................................................................................................................................................... 25
Threat Reduction ....................................................................................................................................................................... 26
DoD Policy and Guidance Documents Relevant to Global Health ................................................................................................... 26
DoD Budget and Funding for Global Health-Related Activities ....................................................................................................... 28
DoD Budgeting and Appropriation Process ................................................................................................................................ 28
Funding for Global Health-Related Activities ............................................................................................................................. 28
Policy Issues .................................................................................................................................................................................... 33
Conclusion ...................................................................................................................................................................................... 35
Appendix A. Detailed Timeline........................................................................................................................................................ 36
Appendix B. Acronym List ............................................................................................................................................................... 38
Sources ........................................................................................................................................................................................... 40
 EXECUTIVE SUMMARY
The Department of Defense (DoD), the largest and oldest agency of the U.S. government, has a long
history of supporting health and medical activities around the world. While DoD itself does not typically
define these efforts as part of “global health,” they do indeed have an impact on the health of
populations throughout the world, including those in low- and middle-income countries. DoD possesses
and utilizes unique and substantial assets for such activities, such as a tremendous geographic reach,
long-standing and influential partnerships with foreign governments and militaries, an ability to rapidly
mobilize significant resources, and expertise in scientific and technical areas including research and
development. In addition, the recent trend in DoD policy of adopting a more balanced approach to its
use of military medical assets (so they perform their more traditional support functions of ensuring the
health of the warfighter while contributing to its efforts to prevent conflict and promote stability) has
made global health-related activities more prominent now than in the past. As a result, DoD has been
increasingly seen – both by some within the department as well as those working outside of it – as part
of the U.S. government’s larger global health enterprise. This view has been bolstered by the emphasis
placed on global health as a tool of soft power and important component of U.S. national security during
the post-9/11 era, which has been marked by U.S. government recognition of HIV/AIDS as a national
security threat, growing concerns about emerging and pandemic disease threats, and U.S. engagement
in nation-building activities in Iraq and Afghanistan.

Even so, DoD is not a development agency, and improving global health is not one of its core objectives;
rather, its primary mission has always been, and continues to be, providing the military forces necessary
to promote and protect the security of the United States. This has led to some ambiguity and tension
regarding the role of DoD in this area, with many in the global health community having reservations
about DoD’s efforts but lacking a full understanding of its work, and DoD at times failing to give due
consideration to the methods and principles that define successful global health programs even as it has
increased its attention to such activities. Adding to misunderstandings and difficulties are differences in
approach, organizational culture, and vocabulary between DoD and others working on global health.

To help provide new information on DoD’s work in this area and contribute to the discussion about its
role in global health, this report presents the first comprehensive description and analysis of DoD’s
organizational structure, activities, strategy, policy, and budget for its activities related to global health.
Overall, the report finds:

 DoD’s evolving views on and engagement with global health-related work should be considered
within a broader national security context. Over the past decade, DoD has increasingly stressed
a balance between maintaining traditional military-to-military warfighting capabilities and
developing capabilities that support the prevention, mitigation, and resolution of conflicts, as
evidenced by recent policy guidance elevating “stability operations” to the same level of
importance as combat operations. In the future, further changes in approach to its health
activities may result from ongoing shifts in national security and defense budgets and priorities,
such as a move away from large-scale “nation-building” activities and a move toward paying
greater attention to Asia.
 DoD’s current global health activities can be categorized into three main, interrelated “focus
areas”: force health protection and readiness (medical research and development, health
surveillance, and training and education in global health), medical stability operations and
partnership engagement (technical assistance and activities designed to build trust, prevent

THE U.S. DEPARTMENT OF DEFENSE AND GLOBAL HEALTH 1

 conflict and/or increase the capacity of partner governments), and threat reduction (activities to
detect, contain, and prevent impacts of intentional or natural biological events).
 Oversight and implementation responsibilities for DoD’s global health-related activities are
spread across a large number of offices across the department, a reflection of the department’s
size, decentralized structure, and organizational culture.
 There is no overarching policy or strategic document that guides the department’s global health-
related efforts, but recent changes in DoD policy and guidance (such as a recent policy guidance
that for the first time elevates the military health system’s role across the phases of conflict and
in both combat and non-combat environments) acknowledge a growing role for global health-
related activities. This report identifies 67 policy and guidance documents which inform and
guide DoD offices with global health-related responsibilities.
 While there is no single DoD “global health budget” line item, this report estimates that the DoD
budget for such activities was more than half a billion dollars in FY 2012 (at least $579.7 million),
drawn from multiple accounts and funding streams across DoD. For comparison, this estimated
funding “floor” is higher than the global health budgets for either the Centers for Disease
Control and Prevention or the National Institutes of Health in FY 2012.
With the removal of U.S. combat troops from Iraq, the planned drawdown in U.S. forces in Afghanistan,
looming cuts to the defense budget, and a time of general fiscal constraint, a new U.S. defense strategy
has been released that shifts the department away from sustained nation-building efforts while placing
a greater emphasis on Asia. Consequently, the policy environment within which decisions about DoD
health activities will be taken is changing significantly. Although the full extent of these changes is
difficult to anticipate, several policy issues that will be important to consider looking ahead include:

 Further consideration and analysis of DoD’s work related to global health may help DoD to
develop a clearer vision for how its global health-related programs relate to one another, how
these activities can best serve its broader organizational objectives, and whether DoD should
place more or less of an emphasis on them going forward, given the benefits and pitfalls. It also
might inform debates, such as whether DoD’s current approach can help improve health in
developing countries, and further discussion about the role DoD should play in U.S. global health
engagement more broadly.
 Given the vast budget and influence of DoD, improved coordination with civilian U.S.
government partners in global health may promote more effective use of resources and ensure
U.S. government efforts in national security and in global health are not working at cross-
purposes or duplicative.
 While the department has raised the policy importance of global health-related efforts, a
corresponding shift in funding and organizational support is not evident. Greater budgetary and
institutional support could help these new priorities to be more broadly and successfully
adopted by increasing their integration into routine planning and operations, but increasing
budget pressure may complicate such efforts.
 Greater attention to, standardization of, and support for tracking and measuring the
effectiveness of DoD’s global health-related activities could assist the department in defining
benchmarks for success and in determining the contributions such activities make to its broader
strategic goals.

2 THE U.S. DEPARTMENT OF DEFENSE AND GLOBAL HEALTH

  DoD and external groups working on the ground might explore ways to improve meaningful and
regular attempts at communication, given concerns among some that DoD’s national security
objectives at times become prioritized over the objectives of the global health and development
community, which may hinder progress toward improving health. Such communication might
better support shared objectives and clarify differences and roles.
 Finally, DoD faces a more general communication and public diplomacy challenge due to a lack
of external understanding of DoD’s work in this area, potentially undermining support from the
public, Congress, and other key stakeholders. Increased communication efforts and more
transparency about its work in this area may clarify the contribution of, and expectations for,
these DoD activities.
The Department of Defense is in the midst of a period of significant transition, and over the next several
years, changes in the national defense context and pressures on the department’s budget may
necessitate tough choices about how to prioritize and most effectively utilize the military’s global
health-related assets. Against this backdrop, it will be important to consider whether the department’s
engagement in, approach to, and objectives for its global-health activities should be reexamined or
clarified — including the extent to which global health-related activities should be part of its work going
forward. Additionally, further efforts to understand how DoD fits into the larger landscape of U.S. and
international engagement on global health will be important, particularly since any scaling back in DoD’s
engagement may create a gap that other organizations might need to fill.

THE U.S. DEPARTMENT OF DEFENSE AND GLOBAL HEALTH 3

 INTRODUCTION
The Department of Defense (DoD) is the oldest and largest U.S. executive branch department. It is
currently the nation’s largest employer and oversees activities in virtually every country in the world.
Since its creation, the core mission of DoD has been to “provide the military forces needed to deter war
and protect the security of the United States.”1 Over time, the way the department approaches and
carries out its mission has changed along with shifts in national security circumstances and priorities. In
recent decades an emphasis on traditional warfighting capabilities and military-to-military combat
operations has given way to an approach that emphasizes a balance between warfighting and the
prevention, mitigation, and resolution of conflict. While such non-conventional roles have long been a
part of DoD’s approach, in recent years they have received noticeably greater attention and policy
support from the U.S. national security and defense establishment. As a consequence the department
now finds itself squarely within the nexus of a more multifaceted, “whole-of-government” approach to
national security that by design embraces the tools of diplomacy, development and defense
together.2,3,4

As part of the shift toward a more balanced approach and in response to a growing sense among U.S.
policymakers that global health is important for U.S. national security, DoD has increasingly emphasized
and engaged in global health activities, including medical research and development, technical
assistance and capacity building, health infrastructure support, and health service delivery. Yet, because
DoD is not a development agency and improving global health is not one of its core objectives, it has not
always been clear to those inside and outside the department how global health fits into its mission. In
fact, the department itself typically does not define its activities in this area as “global health.” Many in
the global health community have little knowledge of DoD’s work in global health and struggle to
understand what the department does in this area and how it intersects with the efforts of other U.S.
government agencies and global health actors. Exacerbating the misunderstandings have been
differences in approach, organizational culture, and vocabulary between DoD and the global health
community at large that have at times made communication and mutual understanding more difficult.

This report helps address these information gaps by providing the first comprehensive assessment of
DoD’s role in global health, looking across the entire department. It summarizes the history and current
policy context of DoD’s engagement with global health, identifies the components and elements within
DoD involved in global health-related activities, and describes the main types of activities that comprise
its work in this area. The report also examines how the department coordinates its activities with other
actors, identifies the policy and guidance documents that apply to its global health-related work, and
summarizes what is known about its budget for these activities. Finally, the report discusses key issues
to consider as policymakers – both inside and outside the department – gauge what steps should be
taken to improve the department’s efforts related to global health.

METHODS
Data used in this study were collected through a comprehensive desk review of official documents and
the literature, combined with semi-structured interviews with key stakeholders at DoD and other
organizations. Interviews took place through a two-stage process: an initial set of interviewees was
selected using purposeful sampling designed to ensure representation from all major components of the
department as well as perspectives from external experts, incorporating viewpoints that span policy,
planning and implementation of DoD’s global health-related activities; additional interviewees were
identified through the initial stakeholders. Overall, 32 stakeholders were interviewed, including 26 DoD

4 THE U.S. DEPARTMENT OF DEFENSE AND GLOBAL HEALTH

 employees (military and civilian) and 6 individuals outside the department. All data were systematically
reviewed and analyzed to identify the key offices, functions, and activities of DoD’s global health
engagement discussed in this report. DoD itself does not define what constitutes a “global health”
activity; therefore, for the purposes of this report, we consider the department’s “global health-related”
activities and policies to be those with actual or potential impacts on the health of populations in low-
and middle-income countries. In addition to the main findings presented in this report, an
accompanying Technical Volume (with additional detail on the components and elements related to
global health as well as guidance and policy documents) is also available.

HISTORY AND CONTEXT

The Department of Defense is the oldest and largest U.S. executive branch department. It traces its
roots back to the American Revolution with the formation of the military services of the Army, Navy and
Marine Corps in 1775 and the creation of the War Department – DoD’s predecessor – in 1789. The
military services remained independent until after World War II, but by 1949 Congress had unified the
services (including a newly formed Department of the Air Force) within a single Department of Defense
overseen by a civilian Secretary of Defense.5 According to the department, it is the country’s largest
employer, with approximately 1.4 million active duty military service members, 700,000 civilian
employees, and over 1 million individuals serving in the National Guard and Reserve forces. The
department oversees activities in virtually every country in the world, and at any given time, more than
450,000 DoD employees are stationed outside the U.S.6 For FY 2012, the base DoD budget was $531
billion, comprising approximately 20% of the total U.S. federal budget.

Since its creation, the overarching mission of the Department of Defense has been to “provide the
military forces needed to deter war and protect the security of the United States.”7 While its
fundamental mission has remained the same, the strategies, available resources, and activities the
department implements in pursuit of its mission have changed significantly over time, shaped strongly
by changing perceptions of the most critical threats to U.S. national security. For example, prior to and
during World War II, the emphasis of the department was on developing and deploying conventional
warfare capabilities and working with allies in countering the spread of fascism. In the Cold War period
that followed, the department prioritized containment of the Soviet Union, limiting the influence of
communism (a prime motivator for engagement in Korea and Vietnam), and nuclear deterrence.

More recently, the events of September 11th, 2001, and their aftermath have given way to yet another
period, fundamentally re-shaping the nation’s approach to national security, including the way in which
DoD carries out its mission. As the 2002 National Security Strategy stated: “Defending our Nation against
its enemies is the first and fundamental commitment of the Federal Government. Today, that task has
changed dramatically.”8 In the post-9/11 era, non-state actors in weak and failing states have been
emphasized as threats to U.S. national security, because “poverty, weak institutions, and corruption can
make weak states vulnerable to terrorist networks.”9 In the years after the 2001 attacks, the U.S.
became engaged in long-term, unconventional wars in Iraq and Afghanistan, conflicts that DoD
describes as “unlike those that came before,”10 and over this time period, DoD placed greater emphasis
on policies and activities to support counterterrorism, counterinsurgency, homeland defense, and
fostering stability in countries and regions around the world. By 2004, it was recognized that such non-
conventional operations had already become, and would continue to be, a significant component of
DoD’s work that required more departmental resources and attention.11

THE U.S. DEPARTMENT OF DEFENSE AND GLOBAL HEALTH 5

 As a reflection of this change in perspective, in 2005, the department issued a new policy directive
declaring “stability operations” (defined by DoD as “military activities undertaken to maintain or
reestablish a safe and secure environment in areas outside the U.S.”) as a “core military mission” that
“shall be given priority comparable to combat operations and be explicitly addressed and integrated
across all DoD activities.”12 This was a notable development, marking the first time the department
prioritized activities previously defined as nation-building, such as infrastructure reconstruction and
humanitarian relief, on par with traditional combat operations. On the heels of this change, the U.S.
Army revised its Field Manual (FM) 3-24 on counterinsurgency in 2006, highlighting the importance of
preparing for “full spectrum operations” that explicitly incorporate conflict prevention, reconstruction,
and stability operations alongside combat operations — emphases echoed in the Army’s 2008 updated
doctrinal guidance of its Operations manual (FM 3-0) and Stability Operations manual (FM-3-07).13,14,15

While the department remains heavily focused on combating terrorism (the most recent National
Defense Strategy, from 2008, portrays DoD’s role as “defined by a global struggle against a violent
extremist ideology”16), current domestic political and economic pressures, combined with changing
views on the national security environment (influenced by the Arab Spring protests, the U.S. military
withdrawal from Iraq and planned reductions in Afghanistan, and growing concerns about China and
Iran) have led the White House, Congress and the department to again reevaluate DoD’s strategy,
policy, and budgets. In January 2012, the White House and DoD issued a new high-level review of U.S.
defense strategy, one which noted an “increasingly complex set of challenges and opportunities” in the
global security environment “to which all elements of U.S. national power must be applied” while also
recognizing that the “balance between available resources and our security needs has never been more
delicate.”17 These new realities mean the department now faces, for the first time in over a decade, cuts
to its budget and personnel at the same time that it attempts to reposition itself to address the
country’s preeminent national security concerns.18

It is within this broader historical context that DoD’s changing role related to global health must be
considered.

EVOLUTION OF DOD’S GLOBAL HEALTH-RELATED ACTIVITIES

While attention to DoD’s role in global health has grown in recent years, the department has a long
history of involvement in health and medical activities at home and abroad (see Figure 1 and Appendix
A). DoD incorporated health projects as part of its overseas military activities at least as far back as a
Philippines campaign in the late 19th century, as commanders saw strategic value in implementing
health services in local communities in order to foster support for U.S. forces.19 Through investments in
research and development made to protect U.S. personnel from infectious diseases, the department
contributed to a number of key medical and public health milestones in the early 1900s, such as
identifying the mosquito as the vector of yellow fever and demonstrating the potential health benefits
of large-scale malaria and yellow fever prevention campaigns.

Such efforts continued throughout the first half of the 20th century and into the post-World War II
period. The U.S. military established its first overseas medical research laboratory in 1945 in Guam (later
transitioned to Indonesia), followed shortly thereafter by others in Egypt and Thailand.20 DoD-supported
research led to the first vaccines for influenza and Hepatitis A and to new drugs for treating malaria. In
the late 1960s and early 1970s the military campaign in Vietnam featured a prominent role for health
engagement, including medical civic action programs (MEDCAPs), short-term health care delivery
training activities undertaken by military medical personnel overseas.21 At the conclusion of the Cold
War, DoD also began working with countries on containment of biological threats and dedicated more

6 THE U.S. DEPARTMENT OF DEFENSE AND GLOBAL HEALTH

 resources and attention to disaster assistance and humanitarian aid. More recently, health projects have
been a prominent component of the U.S. military campaigns in Iraq and Afghanistan.22,23,24

Despite this long history, attention to DoD’s role in global health has increased in recent years, and DoD
itself has linked global health-related activities more often and more explicitly to achievement of its
objectives than at any time in the past. Part of the reason for this is that global health overall has been
increasingly linked to U.S. national security. There has been a growing perception among policymakers
that poor health conditions and lack of
health system capacity in other FIGURE 1. SELECTED TIMELINE25OF DOD GLOBAL HEALTH-RELATED
ACTIVITIES AND MILESTONES
countries can contribute to the
1898: Philippines military campaign adopts civil-military approach,
development of or be a symptom of including health projects
weak and failing states that threaten
1900: Army researchers show yellow fever is transmitted by
U.S. interests.26,27,28 An important mosquitoes

Prior to 1946
turning point in linking health to
1903: Army institutes first successful large-scale malaria prevention
national security came in the 1990s program in support of Panama Canal construction
and early 2000s, when the U.N.
1909: Army develops first typhoid vaccine
Security Council and the U.S.
1940s: Military scientists develop first inactivated influenza vaccines
intelligence community declared HIV a
national security threat and warned of 1945: First Navy overseas laboratory established (in Guam, later
moved to Indonesia)
potential societal and political
instability resulting from the 1959: First Army overseas laboratory established (in Thailand)
expanding HIV/AIDS epidemics in sub- 1960s-1970s: Vietnam war operations adopt civil-military approach,
Saharan African countries. 29,30,31,32
The including introduction of medical civic action programs
(MEDCAPs)
concept of emerging infectious
1946-2000

diseases as a security threat also 1985: Military researchers develop prototype Hepatitis A vaccine
began to take hold in the 1990s with 1989: New malaria drug Mefloquine, co-developed by military
researchers, licensed in the U.S.
the 1992 release of an Institute of
Medicine report warning about the 1991: Cooperative Threat Reduction (CTR) program initiated
issue, followed by the 1997 release of 1994: Overseas Humanitarian, Disaster, and Civic Aid (OHDACA)
a related Presidential Decision funding authority instituted
Directive by the Clinton 2002: Military completes genetic sequencing of P. falciparum
Administration, along with other malaria parasite
33,34
documents. Adding to the mix of 2003: Army co-initiates largest ever Phase III HIV/AIDS vaccine trial
concerns and highlighting the links in Thailand
2001-Present

between terrorism, biological threats, 2005: DoD Instruction 3000.05 raises “stability operations” to same
and national security were the first level of priority as combat operations across the military
deadly bioterrorism attacks ever made 2007: International Health Division established within the Pentagon
on U.S. soil, when mailed anthrax 2009: Navy lab first in the world to identify human case of emerging
killed 5 people and infected 17 others H1N1 pandemic influenza
35
in 2001. The international spread of 2010: DoD Instruction 6000.16 elevates the military health service
SARS in 2002-2003, H5N1 avian support of “stability operations” to same priority as combat
operations support role
influenza (“bird flu”) starting in 2003,
and the H1N1 influenza pandemic in 2009 helped solidify infectious diseases as a national security issue
in policymakers’ minds, as these events illustrated how globalization and poor health conditions abroad
could threaten the health and economic security of the U.S. and its allies.36,37,38

These trends have had an impact on how DoD conceives of and implements its global health-related
activities, including its medical research and development, technical assistance and partnership building

THE U.S. DEPARTMENT OF DEFENSE AND GLOBAL HEALTH 7

 on health with foreign nations, biosecurity efforts, and use of health in “winning hearts and minds” in
both peace and war. Language referencing the strategic importance of global health is now prominently
featured in the highest defense policy guidance, from national-level strategies issued by the White
House to internal DoD’s strategic guidance documents (see Box 1). DoD ’s most recent National Military
Strategy, for example, highlights the importance of the department’s “theater security cooperation”
activities, referring to the country partnership and capacity building exercises that often include global
health-related work. In its most recent Quadrennial Defense Review, the legislatively mandated review
of DoD strategies and priorities that is presented to Congress every four years (last released in 2010),
the department references the contributions that its public health work and related efforts make to
addressing the root causes of terrorism and also states an intention to increase support for global
infectious disease surveillance and response to help address biological threats worldwide.

BOX 1. EXCERPTS FROM NATIONAL SECURITY AND DOD STRATEGY DOCUMENTS RELEVANT TO GLOBAL
HEALTH

National Security Strategy (White House, 2010)

 “The United States has a moral and strategic interest in promoting global health…We see it as a
fundamental to our own interests to support a just peace around the world…and we are promoting
the dignity of all men and women through our support for global health, food security, and
cooperative responses to humanitarian crises.”

National Strategy for Countering Biological Threats (White House, 2009)

 “Many nations struggle daily to address the impact of naturally-occurring infectious disease within
their borders…We will seek to advance access to and effective use of technologies to mitigate the
impact from outbreaks of infectious disease, regardless of their cause.”

National Military Strategy (DoD, 2011)

 “[The military] shall actively partner with other US government agencies to pursue theater security
cooperation…humanitarian assistance and disaster relief activities employ the Joint Force to address
partner needs and sometimes provide opportunities to build confidence and trust between erstwhile
adversaries.”

Quadrennial Defense Review (DoD, 2010)

 “Circumstances are ripe for violent ideologies to spread among a population when governments
struggle to provide basic services, justice and security, or the conditions for economic opportunity.
Civil affairs forces address these threats by serving as the vanguard of DoD’s support to U.S.
government efforts to assist partner governments in the fields of rule of law, economic stability,
governance, public health and welfare, infrastructure, and public education and information.”
 “Detecting, diagnosing, and determining the origin of a pathogen will enable U.S. authorities to better
respond to future disease outbreaks and identify whether they are natural or man-made. Accordingly,
we are expanding the biological threat reduction program…in order to create a global network for
surveillance and response.”

The overall trend in departmental policy has been toward adoption of a more balanced approach with
its military medical assets, so that they not only perform traditional support functions for ensuring the
health of the warfighter but also contribute more concretely to the department’s efforts to prevent
conflict and assist in transitioning unstable, conflict-prone environments to more secure “post-conflict”
and reconstruction environments.39 This has placed global health-related activities in a more prominent
role in military planning and so-called “stability operations” now than in the past. Most recently, this
policy change was codified in a 2010 DoD Instruction that declared Military Health System (MHS) assets’

8 THE U.S. DEPARTMENT OF DEFENSE AND GLOBAL HEALTH

 support for stability operations overseas “be given priority comparable to combat operations and be
explicitly addressed and integrated across all MHS activities.”40 This language represents a marked
change from past doctrine and has challenged the department to consider even wider integration of
global health-related activities within the context of its overseas operations.

Today, multiple organizational components and elements across DoD are involved in global health-
related work. Together their efforts fall into three main categories, or “focus areas,” of global health-
related activity: force health protection and readiness, medical stability operations and partnership
engagement, and threat reduction. These focus areas are discussed further below, following the
description of the organization and structure of DoD presented in the next section.

ORGANIZATIONAL STRUCTURE AND APPROACH

To effectively assess DoD’s engagement in global health, one must first understand the department’s
overall organizational structure and approach. This section provides an overview of DoD’s structure and
its leadership and planning practices. It identifies the components, offices, agencies, and other elements
within the department that have primary responsibility for its global health-related activities as
determined through analysis of existing literature and key informant interviews.

Importantly, there is no single DoD entity designated with primary authority over all of DoD’s global
health-related activities; rather, these activities are carried out by different offices and agencies across
the department, some of which are specifically charged with such efforts and others that carry them out
as part of a broader set of responsibilities. Even as DoD plans and carries out many “joint” activities that
share resources and personnel across the military departments and other components of the
department, organizational oversight and participation in DoD’s global health-related activities remain
diffuse and multifaceted. Figure 2 shows in one chart many of the key components and constituent
elements within DoD that are engaged in one way or another in global health-related work, offering a
sense of the scope and complexity of DoD ’s organizational involvement in this area. After a discussion
below of how DoD approaches leadership and planning, this section describes the principal components
and elements of DoD that are involved in global health-related activities (see Technical Volume for more
details).

THE U.S. DEPARTMENT OF DEFENSE AND GLOBAL HEALTH 9

 10
FIGURE 2. DOD’S ORGANIZATIONAL INVOLVEMENT IN GLOBAL HEALTH

Notes: USD - Undersecretary of Defense, ASD - Assistant Secretary of Defense, AFRICOM - Africa Command, CENTCOM - Central Command, PACOM - Pacific Command, SOUTHCOM - Southern Command, SOCOM - Special Operations
Command, TRANSCOM - Transportation Command, Dept. - Department. *Under the ASD (Health Affairs) is Force Health Protection and Readiness’ International Health Division, Global Civil-Military Medicine Division, and Medical
Countermeasures Division. Under the ASD (Special Operations/Low Intensity Conflict) is Partnership Strategy and Stability Operations’ Humanitarian Assistance, Disaster Relief and Global Health Directorate.

THE U.S. DEPARTMENT OF DEFENSE AND GLOBAL HEALTH

 LEADERSHIP AND PLANNING
As specified in the U.S. Constitution, the President serves as the Commander-in-Chief of the U.S.
military, while Congress holds the authority to make declarations of war and controls defense funding.
Additionally, under the War Powers Resolution of 1973, Congress reserves the power to authorize the
use of armed forces in military action abroad.41 Under the direction of the President, the Secretary of
Defense exercises authority, direction, and control over the Department of Defense. The Secretary, a
civilian Cabinet-level official appointed by the President and confirmed by the U.S. Senate, is the
principal defense policy adviser to the President. The Chairman of the Joint Chiefs of Staff, the country’s
senior ranking active duty military member, serves as the principal military adviser to the President and
Secretary of Defense.

Although constituted as one department that ultimately requires all components to report to the
Secretary of Defense, DoD is perhaps better understood as an interrelated set of constituent
organizations, each overseeing a diverse set of activities. Each major organizational component with
DoD functions in a semi-independent manner, and each has its own history, purpose, objectives,
approach, culture, and personnel. While these DoD components share the same overarching set of
strategic and policy objectives as described above, since no single office or service is designated with
primary authority over all DoD global health-related efforts each of these components may take their
own approach and pursue their own set of activities. These activities may or may not be coordinated
with other departmental or external partners’ activities.

An iterative process of planning, prioritization, and budgeting is undertaken by the department to

identify, develop, and refine its objectives, and to prioritize activities and available resources in order to
be able to best meet these objectives.42 The role and scope that global health-related activities occupy
within this process depends on many factors, from the available budget to the priorities of decision-
makers, and the perceived links between such activities and departmental objectives. Where global
health-related activities are planned for and carried out, they must be justified and supported internally
through their link to national security objectives.

Thus, improvement of population health overseas in and of itself is not the central objective of DoD’s
efforts in this area. Better population health may be desired and seen as a welcome secondary outcome,
but DoD (as has been stated by its leaders) is not positioned nor intended to serve as a development
agency.43 At times this has meant the department’s on-the-ground health activities overseas have had a
focus on shorter-term, quick impact health projects aimed to contribute to the more immediate
objectives of DoD rather than a longer-term, more sustainable approach to health programs that is more
of a hallmark of traditional global health efforts, and decisions on research and development are made
with the protection of the U.S. warfighter in mind, not necessarily persons living in developing countries.

KEY COMPONENTS
For the purposes of this report, component is used to refer to the broadest organizational level within
the department, while element, office, unit and agency are used to describe constituent sub-
components.* U.S. Code identifies six components of DoD, and all are involved to some extent in
overseeing and implementing global health-related activities. However, most of these activities are
carried out under the direction of four principal components (see Figure 3):

*
While this report uses component as explained here for consistency, the term “component” is sometimes used by the military
to refer to a subordinate command, such as at a COCOM (e.g., the Navy “component” of AFRICOM).

THE U.S. DEPARTMENT OF DEFENSE AND GLOBAL HEALTH 11

 1. the Office of the Secretary of Defense (OSD),
2. the Organization of the Joint Chiefs of Staff (Joint Chiefs),
3. the Combatant Commands (COCOMs), and
4. the Military Departments (the Departments of the Air Force, Army, and Navy; the Marine Corps
is integrated into the Department of the Navy).44

The final two components of DoD, Field

FIGURE 3. DOD ORGANIZATION OVERVIEW
Agencies and Field Activities, serve
mostly a support function to the other
components, and when referenced in
this report they are included under the
primary component to which they report
(e.g., the Defense Security Cooperation
Agency, a DoD field agency, reports to a
division of the Office of the Secretary of
Defense).

Each of these four primary components has a unique and often complex organizational structure of
constituent elements (offices, units, and programs) that are assigned a range of roles and
responsibilities for planning, implementing, and collaborating on global health activities.

1. OFFICE OF THE SECRETARY OF DEFENSE

The Office of the Secretary of Defense (OSD) is responsible for policy development, planning, fiscal and
FIGURE 4. OFFICE OF THE SECRETARY OF DEFENSE: ELEMENTS RELATED TO GLOBAL HEALTH

Notes: USD - Undersecretary of Defense. ASD - Assistant Secretary of Defense. *Under the ASD (Health Affairs) is Force Health Protection and Readiness’ International
Health Division, Global Civil-Military Medicine Division, and Medical Countermeasures Division. Under the ASD (Special Operations/Low Intensity Conflict) is Partnership
Strategy and Stability Operations’ Humanitarian Assistance, Disaster Relief and Global Health Directorate.

12 THE U.S. DEPARTMENT OF DEFENSE AND GLOBAL HEALTH

 resource management, program evaluation, and overseeing and advising the other components and
activities of DoD. Under the guidance of and reporting to the Secretary of Defense are a number of
Under Secretaries of Defense (USDs), each of whom has an office and staff and is responsible for a
particular set of issues and activities. In turn, elements of the USD offices are overseen by Assistant
Secretaries of Defense (ASDs), who also may have Deputy Assistant Secretaries of Defense (DASDs)
under them.

Figure 4 provides an organizational overview of the primary OSD elements whose responsibilities
include global health-related work. For example, the office of the USD for Personnel and Readiness is
responsible for policy and programs related to readiness and protection of DoD personnel in general and
oversees the activities of the ASD for Health Affairs (ASD-HA), who exercises primary policy oversight
responsibilities for the military health system. Under ASD-HA, key global-health related offices and
agencies include the DASD for Force Health Protection and Readiness (responsible for a variety of health
surveillance, international health, humanitarian and health missions including oversight of the
International Health Division, an office which develops policies and implements programs for the U.S.
military health system’s support of DoD stability operations) and the Center for Disaster and
Humanitarian Assistance Medicine (CDHAM), located within the Uniformed Services University of the
Health Sciences (USUHS). Under the oversight of the USD for Policy, the ASD for Special Operations/Low
Intensity Conflict (ASD-SO/LIC) serves as the principal civilian advisor to the Secretary of Defense on
counterterrorism, civil affairs, psychological operations, and counterproliferation of weapons of mass
destruction (WMDs). Within ASD-SO/LIC is the office of the DASD for Partnership Strategy and Stability
Operations, which oversees development of DoD capabilities in stability, security, transition, and
reconstruction operations and provides policy oversight of the humanitarian and civic assistance funding
authorities managed by the Defense Security
FIGURE 5. ORGANIZATION OF THE JOINT CHIEFS OF Cooperation Agency (DSCA). DSCA, a DoD field
STAFF: ELEMENTS RELATED TO GLOBAL HEALTH agency, reports to the ASD for International
Security Affairs (under the USD for Policy) and
oversees partnership engagement accounts and
activities, including several humanitarian and civic
assistance funding vehicles used by DoD. Finally,
the Defense Threat Reduction Agency (DTRA) is a
DoD field agency that funds and implements
international biological threat reduction programs
under the direction of the office of the ASD for
Nuclear, Chemical, and Biological Defense
Programs (itself under the USD for Acquisitions,
Technology, and Logistics).

2. ORGANIZATION OF THE JOINT CHIEFS OF STAFF

The Organization of the Joint Chiefs of Staff (Joint
Chiefs) represents and coordinates the Military
Departments and supports the activities of the
Combatant Commands (COCOMs, discussed
below). The Joint Chiefs consists of the Joint
Chiefs of Staff (which is comprised of the
Chairman and Vice Chairman of the Joint Chiefs
and the leadership of each Military Department—
the Army, Navy, Air Force, and Marine Corps) and

THE U.S. DEPARTMENT OF DEFENSE AND GLOBAL HEALTH 13

 the Joint Staff. As outlined in the 1986 Goldwater-Nichols Act, the Chairman of the Joint Chiefs is
considered the nation’s highest ranking military officer and serves as the principal military adviser to the
President and his Cabinet, including the Secretary of Defense.

Key elements with global health-related responsibilities within the Joint Chiefs include the office of the
Joint Staff Surgeon and the Health Services Support (HSS) Division (see Figure 5). The Joint Staff Surgeon
serves as the chief medical advisor to the Chairman of the Joint Chiefs, the Joint Staff, and Combatant
Command Surgeons for issues related to operational medicine and force health protection. The HSS
Division, housed within the Logistics Directorate (J-4), is responsible for coordinating international
health assistance policies and operations across the military departments and COCOMs.

3. COMBATANT COMMANDS
DoD assigns primary responsibility for planning and conducting military operations around the world to
nine Unified Combatant Commands (COCOMs). Each COCOM, led by a Combatant Commander from one
of the Military Departments, functions with a high degree of autonomy and authority over all DoD
activities that occur within its designated area of responsibility (AOR). There are six COCOMs with
geographic AORs: Africa Command (AFRICOM), Central Command (CENTCOM), European Command
(EUCOM), Northern Command
FIGURE 6. GEOGRAPHIC COCOMS’ AREAS OF RESPONSIBILITY
(NORTHCOM), Pacific Command
(PACOM), and Southern Command
(SOUTHCOM) (see Figure 6).45 The
other three COCOMs have functional
AORs: Special Operations Command
(SOCOM) oversees special operations
forces and operations worldwide;
Strategic Command (STRATCOM)
oversees nuclear, space, and cyber
capabilities (among other
responsibilities); and Transportation
Command (TRANSCOM) coordinates
transportation assets and oversees
movement of military hardware and
personnel.

COCOMs are staffed by active duty

military personnel drawn from all Military Departments, alongside DoD civilian personnel. The COCOM
staff plans and conducts operations in support of and under the direction of the Combatant
Commander. Each Military Department maintains representation within the COCOMs through their
respective elements (regional offices) – for example, the U.S. Army’s presence in AFRICOM is called U.S.
Army Africa, while the U.S. Navy presence in SOUTHCOM is called U.S. Naval Forces Southern Command
(USNAVSO).

Every COCOM designates its own priorities, plans, budget, and set of global health-related activities
(with input and guidance provided by OSD, the Military Departments, and Joint Staff). Geographic
COCOMs whose AORs include developing countries with significant disease burdens and/or a history of
medical engagement with the U.S. military may dedicate more staff and time to global health-related
activities compared to others. For example, AFRICOM, PACOM, and SOUTHCOM engage in many
exercises and operations every year targeted at health, reflecting the relative priority of such activities

14 THE U.S. DEPARTMENT OF DEFENSE AND GLOBAL HEALTH

 to these COCOMs and their partner countries. In fact, AFRICOM cites prevention and containment of
infectious diseases, such as HIV/AIDS and malaria, as one of its key strategic objectives for engagement
on the African continent.46 Similarly, functional COCOMs may also have a role in global health-related
work. For example, TRANSCOM is responsible for developing policy and standardizing procedures for
global patient and medical asset movements, SOCOM may develop and help implement health activities
in support of counterterrorism efforts or other special operations missions, and STRATCOM is involved
in the department’s biosecurity efforts and biological threat reduction programs in other countries.

While the organizational layout of each COCOM may differ, most have distinct offices with
responsibilities over global health-related work. For example, each COCOM has an Office of the
Command Surgeon responsible for developing and providing medical and force health protection
guidance to the Combatant Commander and senior staff. Geographic COCOMs have offices covering
Operations, Logistics, and Force Protection, responsible for ensuring that operations have adequate
logistical and force health protection support. Since health support is considered a key logistics element
of field operations, military health assets such as medical field units are requested and deployed to
support COCOM missions, and the Operations, Logistics, and Force Protection office provides policy and
technical support to these deploying health assets. Other relevant COCOM offices are those responsible
for Strategies, FIGURE 7. AFRICA COMMAND: ELEMENTS RELATED TO GLOBAL HEALTH
Plans, Programs,
and Policy, and
Partnership
Engagement,
Cooperation,
and/or Security
Assistance, which
focus on planning
and facilitating
communications
and operations
between the
COCOM, the
service
components,
countries, and
other partners. As
an illustrative
COCOM example,
Figure 7 shows AFRICOM’s key elements related to global health; other COCOMs may have slightly
different organizational structures. See the Technical Volume for more information on COCOMs’
relevant elements and organization.

4. MILITARY DEPARTMENTS
As outlined in U.S. Code, there are three Military Departments: the Department of the Air Force, the
Department of the Army, and the Department of the Navy (the U.S. Marine Corps is integrated within
the Department of the Navy). A brief description of key elements within these departments is presented
here, with more detailed information in Boxes 2-4 and in the accompanying Technical Volume.

THE U.S. DEPARTMENT OF DEFENSE AND GLOBAL HEALTH 15

 Each Military Department has a different organizational structure and set of offices that oversee their
global health-related work, but there are some similarities. For example, each department has a
Surgeon General who is responsible for formulating policy and providing advice on force health
protection and other medical matters to department leaders.47 Staff from all the Military Departments
support health operations overseas through personnel assigned to the different COCOMs. Additionally,
while the programs and centers highlighted below are placed organizationally under the department
exercising official oversight, it is important to note that, in practice, much of the planning and execution
of these activities is performed jointly. In other words, DoD programs related to global health often
involve the combined resources and personnel of more than one of the Military Departments.

Department of the Army

The Department of the Army’s key elements related to global health (see Box 2) fall largely under the
purview of the Army Surgeon General, the department’s chief medical officer who oversees both the
Office of the Surgeon General and the U.S. Army Medical Command (Army MEDCOM). The Office of the
Surgeon General is primarily responsible for developing policy and budgets for medical activities, while
Army MEDCOM primarily executes activities.

BOX 2. DEPARTMENT OF THE ARMY: ELEMENTS RELATED TO GLOBAL HEALTH

Notes: --- line around a box indicates a joint activity across military departments with the Army as lead agent.

Many of the relevant Army offices are organizationally placed under the Army’s Office of the Surgeon General
or under the U.S. Army Medical Command (MEDCOM). Key elements related to global health under the Army’s
Office of the Surgeon General include:

16 THE U.S. DEPARTMENT OF DEFENSE AND GLOBAL HEALTH

 BOX 2. DEPARTMENT OF THE ARMY: ELEMENTS RELATED TO GLOBAL HEALTH
 Armed Forces Health Surveillance Center (AFHSC): AFHSC is the central epidemiological resource for
the U.S. military, responsible for collecting, providing, and analyzing epidemiologic information on the
health status of U.S. personnel as well as overseeing overseas surveillance and health research
programs. Incorporated within AFHSC is the Global Emerging Infections Surveillance and Response
System (GEIS) Operations Division, which supports the department’s integrated surveillance and
response efforts focused on emerging infectious diseases globally.
 Defense Medical Readiness Training Institute (DMRTI): DMRTI offers joint medical readiness training
courses as well as professional medical programs for military medical officers. Courses include trauma
care, burn care, disaster preparedness, humanitarian assistance, and emergency response to
chemical, biological, nuclear, and other events.
 U.S. Military Infectious Diseases Research Program (MIDRP): Overseen by the Surgeon General but
operated under the aegis of the U.S. Army Medical Research and Materiel Command (USAMRMC),
MIDRP directs funding for and provides oversight of a portfolio of infectious disease research projects
focused on developing products to protect U.S. forces from diseases such as malaria, dengue,
diarrhea, and leishmaniasis.
 U.S. Military HIV Research Program (MHRP): MHRP’s primary focus is developing an effective HIV
vaccine and, in some limited circumstances, providing HIV prevention, treatment, and care services as
part of the President’s Emergency Plan for AIDS Relief (PEPFAR) at several sites in Africa and Asia.
Although overseen by the Army Surgeon General, MHRP’s activities are primarily centered at the
Walter Reed Army Institute of Research (WRAIR, see below).
Key elements related to global health under Army MEDCOM include:

 U.S. Army Medical Research and Materiel Command (USAMRMC): Through USAMRMC, the Army’s
medical research is unified under a single major subordinate command of MEDCOM. As such, it is the
Army’s medical materiel developer, with responsibility for medical research, development, and
acquisition and medical logistics management.
 Walter Reed Army Institute of Research (WRAIR): As part of USAMRMC, WRAIR conducts biomedical
research that delivers products to prevent and treat health threats to U.S. Army personnel. WRAIR is
the leading military research unit for infectious disease product development and houses the Center
for Infectious Disease Research (this includes multiple research divisions such as the Division of
Retrovirology, which is home to MHRP’s efforts and undertakes HIV/AIDS research and vaccine
development; the Division of Malaria, which is home to the Military Malaria Research Program
(MMRP) and supports the development of malaria diagnostics, drug, and vaccine development efforts;
and the Bacterial Diseases Branch, which is home to the Multi-drug Resistant Organism Repository
and Surveillance Network (MRSN)). In addition, WRAIR is host to a number of joint military infectious
disease research initiatives, including the Joint Military Malaria Vaccine Initiative. WRAIR is also
responsible for oversight of the Army’s overseas infectious disease laboratories in Kenya (the U.S.
Army Medical Research Unit-Kenya, or USAMRU-K) and Thailand (Armed Forces Research Institute of
Medical Sciences, or AFRIMS).
 U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID): Also under USAMRMC, this
institute conducts basic and applied research on biological threats, with the aim of producing medical
prevention and treatment solutions to protect military service members.

Department of the Navy

The Department of the Navy incorporates both the U.S. Navy and the U.S. Marine Corps. The Navy’s key
global health-related elements fall largely under the purview of the Navy Surgeon General who oversees
the Office of the Navy Surgeon General as well as the Navy’s Bureau of Medicine and Surgery (BUMED),

THE U.S. DEPARTMENT OF DEFENSE AND GLOBAL HEALTH 17

 which is the headquarters command for medical issues where policies and direction for Navy Medicine
are developed and implementation overseen (see Box 3). Many of the relevant offices related to global
health are under BUMED. Additionally, the Navy maintains two large hospital ships (the USNS Mercy and
USNS Comfort) and a number of smaller vessels that are often utilized for overseas humanitarian
assistance, disaster relief, and “medical diplomacy” missions to developing countries.

Department of the Air Force

As with the other Military Departments, the Air Force has an Office of the Air Force Surgeon General

BOX 3. DEPARTMENT OF THE NAVY: ELEMENTS RELATED TO GLOBAL HEALTH

Notes: --- line around a box indicates a joint activity across military departments with the Navy as lead agent.

Key elements within the Department of the Navy include:

 The Naval Medical Research Center (NMRC), which performs medical research, development, testing,
evaluation and surveillance, and also oversees the three laboratories the Navy maintains overseas –
known as Naval Medical Research Units (NAMRUs). The Navy laboratories are located currently in
Peru, Egypt, and Hawaii (a temporary location for NARMU-2 following the closure of its Indonesia
location in 2009). NMRC also oversees DoD’s Defense HIV/AIDS Prevention Program (DHAPP), which
works with African militaries to develop and implement HIV prevention and treatment programs
among African military personnel.
 The Future Operations—Theater Engagement Office (also within BUMED) is involved in helping
coordinate the Navy’s involvement in humanitarian assistance and disaster relief missions with other
DoD components, other U.S. government agencies, and civil society.

18 THE U.S. DEPARTMENT OF DEFENSE AND GLOBAL HEALTH

 responsible for medical and force health BOX 4. DEPARTMENT OF THE AIR FORCE: ELEMENTS
protection matters. The Department of the RELATED TO GLOBAL HEALTH
Air Force also has an International Health
Specialists Program, instituted in 2000 to
develop a cadre of military medical
professionals with skills and knowledge in
global health. Unique among the Military
Departments, this program trains and places
Air Force personnel in global health-related
positions across DoD (see Box 4).

COORDINATION WITH USG AGENCIES

AND OTHER PARTNERS
A key question regarding DoD’s engagement
in global health-related activities is the extent
to which the department coordinates its
activities with other U.S. government (USG)
agencies, multilateral organizations, and non-
governmental actors. This section identifies
key partners for DoD on global health and
describes coordination efforts.

USG INTERAGENCY COORDINATION

DoD coordinates with many different U.S.
government agencies and departments
working in global health. Interagency partners
of particular importance have been the
Notes: --- line around a box indicates a joint activity across military departments
Department of State, the U.S. Agency for with the Air Force as lead agent.
International Development (USAID), and the
Department of Health and Human Services Key elements within the Department of the Air Force
(HHS) (see Figure 8). include:

Besides their connections to the headquarters  The International Health Specialists program
under the Air Force Surgeon General’s office is
offices of these U.S. agencies and
unique among the Military Departments,
departments, DoD personnel also work in the selecting and training military personnel for
field with their staff. Procedures and positions related to global health across DoD.
guidelines for such field-level interagency
coordination may be facilitated through  Falling under the U.S Air Force School of
Aerospace Medicine (USAFSAM), the Defense
formal agreements or partnerships between
Institute for Medical Operations (DIMO) helps
the organizations, but often the work
organize medical training missions and medical
overseas is done in a more informal and ad courses for military and civilian personnel, which
hoc way, depending on country circumstances often take place in partner countries.
and the direction of the U.S. Ambassador. The
Technical Volume contains further information about DoD’s interagency coordination, including more
details about points of contact with USAID.

Department of State: DoD has interacted with the Department of State in several ways. The first way is
through DoD’s representation on planning and working committees of the Global Health Initiative (GHI),

THE U.S. DEPARTMENT OF DEFENSE AND GLOBAL HEALTH 19

 though with the recent FIGURE 8. KEY USG PARTNERS OF DOD ELEMENTS RELATED TO
recommendation to close the GHI office GLOBAL HEALTH
at the Department of State, it is unclear
whether this method of coordination
will continue into the future. DoD
representatives to the GHI have
typically come from OSD’s International
Health Division, located within office of
the ASD for Health Affairs. Secondly,
DoD helps shape the execution and
coordination of the President’s
Emergency Plan for AIDS Relief
(PEPFAR, the U.S. government’s global
HIV/AIDS effort), particularly in relation
to activities undertaken in partnership
with foreign militaries, and is often
represented by staff of the Defense HIV/AIDS Prevention Program (DHAPP) in several PEPFAR working
groups convened by the Department of State’s Office of the Global AIDS Coordinator (OGAC). Third, the
Defense Security Cooperation Agency (DSCA) also works with the Department of State when
determining country allocations and humanitarian assistance projects funded through DSCA accounts, as
required by the Foreign Assistance Act of 1961. Additionally, the Defense Threat Reduction Agency
(DTRA) Cooperative Biological Engagement (CBE) program works in partnership with the Department of
State’s Office of Cooperative Threat Reduction’s Biosecurity Engagement Program in formulating and
implementing its biological threat reduction activities worldwide. Finally, the Department of State also
supports a number of its representatives at the various COCOM headquarters; according to a 2012
Government Accountability Office (GAO) report, more than 30 Department of State employees are
assigned to COCOMs.48

U.S. Agency for International Development (USAID): DoD interacts with and collaborates with USAID in
a number of ways. One important point of contact is USAID’s Office of Civilian-Military Cooperation
(CMC), which in the last few years has served as a point of coordination on joint USAID-DoD activities in
Afghanistan and Iraq. DoD also interacts often with USAID’s Office of Foreign Disaster Assistance (OFDA),
especially when preparing for and carrying out interagency overseas disaster response activities. OFDA is
the lead U.S. agency for overseas disaster response, but DoD is often involved, especially when there are
significant transportation needs or other military assets that need to be mobilized. To assist
communication and coordination between the two organizations, the Department of Defense assigns a
number of representatives to work at USAID, and USAID sends representatives to serve at various DoD
COCOM headquarters. According to GAO, in early 2012 there were a total of 12 USAID representatives
serving at five of the six geographic COCOMs (all but NORTHCOM).

Department of Health and Human Services (HHS): DoD’s key points of coordination with HHS include:
emerging disease surveillance and field epidemiology training program partnerships between the
Centers for Disease Control and Prevention’s (CDC) Center for Global Health/Global Disease Detection
unit and the staff of DoD at its overseas laboratories and within the Global Emerging Infections
Surveillance and Response System (GEIS) Operations Division; the development of Memoranda of
Understanding (MOUs) and coordinated infectious disease research projects between HHS’s National
Institutes of Health (NIH) and the Walter Reed Army Institute of Research (WRAIR) and other DoD
medical research centers, DoD’s overseas laboratories, and the Army-led Military Infectious Disease

20 THE U.S. DEPARTMENT OF DEFENSE AND GLOBAL HEALTH

 Research Program (MIDRP), among others; and interactions on policy issues between HHS’s Office of
Global Affairs and various DoD offices.

COORDINATION WITH OTHER ORGANIZATIONS

DoD also regularly interacts on global health-related activities with organizations outside the U.S.
government, such as multilateral organizations and non-governmental organizations (NGOs). Key
multilateral relationships include DoD’s participation in the North Atlantic Treaty Organization (NATO)
and its interactions with agencies of the United Nations (U.N.). NATO is a “security alliance” of 28
countries from North America and Europe who have agreed to a shared goal of safeguarding the
freedom and security of the countries in the alliance through political and military means. Some of the
activities that DoD works on with NATO are focused on global health. For example, in Afghanistan, NATO
allies formed the International Security Force Afghanistan (ISAF), which has a mission of conducting
coordinated operations that “reduce the capability and will of the insurgency, support the growth in
capacity and capability of the Afghan National Security Forces, and facilitate improvements in
governance and socio-economic development” in that country.49 As part of this effort, ISAF members
support public health programs in Afghanistan, in partnership with the Afghan government. DoD also
participates in NATO’s Committee of the Chiefs of Military Medical Services (COMEDS), which acts as
“the central point for the development and coordination of military medical matters and for providing
medical advice to the NATO Military Committee.”50 According to NATO, it has sought to develop best
practices and communication channels for alliance members related to humanitarian missions.51

DoD interacts with several health-focused U.N. agencies, including the World Health Organization
(WHO). The U.S. Navy, for example, has assigned medical liaisons to be stationed at WHO, responsible
for improving coordination on information-sharing on epidemic and pandemic planning and response,
among other activities. On international disaster response and humanitarian assistance issues, DoD
personnel have worked with the Office for the Coordination of Humanitarian Affairs (OCHA) and other
UN agencies when coordinating, planning, and implementing DoD overseas relief operations.

DoD also interacts and coordinates with many non-governmental organizations (NGOs) and civil society
groups through its health activities overseas, and has even developed and published a handbook with
guidelines for understanding and interacting with NGOs.52 At times, the department will work with
these organizations when planning and implementing humanitarian and disaster relief operations in the
field.53 For example, DoD has worked with a number of NGOs in Afghanistan and Iraq on health-focused
projects, and the department has frequently collaborated with NGOs during humanitarian aid missions,
such as the 2010 Haiti earthquake and the Indian Ocean tsunami in 2004.54,55,56,57

DOD’S GLOBAL HEALTH FOCUS AREAS

The components of DoD engage in a range of global health-related activities, from scientific research
and training, education, and technical assistance, to developing and implementing health programs
overseas. The department pursues these activities in support of its broader objectives, such as deterring
conflict, winning wars, and protecting U.S. national security. Based on the literature review and key
informant interviews, we identified the following three main “focus areas” of DoD global health-related
activity:

 Force health protection and readiness: activities such as medical research, prevention,
surveillance, care, treatment, and other DoD programs that keep its personnel healthy and

THE U.S. DEPARTMENT OF DEFENSE AND GLOBAL HEALTH 21

 prepared for their responsibilities, which also have applications to the health of populations in
developing countries;
 Medical stability operations and partnership engagement: health-focused programs and
technical assistance projects in other countries aimed at building partnerships and trust,
preventing conflict, fostering stability, and/or increasing capacities of partner governments,
militaries, or other organizations; and
 Threat reduction: activities such as laboratory construction, biosecurity training and other
support for health surveillance, preparedness, and response capacities overseas that are
undertaken to better prevent, detect, contain, and/or ameliorate the impacts of natural and
intentional biological events on U.S. national security.
Each of these focus areas is discussed in more detail below. The focus areas are not necessarily mutually
exclusive – a particular activity could be considered as fitting in more than one focus area – nor are they
meant to comprehensively cover every possible DoD activity related to global health. Instead, the focus
areas provide an accessible framework through which to consider how and why DoD engages in such
activities. DoD’s components contain elements and offices dedicated to these focus areas (see earlier
Key Components section).

FORCE HEALTH PROTECTION AND READINESS

Ever since the creation of an organized U.S. military, the promotion of health and the prevention of
illness among its personnel has been of critical importance, and it remains the primary goal of the
military medical system today. Because military personnel can and do deploy to any country and to any
environment around the world, DoD’s “force health protection and readiness” (FHP&R or FHP) efforts
must understand and prepare for a broad range of potential health threats, from diseases that can
spread globally (such as influenza) to threats that are endemic only in developing countries (such as
malaria and dengue) to injuries, mental health issues, and non-communicable diseases. Many of the
efforts and advances made in the name of FHP are relevant to civilian populations, including people in
developing countries.

Within FHP, we identified the following key areas of DoD activity that are particularly relevant to global
health: 1) Medical Research and Development, 2) Health Surveillance, and 3) FHP Education and
Training. These are discussed below (also see examples in Box 5).

MEDICAL RESEARCH AND DEVELOPMENT

DoD has performed a significant amount of medical research and development in support of FHP and,
through these efforts, has made discoveries and developed products that have broad public health
applications. For example, the military has long been a primary driver of research and development for a
number of vaccines, from being the first to develop and test influenza vaccines in the 1940s and 1950s,
to (more recently) advancing the science on the first malaria and HIV vaccines shown to be efficacious in
late-stage clinical trials.58,59,60,61 This work is funded and undertaken by DoD to develop products for the
protection of its personnel, but real benefits can accrue to the health of civilian populations as these
products are tested, licensed, and made available. In fact, DoD has had a major role in developing or
licensing an estimated 40 percent of all currently available vaccines for adults in the United States.62

While its work on vaccines represents a very visible set of products relevant to global health, many other
kinds of health technologies have also benefitted from military investments, such as drug treatments for
malaria and leishmaniasis, repellents and other vector control tools, and disease diagnostics. Research
to support this kind of medical countermeasure development for FHP is a primary justification for Army

22 THE U.S. DEPARTMENT OF DEFENSE AND GLOBAL HEALTH

 and Navy investments in their respective overseas laboratories.63 In addition to its work on infectious
disease product development, the military has also funded research and made advances in other areas
of medicine and public health, including combat-related health care (such as treatment of injuries and
burns) and mental health issues (such as post-traumatic stress disorder).

HEALTH SURVEILLANCE
A key part of FHP is maintaining awareness of the current status of and any potential or ongoing
changes to the incidence and prevalence of health threats of concern. To this end (providing early
identification of emerging diseases), DoD supports surveillance systems, advanced diagnostic capacities,
and communication systems to track the health of its personnel and general population health. The U.S.
military, in fact, developed one of the earliest
real-time surveillance systems to track BOX 5. FORCE HEALTH PROTECTION AND READINESS:
respiratory disease epidemics among its EXAMPLE ACTIVITIES
personnel due to the threat they pose to Medical Research and Development
force readiness.64 The ongoing relevance of  The U.S. Army cosponsored the Phase III trial of an HIV
the military’s infectious disease surveillance vaccine in Thailand.
was recently underscored when a U.S. Navy
laboratory became the first in the world to  The Walter Reed Army Institute of Research (WRAIR)
and Military Infectious Disease Research Program
identify individuals infected with the newly
(MIDRP) fund research projects to help develop
emerging H1N1 pandemic influenza virus in vaccines, drugs, and other products to protect against
65
2009. As part of its FHP health surveillance malaria, dengue, and other infectious diseases.
efforts, DoD also funds and carries out
surveillance projects overseas. Through Health Surveillance
these, DoD develops systems and shares  The Global Emerging Infections Surveillance and
Response System (GEIS) supports routine infectious
information in cooperation with other USG
disease surveillance and research projects that utilize
agencies and its foreign military and civilian DoD’s network of laboratories at home and abroad.
partners.66
 The Armed Forces Research Institute of Medical
FHP EDUCATION AND TRAINING FOR U.S. Sciences (AFRIMS) conducts surveillance of drug-
resistant malaria along the Thai-Cambodia border with
PERSONNEL
local collaborators.
DoD devotes time and resources to FHP
education and training, including skills and FHP Education and Training
knowledge relevant to global health, for its  The U.S. Air Force oversees the International Health
personnel. The department supports several Specialist program, recruiting military personnel for
medical schools, such as the U.S. Army specialized training and specialized global health-
focused deployments across DoD.
Medical Department Center and School, the
Air Force School of Aerospace Medicine, and  DoD’s joint Uniformed Services University of the Health
the joint Uniformed Services University of the Sciences (USUHS) developed and implements a
Health Sciences, which are among the few specialized degree track in global health for military
institutions in the U.S. to offer courses and health professionals.
degrees in tropical medicine. Many elements
within DoD support medical and public health training for personnel, both through internal DoD courses
and by subsidizing education pursued by its personnel in civilian universities and other institutions.
Often, military medical personnel are assigned to military public health organizations, such as the U.S.
Army Public Health Command and the U.S. Navy and Marine Corps Public Health Centers, where these
skills are applied and developed. In addition, DoD organizes a number of medical operations in foreign
countries for the explicit purpose of providing relevant field experience and a “real-life” training

THE U.S. DEPARTMENT OF DEFENSE AND GLOBAL HEALTH 23

 environment for its personnel while at the same time providing services to local populations overseas;
medical civic action programs (MEDCAPS) are one example of this training.67,68,69,70

MEDICAL STABILITY OPERATIONS AND PARTNERSHIP ENGAGEMENT

DoD engages in a variety of activities intended to promote stability, reduce conflict, and build
relationships and trust with foreign partners; a subset of these activities have a health focus. Because
this group of activities is so broad and the contexts in which they are used so diverse, the terminology
used to describe them and the boundaries around them are not always clear and fixed. Activities falling
within this focus area have been referred to at different times, by different DoD elements as “stability
operations,” “humanitarian assistance,” “partnership engagement,” “security cooperation,” “civil-
military operations,” ”low-intensity conflict,”
“irregular warfare,” and “hybrid warfare.”71 BOX 6. MEDICAL STABILITY OPERATIONS AND
These terms overlap with each other to some PARTNERSHIP ENGAGEMENT: EXAMPLE ACTIVITIES
extent, they are not applied uniformly across Medical Stability Operations
DoD, and their use has evolved over time.  U.S. Central Command (CENTCOM) supports joint civil-
Recognizing that interpretations about what military provincial reconstruction teams (PRT) in
is included under these various terms may Afghanistan to engage in health delivery and health
differ, we highlight two categories of system reconstruction activities.
activities, Medical Stability Operations (MSOs)  The Defense Security Cooperation Agency (DSCA)
and Partnership Engagement, which approves health-focused projects in several Asian
encompass most of the activities of interest in countries through the Overseas Humanitarian, Disaster,
this focus area. These are discussed below and Civic Aid (OHDACA) account.
(also see examples in Box 6).  The Combined Joint Task Force-Horn of Africa (CJTF-
HOA) provides funding and personnel support to build
MEDICAL STABILITY OPERATIONS health clinics and provide other health care services in
DoD currently defines stability operations as targeted areas of East Africa.
“an overarching term encompassing various
military missions, tasks, and activities  The U.S. Navy and U.S. Southern Command
(SOUTHCOM) deployed the USNS Comfort hospital ship
conducted outside the United States in
to Haiti following the earthquake that strikes the
coordination with other instruments of country.
national power to maintain or reestablish a
safe and secure environment, provide Partnership Engagement
essential governmental services, emergency  U.S. Africa Command (AFRICOM) developed a
conference and workshop on pandemic influenza
infrastructure reconstruction, and
72 preparedness for East African military partners to
humanitarian relief.” According to a DoD develop local surveillance and response capacity.
Instruction released in 2010, military health
system assets are now explicitly required to  The U.S. Navy provides outbreak response training
provide medical support to the department’s seminars to government health officials and military
partners through the Naval Medical Research Unit
broader stability operations efforts, a role
(NAMRU) in Peru.
termed “medical stability operations”
73
(MSOs). MSO efforts are typically  The Defense Institute for Medical Operations (DIMO)
undertaken to materially affect the health supports train the trainer programs overseas on topics
situation on the ground in the country, which such as disaster management, FHP, and surveillance.
is intended to contribute to greater stability
and lessen conflict in the local environment or otherwise help achieve the department’s objectives.

These efforts take place in conditions that range from highly insecure areas of active conflict to conflict-
free environments in friendly countries. In areas where instability or conflict is present, activities in this

24 THE U.S. DEPARTMENT OF DEFENSE AND GLOBAL HEALTH

 focus area may include delivering health care, building health infrastructure, or providing technical
assistance in the context of counterinsurgency operations. For example, the Commander’s Emergency
Response Program (CERP) and Provincial Reconstruction Team (PRT) activities in Iraq and Afghanistan
used DoD assets to construct medical clinics and carry out health interventions as a component of
combat and counterterrorism operations in those countries.74,75,76,77 Similarly (though at a different level
of instability and conflict), the work of the Combined Joint Task Force-Horn of Africa (CJTF-HOA) in
AFRICOM includes implementing health projects as part of counterterrorism efforts in several East
African countries, including in its home base of Djibouti.78

In areas free of conflict, MSO operations may include “health diplomacy” efforts (for example, planned
deployments of Navy hospital ships to provide health care to underserved populations in foreign
countries), military-to-military health training (for example, training African militaries about HIV
prevention within their armed forces), joint medical operations in the field with foreign military and
civilian partners (such as joint civilian health delivery exercises planned and undertaken with allied
militaries), military-to-civilian health engagement (for example, U.S. military health personnel providing
health care and training in foreign countries through MEDCAPs, dental civic action programs
(DENTCAPs), veterinary civic action programs (VETCAPs), and similar programs), and providing health
support during a disaster response (for example, the post-earthquake response in Haiti).79,80,81,82,83

PARTNERSHIP ENGAGEMENT
DoD often conducts activities that are designed to build partnerships with foreign governments and
strengthen the U.S. position and influence in countries and regions around the world, with the goal of
promoting greater stability and security. These activities are often leveraged to support COCOM country
engagement plans within their areas of responsibility. Partnership engagement can take many forms
and may include such activities as hosting conferences and technical training sessions in foreign
countries, donation of medical supplies and materiel, bringing foreign nationals to the U.S. to receive
specialized medical education and training, or conducting joint training sessions and medical operations
in the field. It can also take the form of longer-term relationships forged through facilities and
institutions built in partnership with host nations. The Army and Navy overseas laboratories, for
example, are often touted as anchors for country (and even regional) partnerships, and the relationships
developed through such institutions help forge bonds between the U.S. military and key allies.84 As local
nationals comprise the bulk of the staff at these laboratories, host countries develop ownership and a
sense of partnership through the facilities, leading to relatively stable relationships over time. The U.S.
Navy laboratory in Egypt, for example, has been in continuous operation and a point of contact between
the U.S. and Egypt since the lab’s founding in 1946 (and the only official U.S. facility in the country that
was not closed during the break in U.S.-Egypt diplomatic relations from 1967-1973).85

Working in conjunction with other parts of the U.S. government, DoD is often called upon to assist
foreign countries in responding to natural disasters (such as earthquakes, tsunamis, and hurricanes) or
other emergencies (such as large scale population and refugee movements),86 activities that are
encompassed within the Medical Stability Operations and Partnership Engagement focus area. DoD
participation in disaster responses are specifically authorized under U.S. Code and other legislation and
policy documents; according to Joint Staff policy, DoD may become involved such activities when the
need for relief is “gravely urgent” or the humanitarian emergency “dwarfs the ability of normal [non-
DoD] relief.”87,88

THE U.S. DEPARTMENT OF DEFENSE AND GLOBAL HEALTH 25

 THREAT REDUCTION
DoD contributes to the U.S. government’s overall efforts to prevent the proliferation of weapons of
mass destruction (WMD), a set of activities often termed “threat reduction” that, particularly in the
context of biological nonproliferation, can have implications for global health (see examples in Box 7).
While the roots of threat reduction extend to the post-World War II period of nuclear nonproliferation
activities, current DoD efforts in this focus area originated principally from the Nunn-Lugar Cooperative
Threat Reduction (CTR) program instituted in 1991, which focused on containment and elimination of
nuclear and other WMDs in the former Soviet Union through destruction of potentially dangerous
materials and supporting infrastructure as
well as redirection of scientists from BOX 7. THREAT REDUCTION: EXAMPLE ACTIVITIES
developing WMDs to engaging in other, more  The Defense Threat Reduction Agency (DTRA) funds
beneficial scientific pursuits. The initial and oversees the renovation and expansion of the
geographic focus for CTR was Eastern Europe country of Georgia’s main infectious disease laboratory.
and Russia, but more recently, DoD has  DTRA works with partners in East Africa to develop and
expanded its threat reduction efforts to apply safer laboratory practices to improve biosecurity.
include Asian, African, and Middle Eastern
countries.89

In its engagement with biological threat reduction, DoD seeks to prevent and prepare for biological
incidents, such as international and domestic infectious disease outbreaks and epidemics, whether they
be due to natural, accidental, or intentional causes. To these ends, the department focuses on
identification and containment of dangerous pathogens through improved detection and more secure
laboratories and medical practices. A particular emphasis of DoD’s biological threat reduction effort has
been bolstering foreign countries’ capabilities to safely identify and handle pathogens in their
laboratories, which DoD supports through training and equipping key governmental and military
partners overseas.90 For example, DTRA has funded the rehabilitation and expansion of the infectious
disease laboratory network in the former Soviet Republic of Georgia and has supported laboratory
biosecurity in Kenya and Uganda, among other locations.91,92,93

DOD POLICY AND GUIDANCE DOCUMENTS RELEVANT TO GLOBAL HEALTH

DoD has no single overarching guidance or policy document to tell DoD components how, when, or
where to engage in global health-related activities. Rather, planning and implementation of these
activities takes place under the guidance of broader, more general departmental policy and planning
documents.94,95 Global health-related activities are integrated into the overall work of DoD to the extent
they are perceived to contribute to its objectives, whether those objectives be longer-term national
security or strategic goals or more short-term operational goals of military officers on the ground.

So, while no single global health strategy or authoritative global health guidance document has been
released by DoD, there are numerous related and relevant policy and guidance documents available that
direct and shape the department’s activities in this area. These range from the high-level national
security strategy documents that reference the strategic importance of global health (as described in the
History and Context section above), to Directives and Instructions issued by OSD, to Military
Department-specific handbooks on how to implement health projects on the ground. This study sought
to identify and collect information on as many of these key related documents as possible. A brief
summary of key documents is presented here, but further information may be found in the

26 THE U.S. DEPARTMENT OF DEFENSE AND GLOBAL HEALTH

 accompanying Technical Volume, which contains a full listing and more complete descriptions of
relevant documents.

For the purposes of this study, two main categories of relevant documents were defined: policy
documents and guidance documents. Policy documents were defined as those documents that assign
global health-related responsibilities and/or require action(s) on the part of one or more of DoD’s
elements related to global health; these policy documents include DoD Directives and Instructions and
National Security Presidential policy directives (considered “authoritative and directive”).96,97 Guidance
documents were defined as those that lay out strategies, frameworks, and other concepts to guide DoD
planners and decision-makers but do not typically require action or assign responsibilities. Examples of
guidance documents include national level strategies, Joint Publications from the Joint Staff, and
handbooks released by the Military Departments such as Army Field Manuals (considered “authoritative
but not directive”).

Overall, 67 documents relevant to DoD’s global health-related activities were identified. These include
26 policy documents and 41 guidance documents. Of these, we identified the following eleven as key
policy and guidance documents for the department:

Policy

 Military Health Support to Stability Operations (DoD Instruction (DoDI) 6000.16, 2010): This
document establishes policies and responsibilities for how military health system assets support
DoD’s stability operations efforts, for the first time elevating its “non-combat” support role to
the same level as that of the “combat” role.
 Humanitarian and Civic Assistance Activities (DoDI 2205.02, 2008): This document establishes
policy and responsibilities for the conduct of humanitarian and civic assistance activities
governed by section 401 and 407 of Title 10 of the U.S. Code.
 Presidential Decision Directive/National Science and Technology Council-7 (PPD/NSTC-7) on
Emerging Infectious Diseases (1996): This document establishes policies and implementing
actions of U.S. agencies, including DoD, regarding support for domestic and international
surveillance and response capabilities against emerging infectious disease threats.
 National Security Presidential Directive-44 (NSPD-44) on Management of Interagency Efforts
Concerning Reconstruction and Stabilization (2005): This document sets priorities and assigns
responsibilities related to U.S. government support for reconstruction and stability operations
overseas.
 Geneva Conventions (1949): A set of international treaties that, among other things, require
that militaries of signatory countries (the U.S. is one), when occupying another country, provide
minimum levels of protection to local civilians against certain consequences of war, such as
disruption of public health services (article 56).
Guidance

 National Security Strategy (2010): Drafted by the White House and Executive Agencies, this
document frames and outlines current U.S. national security priorities, objectives, and approach
at the broadest level. In the most recent release of the strategy, global health is emphasized as
critical to national security.

THE U.S. DEPARTMENT OF DEFENSE AND GLOBAL HEALTH 27

  National Strategy for Countering Biological Threats (2010): The White House released this first
ever strategy to provide a framework for government support for U.S. biodefense. The strategy
includes an emphasis on efforts to improve international infectious disease surveillance and
biosecurity in overseas laboratories, to which DoD contributes.
 DoD Quadrennial Defense Review (QDR, 2010): A report submitted by DoD to Congress every
four years, this document “establish[es] the Department’s key priority objectives” and
“communicate[s] the Secretary’s intent for the next several years of the Department’s work.”
Partnership engagement, stability operations, and threat reduction are among the global health-
related areas emphasized in the most recent QDR.
 Joint Publication 3-29: Foreign Humanitarian Assistance (2009): This document provides
guidance to the U.S. military on “planning, executing, and assessing foreign humanitarian
assistance operations.”
 Army Field Manual (FM) 3-07: Stability Operations (2008): This document sets guidance for the
“identification and development of DoD capabilities to support stability operations.” Public
safety and welfare activities, which include public health programs, are cited in the guidance as
important components of stability operations and contributors to stability.
 Military Support for Stabilization, Security, Transition, and Reconstruction (SSTR) Operations
Joint Operating Concept 2.0 (2006): This document provides military commanders guidance on
how to plan for and conduct SSTR operations that support national strategic objectives, “to
assist governments or regions under serious stress.” Support for health systems and care is
included among the relevant types of activities commanders could support.

DOD BUDGET AND FUNDING FOR GLOBAL HEALTH-RELATED ACTIVITIES98,99

DOD BUDGETING AND APPROPRIATION PROCESS
DoD produces its budget request every two years through a process known as the Planning,
Programming, Budgeting, and Execution (PPBE) system. Under the PPBE process, many actors within
DoD contribute to the development of the DoD budget.100 In the off-years, DoD conducts a smaller
executive budget planning process that focuses mainly on budget execution, reviewing the status of
ongoing efforts, and updating budget estimates when needed. Recent DoD budgets have been
comprised of a DoD Base Budget (covering most of DoD’s recurring expenses) and a DoD Overseas
Contingency Operations (OCO) Fund (used to fund activities related to the global war on terror,
including the wars in Iraq and Afghanistan). Together, Base and OCO funding make up the Total DoD
Budget requested by the President each spring. The department’s Total Budget request for FY 2013 was
$613.9 billion, which represented a 4.9% decrease from the FY 2012 enacted level of $645.7 billion.
Congress appropriates DoD’s budget through designated appropriation titles, and these can be divided
across the four main DoD component budgets (Air Force, Army, Navy, and “Defense-Wide”).101 Table 1
presents a breakdown of FY 2012 enacted funding levels for DoD’s Total Budget across these titles and
components. Additionally, DoD supplemental appropriations provide for costs related to an emergency
activities (such as disaster relief), contingencies, or other activities in need of more immediate funding
that are deemed too urgent to be postponed until the next regular budget cycle.

FUNDING FOR GLOBAL HEALTH-RELATED ACTIVITIES

Specific DoD budget information, particularly for its work on global health-related activities, is complex
to compile and analyze. There is no single “global health” budget account within DoD; instead, such

28 THE U.S. DEPARTMENT OF DEFENSE AND GLOBAL HEALTH

 activities at the department are funded through numerous funding streams that fall within the large
appropriation titles described above. Of the main appropriations titles, two are of particular relevance
to DoD’s global health activities: “Operation and Maintenance (O&M)” and “Research, Development,
Test, and Evaluation (RDT&E),” though funding for global health-related activities comprises only a small
proportion of each and such activities may also be funded through titles other than these two. Some
accounts within DoD’s appropriations titles, such as the Overseas Humanitarian, Disaster, and Civic Aid
(OHDACA) account within O&M, are more easily identifiable and the amounts associated with them
more transparent. In other cases, global health-related programs are specified as a budget activity or
line-item in appropriations bills; such activities often have congressionally-directed funding levels for
particular purposes and activities. For example, FY 2012 directed funding amounts may be readily
identified for programs such as the Military HIV Research Program (MHRP), which received $22.8 million
for its HIV research activities, and the DoD HIV/AIDS Prevention Program (DHAPP), which received $8
million for its efforts to prevent the spread of HIV among African militaries’ personnel.
102
TABLE 1. DOD BUDGET: FY 2012 ENACTED FUNDING BY APPROPRIATIONS TITLE AND COMPONENT
FY 2012 ENACTED FY 2012 ENACTED FUNDING BY COMPONENT
FUNDING (IN THOUSANDS)
APPROPRIATIONS TITLE
OVERALL Dept. of Dept. of Dept. of Defense-
(IN THOUSANDS) the Air Force the Army the Navy Wide*
Base Budget Funding 530,624,709 144,869,575 133,941,005 156,816,336 94,997,793
Military Personnel 141,818,404 35,354,898 60,141,575 46,321,931 0
Operation and Maintenance (O&M) 197,213,485 44,876,904 40,895,581 45,549,003 65,891,997
Procurement 104,527,376 36,400,921 19,571,678 43,481,596 5,073,181
Research, Development, Test, and
71,375,712 26,222,107 8,385,090 17,673,888 19,094,627
Evaluation (RDT&E)
Military Construction 11,366,701 1,459,808 4,175,532 2,256,008 3,475,353
Family Housing 1,682,946 489,565 670,355 468,835 54,191
Revolving and Management Funds 2,640,085 65,372 101,194 1,065,075 1,408,444
OCO Funding 115,082,877 16,796,526 67,445,544 15,693,315 15,147,492
Military Personnel 11,293,469 1,493,046 7,826,623 1,973,800 0
Operation and Maintenance (O&M) 86,775,842 10,594,792 54,436,168 11,166,702 10,578,180
Procurement 16,052,195 4,472,267 5,264,764 2,309,226 4,005,938
Research, Development, Test, and
526,358 259,600 18,513 53,884 194,361
Evaluation (RDT&E)
Military Construction 0 -35,179 -154,524 189,703 0
Family Housing 0 0 0 0 0
Revolving and Management Funds 435,013 12,000 54,000 0 369,013
Total DoD Budget Funding 645,707,586 161,666,101 201,386,549 172,509,651 110,145,285
Notes: *The Defense-Wide component encompasses programs that support the entire Pentagon. It is comprised of the OSD, the Unified
Combatant Commands, Defense Agencies, and Field Activities. Note: OCO means Overseas Contingency Operations.

However, most global health-related activity budgets are not specified in appropriations bills, and the
information is not readily available. This is due to several reasons. First, identifying which DoD activities
should be considered “global health” is problematic, given the lack of standardization and absence of a
common definition across DoD components for such activities. In addition, support for global health-
related activities may comprise only a proportion of the funding in a given budget, and the specific,
project-level information needed to fully identify the global health portion is often not available.
Furthermore, such activities may be funded through more than one account or title, each of which may
be controlled by a different office or Military Department, making the funding picture even more
complex. Therefore, identifying, tracking, and arriving at a comprehensive total DoD budget for “global
health” is difficult.

THE U.S. DEPARTMENT OF DEFENSE AND GLOBAL HEALTH 29

 While a full and complete analysis of the department’s relevant funding and accounts is not practicable
for the reasons described above, there are some identifiable budgets and funding streams. Below, we
present information on these that is as comprehensive as possible, given currently available public
information. The identified funding streams may be classified into two principal groups:

 funding streams primarily used to support global health-related activities, where amounts are
specified exactly or can be estimated (see Table 2), and
 funding streams in which a portion is used for global health-related activities but where the
amounts supporting these health activities cannot be disaggregated, identified, or estimated
with currently available information (see Table 3).
In Tables 2 and 3, the funding streams are placed into the most relevant of the three DoD global health
“focus areas” defined earlier in this report (Force Health Protection and Readiness, Medical Stability
Operations and Partnership Engagement, and Threat Reduction).

In addition to these funding streams, DoD global health-related activities may be supported by funding
received from non-DoD organizations, such as the Henry M. Jackson Foundation for the Advancement of
Military Medicine, and through interagency transfers between U.S. government agencies and
departments, such as the $148.5 million in FY 2011 PEPFAR funding that was transferred from the Global
Health and Child Survival (GHCS)—State Department account (now part of the Global Health Programs
account).103

As shown in Table 2, DoD dedicated no less than $579.7 million in identifiable funding to global health-
related activities in the FY 2012 budget. The full amount the department dedicated to these activities is
likely much higher than this, taking into account the additional funding likely drawn from accounts
shown in Table 3, for which the health portion cannot be characterized. In comparison, this DoD global
health-related activities funding “floor” of $579.7 million is greater than both the CDC budget for global
health activities and the NIH budget for global health activities in the same year, which amounted to
$348.9 million and $511.5 million in FY 2012, respectively.104

Most of these accounts are administered either by COCOMs, Military Departments, or the Defense
Security Cooperation Agency (DSCA). The DoD components overseeing these funds are responsible for
determining which programs and activities best fulfill the missions ascribed to a specific funding stream
and for outlining the program-level objectives of these efforts. The missions, requirements, and project
planning and allocation processes for these funding streams may vary, depending on the account and
which office(s) has authority over the funding. For example, DSCA-controlled Humanitarian and Civic
Assistance (HCA) program funds permit DoD Combatant Commanders to carry out a range of
humanitarian projects at their discretion. On the other hand, some of the Army infectious disease
research funding is distributed through a peer-reviewed, competitive grant distribution process for
military medical researchers, based on prioritization of product requirements in military medical
countermeasure product development programs. Likewise, Global Emerging Infections Surveillance and
Response System (GEIS) funding reflects DoD’s prioritization of infectious disease surveillance efforts in
order to address threats to national security posed by emerging and reemerging diseases. Cooperative
Biological Engagement (CBE) program funding, in contrast, supports projects to assist partner countries
in meeting their health priorities, including helping them comply with the International Health
Regulations and properly manage dangerous pathogens and infectious disease surveillance information.

30 THE U.S. DEPARTMENT OF DEFENSE AND GLOBAL HEALTH

 105
TABLE 2. DOD FUNDING STREAMS WITH AMOUNTS SPECIFIC TO GLOBAL HEALTH-RELATED ACTIVITIES
FOCUS FY 2012 AGENCY/OFFICE(S)
AREA NAME DESCRIPTION FUNDING WITH OVERSIGHT
Supports the Army medical overseas research laboratories for bio-surveillance and clinical Army Medical
Army Overseas Lab Direct Support $3.0m
research of investigational products such as drugs and medical devices. Command
Funding designated in the Army RDT&E budget supporting laboratory research and
Army RDT&E Infectious Disease R&D a WRAIR, NMRC,
development of vaccines, drugs, and prevention tools for infectious diseases of importance to $60.9m
Funding USAMRIID
the military, including HIV.
Global Emerging Infections System Supports DoD global infectious disease surveillance efforts to address threats to national Armed Forces Health
$47.2m
(GEIS) security posed by emerging and re-emerging diseases through funding and technical assistance. Surveillance Center
Military HIV Research Program MHRP funds are used to advance HIV vaccine research and development, help protect the
$22.8m WRAIR and NMRC
(MHRP) military blood supply from HIV, and protect military personnel from HIV infection risks.

READINESS
Navy Laboratory Support – Medical Supports U.S. and overseas laboratories for medical research on vaccines for Malaria, Diarrheal
b Department of the
Development and Navy RDT&E Diseases, Dengue Fever; surveillance and outbreak response; and other efforts in support of $37.2m
Navy, NMRC
Infectious Disease Research Funding military medical importance.

THE U.S. DEPARTMENT OF DEFENSE AND GLOBAL HEALTH

FORCE HEALTH PROTECTION AND
Supports medical research at Uniformed Services University of the Health Sciences (USUHS) in
USUHS In-House Laboratory
areas of military medical importance to the Department of Defense such as Combat Casualty $0.4m USUHS
Independent Research
Care, Infectious Diseases, Military Operational Medicine, and Biological Defense.
Afghan Security Forces Fund Provide the resource foundation needed to Train and Equip the Afghan National Security Force c Department of the
$39.7m
(ASFF) (ANSF) and Afghan Local Police (ALP), including their medical corps. Army
Commander’s Emergency Response This program allows the use of Army O&M funds “for the purpose of enabling military Estimated U.S. Military
Program commanders in Afghanistan to respond to urgent, small-scale, humanitarian relief and d Commanders in
$28.0m
(CERP) reconstruction requirements within their areas of responsibility.” Afghanistan
Defense HIV/AIDS Prevention Focuses on military-to-military efforts to assist partner militaries in developing and executing an Department of the
$8.0m

PARTNERSHIP
ENGAGEMENT
Program (DHAPP) effective HIV prevention strategy as well as treatment and care programs. Navy

OPERATIONS AND
MEDICAL STABILITY
Overseas Humanitarian, Disaster, Supports military humanitarian efforts overseas, for example through transport of relief supplies Estimated Defense Security
e
and Civic Aid (OHDACA) and other humanitarian activities worldwide. $73.0m Cooperation Agency

Funds projects to assist partner countries to comply with World Health Organization’s (WHO)
Cooperative Biological Engagement USD – AT&L and the
International Health Regulations (IHR), consolidate dangerous infectious disease research to a
Program $259.5m Defense Threat
minimal number of secure facilities, and enhance awareness of infectious disease outbreaks of

THREAT
(CBE) Reduction Agency
natural and/or deliberate origin.

REDUCTION
Notes: Many of these funding streams are subject to OSD and Joint Chiefs’ guidance and oversight in order to ensure resources are used in appropriate ways that meet major personnel, material, and logistics
requirements. “m” means millions. R&D is Research and Development. RDT&E is Research, Development, Test, & Evaluation. O&M is Operations and Management. USUHS is the Uniformed Services University
of the Health Sciences. AT&L is Acquisition, Technology, and Logistics. WRAIR is the Walter Reed Army Institute of Research. NMRC is the Naval Medical Research Center. USAMRIID is the U.S. Army Medical
Research Institute of Infectious Diseases. USD is Under Secretary of Defense. a This row is a consolidation of 7 Army RDT&E Budget lines focused on military medical research focused on HIV, infectious diseases,
and laboratory research related to global health, including but not limited to Basic Research – In-House Laboratory Independent Research, Basic Research – Medical Research in Infectious Diseases, Applied
Research – DoD Medical Defense Against Infectious Diseases, and Applied Research – HIV Exploratory Research. b This row is a consolidation of Defense Health Program funding support for Navy labs and a
Navy RDT&E budget line supporting malaria vaccine research. c Of $11.2 billion total for ASFF, health amount is amount designated for medical purposes. d Of $400 million total for CERP, health amount based
on proportion found to be dedicated to health in an analysis of prior years’ CERP funding by sector; see Johnson G, Ramachandran V, Walz J (2012). CERP In Afghanistan: Refining Military Capabilities in
Development Activities. PRISM Vol 3(2):81-98. e Of $107.7 million total for OHDACA, health amount based on proportion found to be dedicated to health in an analysis of prior years’ OHDACA funding by
sector; see Bourdeaux ME, Lawry L, Bonventre E, Burkle Jr FM (2010). Disaster Medicine And Public Health Preparedness; 4: 66-73.

31
 TABLE 3. DOD FUNDING STREAMS USED TO SUPPORT GLOBAL HEALTH-RELATED ACTIVITIES BUT LACKING
106
AMOUNTS SPECIFIC TO SUCH ACTIVITIES
AGENCY/
OFFICE(S)
FOCUS FY 2012 WITH
AREA NAME DESCRIPTION FUNDING* OVERSIGHT
“Enables the Chairman of the Joint Chiefs of Staff to act quickly to
support the Combatant Commanders when they lack the flexibility
Combatant
and resources to solve emergent challenges and unforeseen
Commander Joint Chiefs of
contingency requirements critical to joint war fighting readiness and $45.9m
Initiative Fund Staff
national security interests.” Funds may be used for humanitarian
(CCIF) and civic assistance, to include urgent and unanticipated
humanitarian relief and reconstruction assistance.
Exercise Related
Funds “unspecified minor military construction outside the United
Minor Joint Chiefs of
States in support of the Joint Chiefs of Staff Exercise program” $8.4m
Construction Staff
(through the COCOMs).
(ERC)
Foreign Military Secretary of
Supports the procurement of defense articles and services to $6.3b
Financing State, Secretary
enhance the capacity of foreign security forces. (inc. OCO)
(FMF) of Defense
MEDICAL STABILITY OPERATIONS AND PARTNERSHIP ENGAGEMENT

Global Security “Pools resources and expertise from the Department of State, DoD,
Secretary of
Contingency and U.S. Agency for International Development to provide security
$200.0m State, Secretary
Fund sector and stabilization assistance for emergent challenges and
of Defense
(GSCF) opportunities.”
Global Train and “Build[s] partnership capacity for time-sensitive, new and emerging‖ Defense
Equip counter-terrorist operations, or to participate in or support military Security
$350.0m
(“Section 1206” and stability operations in which the US armed forces are a Cooperation
funding) participant.” Agency (DSCA)
Humanitarian Permits Combatant Commanders to use Operations and
and Civic Maintenance (O&M) funds to carry out a range of humanitarian $14.9m Joint Chiefs of
Assistance projects that complement but do not duplicate other U.S. social or (FY2010) Staff
(HCA) economic assistance to beneficiary country.
International “Provides training on a grant basis to students from allied and
Military friendly nations” and “is a key component of U.S. security
Education (IMET) assistance” that “presents democratic alternatives to key foreign $105.8m DSCA
and Expanded military and civilian leaders.” The E-IMET program “exposes students
IMET (E-IMET) to the civilian community and its important democratic institutions.”
Navy RDT&E
Supports defense research sciences’ basic research in medical
Defense Department of
sciences and biology, including on infectious organisms of military $20.3m
Research the Navy
relevance.
Sciences Funding
“Provides unique partnership capacity-building capabilities to
Combatant Commanders and U.S. Ambassadors through
National Guard
partnerships between U.S. states, territories and the District of $13.2m
State Partnership
Columbia and foreign countries. The SPP supports U.S. national a National Guard
Program (FY2011)
interests and security cooperation goals by engaging partner nations
(SPP) via military, socio-political and economic conduits at the local, state
and national level.”
Operation “Provides military support to the Trans Sahara Counter Terrorism
Enduring Partnership (TSCTP) program. OEF-TS engagement in TSCTP focuses Africa
$52.2m
Freedom-Trans on overall security and cooperation rather than solely on Command
(OCO)
Sahara counterterrorism. The OEF-TS partnership comprises the United (AFRICOM)
(OEF-TS) States and ten African countries.”
PACOM Asia Pacific
Supports PACOM security cooperation activities such as
Pacific Regional $15.0m Command
humanitarian assistance.
Initiative (PACOM)
Notes: *exceptions in Fiscal Year are noted after funding amounts. “m” means millions, “b” means billions. a $7.1m from COCOMs, $6.1m
from National Guard Bureau. OCO is Overseas Contingency Operations funding.

32 THE U.S. DEPARTMENT OF DEFENSE AND GLOBAL HEALTH

 POLICY ISSUES
DoD is entering a period of transition in the wake of the Iraq war and the imminent drawdown of forces
from the war in Afghanistan. In addition, there have been recent changes made to U.S. defense strategy
that call for, among other things, less emphasis on large-scale “nation-building” activities and greater
attention directed toward the Asia region.107 At the same time, the department confronts a resource-
constrained funding environment unlike any it has faced in the last 10 years, with looming austerity
measures that could shrink its budget and lead to further changes to its priorities and operations in the
coming years.

These broad trends in the defense policy environment are sure to affect how the department engages in
activities related to global health going forward, and it is against this backdrop that a number of key
policy issues related to its engagement can be considered. These include a set of issues that are
primarily internal to DoD and a set of broader issues related to how the department’s activities fit within
and are coordinated with efforts of other global health actors.

Internal DoD policy issues and questions include:

 Mission and priorities. Improving global health is not a primary mission for DoD, but the
department has increasingly connected its engagement on global health-related activities to
achievement of its core national security objectives. In considering the role and contribution of
these activities to DoD’s broader mission and strategic plans, some questions that may be
considered include: What are the benefits and pitfalls in prioritizing global health-related
activities even more explicitly or in shifting away from these types of efforts? Given recent shifts
in strategy and looming budget cuts, should the department place more or less emphasis on
these kinds of activities going forward? Does DoD’s engagement with global health in fact
support its operational and strategic objectives and national security goals? Does its approach
improve the health of populations in developing countries, and are these efforts sustainable?
 Organization and strategy. Reflecting the size and decentralized structure of department,
multiple departments and offices within DoD have authority over the department’s global
health-related work, and multiple policy documents guide the department’s work in this areas.
This has led to some obstacles in coordinating across military departments, COCOMs, and other
components, meaning there is room for additional guidance that would help lay out a clearer
vision for how DoD’s various global health-related activities relate to one another and how
together they support DoD’s broader mandate and strategic goals.
 Support and funding. The department has raised the policy importance of stability operations,
conflict prevention, and reconstruction missions that often incorporate global health-related
activities, but there has been little evidence of a corresponding shift in funding and
organizational support toward these mission sets. This has made it more challenging for DoD
components and elements seeking to adopt and integrate these activities into their operations.
More concrete support – in terms of budgets and staffing – could aid in this transition.
Moreover, the lack of clear information about and tracking of budgets and funding hinders the
department itself from a deeper understanding of its own investments in this area. Additional
data and analysis on how this funding is derived and how it is used could facilitate more
effective use of resources and support efforts to monitor and evaluate the department’s global
health-related activities.

THE U.S. DEPARTMENT OF DEFENSE AND GLOBAL HEALTH 33

  Measurement and evaluation. Currently, there is a general lack of monitoring and evaluation
data for DoD humanitarian assistance projects overseas,108 leaving purported links between DoD
’s global health programs and its national defense mission tenuous and open to subjective
judgment of their worth. By supporting greater standardization of and support for tracking and
measuring the effectiveness of its global health activities, the department might be able to
better define benchmarks for success and identify lessons learned and best practices for its
global health-related activities.
 Internal expertise. Most DoD personnel who work in or are interested in pursuing global health
related work face an unclear training and career path in the department, with training and
career development in this area limited to a few programs with low visibility and priority. If
global health-related activities are judged important, a better prepared workforce with the
necessary skills and knowledge will be important. This could occur through a number of
avenues, including systematic incorporation of and greater support for existing global health
instruction into personnel development elements, such as the Air Force’s International Health
Specialists program, as well as regular instruction at military service academies.
Broader policy issues and questions for DoD include:

 DoD in the context of U.S. global health efforts overall. As mentioned above, DoD is not a
development organization, and improving global health is not its primary mission. Yet the
department has shown an increasing interest in this area and brings unique and sizeable
contributions to bear, such as an ability to rapidly mobilize significant assets, long-standing
relationships with many partner governments and militaries, and a reserve of scientific and
medical knowledge and capabilities. While there are a number of examples of successful and
productive DoD interagency work on global health efforts (such as HIV prevention programs in
PEPFAR countries and collaborative infectious disease research and development), in many
cases it remains an open question for policymakers inside and outside the department as to
where and when integration of DoD’s global health activities with other U.S. global health
efforts makes sense and can be additive.
 Balancing national security and global health objectives. Global health practitioners outside
the department have expressed concerns that given the size and influence of DoD, national
security objectives at times become prioritized over the objectives of the global health and
development community, which can hinder progress toward health improvements.109,110 In
certain circumstances, such as Afghanistan and Iraq, NGOs have at times expressed reluctance
or refused to work with DoD, because they believe doing so negatively impacts their ability to
carry out their work and increases risks to their staff and programs in the field.111,112,113 To better
outline expectations, roles, and other issues, DoD and external groups working on the ground
might explore ways to improve meaningful and regular attempts at communication to better
support shared objectives and understand differences.
 Interagency coordination and communication. Adequate communication and coordination with
U.S. civilian agency partners is necessary to promote the most effective use of resources and
ensure that U.S. government efforts are not working at cross-purposes in developing countries.
Recent evaluations by GAO of the extent and the quality of DoD’s interagency collaboration on
humanitarian assistance projects concluded the department needs to improve in this area.114
While DoD has conceded that interagency collaboration could be improved it has also reported
progress in addressing these concerns and maintained that at times lack of capacity on the
civilian side has contribute to coordination and communication difficulties.115,116,117

34 THE U.S. DEPARTMENT OF DEFENSE AND GLOBAL HEALTH

  Public understanding of DoD’s global health efforts. The department faces an ongoing
challenge in publicizing its efforts related to global health among key stakeholders (such as the
public, global health colleagues, the U.S. Congress, and the policymakers in countries where DoD
works) who may be unaware of or have misconceptions about such efforts. Greater efforts to
shed light on and increase transparency surrounding its work in this area could assist in
correcting existing external misperceptions and improve dialog with stakeholders.

CONCLUSION
The Department of Defense, the largest and oldest U.S. government agency, has a long history of
engaging in activities that can impact global health. Its policies, strategic emphasis, and budget in
support of global health-related activities has shifted over time, often in parallel with broader changes in
perceptions about U.S. national security threats and the role of the U.S. military in countering those
threats. Recently, global health-related programs at the department have received greater attention
than in the past: this is partly because global health in general is seen as an increasingly important U.S.
national security issue and because the department itself has shifted strategy and policy, emphasizing
the importance and role of its global health–related activities to a greater extent.

This report shows that oversight and implementation of the department’s global health-related efforts is
complex and diffuse. Responsibilities for such activities are not centralized within a single DoD office,
but instead, like many DoD activities, these efforts are overseen by many offices across the department,
with all major components of the department (from the Office of the Secretary of Defense, the
Combatant Commands, the Military Departments, to the Joint Chiefs of Staff) playing a role. Although
the department has not issued an overarching policy to guide these components on global health-
related work, a number of policy documents provide some guidance and direction for such efforts. Still,
each component has tended to develop and implement global health activities in an independent way,
meaning these varied efforts may or may not be well-coordinated, monitored and evaluated, or
consistently integrated into the broader DoD strategic and military plans. This diffusion of oversight and
activity is a reflection of DoD’s size and overall organizational structure. From the department’s
perspective it remains an open question whether more integration and greater consolidation of its
global health-related activities would be beneficial to achieving its strategic objectives for these efforts,
let alone whether it would contribute to improving the global health impact of these activities.

The Department of Defense is in the midst of a period of significant transition, and over the next several
years, changes in the national defense context and pressures on the DoD budget may necessitate tough
choices about how to prioritize and most effectively utilize the military’s global health-related assets.
Against this backdrop, it will be important to consider whether the department’s engagement in,
approach to, and objectives for its global-health activities should be reexamined or clarified — including
the extent to which global health-related activities should be part of its work going forward.

For the wider U.S. global health community, examining and understanding DoD’s efforts in this area may
prove worthwhile, despite lingering reservations or potential challenges they may encounter in
partnering with DoD on global health. Given that the department has tremendous geographic reach,
long-standing and influential partnerships with governments and militaries, an ability to rapidly mobilize
significant resources, and a well of knowledge and substantial investments in scientific and technical
areas such as research and development, further efforts to understand how DoD fits into the larger
landscape of U.S. and international engagement on global health will be important, particularly since
any scaling back in DoD’s engagement may create a gap that other organizations might need to fill.

THE U.S. DEPARTMENT OF DEFENSE AND GLOBAL HEALTH 35

 APPENDIX A. DETAILED TIMELINE118
TABLE A-1. DETAILED TIMELINE
TIME DOD MEDICAL RESEARCH MILESTONES OTHER DOD MILESTONES OTHER NOTABLE EVENTS
PERIOD
1818: U.S. Army Medical Department (AMEDD) established
1842: U.S. Navy Bureau of Medicine and Surgery (BUMED)
established
1880: Military scientists discover
1800s

causative agent for strep pneumonia

1893: U.S. Army Medical School and Walter Reed Army
Institute of Research (WRAIR) founded
1898: U.S. military campaign in Philippines utilizes civil-
military stabilization approach
1900: Army researchers show yellow
fever transmitted by mosquitoes
1900-1903: Army institutes 1904: U.S. begins Panama
successful malaria prevention Canal construction
program in support of Panama Canal
construction
1900 –1945

1909: Army produces first typhoid 1913: Panama Canal

vaccine completed
1940-1945: Army establishes first
system for blood banking, storage
1940s: Military scientists develop
first inactivated influenza vaccines
1945: First Navy overseas laboratory established (initially in
Guam, later moved to Taiwan, then Indonesia); now termed
NAMRU-2
1946: Naval Medical Research Unit 3 (NAMRU-3) established Late 1940s: Marshall Plan
(Cairo, Egypt) for Reconstruction of
Europe; Berlin Airlift
1957: Military scientists develop first
surveillance system for epidemic
respiratory disease
1959: First Army overseas laboratory, the Armed Forces
Research Institute of Medical Sciences (AFRIMS), founded in
Bangkok, Thailand
1946-1980

1961: Military scientists isolate 1961: Foreign Assistance Act assigns State Department the
rubella virus lead role in foreign military assistance programs
1963: Military “Medical Civic Action Programs” (MEDCAPs) 1965-1973: U.S. troop
implemented in Vietnam involvement in the Vietnam
War
1967: Army implements the Civil Operations and
Revolutionary Development Support (CORDS) approach in
Vietnam conflict, introducing integrated civilian-military
Provisional Advisory Teams (PATs)
1969: U.S. Army Research Unit – Kenya (USAMRU-K) founded
1976: Inaugural class at the Uniformed Services University of
the Health Sciences (USUHS)
1982: U.S. Army designated as lead agent for U.S. military
infectious disease research
1983: Navy Medical Research Unit 6 (NAMRU-6) founded in
Lima, Peru (initially as a detachment, made command level in
2011)
1985: Military develops prototype
1980s

Hepatitis A vaccine
1986: Military HIV Research Program (MHRP) created by U.S.
Congress
1987: Congress enacts Title 10 legislation; provides DoD with
authority to provide Humanitarian and Civic Assistance (HCA)
1988: Navy Medical Research Detachment–Cambodia
(NAMRU Det-Cambodia) founded (a part of NAMRU-2)

36 THE U.S. DEPARTMENT OF DEFENSE AND GLOBAL HEALTH

 TABLE A-1. DETAILED TIMELINE
TIME DOD MEDICAL RESEARCH MILESTONES OTHER DOD MILESTONES OTHER NOTABLE EVENTS
PERIOD
1989: New antimalarial drug 1989: Fall of the Berlin Wall
Mefloquine, co-developed by the
military, licensed in the U.S.
1991: Congress establishes the Nunn-Lugar Cooperative
Threat Reduction (CTR) Program
1991: Congress provides DoD authority to support 1992-1994: U.S. military
humanitarian assistance and reconstruction through the intervention in Somalia
Commander-in-Chief Initiative fund (CINC), later renamed the
Combatant Commander’s Initiative Fund (CCIF)
1992: Second generation Japanese 1992-1995: Bosnian War,
1990s

Encephalitis vaccine, co-developed with U.S. military

by the Army, approved for use in the intervention in 1995
U.S.
1994: New typhoid vaccine, co- 1994: Overseas Humanitarian, Disaster, and Civic Aid 1994-1995: U.S. military
developed by the Army, approved for (OHDACA) program established by Congress intervention in Haiti
use in the U.S.
1999: Center for Disaster and Humanitarian Medicine 1999: U.S. military
(CDHAM) chartered at Uniformed Services University intervention in Kosovo War
2000: New antimalarial drug 2000: Air Force International Health Specialist program
Malarone, discovered and developed established
primarily by the military, licensed in
the U.S.
2000:Congress provides funds to Defense Health Program to
support military-to-military HIV prevention programs
2001: September 11
terrorist attacks; Anthrax
mailings; Operation
Enduring Freedom
(Afghanistan) begins
2002: Combined Joint Task Force – Horn of Africa (CJTF-HOA)
established
2002: Military completes genetic 2002: First Provincial Reconstruction Teams (PRTs)
sequencing of malaria parasite (P. established in Afghanistan
falciparum)
2003: Army co-initiates largest Phase 2003: Commander’s Emergency Response Program (CERP) 2003: Operation Iraqi
III trial of an HIV vaccine candidate in created by Iraq Provisional Authority using seized Iraqi Funds Freedom begins
Thailand
2000-Present

2004: First malaria vaccine candidate 2004: Congress provides first appropriated funds to CERP 2004: Indian Ocean (South
demonstrating efficacy, co- program in Afghanistan and Iraq Asian) earthquake and
developed by military, enters Phase tsunami
III trials in Africa
2005: DoD(I) 3000.05 states that DoD stability operations are
of the same level of importance as DoD combat operations
2006: Revised U.S. Army Counterinsurgency Manual
published
2006: In the National Defense Authorization Act, Congress
establishes “Section 1206” mechanism, allowing DoD to use
funds to train and equip foreign militaries for
counterinsurgency and stability operations
2007: DoD International Health Division established within
Office of the Assistant Secretary of Defense-Health Affairs
2007: U.S. Africa Command (AFRICOM), a new DoD
geographic combatant command with responsibility for
operations across Africa, is created
2009: Thailand HIV vaccine trial, co- 2009: Indonesia forces closure of NAMRU-2 in Jakarta 2009: 2009-H1N1 influenza
sponsored by the military, provides pandemic
evidence of partial efficacy
2011: DoD-supported laboratory in Tblisi, Georgia opens 2011: Withdrawal of U.S.
combat personnel from
Iraq

THE U.S. DEPARTMENT OF DEFENSE AND GLOBAL HEALTH 37

 APPENDIX B. ACRONYM LIST
TABLE B-1. ACRONYMS
AFHSC: Armed Forces Health Surveillance Center
AFRICOM: U.S. Africa Command
AFRIMS: Armed Forces Research Institute of Medical Sciences
AOR: Area of Responsibility
ASD: Assistant Secretary of Defense
ASD-HA: Assistant Secretary of Defense for Health Affairs
ASD-SO/LIC: Assistant Secretary of Defense for Special Operations/Low Intensity Conflict
BUMED: U.S. Navy Bureau of Medicine and Surgery
CBE: Cooperative Biological Engagement Program
CDC: U.S. Centers for Disease Control and Prevention
CDHAM: Center for Disaster and Humanitarian Assistance Medicine
CENTCOM: U.S. Central Command
CERP: Commander’s Emergency Response Program
CJTF-HOA: Combined Joint Task Force-Horn of Africa
CMC: USAID’s Office of Civilian-Military Cooperation
COCOM: Combatant Command
COMEDS: Committee of the Chiefs of Military Medical Services, NATO
CTR: Cooperative Threat Reduction
DASD: Deputy Assistant Secretary of Defense
DENTCAP: Dental Civic Action Program
DHAPP: Defense HIV/AIDS Prevention Program
DIMO: Defense Institute for Medical Operations
DMRTI: Defense Medical Readiness Training Institute
DoD: Department of Defense
DoDI: Department of Defense Instruction
DSCA: Defense Security Cooperation Agency
DTRA: Defense Threat Reduction Agency
EUCOM: U.S. European Command
FHP(&R): Force Health Protection (and Readiness)
FM: Field Manual
FY: Fiscal Year
GAO: Government Accountability Office
GEIS: Global Emerging Infections Surveillance and Response System
GHCS: Global Health and Child Survival (now Global Health Programs account)
GHI: U.S. Global Health Initiative
HCA: Humanitarian and Civic Assistance

38 THE U.S. DEPARTMENT OF DEFENSE AND GLOBAL HEALTH

 TABLE B-1. ACRONYMS
HHS: U.S. Department of Health and Human Services
HIV/AIDS: Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome
HSS: Health Support Services
ISAF: International Security Force Afghanistan
MEDCAP: Medical Civic Action Program
MEDCOM: Medical Command
MEDRETE: Medical Readiness Training Exercise
MIDRP: Military Infectious Disease Research Program
MHRP: Military HIV Research Program
MHS: Military Health System
MMRP: Military Malaria Research Program
MOU: Memorandum of Understanding
MRSN: Multi-drug Resistant Organism Repository and Surveillance Network
MSO: Medical Stability Operation
NAMRU: Naval Medical Research Unit
NATO: North Atlantic Treaty Organization
NGO: Non-Governmental Organization
NIH: National Institutes of Health
NMRC: Naval Medical Research Center
NORTHCOM: U.S. Northern Command
NSPD: National Security Presidential Directive
O&M: Operations and Maintenance
OCHA: U.N. Office for the Coordination of Humanitarian Affairs
OFDA: Office of Foreign Disaster Assistance
OCO: Overseas Contingency Operations
OGAC: Office of the Global AIDS Coordinator
OHDACA: Overseas Humanitarian, Disaster, and Civic Aid
OSD: Office of the Secretary of Defense
PACOM: U.S. Pacific Command
PDD/NSTC: Presidential Decision Directive/National Science and Technology Council
PEPFAR: The U.S. President’s Emergency Plan for AIDS Relief
PRT: Provincial Reconstruction Team
QDR: Quadrennial Defense Review
RDT&E: Research, Development, Test, and Evaluation
SARS: Severe Acute Respiratory Syndrome
SOCOM: U.S. Special Operations Command
SOUTHCOM: U.S. Southern Command
SSTR: Stabilization, Security, Transition, and Reconstruction

THE U.S. DEPARTMENT OF DEFENSE AND GLOBAL HEALTH 39

 TABLE B-1. ACRONYMS
STRATCOM: U.S. Strategic Command
TRANSCOM: U.S. Transportation Command
U.N.: United Nations
U.S.: United States (of America)
USAFSAM: U.S. Air Force School of Aerospace Medicine
USAID: U.S. Agency for International Development
USAMRMC: U.S. Army Medical Research and Materiel Command
USAMRIID: U.S. Army Medical Research Institute of Infectious Diseases
USAMRU U.S. Army Medical Research Unit
USD: Undersecretary of Defense
USG: U.S. Government
USNAVSO: U.S. Naval Forces Southern Command
USNS: United States Naval Ship
USUHS: Uniformed Services University of the Health Sciences
VETCAP: Veterinary Civic Action Program
WHO: World Health Organization
WMD: Weapon of Mass Destruction
WRAIR: Walter Reed Army Institute of Research

SOURCES
1
Department of Defense (DoD),“About the DoD,” webpage, available at: http://www.defense.gov/about/.
2
G. Bonventre, K. Hicks, and S. Okutani, An Analysis of Global Health Engagement by the U.S. Department of Defense, Center for Strategic and
International Studies (CSIS), April 2009, available at: http://csis.org/publication/us-national-security-and-global-health.
3
White House, “Fact Sheet: U.S. Global Development Policy,” September 2010, available at: http://www.whitehouse.gov/the-press-
office/2010/09/22/fact-sheet-us-global-development-policy.
4
Department of State, Quadrennial Diplomacy and Development Review: Leading Through Civilian Power, 2010. available at:
http://www.state.gov/documents/organization/153108.pdf.
5
DoD,“About the DoD,” webpage, available at: http://www.defense.gov/about/.
6
DoD,“About the DoD,” webpage, available at: http://www.defense.gov/about/.
7
DoD,“About the DoD,” webpage, available at: http://www.defense.gov/about/.
8
White House Archives, National Security Strategy 2002, available at: http://georgewbush-
whitehouse.archives.gov/nsc/nss/2002/nssintro.html
9
White House Archives, National Security Strategy 2002, available at: http://georgewbush-
whitehouse.archives.gov/nsc/nss/2002/nssintro.html
10
DoD, National Defense Strategy June 2008, available at: http://www.defense.gov/news/2008%20national%20defense%20strategy.pdf.
11
Defense Science Board, Transition to and From Hostilities, Report to the Office of the Secretary of Defense for Acquisitions, Technology and
Logistics, December 2004, available at: http://www.acq.osd.mil/dsb/reports/ADA438417.pdf.
12
DoD, “Stability Operations,” DoD Instruction 3000.05, available at: http://www.dtic.mil/whs/directives/corres/pdf/300005p.pdf.
13
Department of the Army, Counterinsurgency, Field Manual 3-24, December 2006, available at: http://www.fas.org/irp/doddir/army/fm3-
24.pdf.
14
Department of the Army, Operations, Field Manual 3-0, available at: http://usacac.army.mil/cac2/Repository/Materials/FM3-
0(FEB%202008).pdf.
15
DoD, “Stability Operations,” DoD Instruction 3000.05, available at: http://www.dtic.mil/whs/directives/corres/pdf/300005p.pdf.
16
DoD, National Defense Strategy June 2008, available at: http://www.defense.gov/news/2008%20national%20defense%20strategy.pdf.
17
DoD, Sustaining U.S. Global Leadership: Priorities for 21st Century Defense, January 2012. available at:
http://www.defense.gov/news/Defense_Strategic_Guidance.pdf.
18
DoD, Defense Budget Priorities and Choices, January 2012, available at: http://www.defense.gov/news/Defense_Budget_Priorities.pdf.

40 THE U.S. DEPARTMENT OF DEFENSE AND GLOBAL HEALTH

 19
S. Barakat, S. Deely, and S.A. Zyck, “'A tradition of forgetting': stabilisation and humanitarian action in historical perspective,” Disasters, 2010:
34 (Suppl .3), pp. S297-319.
20
J.B. Peake, et al., The Defense Department’s Enduring Contributions to Global Health: The Future of the U.S. Army and Navy Overseas Medical
Research Laboratories, CSIS, June 2011, available at: http://csis.org/publication/defense-departments-enduring-contributions-global-health.
21
R.J. Wilensky, Military medicine to win hearts and minds: aid to civilians in the Vietnam War, Texas Tech University, 2004.
22
L. Rubenstein, Health Initiatives and Counterinsurgency Strategy in Afghanistan, U.S. Institute of Peace Brief, March 2010. available at:
http://www.usip.org/publications/health-initiatives-and-counterinsurgency-strategy-in-afghanistan.
23
D.A. Tarantino and S. Jawad, Iraq Health Care Reconstruction: An After Action Review, CSIS Report, August 2007, available at:
http://csis.org/images/stories/globalhealth/Iraq%20AAR%20final%201%20OCT.pdf.
24
D. Thompson, “The Role of Medical Diplomacy in Stabilizing Afghanistan,” Defense Horizons, May 2008, available at:
http://www.ndu.edu/CTNSP/docUploaded/DH63.pdf.
25
Sources listed in footnote #120 below.
26
National Intelligence Council, Strategic Implications of Global Health, Intelligence Community Assessment 10-D, November 2008, available at:
http://www.dni.gov/nic/PDF_GIF_otherprod/ICA_Global_Health_2008.pdf.
27
S. Patrick, Weak States and Global Threats: Assessing Evidence of “Spillovers,” Center for Global Development, Working Paper 73, January
2006, available at: http://www.cgdev.org/files/5539_file_WP_73.pdf.
28
Congressional Research Service (CRS), Weak and Failing States: Evolving Security Threats and U.S. Policy, RL34253, August 2008, available at:
http://www.fas.org/sgp/crs/row/RL34253.pdf.
29
United Nations Security Council, UN Security Council Resolution 1308, S/RES/1308, 2000, available at: http://daccess-dds-
ny.un.org/doc/UNDOC/GEN/N00/536/02/PDF/N0053602.pdf?OpenElement.
30
A. De Waal, “HIV/AIDS and the challenges of security and conflict,” Lancet 375(9708):22-23, 2 January 2010.
31
National Intelligence Council, The Global Infectious Disease Threat and Its Implications for the United States, National Intelligence Estimate
January 2000, available at: http://www.dni.gov/nic/PDF_GIF_otherprod/infectiousdisease/infectiousdiseases.pdf.
32
H. Feldbaum, K. Lee, and P. Patel, “The National Security Implications of HIV/AIDS,” PLoS Med, 2006: 3(6), p. e171.
33
Institute of Medicine, Emerging infections: microbial threats to health in the United States, 1992.
34
White House Office of Science and Technology Policy, “Emerging Infectious Diseases,” National Science and Technology Council Presidential
Decision Directive 7 (PDD-7), June 1996, available at: http://www.afhsc.mil/viewDocument?file=pdd-nstc-7.pdf.
35
D. Heyman, Lessons from the Anthrax Attacks, CSIS Report on a National Forum on Biodefense, April 2002, available at:
http://www.fas.org/irp/threat/cbw/dtra02.pdf.
36
White House Office of Science and Technology Policy, “Emerging Infectious Diseases,” National Science and Technology Council Presidential
Decision Directive 7 (PDD-7), June 1996, available at: http://www.afhsc.mil/viewDocument?file=pdd-nstc-7.pdf.
37
H. Feldbaum, U.S. Global Health and National Security Policy, CSIS, April 2009, available at:
http://csis.org/files/media/csis/pubs/090420_feldbaum_usglobalhealth.pdf.
38
D.M. Morens, G.K. Folkers, and A.S. Fauci, “The Challenge of Emerging and Re-Emerging Diseases,” Nature, July 8, 2004: 430, pp. 242-249.
39
Defense Science Board, Transition to and From Hostilities, Report to the Office of the Secretary of Defense for Acquisitions, Technology and
Logistics, December 2004, available at: http://www.acq.osd.mil/dsb/reports/ADA438417.pdf.
40
DoD, Military Health Support for Stability Operations, DoD Instruction 6000.16, available at:
http://www.dtic.mil/whs/directives/corres/pdf/600016p.pdf.
41
CRS, Declarations of War and Authorizations for the Use of Military Force: Historical Background and Legal Implications, RL31133, March
2011.
42
Joint Staff, Joint Operation Planning, Joint Publication 5-0, August 2011, available at: http://www.dtic.mil/doctrine/new_pubs/jp5_0.pdf.
43
R. Gates, “Speech to U.S. Global Leadership Coalition,” July 15, 2008, available at:
http://www.defense.gov/speeches/speech.aspx?speechid=1262.
44
USC Title 10.
45
Geographic COCOM Area of Responsibility (Figure 5), available at: http://www.acq.osd.mil/dpap/pacc/cc/images/map.JPG.
46
W.E. Ward, “Statement to House Armed Services Committee by William E Ward, Commander, U.S. Africa Command,” March 13, 2008,
available at: http://www.africom.mil/getArticle.asp?art=1679.
47
The U.S. Marine Corps Medical Officer (who acts as the head medical officer for the Marine Corps) sits within the Navy Surgeon General’s
office, but also reports to the Commandant of the Marine Corps and serves as the primary advisor to the Commandant.
48
Government Accountability Office (GAO), Humanitarian and Development Assistance: Project Evaluation and Better Information Sharing
Needed to Manage the Military’s Efforts, GAO-12-359, February 2012.
49
International Security Assistance Force Afghanistan, About ISAF: Mission, available at: http://www.isaf.nato.int/mission.html.
50
North Atlantic Treaty Organization, “Committee of the Chiefs of Military Medical Services in NATO,” webpage, available at:
http://www.nato.int/cps/en/natolive/topics_49168.htm.
51
NATO Civil-Military Fusion Centre, website, available at: http://www.cimicweb.org/.
52
Center for Disaster and Humanitarian Assistance Medicine (CDHAM) and OSD-HA/International Health Division, Guide to Nongovernmental
Organizations for the Military, available at: http://www.cdham.org/ngo-handbook.
53
A. Lawlor, et al., Navy–NGO Coordination for Health-Related HCA Missions: A Suggested Planning Framework, Center for Naval Analysis,
November 2008, available at: http://www.cna.org/sites/default/files/Navy_NGO%20Coordination.pdf.
54
P.S. Auerbach, et al., “Civil–Military Collaboration in the Initial Medical Response to the Earthquake in Haiti,” New England Journal of
Medicine, 2010: 362, p. e32.
55
M. Pueschel, “Civil-Military Medical Response to Haiti Earthquake May Be Viewed as Model for Disaster Relief,” available at:
http://intlhealth.fhpr.osd.mil/newsID135.mil.aspx.

THE U.S. DEPARTMENT OF DEFENSE AND GLOBAL HEALTH 41

 56
E. Schwartz, The U.S. Military and NGOs: Breaking Down the Barriers, U.S. Army War College Strategy Research Project, March 2007, available
at: http://www.dtic.mil/cgi-bin/GetTRDoc?AD=ADA469613.
57
M. Pueschel, “DoD Reaching out to NGOs for Global Medical Mission,” available at: http://fhp.osd.mil/intlhealth/news.jsp?newsID=119.
58
A.W. Artenstein, et al., “History of U.S. military contributions to the study of vaccines against infectious diseases,” Military Medicine, April
2005: 170(4 Suppl), pp. 3-11.
59
D.G. Heppner, Jr., K.E. Kester, and C.F. Ockenhouse, “Towards an RTS,S-Based, Multi-Stage, Multi-Antigen Vaccine Against Falciparum
Malaria: Progress at the Walter Reed Army Institute of Research,” Vaccine, 2005: 23, pp. 2243–2250.
60
U.S. Military HIV Research Program, “Phase III Trial Thailand,” fact sheet, available at:
http://www.hivresearch.org/media/pnc/9/media.439.pdf.
61
Research America, “DoD: The U.S. Commitment to Global Health,” fact sheet, available at:
http://www.researchamerica.org/uploads/DoDFactsheet.pdf.
62
J. Grabenstein, et al., “Immunization to protect the US armed forces,” Epidemiologic Reviews, June 2006: 28(1), pp. 3-26.
63
J.B. Peake, et al., The Defense Department’s Enduring Contributions to Global Health: The Future of the U.S. Army and Navy Overseas Medical
Research Laboratories, CSIS, June 2011, available at: http://csis.org/publication/defense-departments-enduring-contributions-global-health.
64
M.G. Ottolini and M.W. Burnett, “History of U.S. military contributions to the study of respiratory infections,” Military Medicine, 2005: 170 (4
Suppl.), pp. 66-70.
65
CDC, “Swine influenza A (H1N1) infection 1. in two children—southern California, March–April 2009,” MMWR Morbidity and Mortality
Weekly Report 2009: 58, pp. 400-402.
66
K.L. Russell, et al., “The Global Emerging Infection Surveillance and Response System (GEIS), a U.S. government tool for improved global
biosurveillance: a review of 2009,” BMC Public Health, March 4, 2011: 11 (Suppl. 2), p. S2.
67
A. Smith and C. Llewellyn, “Humanitarian Medical Assistance in U.S. Foreign Policy: Is there a Constructive Role for Military Medical
Services?”, Summer 1992: pp. 70-78.
68
E. C. Ritchie and R.L. Mott, “Military Humanitarian Assistance: The Pitfalls and Promise of Good Intentions,” Chapter 25 in: Military Medical
Ethics, Vol 2, 2004.
69
G.H. Avery and B.J. Boetig, “Medical and Public Health Civic Action Programs: Using Health Engagement as a Tool of Foreign Policy,” World
Medical & Health Policy 2010: 2(1).
70
J.M. Crutcher and H.J. Beecham, “Short-Term Medical Field Missions in Developing Countries: A Practical Approach,” Military Medicine 1995:
160, pp. 339-343.
71
GAO, Hybrid Warfare, briefing to Congress, GAO-10-1036R.
72
DoD, “Stability Operations,” DoD Instruction 3000.05, available at: http://www.dtic.mil/whs/directives/corres/pdf/300005p.pdf.
73
DoD, “Military Health Support for Stability Operations,” DoD Instruction 6000.16, available at:
http://www.dtic.mil/whs/directives/corres/pdf/600016p.pdf.
74
G. Johnson, V. Ramachandran, and J. Walz, The Commander’s Emergency Response Program in Afghanistan: Refining U.S. Military Capabilities
in Stability and In-Conflict Development Activities, Center for Global Development Working Paper 265, September 2011, available at:
http://www.cgdev.org/files/1425397_file_Johnson_Ramachandran_Walz_CERP_FINAL.pdf.
75
Center for Army Lessons Learned, “Chapter 4: Commander's Emergency Response Program,” in Commander's Guide to Money as a Weapons
System Handbook, Handbook 09-27, April 2009, available at: http://usacac.army.mil/cac2/call/docs/09-27/.
76
DoD ASD(HA)/FHP&R/International Health Division, “DoD Making Strides in Preparing for Afghanistan Health Missions,” available at:
http://intlhealth.fhpr.osd.mil/newsID142.mil.aspx.
77
DoD ASD(HA)/FHP&R/International Health Division, “MHS Seeks to Improve Upon Health Reconstruction Lessons in Afghanistan,” available
at: http://intlhealth.fhpr.osd.mil/newsID139.mil.aspx.
78
Combined Joint Task Force – Horn of Africa, website, available at: http://www.hoa.africom.mil/index.asp.
79
M.S. Baker and P. Ryals, “The Medical Department in military operations other than war, Part II: Medical civic assistance program in
Southeast Asia,” Military Medicine, 1999: 164(9), pp. 619-25.
80
D. Agner and S. Murphy, “Cooperative health engagement in stability operations and expanding partner capability and capacity,” Military
Medicine 174(8):iii-vii, August 2009.
81
CRS, Peacekeeping and Related Stability Operations: Issues of U.S. Military Involvement, RL33557, August 2006, available at:
http://www.au.af.mil/au/awc/awcgate/crs/rl33557.pdf.
82
J.P. Chretien, “U.S. Military Global Health Engagement Since 9/11: Seeking Stability Through Health,” Global Health Governance, 2011: Vol
IV(2), available at: http://www.ghgj.org/JeanPaulChretien.pdf.
83
DoD ASD(HA)/FHP&R/International Health Division, “Comfort Mission Shows Renewed MHS Humanitarian Focus,” webpage, available at:
http://intlhealth.fhpr.osd.mil/newsID112.mil.aspx.
84
J.B. Peake, et al., The Defense Department’s Enduring Contributions to Global Health: The Future of the U.S. Army and Navy Overseas Medical
Research Laboratories, CSIS, June 2011, available at: http://csis.org/publication/defense-departments-enduring-contributions-global-health.
85
R.G. Hibbs, "NAMRU-3: forty-six years of infectious disease research," Military Medicine, 1993: 158, p. 484-488.
86
D.J. Licina, “Disaster Preparedness—Formalizing a Comparative Advantage for the Department of Defense in U.S. Global Health and Foreign
Policy,” Military Medicine, 2011: 176(11).
87
DoD, Doctrine for Joint Operations 2006, rev. 2008, Joint Pub 3-0.
88
DoD, Joint Tactics, Techniques, and Procedures for Foreign Humanitarian Assistance, Joint Pub 3-07.6, August 2001.
89
Defense Threat Reduction Agency, “Biological Threat Reduction Program, available at:
http://www.dtra.mil/Missions/NunLugar/BiologicalThreatReductionProgram.aspx.
90
National Academies, The Biological Threat Reduction Program of the Department of Defense: From Foreign Assistance to Sustainable
Partnerships, National Academies Press, 2007.

42 THE U.S. DEPARTMENT OF DEFENSE AND GLOBAL HEALTH

 91
CDC Center for Global Health, “South Caucasus,” fact sheet, available at:
http://www.cdc.gov/globalhealth/SMDP/pdf/South_caucasus_factsheet.pdf.
92
See DTRA note in the U.S. Global Health Initiative, Georgia Country Strategy, available at:
http://www.ghi.gov/documents/organization/175130.pdf.
93
G. Hess, “Biosecurity effort expands to Africa,” Chemical and Engineering News, April 2011, available at:
http://dtirp.dtra.mil/pdfs/ng_11apr11_1.pdf.
94
E.V. Bonventre, K.H. Hicks, and S.M. Okutani, U.S. National Security and Global Health: An Analysis of Global Health Engagement by the U.S.
Department of Defense, CSIS, April 2009, available at: http://csis.org/publication/us-national-security-and-global-health.
95
H.A. Irish, “A ‘Peace Corps With Guns’: Can the Military be a Tool of Development?”, Chapter 3 in The Interagency and Counterinsurgency
Warfare: Stability, Security, Transition, and Reconstruction Roles, U.S. Army Strategic Studies Institute, August 2007, available at:
http://www.strategicstudiesinstitute.army.mil/pdffiles/pub828.pdf.
96
DoD, “DoD Issuances,” June 5, 2011, available at: http://www.dtic.mil/whs/directives/corres/writing/DoD_Issuances.ppt.
97
DoD, “DoD Website for DoD Issuances,” website, available at: http://www.dtic.mil/whs/directives/.
98
Chairman of the Joint Chiefs of Staff Instruction, “Chairman of the Joint Chiefs of Staff, Combatant Commanders, and Joint Staff Participation
in the Planning, Programming, Budgeting, and Execution Systems,” CJCSI 8501.01A, December 3, 2004.
99
CRS, A Defense Budget Primer, December 9, 1998.
100
For more information about the PBBE process, see DoD, “Chairman of the Joint Chiefs of Staff, Combatant Commanders, and Joint Staff
Participation in the Planning, Programming, Budgeting, and Execution System,” Chairman of the Joint Chiefs of Staff Instruction 8501.01A,
December 3, 2004.
101
There are typically two principal appropriation bills passed by Congress each year: the DoD Appropriations Act and the Military Construction
Appropriations Act.
102
DoD Comptroller, FY 2013 Budget Request Overview Book, February 2012,
available at: http://comptroller.defense.gov/defbudget/fy2013/FY2013_Budget_Request_Overview_Book.pdf.
103
OGAC, PEPFAR FY 2011 Operational Plan, December 2011, available at: http://www.pepfar.gov/about/c50005.htm.
104
Kaiser Family Foundation, “Budget Tracker: Status of U.S. FY2012 Funding for Key Global Health Related Accounts,” available at:
http://www.kff.org/globalhealth/8045.cfm.
105
Consolidated Appropriations Act, 2012 (P.L. 112-74), available at: http://www.gpo.gov/fdsys/pkg/BILLS-112hr2055enr/pdf/BILLS-
112hr2055enr.pdf; Military Construction and Veterans Affairs and Related Agencies Appropriations Act, 2012 (H.R. 2055) Conference Report
[enrolled as Consolidated Appropriations Act, 2012 (P.L. 112-74)]: Joint Explanatory Statement of the Committee of Conference, available at:
http://rules.house.gov/Legislation/legislationDetails.aspx?NewsID=667; DoD Fiscal Year (FY) 2013 President's Budget Submission—Army
Justification Book: Research, Development, Test & Evaluation, Army RDT&E - Volume I, Budget Activity 1, Feb. 2012, available at:
http://asafm.army.mil/Documents/OfficeDocuments/Budget/BudgetMaterials/FY13/rforms//vol1.pdf, p. 23, 92 (PE 0601101A, Project 91-C; PE
0601102A, Project S13); DoD Fiscal Year (FY) 2013 President's Budget Submission—Army Justification Book: Research, Development, Test &
Evaluation, Army RDT&E - Volume I, Budget Activity 2, Feb. 2012, available at:
http://asafm.army.mil/Documents/OfficeDocuments/Budget/BudgetMaterials/FY13/rforms//vol2.pdf, p. 261, pp. 271-277 (PE 0602787A,
Project 870; PE 0602787A, Project 873); DoD Fiscal Year (FY) 2013 President's Budget Submission—Army Justification Book: Research,
Development, Test & Evaluation, Army RDT&E - Volume I, Budget Activity 3, Feb. 2012, available at:
http://asafm.army.mil/Documents/OfficeDocuments/Budget/BudgetMaterials/FY13/rforms//vol3.pdf, p. 35-42, 147-151 (PE 0603105A,
Projects H29 and T16; PE 0603002A, Project 810); DoD Fiscal Year (FY) 2013 President's Budget Submission—Army Justification Book: Research,
Development, Test & Evaluation, Army RDT&E - Volume I, Budget Activity 4, Feb. 2012, available at:
http://asafm.army.mil/Documents/OfficeDocuments/Budget/BudgetMaterials/FY13/rforms//vol4.pdf, p. 263, 265-276 (PE 0603807A, Projects
808 and 811); DoD FY 2013 President's Budget: Operation and Maintenance Programs (O-1) and Revolving and Management Funds (RF-1), Feb.
2012, available at: http://comptroller.defense.gov/defbudget/fy2013/fy2013_o1.pdf, p. 6, 10, 68; DoD Budget FY 2013: Justification for FY 2013
Overseas Contingency Operations Afghanistan Security Forces Fund (ASFF), Feb. 2012, available at:
http://asafm.army.mil/Documents/OfficeDocuments/Budget/BudgetMaterials/FY13/OCO//asff.pdf; DoD Budget FY 2013: Defense Health
Program FY 2013 Budget Estimates—Operation and Maintenance, Procurement, Research, Development, Test and Evaluation, Feb. 2012,
available at: http://comptroller.defense.gov/defbudget/fy2013/budget_justification/pdfs/09_Defense_Health_Program/DHP_PB13_Vol_I-
II.pdf, p. 9, 76, 92, 96-98, 125-6; KFF personal communication with Armed Forces Health Surveillance Center/GEIS Operations Division, August
23, 2012; DoD FY2013 President's Budget Submission: Navy Justification Book Volume 3: Research, Development, Test & Evaluation, Navy
Budget Activity 5, February 2012, available at: http://www.finance.hq.navy.mil/FMB/13pres/RDTEN_BA5_book.pdf, p. 979 (PE 0604771N:
Medical Development, Project 0933 Medical/Dental Equipment Development).
106
Consolidated Appropriations Act, 2012 (P.L. 112-74), available at: http://www.gpo.gov/fdsys/pkg/BILLS-112hr2055enr/pdf/BILLS-
112hr2055enr.pdf; Military Construction and Veterans Affairs and Related Agencies Appropriations Act, 2012 (H.R. 2055) Conference Report
[enrolled as Consolidated Appropriations Act, 2012 (P.L. 112-74)]: Joint Explanatory Statement of the Committee of Conference, available at:
http://rules.house.gov/Legislation/legislationDetails.aspx?NewsID=667; Department of State, Congressional Budget Justification: Department of
State Operations, Fiscal Year 2013, Feb. 2012, available at: http://www.state.gov/documents/organization/181061.pdf; DoD Fiscal Year 2013
Budget Estimates: Justification for FY 2013 Operation and Maintenance, Defense-Wide, Vol. 1, Feb. 2012, available at:
http://comptroller.defense.gov/defbudget/fy2013/budget_justification/pdfs/01_Operation_and_Maintenance/O_M_VOL_1_PARTS/Volume_I
_Part_I.pdf, p. 485-487, 871, 882; DSCA, “IMET,” webpage, available at:
http://www.dsca.mil/home/international_military_education_training.htm; National Guard, “National Guard State Partnership Program,”
webpage, available at: http://www.nationalguard.mil/features/spp/default.aspx; DoD, FY 2013 President’s Budget: Contingency Operations
(Base Budget), Feb. 2012, available at: http://comptroller.defense.gov/defbudget/fy2013/FY2013_OCOTF.pdf; GAO, State Partnership Program:
Improved Oversight, Guidance, and Training Needed for National Guard's Efforts with Foreign Partners, May 2012, available at:

THE U.S. DEPARTMENT OF DEFENSE AND GLOBAL HEALTH 43

 http://www.gao.gov/assets/600/590840.pdf; Department of Defense Budget FY 2013: Construction Programs (C-1), Feb. 2012, available at:
http://comptroller.defense.gov/defbudget/fy2013/fy2013_c1.pdf; Joint Chiefs of Staff, “CJCSI 4600.02A: Exercise-Related Construction (ERC)
Program Management,” instruction, March 18, 2011, available at: http://www.dtic.mil/cjcs_directives/cdata/unlimit/4600_02.pdf; GAO,
Humanitarian and Development Assistance: Project Evaluations and Better Information Sharing Needed to Manage the Military’s Efforts, Feb.
2012, available at: http://www.gao.gov/assets/590/588334.pdf; DoD FY2013 President's Budget Submission: Navy Justification Book Volume 1:
Research, Development, Test & Evaluation, Navy Budget Activities 1, 2, and 3, February 2012, available at:
http://www.finance.hq.navy.mil/FMB/13pres/RDTEN_BA1-3_BOOK.pdf , p. 91 (PE 0601153N: Defense Research Sciences, BA-1 Basic Research).
107
DoD, Sustaining U.S. Global Leadership: Priorities for 21st Century Defense, January 2012, available at:
http://www.defense.gov/news/Defense_Strategic_Guidance.pdf.
108
GAO, Humanitarian and Development Assistance: Project Evaluation and Better Information Sharing Needed to Manage the Military’s
Efforts, GAO-12-359, February 2012.
109
J.P. Chretien, “U.S. Military Global Health Engagement since 9/11: Seeking Stability through Health,” Global Health Governance, Spring 2011:
4(2), available at: http://www.ghgj.org/JeanPaulChretien.pdf.
110
D.L. Byman, “NGOs and the Military: Uncertain Partners,” Survival, Summer 2001: 43(2), pp. 97-114.
111
World Health Organization Global Health Cluster Working Group, Civil-military coordination during humanitarian health action, position
paper, available at:
http://www.who.int/hac/global_health_cluster/about/policy_strategy/ghc_position_paper_civil_military_coord_2_feb2011.pdf.
112
N. Bristol, “Military incursions into aid work anger humanitarian groups,” Lancet, 2006: 367(9508), pp. 384-6.
113
M.J. Morton and G.M. Burnham, Dilemmas and controversies within civilian and military organizations in the execution of humanitarian aid
in Iraq: a review, American Journal of Disaster Medicine, Nov-Dec 2010: 5(6), pp. 385-91.
114
See the following GAO reportsHumanitarian and Development Assistance: Project Evaluation and Better Information Sharing Needed to
Manage the Military’s Efforts, GAO-12-359, February 2012; Defense Management: U.S. Southern Command Demonstrates Interagency
Collaboration, but Its Haiti Disaster Response Revealed Challenges Conducting a Large Military Operation, GAO-10-801, July 2010; Provincial
Reconstruction Teams in Afghanistan and Iraq, GAO-09-86R, October 2008; Defense Management: Improved Planning, Training, and
Interagency Collaboration Could Strengthen DoD’s Efforts in Africa, GAO-10-794, July 2010; National Security: An Overview of Professional
Development Activities Intended to Improve Interagency Collaboration, GAO-11-108, November, 2010; National Security: Key Challenges and
Solution to Strengthen Interagency Collaboration [Testimony], GAO-10-822T, June 2010; Interagency Collaboration Practices and Challenges at
DoD’s Southern and Africa Commands [Testimony], GAO-10-962, July 2010; Military Operations: Actions Needed to Improve Oversight and
Interagency Coordination for the Commander’s Emergency Response Program in Afghanistan, GAO-09-615, May 2009; Military Operations:
Actions Needed to Improve DoD’s Stability Operations Approach and Enhance Interagency Planning, GAO-07-549, May 2009.
115
See the DoD written responses to the recommendations made in the GAO reports listed above, and: Office of the Under Secretary of
Defense for Policy, Preserving Stability Operations Capabilities to Meet Future Challenges: Biennial Assessment of Stability Operations
Capabilities, February 2012, available at: http://www.ccoportal.org/sites/ccoportal.org/files/biennial_assessment_of_stability_operations.pdf;
DoD, Report to Congress on the Integration of Interagency Capabilities into Department of Defense Planning for Stability Operations, May 2009,
available at:
http://pksoi.army.mil/doctrine_concepts/documents/Rpt%20to%20Congress%20on%20the%20Integration%20of%20IA%20Caps%20into%20D
oD%20Planning%20(May%2009).pdf.
116
Secretary of Defense, Report to Congress on the Implementation of DoD Directive 3000.05, April 2007, available at:
http://policy.defense.gov/downloads/Congressional_Report_on_DoDD_3000-05_Implementation_final_2.pdf.
117
GAO, Humanitarian and Development Assistance: Project Evaluation and Better Information Sharing Needed to Manage the Military’s
Efforts, GAO-12-359, February 2012.
118
C. Ockenhouse, “History of U.S. Military Contributions in Malaria,” Military Medicine, 2005: 170 (Suppl 4-April); J.B. Peake, et al., The Defense
Department’s Enduring Contributions to Global Health: The Future of the U.S. Army and Navy Overseas Medical Research Laboratories, CSIS,
June 2011, available at: http://csis.org/publication/defense-departments-enduring-contributions-global-health; J. Grabenstein, et al,
“Immunization to Protect the US Armed Forces: Heritage, Current Practice and Prospects,” Epidemiologic Reviews 2006: 28. Walter Reed Army
Institute for Research (WRAIR) Index of Publications 2009; Barakat, Deely, and Zyck, “A tradition of forgetting: stabilisation and humanitarian
action in historical perspective,” Disasters, 2010: 34 (Suppl 3), pp. S297-319; CRS, Africa Command: U.S. Strategic Interests and the Role of the
U.S. Military in Africa, July 2011; A. Artenstein, et al., “History of U.S. Military Contributions to the Study of Vaccines against Infectious
Diseases,” Military Medicine 170(Suppl 4-April), 2005; CRS, The Department of Defense Role in Foreign Assistance: Background, Major Issues,
and Options for Congress, RL34639, 2008; USAID Office of Military Affairs, Civil Military Program Operations Guide, April 2010; N. Bensahel and
S. Harting, A Civil Affair: U.S. Government Efforts to Generate Civilian Capacity, Stanley Foundation Project Brief, 2008; M. Ottolini and M.
Burnett, “History of U.S. Military Contributions to the Study of Respiratory Infections,” Military Medicine, 2005: 170(4 Suppl-April); D. Reveron,
“Weak States and Security Assistance,” PRISM, 2009: 1(3); White House, National Security Decision Directive 38, available at:
http://www.state.gov/m/pri/nsdd/; Institute of Medicine, Battling Malaria: Strengthening the U.S. Military Malaria Vaccine Program, 2006;
Military HIV Research Program (MHRP), "Africa," pamphlet, available at: www.hivresearch.com; GAO, Department of Defense: Changes Needed
to the Humanitarian and Civic Assistance Program, 1993; CRS, Peacekeeping and Related Stability Operations: Issues of US Military Involvement,
2006 RL33557; RAND, America's Role in Nation-Building from Germany to Iraq, 2003; M. Manwaring, “Peace and Stability Lessons from Bosnia,”
Parameters, Winter 1998; J. Lange, Civilian-Military Cooperation and Humanitarian Assistance: Lessons From Rwanda, National Defense
University, 1996; W. Hamblet and J. Kline, “Interagency Cooperation: PPD 56 and Complex Contingency Operations,” Joint Forces Quarterly,
Spring 2000; Center for Disaster and Humanitarian Assistance Medicine, website, available at: www.cdham.org; Ward, et al., “A Global
Engagement Enhancer: The International Health Specialist,” Air & Space Power Journal, Fall 2002; J.P. Chretien, “U.S. Military Health
Engagement since 9/11: Seeking Stability through Health,” Global Health Governance, IV(2); J. Piombo, “Military Provision of Humanitarian and
Civic Assistance,” Center for Complex Operations Case Study No. 5, Naval Postgraduate School; MHRP, "Military Medicine: Building on a

44 THE U.S. DEPARTMENT OF DEFENSE AND GLOBAL HEALTH

 tradition of success in infectious diseases," pamphlet, available at: www.hivresearch.com; GAO, Actions Needed to Improve Oversight and
Interagency Coordination for the Commander's Emergency Response Program in Afghanistan, May 2009; Patterson and Robinson, “The
Commander as Investor,” PRISM 2(2), 2010; D. Tarantino, “Asian Tsunami Relief: Department of Defense Public Health Response,” Military
Medicine, 2006: 171(10); CRS, Quadrennial Defense Review 2010: Overview and Implications for National Security Planning, May 2010; Derleth
and Alexander, “Stability Operations: From Policy To Practice,” PRISM, 2010: 2(3); W. Bowers, “Pakistan Earthquake Relief Operations,” PRISM,
2009: 2(1); B. Stone, “Blind Ambition: Lessons Learned and Not Learned in an Embedded PRT,” PRISM, 2009: 1(4); GAO, Provincial
Reconstruction Teams in Afghanistan and Iraq, GAO-09-86R, 2008; DoD ASD(HA)/FHP&R/International Health Division, website, available at:
http://intlhealth.fhpr.osd.mil/home.aspx.

THE U.S. DEPARTMENT OF DEFENSE AND GLOBAL HEALTH 45

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