HHS and Health Diplomacy
BY JIMMY KOLKER
I first recognized the U.S. Department of Health and Human Services’ unique value to our diplomacy as chief of mission in Burkina Faso during a meningitis outbreak, which had been hidden by local authorities because the capital was filled with visitors to a biennial African film festival.
Within days, the Centers for Disease Control and Prevention sent three of the world’s leading meningitis experts to help Burkina urgently map and ultimately control the outbreak. Later, as HHS assistant secretary for global affairs from 2014 to 2017, and the first person with a Foreign Service background to have a leadership role at the department, I came to understand and appreciate its contribution more fully.
HHS is a major global actor. There are nearly 2,000 HHS staff under chief-of-mission authority overseas—1,500 Locally Employed staff and 500 Americans. These include HHS attachés, who advise chiefs of mission and country teams on health policy in Geneva, Beijing, Brasilia, Mexico City, Pretoria and New Delhi. And the Centers for Disease Control and Prevention, an HHS agency, has staff in more than 60 countries, and the CDC country director often provides wide-ranging health expertise on the country team.
HHS staff members are typically hired for domestic priorities, yet their skills are of growing value internationally.
At the same time, HHS is intensely domestic in its culture, systems and thinking. With unmatched health, medical and scientific expertise, HHS staff members are typically hired for domestic priorities, yet their skills are of clear and growing value internationally. Our relationships with low- and middle-income countries no longer reflect a classic “donor-recipient” model. Even poor countries like Burkina want a technical partnership, where our best experts help build the capacity of national counterparts.
Because U.S. missions abroad are unaware of it and because HHS’s own staffing patterns and funding historically fulfill a domestic mandate and are not easily adaptable to overseas activity or assignment, this tremendous U.S. government asset—expertise-in-person—is underutilized.
HHS’s role and mandate began to change, however, in 2004 when the President’s Emergency Plan for AIDS Relief, the President’s Malaria Initiative and the Global Health Security Agenda all named HHS as an implementer. Approximately $2 billion in PEPFAR money goes annually to HHS—not just to CDC, but also to the National Institutes of Health, the Food and Drug Administration, and the Health Resources and Substance Abuse and Mental Health Services Administrations (HRSA and SAMHSA).
The value of HHS’s already-on-the-payroll expertise was nowhere better demonstrated than in the establishment and staffing of the Monrovia Medical Unit during the 2014-2015 Ebola outbreak in West Africa.
The U.S. military delivered Ebola treatment unit structures to Liberia, but did not staff them. USAID-funded nongovernmental organizations and medical personnel from around the world, as well as Liberians themselves, were reluctant to scale up treatment unless they could be assured a developed-world level of care if they became infected. To offer that level of treatment, the U.S. military assembled and customized a field hospital outside of Monrovia.
Of all the options for staffing this unit, the Public Health Service of HHS made the most sense. It consists of vetted U.S. government employees subject to discipline and deployment rules established for this uniformed service who, as individuals, are highly motivated to use their skills to fight Ebola. When the call went out for PHS volunteers, projections for infection were catastrophic. Despite the substantial risk, more than 1,000 of the 6,000 commissioned corps officers volunteered for duty in Liberia.
Deploying the PHS, however, was complicated. The volunteers all had domestic assignments for which it was difficult or impossible to find temporary replacements. There was no direct PHS doctrine or precedent for an operation of this size and character.
My office, Global Affairs, worked with Embassy Monrovia, USAID, CDC and the Pentagon to establish responsibility for reporting chains, security and force protection, and specialized Ebola training. We negotiated the right to practice medicine and prescribe drugs in Liberia, living arrangements, water supply and definitions of health workers for patient access.
HHS’ distinctive value is that its key staff are subject-matter experts, scientists, different from but mutually supportive of generalist diplomats.
In setting treatment protocols, we turned to, among others, Kent Brantly, the missionary doctor who had been evacuated from Monrovia. He eagerly advised what would have been necessary to have saved his own life and the lives of his patients in Liberia in 2014.
HHS also played a vital role in the response to the Zika virus outbreak in Brazil. The HHS Office of Global Affairs led a delegation of senior HHS scientists to meet with counterparts in Brasilia to overcome bottlenecks in cohort studies, sample sharing and institutional arrangements. The 14-point action plan developed, assigning responsibility to HHS divisions and counterpart Brazilian parastatal organizations, proved extremely valuable. Though the Dilma Rousseff government subsequently fell, the institution-to-institution agreements were carried out with very little interference or loss of momentum.
Even before we knew Ebola was a problem, in February 2014, then-HHS Secretary Kathleen Sebelius, together with the State Department and National Security Council, launched the Global Health Security Agenda. A growing, multisectoral partnership, GHSA has become the world’s vehicle for scaling up to prevent outbreaks in the weakest health systems from becoming pandemics, threatening all of us.
GHSA’s premise is that to contain a naturally occurring outbreak, a lab accident or a bioterrorist attack, the first response has to be the health system that identifies the pathogen, does the surveillance, finds its origin and promotes measures to limit its damage. If it is a bioterrorist incident, security services will, of course, be involved. But protecting the public relies on a resilient health infrastructure, and especially the case management, emergency operations centers and established protocols that CDC is so good at. On this basis the U.S. government was able to convene quite a few governments and partners, and strengthen the World Health Organization to promote and scale up worldwide outbreak preparedness and response.
As the HHS presence grows overseas, there is renewed discussion of an “HHS Foreign Service.” While it could ease overseas staffing and rotation issues for which the Civil Service does not have a workable alternative, I don’t see that as the best option. HHS’ distinctive value is that its key staff are subject-matter experts, scientists, different from but mutually supportive of generalist diplomats. An even more important consideration is that nearly all of HHS international assignments use PEPFAR, GHSA and the U.S. President’s Malaria Initiative programmatic money, with no guarantee of career-long sustainability.
In my Foreign Service experience, contacts between health scientists and diplomats were rare, and use of scientific data in démarches or political dialogue was haphazard or non-existent. But today, with the State Department’s Offices of International Health and Biosecurity and Global Health Diplomacy, HHS can be an essential partner to help the two cultures appreciate and take advantage of their respective strengths.