Foreign Relations of the United States, 1977–1980, Volume II, Human Rights and Humanitarian Affairs

306. Memorandum From the President’s Special Assistant for Health Issues (Bourne) to President Carter¹

Washington, January 9, 1978

SUBJECT

• International Health

On July 30th, 1977 you sent me a note referring to the issue of International Health directing me to prepare from you to key members of the Cabinet a memo “directing them to cooperate with you in doing the analysis—I can call them in later for a meeting when I understand from you what we need to do.”² In collaboration with the involved agencies we have completed that analysis producing a 500 page report which we have circulated for comment both within the government, and in the private sector. It will be published as an administration document.³ This memo summarizes the recommendations of that report, and following your trip⁴ I would like to request that we have the meeting you proposed.

I. Goals fo the Study

—To survey and inventory current U.S. government activities in the area of International Health including legislative authorities, budget allocations, policies and programs.

—To examine present goals and philosophies which currently guide our International Health activities, and to assess their effectiveness and relevance to the health needs of the world today.

—To examine the extent to which International Health is integrated with other governmental activities including the formulation of foreign policy, domestic health policy, development assistance as well as commercial and trade policy.

—To review the relationship between the U.S. Government’s International Health programs, private voluntary agencies and multilateral organizations including international financial institutions.

—To review present mechanisms for interagency coordination and for long range planning and goal setting of International Health programs.

—To recommend organizational, programmatic and legislative actions that would improve the existing use of current resources and create a sense of a new Carter initiative as a concrete manifestation of the commitment to meeting global basic human needs.

II. Findings

The United States interests in International Health involve the following: the elimination of the remaining major infectious diseases afflicting mankind (being primarily the product of poor sanitation and malnutrition, and involving for the most part the developing world), the provision of access to a basic minimum level of health care for people everywhere, the pooling of knowledge and fostering of collaborative research activities to advance medical science, the use of medicine as an instrument to form a common bond outside traditional political channels with countries we wish to draw closer to us, and the development of markets overseas for products of the American health industry.

—22 Federal agencies are involved in International Health, spending $522 million in FY 1976, under more than 100 separate legislative mandates.

—Involvement in International Health while traditionally thought of as exclusively an aspect of foreign aid, includes not only development assistance, but commercial, diplomatic, and environmental considerations with the majority of U.S. Government expenditures currently being made outside the developing world.

—There is no government-wide coordinating mechanism to establish overall policy, goals or programmatic priorities. Extraordinary resources exist within the government that are not being utilized with anywhere near their full potential. New scientific discoveries are nowhere near as important as better application of current knowledge and resources.

—The allocation of U.S. resources is not currently tied to any assessment of real global health needs or priorities determined geographically, nor is it in terms of what the remaining major cripplers and killers are as they affect lost human potential and compromised economic development. Even for a given country it is often impossible to tell which Federal agencies have programs there with no overall coordination to work towards mutually agreed upon goals.

—While both you and Secretary Vance have made repeated strong statements about the importance you attach to meeting basic human needs, there is little or no integration of International Health into the formulation and execution of U.S. foreign policy. This is largely due to the lack of an organizational focus with technical expertise in health or other basic human needs at a high level in the State Department. It is also attributable to a traditionally held view that such human concerns are “non-conventional diplomacy”.

—Fragmentation in the Executive Branch is compounded by overlapping and competing jurisdictions among different committees in the Congress.

—The effective use of some of our greatest International Health resources particularly in HEW and DOD is currently severely compromised by specific and generally outdated legislative restrictions.

—There is a disproportionate focus on the development of high technology health care in hospitals and the training of physicians rather than upon prevention and community-based primary care programs to reach poor and rural people. Such international research cooperation as has occurred has overwhelmingly emphasized problems of developed industrialized nations such as cancer and heart disease.

—The resources committed to International Health by the private sector exceed those of the Federal Government. Academic institutions, missionary, private voluntary organizations and other humanitarian groups as well as business express a strong desire to coordinate their efforts with the Federal Government, but believe there is no effective mechanism for doing so.

III. Recommendations

We recommend that a program called “New Directions in International Health” be initiated, which could be identified as an initial fulfillment of your promise to implement a global basic human needs strategy. Consistent with your decisions in the recent memo relating to development assistance,⁵ to stress aid to the poorest people in the world, we feel attention to this group should be given the highest priority in the International Health initiative. We recommend the following goals:

—To develop and pursue a strategy aimed at improving the health status of the 1 billion poorest people in the world.

—To emphasize the delivery of community based primary health care, cost-effective training at the most appropriate level of health personnel as near to the point where they will deliver services, and the development of research programs which place a priority emphasis on the remaining major health problems, especially infectious diseases, of the developing world.

—To encourage special emphasis on dealing with the generic problems of ill health, malnutrition, lack of clean water supplies, over-population and poverty, putting greatest emphasis on the prevention rather than the treatment of disease.

—To focus, coordinate, and when appropriate reshape U.S. goals in International Health to achieve a government-wide coordinated program which would reduce current fragmentation, and insure that existing resources were used more effectively.

—To strengthen existing institutions in our government which already deal with International Health problems, and build a greater awareness of International Health and concern for basic human needs as a more legitimate and consequential element in our foreign policy.

—To establish certain specific new initiatives with which you personally could be identified.

—To engage, through your leadership, the active participation of nations around the world both bilaterally and through multilateral organizations, especially WHO, UNICEF and the World Bank, in this endeavor.

—To encourage greater private sector involvement in International Health activities, and a closer partnership with the Federal Government.

—To plan a more coordinated and effective use of medicine as a tool in our overall diplomacy particularly in dealing with countries that have not traditionally been friendly towards the U.S.

IV. Decisions

A. Improving Coordination and Long Range Planning

The key to a new International Health program is not the expenditure of large amounts of new money, but a reprogramming and better utilization of present resources. Establishing an effective interagency coordinating mechanism can be the difference between success and failure in this endeavor.

Apart from the fragmentation of International Health programs between 22 agencies, a major problem exists because of divided responsibility and authority among the largest agencies. A.I.D. has the bulk of the program funds, but limited technical expertise. H.E.W. has exceptional technical resources, but considerable internal fragmentation; it is legislatively restricted from engaging in international activities that do not directly benefit the U.S. population. The State Department has the formal policy making authority in this area, but currently lacks the organizational structure or technical competence at a high level to carry out this responsibility or to take the lead which theoretically it should. Treasury regularly makes major decisions, particularly regarding the I.F.I.’s, that have extraordinary impact on world health, often without any awareness of that impact. Peace Corps, NASA, DOD, the Commerce Department, C.I.A., the Veterans Administration, E.P.A. and others all have specific specialized areas of interest, but make decisions in their own interests, in isolation, unrelated to any overall coordination or policy.

Among the agencies there is general agreement that a coordinating committee, or committees, need to be set up. There is, however, disagreement as to who should have the lead responsibility. Secretary Califano states, “the chief spokespersons on International Health affairs should be the Secretary of DHEW, the Assistant Secretary for Health and the Surgeon General. Any interagency committee on International Health should be chaired by H.E.W.” This position is opposed by A.I.D. Governor Gilligan is concerned about setting a precedent that would go beyond the health area and comments, “I urge you to resist vigorously any proposals to fragment development assistance responsibilities—especially by dispersing authority to agencies whose primary concerns are domestic.”

The organizational decision paper on development assistance currently being prepared by Henry Owen may have some bearing on this area, however, in the meantime, I believe that given this conflict the most effective coordination can be achieved by:

(a) Overall Coordination—Maintaining overall coordination out of my office as we have done up till now. This would avoid some territorial problems and also would symbolically maintain your own direct interest. It should be clear that this would not be a permanent new structure, but a short term mechanism to insure the momentum of a new initiative establishing overall policy and priorities. I believe in this way we can duplicate the highly successful coordination we have achieved in the drug area, a similarly fragmented field.

(b) Substantive Program Planning—Establishing a committee chaired by DHEW that would be responsible for further developing a government-wide substantive program in International Health. This would involve identifying those disease entities amenable to major assault, geographic regions or countries where U.S. resources could have a major impact, and special generic areas such as vector control, global epidemic surveillance and clean water supplies that might be appropriate to emphasize. In coordination with other agencies they would determine how the available resources could be mobilized and coordinated to deal with the priority areas they had identified. This committee would also establish sub-committees to address the setting of research, manpower development and training priorities.

(c) Coordination with Foreign Policy—Establishing a committee chaired by the Department of State that would review region by region, and country by country, our goals and priorities in the International Health area. The U.S. Government resources going into each country would be carefully inventoried, a determination made of whether current expenditures are adequately coordinated, and aimed at achieving agreed health goals for that country. We anticipate A.I.D. would play the major role in the review of the countries where they are involved. We are prepared to ask the State Department to begin immediately such a review of Africa, and to provide them the appropriate background material which my office has prepared. This committee would also address the issue of how International Health activities could be most effectively coordinated within our missions overseas, and how host countries could best be made aware of the range of resources, such as appropriate training opportunities, now available in the United States. This committee would also address the issue of how International Health could be better incorporated into our overall conduct of foreign policy.

(d) Upgrading the Emphasis on International Health—Understanding that in order to realize fully the U.S. Government’s potential in the International Health field certain internal changes need to be made within the departments. In response to the high priority you have attached to this area some of these changes already have been instituted. DHEW is completing an extensive internal review of its International Health functions, upgrading its emphasis, centralizing coordination and considering the creation of a position of Deputy Assistant Secretary for International Health. The role of C.D.C., which has already established a worldwide reputation for excellence, is to be expanded. The State Department lacks the high level focus with technical competence to permit adequate incorporation of health or basic needs concerns in general into the formulation of foreign policy. More important, a change in philosophy is needed so that concern for basic human needs is accepted as a legitimate aspect of foreign policy. This I believe can only be overcome by clear direction from you. They are moving now to create such a competent high level focus. A similar problem exists in Treasury. The Department needs to heighten its own awareness of International Health in internal decision making. Treasury should acquaint the IDLIs with evolving U.S. policies on International Health, and encourage them to give greater priority to an appropriate role for projects touching on health among their overall development loan programs. In DOD, legislative constraints and old but perpetuated administrative decisions continue to restrict adequate utilization of our single greatest untapped resource in this field. A clear instruction from you to all of the agencies to seek ways to make their resources more readily and effectively available is important.

I believe that the steps outlined above, if you approve, would overcome the problems of fragmentation and the present lack of clearcut long range goals providing the framework for an effective Presidential initiative in this area.

DECISION:⁶

B. Presidential Initiatives

In addition to the significant impact an improved and streamlined planning and coordinating mechanism would have on world health, I believe, certain specific new initiatives should be undertaken which could be identified as reflecting your personal involvement.

(a) World Blindness—More than 30 million people in the world are blind, most of them from preventable causes. A major administration effort to reduce blindness worldwide would have dramatic appeal, could be uniquely and distinctively identified with you from other present International Health emphases, would be geared to the poorest people in the world as well as being relevant to the industrialized nations including the U.S., and would not be vulnerable to the criticism that we were saving lives that would only amount to more mouths to feed. It would of necessity result in a program with special emphasis on the Middle East. It would overlap and complement, (without competing with) the World Health Organization’s highly visible Tropical Disease Research Program. I also believe it would generate strong international and domestic support, for instance, from Lions Clubs. By re-programming existing budgeted funds, this program could be implemented immediately. An enhanced and expanded plan could be prepared for next year’s budget cycle.

DECISION:

(b) Rural Water Supply—It is estimated that by making clean drinking water readily available to all people in the world, 50 million lives a year would be saved. The World Health Organization has set this as a priority, and 1980 is the beginning of the U.N. “Decade of Water”.⁷ Following the two U.N. Conferences this year on Water and Desertification⁸ an interagency coordinating committee chaired by the State Department has been established to develop overall U.S. policy on global water supply.⁹ While less dramatic than some other initiatives, strong clear support by you of the goal of clean drinking water for people everywhere would, in the long run, probably have the most significant lasting impact on world health of anything you could do. Initiating programs that make clean drinking water available also will significantly affect, for the better, the role of women in the developing world, who spend major parts of their lives drawing and carrying water from distant sources. While the potential level of expenditure for this purpose is almost unlimited, a major start can be made now without new funds, and careful consideration can be given to expanding our programs in this area in next year’s budget.

DECISION:

(c) International Health Service Corps—There is a great deal of interest in the possibility of establishing a health oriented volunteer program that would use American volunteers at all levels of health expertise. Such a program, which would clearly be identified as your concept, would be formed building on the Peace Corps in ACTION and the National Health Service Corps in the Health Services Administration in DHEW.

ACTION currently has over 1,000 health volunteers in such service. This number could be expanded and the proportion of health professionals among them increased. ACTION should continue to increase its efforts in health programming in order to ensure effective assignment and performance of these volunteers.

The National Health Service Corps can apply two of its current functions to an International Health Service Corps: (1) to recruit personnel and administer their assignment to positions programmed for them by ACTION; and (2) increase the number of Public Health Service Scholarships awarded annually allowing a like number of scholarship recipients to satisfy their scholarship payback requirements by serving in the International Health Service Corps. A slight modification to existing legislation would result in 150 to 250 scholarship recipients serving annually in the International Health Service Corps. This would have no adverse effect on domestic health manpower needs, yet would greatly improve chances to recruit health professionals for international service. As experience has shown many will eventually return to domestic health service. The Health Services Administration in DHEW could also serve as a recruiting clearing house for other government agencies in International Health and in managing development of U.S. Government personnel for careers in International Health. Estimated cost would be $3–5 million as an additional increment over present expenditures.

DECISION:

(d) Up-Grading the Fogarty International Center at The National Institutes of Health—Specific legislative authority should be developed to upgrade the existing Fogarty International Center at the National Institutes for Health¹⁰ making it a more visible focus as a center of excellence for the development of International Health policy. This action would provide needed organizational strength and authority for the center to carry out long range studies of International Health problems. It would also raise its stature in the U.S. and international scientific communities reflecting the new priority attached to International Health by your Administration. In particular, the Center would address the issue of long range manpower development, stimulating involved mobilization, and coordination of the U.S. academic medical community to build health skills in the developing world. In conjunction with A.I.D. they would work towards the development of International Health consortia among academic institutions in this country that would establish linkages with institutions in the developing world aimed at building their capabilities in research and training. These consortia could in particular address the problems of blindness and world water supplies.

DECISION:

(e) Presidential Scholars in Global Health—The U.S. should establish a program for “Presidential Scholars in Global Health”. Twenty Associate Scholars, all in early stages of their careers, would be selected (by a distinguished public/private panel of scientists) to study problems of implementing change in International Health. In addition, four distinguished Senior Scholars would prepare scholarly papers on contemporary International Health policy problems; they would work and lecture at NIH, and be based at the Fogarty Center. Annual cost would be $650,000, including personnel positions to run the program.

DECISION:

(f) Expanding Private Sector Involvement—The U.S. private sector, i.e., academia, multinational corporations, labor, church-related organizations, private voluntary organizations foundations, and individuals, should be given wider opportunities to contribute to U.S. International Health activities. Their efforts have been significant among the contributions this nation has made in International Health. In many cases they can be more effective, more innovative, and more acceptable in many countries than direct U.S. Government efforts. Recent tax and foreign policy decisions, as well as inflationary erosion of their purchasing power, have reduced private sector capacity to expand or even sustain their past activities. Reversing this trend could substantially reduce the burden on direct U.S. Government expenditures. The U.S. Government should actively seek ways to capitalize on and expand the involvement of the private sector. While the organizational paper being prepared by Henry Owen will address this area within the broader context of development assistance we believe certain specific steps could be taken now to strengthen the role of private voluntary organizations in the health area:

—Strengthen and formalize the PVO-grant making activities of A.I.D. to increase PVO performance on A.I.D. projects.

—Establish an expanded PVO program which is centered in A.I.D. (A.I.D. has recently set up an Office for Private Humanitarian Assistance). It would involve all agencies with significant International Health programs who would assign a PVO liaison coordinator to work with A.I.D.

—Consideration should be given to providing 5 year care support ($1 million per year) to create a consortium of PVOs including the establishment of an Information Clearinghouse for their activities to resolve the present lack of communication and collaboration.

DECISION:

The effectiveness of the new International Health initiative is tied closely to working in a supporting and collaborative way with multilateral organizations such as the World Bank, UNICEF, and the World Health Organization. Following your meeting with Dr. Mahler,¹¹ we have agreed to hold meetings twice a year between top officials of WHO and key representatives of the U.S. Government. Similarly we expect to rely heavily on the continuing close relationship with the National Institute of Medicine of the National Academy of Sciences. Much of the cost of this initiative would be subsumed under the decisions you have already made to increase the foreign aid budget generally. For instance the commitment to make a commitment of $10 million to WHO’s Tropical Disease Research Program.

Consistent with your instructions on the development assistance decision memo we will seek to involve public figures including those from the entertainment industry in building public support for this initiative. We would do this as part of the overall strategy now being developed with the NSC to build public support for foreign aid in general. Focussing public attention on an issue such as health, I believe, humanizes our foreign policy and makes it personally understandable in a way that amorphous impersonal issues like SALT and the Panama Canal are not. However, I think there is a spill over benefit to these harder issues in that good will in general is generated for your foreign policy.

If you approve, in general, of the above recommendations I suggest a meeting in the next couple of weeks as you proposed previously.¹² The meeting should include Califano, Vance, Sam Brown, Harold Brown, Blumenthal, Gilligan and Henry Owen. The meeting should consider the implementation of the recommendations included here. I would like then to develop a public statement for you laying out this strategy either in the form of a message to the Congress, as a separate speech, or as part of a larger statement on global human needs.

1. Source: Carter Library, Staff Office Files, Special Assistant for Health Issues—Peter Bourne Files, Subject Files, Box 34, International Health, 1/9/77–12/1/77. No classification marking. The memorandum is mistakenly dated January 9, 1977. A draft of the memorandum, December 14, is in the Carter Library, Staff Office Files, Special Assistant for Health Issues—Peter Bourne Files, Subject Files, Box 35, International Health, 12/1/77–12/29/77. Hutcheson sent copies of the memorandum to Vance, Blumenthal, Califano, Harold Brown, Sam Brown, and Gilligan under a January 11 covering memorandum, requesting agency responses by January 13. (National Archives, RG 59, Central Foreign Policy File, P780044–1213) In a January 13 memorandum to Moose, Todman, Holbrooke, Vest, Atherton, Maynes, Katz, and Lake, Benson asked for bureau comments on Bourne’s January 9 memorandum, commenting: “Please note that the Bourne memorandum is not a draft.” Benson also provided a copy of a January 13 draft memorandum from Benson to Bourne, prepared in OES, which offered “either minor modification or support of statements” contained in the January 9 memorandum. (National Archives, RG 59, Under Secretaries of State for International Security Affairs—Files of Lucy W. Benson and Matthew Nimetz: Chronological Files, Human Rights Country Files, Security Assistance Country and Subject Files, 1977–1980, Lot 81D321, Box 2, Lucy Wilson Benson Chron Jan 78) The final Department of State response to Bourne’s memorandum, sent to the White House in the form of a January 18 memorandum from Tarnoff to Hutcheson, concurred with the “general proposition” of Bourne’s memorandum but underscored that the President should not be “asked to make decisions on the recommendations” until several of the initiatives had been discussed and further refined. (National Archives, RG 59, Central Foreign Policy File, P780044–1210)
2. Not found. It was presumably sent after Bourne’s July 29 meeting with the President; see Dcoument 292. For the memorandum to Cabinet members, see Document 293.
3. Formally titled New Directions in International Health Cooperation: A Report to the President (Washington, D.C.: Government Printing Office, 1978).
4. The President traveled to Poland, Iran, India, Saudi Arabia, France, Egypt, and Belgium December 29, 1977–January 6, 1978.
5. Presumable reference to a November 9 memorandum from Owen to Carter scheduled for publication in Foreign Relations, 1977–1980, volume III, Foreign Economic Policy.
6. The President did not indicate his decision to approve or disapprove any of the recommendations in this memorandum.
7. See Document 332.
8. The UN Water Conference took place in Mar del Plata, Argentina, March 14–25, 1977; see Document 278. The UN Conference on Desertification took place in Nairobi, Kenya, August 29–September 9, 1977. See Report of the United Nations Water Conference (E/CONF. 70/29) and Report of the United Nations Conference on Desertification (A/CONF. 74/36).
9. See Document 296.
10. Named after late Representative John Edward Fogarty (D–Rhode Island), the Center was established by President Johnson in July 1968 in order to fund international health research as part of a larger “health for peace” initiative.
11. See footnote 4, Document 292.
12. According to a February 17 memorandum from Bourne and McIntyre to Vance, the President had “approved the broad concept” of an international health program. The full text of this memorandum is printed as Document 309.