MILITARY MEDICAL OPERATIONS IN SUB-SAHARAN AFRICA: THE DoD "POINT OF THE SPEAR" FOR A NEW CENTURY C. William Fox, Jr. June 24, 1997 ******* This monograph, selected as a "Distinguished Essay" in the 1997 Chairman of the Joint Chiefs of Staff Strategy Essay Competition, also will be published by the National Defense University, in Volume XV of Essays on Strategy. ******* The views expressed in this report are those of the author and do not necessarily reflect the official policy or position of the Department of the Army, the Department of Defense, or the U.S. Government. This report is cleared for public release; distribution is unlimited. ******* Comments pertaining to this report are invited and should be forwarded to: Director, Strategic Studies Institute, U.S. Army War College, 122 Forbes Ave, Carlisle, PA 17013-5244. Copies of this report may be obtained from the Publications and Production Office by calling commercial (717) 245-4133, DSN 242-4133, FAX (717) 245-3820, or via the Internet at rummelr@carlisle- emh2.army.mil ******* Selected 1993 and all later Strategic Studies Institute (SSI) monographs are available on the Strategic Studies Institute Homepage for electronic dissemination. SSI's Homepage address is: http://carlisle-www.army.mil/usassi/ ******* The author wishes to thank the following colleagues for their comments and assistance: Dr. Dan Henk, a true "Africanist"; Dr. Steven Metz; and Dr. Pauline H. Baker. ii FOREWORD Sub-Saharan Africa poses a somewhat ironic strategic dilemma for the United States in the post-Cold War era. Most authorities are quick to acknowledge that the United States has no vital interests in the region, and the end of the Cold War eliminated the East Bloc/West Bloc competition as an incentive for involvement. Yet, over the past decade, Africa has been the recipient of more U.S. military interventions than all other regions of the world combined. The interventions stem, of course, from complex humanitarian emergencies which the developed world cannot ignore. For a variety of reasons, it seems very likely that Africa will continue to suffer calamities which will require expensive humanitarian interventions. Because of the perceived limited national interest in Africa, U.S. "African" policy does not have a strong constituency in the American political process and lacks coherence and focus. U.S. regional involvements tend to be inconsistent and reactive. The result is that the United States invests much more for "cures" to Africa's ills than might be the case if U.S. policy could place more emphasis on "prevention." For their part, at no time in history have African nations been more receptive to U.S. assistance, or more eager for cooperative efforts to address the difficult issues of national development. While the United States may not have vital interests in Africa, the entire world (including the United States) clearly has an interest in durable regional stability. In view of Africa's huge size and substantial resources, it also clearly is in the interest of the United States to see sustained regional economic development and to maintain unfettered commercial and military access throughout the region. But more importantly, tropical Africa is one of the "Hot-Zone" regions from which devastatingly lethal pandemic diseases can emerge with little warning: the most important access could well be that of disease monitoring and prevention. This may, in fact, be a vital "defense of the homeland" interest for the United States. One Army officer, Lieutenant Colonel C. William Fox, Jr., a physician who has had extensive experience in U.S. activities in Africa over the past two decades, has personally supervised operations that have considerable potential as models for future regional involvement. In this publication, he offers a rationale and vision for future DoD activities in Africa. His account also serves to remind us that substantial strategic benefits can accrue to the United States even from small, tailored teams deployed under creative, energetic leaders.<R> iii RICHARD H. WITHERSPOON Colonel, U.S. Army Director, Strategic Studies Institute iv BIOGRAPHICAL SKETCH OF THE AUTHOR C. WILLIAM FOX, JR., M.D., is en route to assignment as the Commander of Bayne-Jones Army Hospital, Ft. Polk, LA, where he concurrently will serve as Command Surgeon of the Joint Readiness Training Center. Lieutenant Colonel Fox received his undergraduate degree in biology at the University of San Francisco and his medical degree from the Uniformed Services University of the Health Sciences in Bethesda, MD. A Special Forces officer and flight surgeon, he has commanded a variety of unique organizations, including a Special Forces Medical Training Company, an Army airborne forward surgical team, and a Mobile Army Surgical Hospital. He also has served as Command Surgeon for the Army's Special Operations Command. Lieutenant Colonel Fox's operational experience includes numerous Special Forces missions to Latin America and Africa, and a number of complex medical operations on the African continent. He also served in combat in Operation DESERT SHIELD/DESERT STORM. v MILITARY MEDICAL OPERATIONS IN SUB-SAHARAN AFRICA: THE DoD "POINT OF THE SPEAR" FOR A NEW CENTURY Rhetoric Versus Reality. The most prominent characteristic of the U.S. engagement in Sub-Saharan Africa in the mid-1990s is that it is diminishing. Both real U.S. dollar expenditures and significant programs, such as those of the United States Agency for International Development (USAID), which have played a significant role in U.S. assistance in the past, are simply vanishing. Ironically, this is occurring as African states are desperately seeking development strategies that will attenuate the almost overwhelming problems they face. Like it or not, they continue to look to the developed world, particularly the United States, for inspiration and assistance. The United States has both an interest in and opportunity to make a permanent difference in this area of the world. According to the last two National Security Strategy (NSS) reports, the Clinton administration is committed to "addressing" Africa's "economic, political, social, ethnic and environmental challenges" and to "identify[ing] and address[ing] the root causes of [African] conflicts and disasters before they erupt,"1 and to "...identify[ing] [in Africa] those issues where we can make a difference and which most directly affect our interests and target our resources efficiently."2 The National Military Strategy (NMS) asserts that the two fundamental national military objectives are to "promote long-term stability" and "thwart" aggression.3 The rhetoric is sound, but to date is matched by little tangible accomplishment. Unfortunately for Africa and for the United States, the lack of an integrated, coherent implementation of the NSS and NMS for Africa comes at exactly the time when just the opposite is needed. Meanwhile, Africa's problems threaten not only the region, but the developed world as well. A myriad of factors that undermine African regional stability are on a dramatic rise. Africa's annual population growth of 3.2 percent is the highest rate among the world's regions. Some 40 percent of the total African population presently is under the age of 15.4 This and rising expectations for material well-being have resulted in a rapid and unplanned urbanization. Explosive population growth contributes to environmental degradation and depletion of some natural resources (particularly arable soils), deterioration of government services, ethnic conflict, and even, civil war. Particularly worrisome is a concurrent rapid rise in severe epidemic and pandemic diseases. Due to global interconnectivity, these are a threat not only to Africans but to all mankind. Ignoring African 1 disease threats is both reckless and dangerous. In the recent past, subregional instability has resulted in cataclysmic human tragedies such as the genocide in Rwanda in 1993 and 1994. Catastrophes which produce large-scale, egregious suffering will continue to occur in Africa and will likely result in further expensive foreign interventions. The United States will bear some of the costs of such activities. Government reform, sustainable economic development, preservation of the natural environment, and regional cooperation, all goals of the current NSS, will not be achieved if severe threats to human life in Africa are not seriously addressed. A combined and melded effort of "preventive diplomacy"5 and "preventive defense"6 by the United States could be particularly instrumental in assisting Africans to withdraw their continent from the status of a "humanitarian theme park." If the United States will not face the implications of its own NSS for Sub-Saharan Africa, it will find itself on the horns of a substantial dilemma; "pay a little now or pay a lot later." Recent history suggests that U.S. policymakers will not resist domestic and international pressures for intervention to resolve humanitarian emergencies. Future African humanitarian interventions may require commitments of forces on a scale that could significantly impair the U.S. ability to respond to other major crises.7 The United States has the resources and the ability to assist in attenuating many of the most severe African problems. Other countries are looking to the United States for leadership in such efforts. To date, the missing ingredients are leadership and vision–attributes which should characterize the world's remaining superpower. The United States should now implement an NSS which coordinates the programs of developed nations to assist Africans in attacking the conditions which threaten regional stability. A Department of Defense Role? Implementation of the National Security Strategy for Africa would combine the attributes of the commonly discussed foreign policy initiatives found in "preventive diplomacy" with "preventive defense" as discussed by former Secretary of Defense Perry. Preventive diplomacy involves efforts to forestall civil wars and conflict by early intervention, with concerted action to resolve, manage, or contain disputes before they become violent.8 Such diplomacy accommodates the effects of poverty, environmental degradation, inadequate government infrastructure, disease threats, and other factors that increase the likelihood of conflict. Lund, among others, argues that it is feasible to 2 predict state collapse and conflict, and that we ignore the warning signs and delay intervention at our own peril.9 Some U.S. foreign policy analysts, such as Stedman, question the feasibility of preventive diplomacy, characterizing it as too costly.10 This conclusion can be refuted by a careful consideration of all of the attributes of preventive diplomacy.11 Former Secretary of Defense Perry, in a landmark 1996 speech, argued that the post-Cold War era has seen a worldwide decrease in the sense of personal safety, and an increased capacity of humankind for good and for evil.12 He suggested that preventive defense is analogous to preventive medicine. "Preventive medicine creates the conditions which support health, making disease less likely and surgery unnecessary."13 He further argued that, "America must lead the world in preventing the conditions for conflict and creating the conditions for peace."14 While few would contend that the Department of Defense (DoD) is the only, or even the most important, U.S. Government agency appropriate to address African problems, it can play an enormously beneficial role. DoD programs in Africa historically have been very modest in scope, and have been scaled back in the wake of post-Cold War budget cuts and military downsizing. Even so, U.S. preventive defense missions in the 1990s, such as military medical assistance missions, have greatly benefited Africans and significantly advanced U.S. interests. Despite the successes, these efforts have fallen very short of their potential. At least two reasons account for this. First is the inherent conservatism of military staffs, organizations typically reluctant to assume responsibility for highly nontraditional roles. Second, and more troubling, is a structural dilemma in the worldwide distribution of U.S. military forces and missions. DoD activities in foreign countries are implemented by the U.S. Regional Commands–military organizations commanded by senior generals and each responsible for pursuing U.S. military interests over vast areas of the earth's surface. Responsibility for DoD activity in continental Africa is divided between two such commands: the U.S. European Command, whose main focus is Europe, and the U.S. Central Command, whose main focus is in the Arabian Peninsula and Persian Gulf. Islands off the African coasts fall under the purview of two other commands: U. S. Atlantic Command and U. S. Pacific Command (see Figure 1). The headquarters of these commands are staffed by competent, dedicated professionals. However, except in times of major crisis, African issues are not a central focus of any of the four organizations. Carefully crafted, long-range plans for U.S. 3 4 military "engagement" in Africa simply are not part of the organizational interest. There is little coordination between the commands to establish comprehensive, complementary programs for long-range efforts to achieve U.S. regional interests. This results in DoD relations with African countries that appear to be inconsistent and haphazard, driven more by the clout of local U.S. diplomats, convenience and crisis, than by any overarching plan. But, if such an overarching long-term regional plan were to exist, what sort of DoD activities would it embrace? Certainly it will not include significant increases in military funding or material for African armies. No U.S. troops currently are based in Africa, a situation likely to continue. However, military medical missions in the form of MEDFLAG exercises, which feature a wide array of medical activities in Sub-Saharan Africa, have proven to be operational, strategic and political success stories.15 They are the single best means of conducting the kind of melded preventive diplomacy and preventive defense program that is needed to implement the NSS in Africa today. They could form the template and centerpiece of DoD activities in Africa. In the 1996 speech, Secretary Perry discussed the use of DoD programs and tools to create the conditions necessary for conflict prevention. The use of joint training exercises in peacekeeping, disaster relief and rescue operations were some of those he identified. The MEDFLAG exercises are a clear example of the joint training exercises he was describing. They are a tool of preventive defense. In Africa, MEDFLAGs have demonstrated such success as to qualify as the "spear point" in DoD efforts to implement the "National Security Strategy of Engagement and Enlargement." DoD programs such as MEDFLAGs should be one of the key ingredients of any new program to implement the U.S. security strategy in Africa. This is evident from a brief examination of threats that exist in Africa and the benefits realized by the most recent MEDFLAG missions. African Threats Assessed: The Root Causes. Baker and Ausnik argue that in order to preclude or reduce the possibility of ethnic conflict, "an early warning and evaluation system would enable policymakers to minimize military involvement by taking preventive actions early and to better prepare for the mission if a military role is ultimately required."16 These authors go on to offer a predictive model that identifies early warning signs and root causes of ethnic conflict and predicts the development and likely outcome of any potential case. While Baker and Ausnik provide a model for analysis of the 5