As the hunt for Osama bin Laden began to focus on the now infamous compound in Abbottabad, Pakistan, the CIA desperately sought confirmation that he was there. The agency came up with an idea: hire a local doctor to conduct a fake vaccination campaign, which it hoped could lead to obtaining blood samples from bin Laden’s grandchildren that could be analyzed for a DNA match to bin Laden. One could dismiss the campaign as just another imaginative tactic used by the CIA in the search; the fact that it involved a population health ruse could be of no more significance than had the CIA hired agents to sell lottery tickets door to door in the neighborhood. But the selection of a vaccination campaign may not have been mere happenstance, just another case example of the increasing use of a health intervention to advance a specific national security objective.

A clue to such thinking emerged after the United Kingdom’s Guardian revealed the ruse. After at first refusing to comment, a senior administration official told United Press International that it had been intended as “an actual vaccination campaign conducted by real medical professionals.” The statement was only half true. Medical workers were recruited to organize and conduct a vaccination initiative to provide real vaccines for hepatitis B, but the campaign nevertheless was fraudulent from the start as it failed to follow standard immunization procedure, which requires a follow up vaccine that was never administered.

Health and Diplomacy
The relationship among health, national security, and foreign policy has recently gained attention from scholars as well as diplomats. The most obvious use of diplomacy in the health context has been to prevent cross-border infectious disease transmission, and to protect economic interests of domestic corporations in connection with health products. Since the SARS epidemic, diplomatic efforts have strengthened international and regional cooperation to limit transmission of infectious diseases through the World Health Organization’s international health regulations (WHO). The negotiations addressed traditional areas of state concern, especially whether outbreak reporting would continue to be constrained by state sovereignty or rather would yield to a more global approach to information dissemination. This past year, further agreements were reached at the World Health Assembly to address sticky issues about sample sharing and access of poor countries to vaccines. Other contentious subjects of international health negotiations include the marketing of tobacco, and the effort to reconcile patent rights of manufacturers of drugs for HIV/AIDS and other diseases predominant in poor countries with the legitimate demand for affordable life-saving drugs.

In other circumstances, diplomacy has been invoked not to resolve disputes pitting economic interests against health, but simply to advance health, both for its own sake and to promote the emergence of well-governed states that can serve the needs of their populations. In 2009, the National Intelligence Council issued a report on Global Health as a Security Issue, arguing that chronic, non-communicable diseases, neglected tropical diseases, maternal and child mortality, malnutrition, sanitation and access to clean water, and availability of basic health-care were significant to US national security. In Nigeria, for example, diplomatic tools were invoked to overcome politically inspired resistance to a polio vaccination program. An effective health system contributes to long-term economic growth and, arguably, political stability.

In all these cases, health is seen as an independent good, and diplomacy is used to promote it or reconcile it against other interests. But there is another variation on health diplomacy where health benefits are not the primary focus. Health interventions are used as a means of accomplishing other national objectives. The United States has especially sought to use health interventions to improve its image and influence, to counter extremism and terrorism, or to stabilize a country or region in the short-term. These instrumental uses of health—principally to advance national security—have received little scrutiny. That is largely because it is typically assumed that even with the subordination of health as the main policy objective, health benefits will accrue to the affected populations, creating a win-win situation, a version of doing well by doing good.

For example, so long as disaster relief programs are structured to meet real needs and are not manipulated for the purpose of gaining favorable publicity, there is no conflict between aiding victims and advancing the image of the United States among the affected population. Similarly, so long as they follow accepted principles of international aid, public health, and human rights, global health programs can promote health while advancing US influence. Indeed, the United States can sometimes leverage health assistance to promote other goals as well, such as protection of women’s rights. In the realm of long-term stabilization, there is some evidence that health programs can bring about a healthier workforce and thus contribute to economic development. In some circumstances a well-run health system can contribute to people’s confidence that the national government is meeting their needs, and thus contributes to the government’s legitimacy.

The Emergence of Health Instrumentalism
The idea of using health intervention to advance other national objectives has become so mainstream that Secretary of State Hillary Clinton referred to global health investments as a means of protecting the nation’s security, and as a “tool of public diplomacy.” She argued that for many people, health programs are perhaps the “main experience of us as a country and a people,” and can be very powerful. US assistance in prolonging life and preventing disease, she said, “conveys as much about our values as any state visit or strategic dialogue ever could.”

Fair enough. But not all instrumental uses of health interventions demonstrate congruence between the national security objective and the proposed health benefit. The CIA operation in Abbottabad is the most spectacular case with a fraudulent health purpose. But it is not the only example. Take, for example, health programs designed to reduce the risk of terrorism and extremism, or support counterinsurgency campaigns in Afghanistan and in the horn of Africa. These health programs are conducted by the military and civilian agencies. In Afghanistan, the military conducts a large number of health assistance programs; US Agency for International Development (USAID) policy evolved to require that development and health programs serve counterinsurgency goals to win over the population and reinforce central government authority. Health projects as part of the campaign include training local providers, supplying medications to clinics, and constructing facilities, and are employed to achieve either a short-term objective such as security, or a strategic goal to deny potential terrorists the allegiance of the population.

These instrumental uses of health interventions are premised on three assumptions, only the first of which is articulated. First, they assume that health interventions can achieve the national security purpose of influencing the population to invest their support in their own (US-friendly) government, or decrease the attractiveness of extremist or terrorist groups. Second, they assume that the health interventions employed are consistent with the health needs of the population and are beneficial to them. Third, they assume that, even if the interventions do not have positive health benefits, they will at least be neutral, not harming health.

There is reason for skepticism as to whether these assumptions are correct. There is scant evidence that health interventions contribute substantially to achieving objectives like increasing security, securing the allegiance of the population, or stabilizing a region. Two studies conducted by the Feinstein International Center at Tufts University shed some light on the question. In a review of a US military program in Kenya that offers health and education interventions to communities as a means of countering the attractiveness of violent extremism, Mark Bradbury and Michael Kleinman concluded that although people were positive about the initiative, they recognized that the health programs were not sustainable. They were not naïve about the programs’ purpose and were not influenced to change behavior or political allegiances. Bradbury and Kleinman report that the people viewed the modest assistance as “indicative of a lack of serious intent to improve their welfare and develop their communities.” Indeed, the authors conclude recipients recognize that the purpose is to advance “counterterrorism interests of the US and Kenyan governments, rather than their own well-being or security.”

A study by Stuart Gordon of UK assistance in Helmand Province in Afghanistan found that local insecurity was a product of maldistribution of power and resources among tribal groups. The people are exploited by predatory taxation, political influence, and violence, as well as the use of development funding as patronage. As a result, afflicted people were made vulnerable to Taliban infiltration and offers of protection. Additional grievances were stimulated by uneven eradication of opium poppy, the inability of the international community to stop predatory behavior, and civilian casualties caused by NATO military activity. Development-type interventions did nothing to address concerns about power, security and justice, and thus did little to accomplish their purposes. Indeed, some people perceived the development interventions as contributing to insecurity because of corruption and lack of equity in distribution of aid benefits.

More broadly, it is reasonable to question how significantly health interventions can affect either population allegiances or stability in comparison to personal security, opportunities for jobs, a fair justice system, or the distribution of local power. There is considerable evidence that services like education and health, if of high quality, can create positive perceptions of government in the long-term, but the contribution of health programs to a sense of government legitimacy in the short-term is highly speculative. In part this minimal impact may be a product of a disjunction between means and ends, where relatively modest services are expected to affect entrenched power dynamics, personal security, and economic opportunities. Programs are typically too limited in scale to have any impact on a counterinsurgency goal of fostering stronger allegiance to government.

Even when the ends sought are more modest, such as gaining the support of a particular village, there is a paucity of knowledge whether and how health interventions can benefit them, or whether they are structured to achieve the goal. Indeed, we do not even have good metrics for measuring the impacts of those interventions. Moreover, as former USAID global health director, Dr. Anne Peterson, who evaluated civilian and military programs in Afghanistan, has pointed out, even where programs successfully increase the level and effectiveness of health services, they may fall short of the expectations created in communities about the expansion of services. In such cases, the limited assistance provided may breed resentment and anger rather than appreciation and allegiance.

As a result, USAID’s infatuation with development grounded in counterinsurgency policy, however nicely dressed up in “whole of government” language, is starting to recede. Earlier this year USAID Administrator Rajiv Shah acknowledged that power dynamics, not lack of schools and roads, are the drivers of conflict. The same could be said of health. The military, too, though hardly abandoning the use of health as an element of counterinsurgency strategy, is beginning to recognize that at least some of its health programs are too minimalist, or even counter-productive, to have an impact. For example, it has largely abandoned Medical Civil Action Programs (MEDCAPS), which swoop down into a community for a couple of days, treat people, and leave with no prospect of follow up. The military is also becoming somewhat more sophisticated, beginning to resist building clinics that become useless because no provision has been made for supplies and staff in the intermediate term. It is focusing more on programs to provide health care where insecurity has made it impossible for civilian agencies to do so.

Benign Failures or Serious Dangers?
So should these programs be judged merely as benign failures, the equivalent of giving a few lollipops to kids expecting to change the attitude of the population? The assumption that health interventions employed instrumentally actually improve health remains unproven. Warm anecdotes about an operation performed on a child or a clinic newly supplied with drugs mask the fact that counterinsurgency health interventions are typically short-term and unsustainable. Indeed, they are often labeled “quick impact” projects and might be characterized instead as “short-impact” projects. Especially in military-run operations, given short deployments, pressures to act quickly, lack of expertise in systems building, and difficulties of coordination with civilian agencies, the health benefits may thus be marginal at best.

The contrast between counterinsurgency and systemic approaches is evident in Afghanistan, where counter-insurgency health interventions are not harmonized with a major initiative by the United States, the World Bank, and the European Commission to support the Afghanistan Ministry of Public Health in significantly expanding primary health care and reducing child mortality. This long-term initiative in capacity building and service development, which began well before the counterinsurgency strategy was in place and is rooted in community support, is far more likely to advance health and support long-term legitimacy than counterinsurgency interventions. An otherwise highly critical majority staff report for the Senate Committee on Foreign Relations on development assistance in Afghanistan noted earlier this year that the health development initiative is a “remarkable success.” The report noted that by coordinating donor activities and unifying Afghanistan’s health system, the program has dramatically increased access of the Afghan people to primary health care. This initiative had nothing to do with counterinsurgency, and indeed was not coordinated with it; it was designed to improve the health of Afghans, and has done so.

The third assumption is that, at worst, instrumental use of health interventions is neutral; that it doesn’t make health worse. But the possibility of harm should not be discounted. The instrumental use of health interventions to purchase loyalty of local leaders or groups in the name of security or stabilization can exacerbate inequality and inequity, which undermines effective and just health service development. Geographical distortions can also result from an instrumental use of health programs. In Afghanistan, the counterinsurgency policy resulted in concentrating more than 80 percent of development resources to the south and east, and for a time jeopardized the successful national program of health services development.

The bin Laden case also illustrates the most serious risks of using health interventions instrumentally in the service of national security. Pakistan is one of a handful of countries where polio remains endemic, hindering efforts to eradicate the disease from the world. Polio vaccination programs are essential, but depend on the trust of the population, and are highly vulnerable to doubts and hostility sown and exploited by demagogues. Muslim countries in particular have been subjected to claims that vaccination programs are part of a Western conspiracy to control women’s fertility, introduce HIV, or advance some other nefarious purpose. It is no surprise, then, that officials of the WHO, UNICEF, and other groups active in polio campaigns in Pakistan expressed concern whether the CIA’s stunt would undercut their efforts. We can speculate that these consequences were never even weighed by the CIA against the potential intelligence gained about bin Laden’s location.

The United States has shown exemplary leadership in addressing some of the most widespread sources of morbidity and mortality in the world, including HIV/AIDS, malaria, death in childbirth, and others. It is investing tens of billions of dollars in the effort, developing ever more sophisticated approaches to building health systems rather than just one-off interventions against a particular disease. The success of these programs, of course, depends both on the values and purposes by which they are operated, and the perception that they are managed in good faith to advance health. Officials that take great care to build trust and design programs based on population health needs can achieve significant results. In Afghanistan, for example, with the help of an intermediary, polio vaccination programs involved very quiet cooperation among government officials, local leaders, and the Taliban. The goal of such an effort is not to gain a tactical advantage over the Taliban, but to vaccinate children. That is the goal that should drive policy. The use of health interventions for short-term national security objectives is not only a fantasy, but a dangerous one.