Synopsis Series: Civil Military Collaboration by Mario Ricardo Calderón, MD, MPH, FPMER.

SYNOPSIS Latin America and Caribbean Regional Office AIDSCAP/Family Health International 2101 Wilson Blvd., Suite 700 Arlington, VA 22201 Tel: (703) 516-9779 Fax: (703) 516-0839

Project 936-5972.31-4692046 Contract HRN-5972-C-00-4001-00 The AIDS Control and Prevention (AIDSCAP) Project, implemented by Family Health International, is funded by the United States Agency for International Development.

HIV/AIDS Prevention and Control Series

Civil-Military Collaboration

Series Editor

M. Ricardo Calder贸n Latin America and Caribbean Regional Office AIDSCAP/Family Health International

Family Health International (FHI) is a non-governmental organization that works to improve reproductive health around the world, with an emphasis on developing nations. Since 1991, FHI has implemented the AIDS Control and Prevention (AIDSCAP) Project, which is funded by the United States Agency for International Development (USAID). FHI/AIDSCAP has conducted HIV/AIDS prevention programs in 40 countries, and the Latin America and Caribbean Regional Office (LACRO) has implemented interventions in 14 countries within the region.

November 1997 For further information, contact: Latin America and Caribbean Regional Office AIDSCAP/Family Health International 2101 Wilson Blvd, Suite 700 Arlington,VA 22201 Telephone: (703) 516-9779 Fax: (703) 516-0839 Graphic Designer: Deborah Clark

The HIV/AIDS Prevention and Control SYNOPSIS Series

C I V I L - M I L I TA R Y C O L L A B O R AT I O N Series Editor: M. Ricardo Calder贸n AIDSCAP/Family Health International Arlington,VA, USA

Prepared by: Sven Groennings Civil-Military Alliance to Combat HIV and AIDS Hanover, NH, USA

Project Coordinator: Mary L. Markowicz AIDSCAP/Family Health International Arlington,VA, USA

Published by the Latin America and Caribbean Regional Office of The AIDS Control and Prevention (AIDSCAP) Project Family Health International

The opinions expressed herein are those of the writer(s) and do not necessarily reflect the views of USAID or Family Health International. Excerpts from this booklet may be freely reproduced, acknowledging FHI/AIDSCAP as the source.

Acronyms

Acknowledgements

iii

Prologue

Holographic Overview

Introduction

HIV/AIDS in the Military

Military and Civilian Populations: One Society

Toward Civil-Military Collaboration Common Agenda Mutual Benefits Potential Partners Possible Processes

9 9 11 12 13

CMC in Progress Integrated Planning: Peru Beginning Multiple Activities: Brazil Training of Trainers: USA Condom Social Marketing: Africa Community Empowerment: Bolivia

17 18 20 20 21 22

CMC: A Belated Development

Lessons Learned

Recommendations

References

TABLE OF CONTENTS

ACRONYMS AIDS

acquired immune deficiency syndrome

AIDSCAP

AIDS Control and Prevention Project

BCC

behavior change communication

CBO

community-based organization

CMC

civil-military collaboration

CSW

commercial sex worker

FHI

Family Health International

HIV

human immunodeficiency virus

LAC

Latin America and the Caribbean

LACRO

Latin America and Caribbean Regional Office

MOH

Ministry of Health

NACP

National AIDS Control Program

NGO

non-governmental organization

PAHO

Pan American Health Organization

PVO

private voluntary organization

STI

sexually transmitted infection

USAID

United States Agency for International Development

Civil-Military Collaboration

We would like to acknowledge and recognize the contributions, work and efforts of the Implementing Agencies—NGOs, PVOs, CBOs, NACPs/MOH, Social Security Institutes, private sector enterprises—with whom LACRO has worked and for all that we have learned together in HIV/AIDS prevention and control. We are especially grateful to Sven Groennings, the Washingtion liaison of the Civil-Military Alliance to Combat HIV and AIDS, for preparing this SYNOPSIS. The Civil-Military Alliance to Combat HIV and AIDS is a global organization dedicated to the prevention of HIV/AIDS in security and armed forces at home, during deployment on foreign soil and across the civil-military interface with the general population. It emphasizes both the civilian and military contexts of HIV/AIDS and promotes actions with the military sector, civil-military collaboration, and military-to-military technical assistance. The Civil-Military Alliance has undertaken several projects focusing on Africa and Latin America and the Caribbean for USAID through the AIDSCAP Project of Family Health International. For further information on the Civil-Military Alliance, contact: 4 West Wheelock Street, Hanover, NH 03775 Telephone: (802) 649-5296. We take this opportunity to thank all the staff members of AIDSCAP/LACRO for their overall assistance: Joseph Amon, Evaluation Officer; Polly Mott, Senior Program Officer; Marvelín Parsons,Administrative Assistant; Molly Strachan,Associate Program Officer; as well as former staff members: Mimi Binns, Program Officer; Genie Liska, Finance Officer; Manuel Mongalo, Finance Officer; Robert Martínez, Evaluation Officer; Melissa Rosenberger,Associate Program Officer; Isabel Stout, Senior Program Officer; Oscar Viganó, Communications Officer; and other AIDSCAP staff for their insights and recommendations. In addition, we are grateful to Peter Lamptey, FHI Senior Vice President of AIDS Programs and Project Director of AIDSCAP, and Tony Schwarzwalder, Deputy Project Director of AIDSCAP, for their continued support of LACRO’s initiatives. Acknowledgements

iii

ACKNOWLEDGEMENTS

Finally, we wish to extend our appreciation to the Population, Health and Nutrition Team in the Office of Regional Sustainable Development of the USAID LAC Bureau, particularly James B. Sitrick, Jr., for the support and funding of the Information Dissemination Initiative and other LACRO programs.

Civil-Military Collaboration

PROLOGUE

PROLOGUE The HIV/AIDS Prevention and Control SYNOPSIS Series is a summary of the lessons learned by the Latin America and Caribbean Regional Office (LACRO) of the AIDS Control and Prevention (AIDSCAP) Project. AIDSCAP is implemented by Family Health International (FHI) and funded by the United States Agency for International Development (USAID). The series is a program activity of the LACRO Information Dissemination Initiative and was created with several goals in mind: to highlight the lessons learned regarding program design, implementation, management and evaluation based on five years of HIV/AIDS prevention and control experience in LAC countries ˙ to serve as a brief theoretical and practical reference regarding prevention interventions for HIV/AIDS and other sexually transmitted infections (STIs) for program managers, government officials and community leaders, non-governmental organizations (NGOs), private voluntary organizations (PVOs), policy and decision makers, opinion leaders, and members of the donor community to provide expert information and guidance regarding current technical strategies and best practices, including a discussion of other critical issues surrounding HIV/AIDS/STI programming ˙ to share best practices from LAC for adaptation or replication in other countries or regions to advance new technical strategies that must be taken into consideration in order to design and implement more effective prevention and control interventions ˙ to advocate a holistic and multidimensional approach to HIV/AIDS prevention and control as the only way to effectively stem the tide and impact of the pandemic Prologue

AIDSCAP (1991–1997) was originally designed to apply the lessons learned from previous successful small-scale prevention projects (1987–1991) to develop comprehensive programs to reduce the sexual transmission of HIV, the primary mode of transmission of the virus. AIDSCAP applied three primary strategies — Behavior Change Communication (BCC), STD Prevention and Control, and Condom Programming — along with supporting strategies of Behavioral Research, Policy Development and Evaluation. The success of this approach, based on the combination of strategies and targeted interventions, has been widely documented. The AIDSCAP Project, in fact, has been recognized as among the best and most powerful international HIV/AIDS prevention programs to date.1 AIDSCAP has worked with over 500 NGOs, government agencies, community groups and universities in more than 40 countries; trained more than 180,000 people; produced and disseminated some 5.8 million printed materials, videos, dramas, television and radio programs, and advertisements; reached almost 19 million people; and distributed more than 254 million condoms.2 However, the pandemic continues to escalate at a rate that outpaces our successes. Thus, we need to build upon these successes, learn from our experiences, and determine what has worked and what is missing in order to respond with added effect in the future. The magnitude and severity of the HIV/AIDS pandemic calls for boldness, flexibility, wisdom and openness. The world cannot afford to continue to fight HIV/AIDS only with current thinking and tools. We must look toward new thinking and strategies that complement and carry the current state-of-the-art approaches forward in the fight against HIV infection. Therefore, LACRO endorses, promotes and elevates Gender Sensitive Initiatives (GSIs), Civil-Military Collaboration (CMC), Religious-Based Initiatives (RBIs), and Care & Management (C&M) as the new prototype of technical strategies that must be incorporated on par with the strategies vi

Civil-Military Collaboration

implemented to date. Walls, barriers and biases have to come down in order to unlock the strengths, benefits, potential, synergy and/or resources of GSIs, CMC, RBIs and C&M. More importantly, approaches that compartmentalize strategies can no longer be justified. Despite the efforts to integrate and coordinate amongst and between technical strategies and different sectors of society, prevention programming is barely scratching the surface of what a real comprehensive effort should be. One of the most important lessons learned about HIV/AIDS is that it is not only a medical problem, nor is it exclusively a public health problem. Rather, the pandemic is in addition a socioeconomic problem and, as such, threatens both the sustainable development of developing countries and challenges the ethical foundations of the developed world. HIV/AIDS has become a challenge to health, development and humanity. For lasting success, a genuine multidimensional approach is urgently needed. One that demands new forms of wealth distribution, educational opportunities and development; attempts to resolve the inequalities in gender and power; acknowledges the individual, environmental, structural and superstructural causes of and solutions for the pandemic; and aims to balance the disparity between the “haves” and the “have-nots”, resulting in more sustainable, equitable, effective and compassionate efforts. Therefore, the SYNOPSIS Series reaffirms that current HIV/AIDS prevention and control strategies work, and contends that new technical strategies are needed and can be effective and complementary. The Series also strongly advocates for, and will discuss in a separate issue, the Multidimensional Model (MM) for the prevention and control of the pandemic. This model must guide national, regional and international planning and programming in order to achieve measurable and significant gains that can truly affect changes at the individual, societal, environmental and structural levels. We trust the reader will be open to our futuristic thinking and will contribute to the further development of the strategies prePrologue

vii

sented here as well as others. We hope the SYNOPSIS Series will stimulate discussion and reflection, propel continued dialogue, and encourage the pioneering of new combinations of innovative approaches.

M. Ricardo Calder贸n, MD, MPH, FPMER Regional Director Latin America and Caribbean Regional Office AIDSCAP/Family Health International

viii

Civil-Military Collaboration

This SYNOPSIS booklet discusses the importance of civil-military collaboration (CMC) through a holographic approach. Holography is a special photographic technique that produces images of three dimensional objects. This photographic record is called a hologram, and one of its main applications is that any fragment of the hologram can regenerate the entire image, even if the fragment is extremely small. In other words, if a negative from an ordinary picture is cut into two, the print from each half would only show half of the picture. Conversely, if a holographic negative is cut in two, the print from each half would show the entire picture. If these halves are cut again, the print from any one of the pieces will reconstruct the whole picture.3, 4, 5 Utilizing the holographic model, this booklet was written such that any one of the sections (holograms) will provide the reader with an understanding of the whole subject matter. First, we describe the entire strategy or topic of discussion in one sentence, the widespread definition and/or our own definition of the subject (Hologram 1). Next, we present a one-paragraph abstract of the topic, expanding upon the original definition (Hologram 2). Then, we present the topic by providing a summary or recapitulation of the main points of each of the sections of the booklet (Hologram 3). Finally, the entire strategy is again presented by virtue of the complete text of the booklet (Hologram 4). We anticipate that the Holographic Overview of civil-military collaboration will benefit both the seasoned professional and the novice. It provides a quick, general overview of CMC as well as context and background. It also directs the reader to specific parts that may be of most interest or that the reader would like to review first or at a later date. Thus, we hope this approach will enable the reader to make fuller use of the booklet as a reference guide, as it provides a simple and concise definition of CMC, a brief description of the topic, a summary of the discussion, and finally, the complete textâ&#x20AC;&#x201D;all in one document.

Holographic Overview

HOLOGRAPHIC OVERVIEW

HOLOGRAPHIC OVERVIEW:

The reader should note that while we have tried to include the key issues surrounding CMC in this SYNOPSIS, the booklet is not meant as an exhaustive discussion of all of the issues regarding civilian and military collaboration.

The Whole Strategy Hologram 1: The Definition Civil-Military Collaboration in HIV/AIDS prevention and control represents the joint efforts of combined human, physical and economic resources of the civilian and military sectors in order to reduce the spread and impact of the pandemic in each of the sectors and society as a whole.

The Whole Strategy Hologram 2: The Abstract Civil-military collaboration is an important strategy central to the fight against the HIV/AIDS pandemic. In virtually all countries of the world the military is one of the groups most affected by HIV/AIDS. The infection rates for sexually transmitted infections (STIs) are commonly two to five times higher in the military than in comparable civilian populations in peace times, and much higher in conflict situations.6 As studies have shown, HIV transmission is greatly enhanced in the presence of an untreated STI. Military populations, in general, have increased vulnerability to HIV infection, compared to the general civilian populations. Risk factors among the military include high rates of sexual partner change, elevated rates of STIs, low rates of condom use with commercial sex workers and other casual partners, and significant mixing between groups having high and low risk behavior patterns.7 Since military personnel typically infect or become infected by civilians, neither of these sectors can resolve the HIV problem in isolation. The military and the civilian sectors are related in both the causes and the effects of HIV/AIDS, and thus, they are stakeholders in one anotherâ&#x20AC;&#x2122;s success in combating the pandemic. x

Civil-Military Collaboration

The Whole Strategy Hologram 3: The Summary HIV/AIDS in the Military The HIV/AIDS pandemic poses a strategic threat to affected soldiers and has resulted in losses of skilled manpower and senior leadership among many of the worldâ&#x20AC;&#x2122;s armed forces.8 HIV seroprevalence of 20 to 40 percent has been reported among some militaries in eastern and southern Africa, and over 50 percent in countries where the virus has been present for more than 10 years. Military personnel are highly vulnerable to HIV infection because they are regularly away from home for long periods, away from their regular sexual partners, often in search of recreation to relieve loneliness and stress, and free from home and community restraints. Their occupation encourages risk taking, gives them a sense of invulnerability and exposes them to alcohol and drug consumption and commercial sex workers. Civil conflict and large-scale military conscription and/or deployment to an area with high HIV prevalence represent high risk situations and changes that have triggered HIV epidemics.7 Military and Civilian Populations: One Society The military, whose mission is to protect all of society, also interacts with all of society. Those serving in the military and their families are drawn from all regions and sectors of a country and typically serve in several regions during their years of service. Furthermore, the knowledge, attitudes, beliefs and practices of military populations are shaped by the same social, cultural, religious, educational, economic and political influences as their civilian counterparts. Both the civilian and military sectors suffer the socioeconomic and development effects of HIV/AIDS and are related in both its causes and effects. Thus, they are stakeholders in one anotherâ&#x20AC;&#x2122;s success in combating the pandemic. Toward Civil Military Collaboration Civil-military collaboration is a nascent HIV/AIDS prevention and control strategy, and collaboration to date has taken place on a very limited scale. Military and civilian sectors are increasingly recognizing areas of common interest, particularly as the number Holographic Overview

of infected women rises. Women are emerging as a natural bridge for CMC due to the positions they hold within the military, within military families, and within the civilian community supporting the military. The mutual benefits of CMC are classified within the following five areas: setting policy, convening power, expanding reach, exchanging information and know-how, and sharing resources. Many different types of partnerships and collaboration processes are emerging, including joint civil-military conferences at the national and international levels. Partners for collaboration include the Ministries of Health and Education, National AIDS Control and Prevention Commissions or Councils, NGOs and PVOs, and religious-based organizations. CMC in Progress Current CMC efforts to combat HIV/AIDS are taking place in a variety of ways. In Peru, COPRECOS (Commission for the Prevention and Control of HIV/AIDS in the Armed Forces) operates within the overarching cross-sectoral framework of PROCETSS (Program for the Control of STIs and AIDS), the national planning and administrative system for the campaign against HIV/AIDS. Brazil is in the early stages of implementing a variety of activities. A “Protocol of Intentions” frames cooperation between each of the three military services and the Ministry of Health, and a Permanent Interministerial Council has been established to address health problems. The American Red Cross assisted the U.S. Navy in preparing a comprehensive prevention program, with the potential to reach an estimated 900,000 personnel. To date, more than 1,600 Navy Instructor-Trainers have been trained through a training of trainers component. In Africa, condom social marketing, low-cost mass purchasing of condoms from a private organization and sale at a subsidized cost to the consumer, is a strategy being implemented effectively. Bolivia’s Sentinel of Health system is based on the principle that “one can apply to the defense of life the concepts used in defense of the country…the health of the families can be improved if all soldiers, upon returning to their community, teach all that they have learned.”9

xii

Civil-Military Collaboration

CMC: A Belated Development Progress toward civil-military collaboration in HIV/AIDS has been slow and is only now beginning to escalate a decade into the pandemic. Collaboration has been delayed for a variety of reasons. Initially, the military focused on the problem internally, and military medical systems in many countries were slow to launch HIV/AIDS prevention programs. Collaboration has also been inhibited by a prevailing civilian mistrust of the armed forces in many developing countries, including a military practice of treating health data as military intelligence in order to ensure national security. As a result, the military were typically not included or only marginally involved as national planning systems to combat HIV/AIDS developed. Lessons Learned Civil-military collaboration has been slow to develop due to the militaryâ&#x20AC;&#x2122;s initial internal focusing on its own HIV/AIDS problem as well as the militaryâ&#x20AC;&#x2122;s exclusion from national planning efforts. As the pandemic affects all of society, a coordinated and multi-sectoral response is required, one that includes the military sector. The function of the military is to protect society, and it is this social service of protection that must also include the health of the individual and the collective health of the countryâ&#x20AC;&#x2122;s population. The civilian and military populations possess human, physical and economic resources which are synergistic and complementary. In terms of civilian and military partnerships, it is increasingly being recognized that common agendas and mutual benefits exist amongst and within different governmental and non-governmental institutions, including regional and international organizations. CMC builds on both the functional complementarities and commonalities among the sectors and makes more effective use of resources. The military typically has a presence in all geographic areas of a country, thereby having the potential to reach millions of individuals. The military also possesses convening power, the ability to focus the attention of the government on a particular subject and elevate it to the national policy level. Regional approaches are effective as they enable cross-national sharing of programs, initiatives, and policies that can lead to mutual assisHolographic Overview

xiii

tance across countries and regional utilization of expertise. Cultural affinity and common languages facilitate regional approaches. International support, as well as a brokering and/or coordinating body, is essential to bring together the international organizations, donors, experts and the civilian and military sectors. To be successful, program development: (a) must be sensitive to the various cultural contexts, affinities and differences at every level inside and outside national boundaries; (b) needs more attention and time to provide innovative HIV/AIDS prevention and control models; and (c) should be based on, but not limited to, current needs in policy knowledge, training of trainers assistance, and international exchange of preventive and cost-effective efforts. Recommendations Actions recommended to advance CMC include: (a) information dissemination regarding current efforts and lessons learned; (b) advancement of the brokering role to bring interested parties together; (c) expansion of the focus on the military to include peacekeeping troops, police, prison guards, and maritime personnel; (d) utilization of key personnel of more mature programs to assist those programs under development; (e) policy dialogue to establish an environment conducive to civilian and military cooperation; (f) planning and implementation of joint endeavors with potential for expansion and replication; and (g) monitoring and evaluation of interventions in order to strengthen, diversify and expand CMC programming.

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Civil-Military Collaboration

Hologram 4: The Detailed Description

INTRODUCTION Civil-military collaboration (CMC) is an important strategy central to the fight against HIV/AIDS for two main reasons: the military is one of the groups most affected by the pandemic in virtually all parts of the world; and military personnel typically become infected by civilians, and similarly the military infect civilians. As its HIV/AIDS problem is not purely military, the military cannot solve it internally nor single-handedly. It is not solely a public health problem, but also a political, economic and security threat Civil-military collaboration requiring a coordinated, multi-sectoral response. Therefore, civil-military colis an important strategy central laboration becomes an essential technical strategy in HIV/AIDS prevention. to the fight against HIV/AIDS for Furthermore, CMC can be advantageous in testing, counseling, care, two main reasons: the military research, training of personnel, condom social marketing, outreach to families is one of the groups most and community relations as well as in providing educational materials and affected by the pandemic in programs for prevention. virtually all parts of the world; and military personnel typically become infected by civilians, and similarly the military infect civilians.

Introduction

The military is defined at its core as the uniformed personnel of the army, navy and air force but is often expanded to include the coast guard, the militaryâ&#x20AC;&#x2122;s civilian personnel, military families and child soldiers. Two large peripheral groups, the national police and seafarers, have military characteristics and are sometimes included in discussions of the military. In Peru, for example, the national police are included in an inte1

INTRODUCTION

The Whole Strategy

grated HIV/AIDS/STI planning system for its armed services. Seafarers are also a closely related occupation with parallel lifestyles, including high pay, extensive travel, long periods away from home, shipping functions on behalf of the military, and sometimes naval reserve officer status. For the purposes of this booklet, however, For the purposes of this the military is defined as the former, the uniformed personnel of the army, navy, booklet, the military is defined and air force as well as the coast guard, the militaryâ&#x20AC;&#x2122;s civilian personnel, military as the uniformed personnel of families and child soldiers. the army, navy, and air force as

Civil-military collaboration is an emerging technical strategy that now has well as the coast guard, the momentum; the forces of impetus are advocacy and the creation of processes by which it will occur. Accordingly, this militaryâ&#x20AC;&#x2122;s civilian personnel, booklet is intended to be an instrument of leadership for new ventures; its cenmilitary families and child tral purpose is to stimulate creative civil-military responses to the HIV/AIDS soldiers. problem. The opening sections set the stage for collaboration by presenting the military problem and the perspective that the military and civilian sectors are closely related parts of a society and stakeholders in one anotherâ&#x20AC;&#x2122;s success in the struggle against HIV/AIDS. Next, the booklet considers possible civil-military agendas and processes for achieving collaborations between the military and civilian sectors of government and non-governmental organizations (NGOs). Thereafter, it illustrates the practice of collaboration by presenting brief vignettes of various kinds of activities occurring in different countries. Finally, following a discussion of why CMC generally has been slow to develop but is now becoming a necessary and vital technical strategy, the booklet sets forth lessons learned to date and concludes with recommendations.

Civil-Military Collaboration

The infection rate for sexually transmitted infections (STIs) is commonly two to five times higher in the military than it is in the civilian population.6 During times of war and civil strife, the rate can become up to 100 times higher. As studies have shown, HIV transmission is greatly enhanced in the presence of an untreated STI. Some militaries in eastern and southern Africa are reporting HIV prevalence of 20 percent to 40 percent and as high as 50 percent in countries where the virus has been present for more than 10 years. In Asia, the data on HIV infections among the military are stunning: for example one-fifth of the soldiers in one province in Cambodia and 13-14 percent of recruits from the northern provinces of Thailand were seropositive. Interestingly, at one military camp in Rwanda, 70 percent of the soldiers reported being more afraid of HIV than of being at war. It is likely that United Nations and other peacekeeping forces have a higher probability of becoming infected with HIV than of being killed in military action. Most military personnel are in the age group at greatest risk of contracting HIV: 15 to 35 years of age. This is the sexually most active and most infected age group in any countryâ&#x20AC;&#x2122;s population. Military personnel are highly vulnerable to infection as they are regularly away from home for long periods, away from their regular sexual partners, and often search for recreation to relieve loneliness and stress. They are in an occupation that encourages risktaking, and their training gives them a sense of strength and invulnerability. Off-duty soldiers and navy sailors are free from home and community restraints, often consume alcohol and sometimes drugs, and have money to spend. They belong to a culture that is especially macho and considerably sexist. The special circumstances of the military lead commercial sex workers (CSWs) to be near military bases; indeed, the presence of military bases leads to increases in the number of CSWs.

HIV/AIDS in the Military

HIV/AIDS IN THE MILITARY

Large numbers of military personnel engage in casual and commercial sex. In peacetime, 45 percent of the Royal Dutch Navy were found to have had sex with CSWs or other members of local populations while on mission.10 There were parallel findings in the United States Navy: in a study of 1,744 crew members on 11 ships who were on a six-month deployment, 42 percent reported contact with one or more CSWs and 10 percent had contracted a STI. A 1991 survey of more than 18,000 U.S. army soldiers found that half perceived themselves to have been at risk of infection during the previous two years. The soldiers reported a much greater number of contacts with high-risk partners than the civilian population.

The infection rate for sexually transmitted infections (STIs) is commonly two to five times higher in the military than it is in the civilian population. During times of war and civil strife, the rate can become up to 100 times higher.6

Port cities and garrison towns tend to have higher risk factors for the transmission of HIV. Port cities are centers for trucking, shipping and trading, are visited by countless seafarers and sailors, and typically have large concentrations of CSWs. The cities and towns that develop near naval and army bases to supply them with goods and services, commonly known as garrison towns, often have similar risk factors. The interaction between the civilian and military populations in these areas is demonstrative of the need for collaboration between the two sectors on issues which affect both, such as HIV/AIDS.

War typically has spread sexually transmitted diseases as populations are displaced, women sell sex to provide for their families, soldiers turn to CSWs, and rapes occur. â&#x20AC;&#x153;The classic association of war and disease substantially accounts for the presently observed geographical distribution of reported clinical AIDS cases in Uganda.â&#x20AC;?11 There have been reports from Bosnia and Rwanda that rape has become a weapon of war, possibly spreading HIV. During the recent period of inter-tribal killings, tortures, burnings 4

Civil-Military Collaboration

and lootings in Rwanda, women were often told they were about to get HIV before they were raped by soldiers.12 A case study initiated during the civil war in Liberia indicated that foreign troops contribute to child prostitution and take advantage of the extreme poverty of local women and girls. This research was conducted as a result of the concern of the increasing prevalence of HIV/AIDS. The study also found that the military personnel perceived the use of young girls for sex as a means of avoiding HIV infection, based on the misconception the girls were too young to be HIV-positive.13 Another particular problem of civil wars and ethnic conflicts is the use of children as soldiers. Child soldiers are typically under the age of 18, with some as young as 7. Globally, it is estimated that there were more than 250,000 child soldiers in 1995-1996, predominantly in Africa but also found in Asia and among Latin American countries, such as Guatemala and Peru. Many of these young people become sexually active or are exploited sexually in these circumstances. Even as the fighting subsides and troops return home, there is a danger that HIV/AIDS will continue to spread into the general population. When the 150,000 Cuban troops returned from Angola and Mozambique, HIV/AIDS was found to be their second most prevalent disease.12 As a result of HIV/AIDS, militaries in some countries, particularly those in eastern and southern Africa, are losing continuity at the command level as well as among personnel within the lower ranks. Militaries face increased recruitment and training costs for replacements and a growing need for international training of replacements. Overall, they face a potential reduction in the nationâ&#x20AC;&#x2122;s preparedness, internal stability and external security.14 Furthermore, some foreign policy analysts see HIV/AIDS in the militaries of developing countries as a threat, not only to the wellbeing of the nation, but to the peacekeeping troops that may have to go in to maintain peace or to quell upheavals.

HIV/AIDS in the Military

There is no way to isolate the military from the rest of society; it is an integral part of society. Its mission is to protect society, and as such, it must interact with society. The military and their families generally constitute five percent of any society, are drawn from all regions and sectors of a country, and normally serve and live in several regions throughout their years of service. Moreover, the military mind is not purely military. It is in part shaped by civilian relationships. The fundamental knowledge, values and attitudes of military personnel were shaped prior to their military service by families, education, religion, peers, and prevailing cultural practices. It is mainly prior to military service that men develop their self-image and their attitudes toward women. It is the combination of such culturally determined influences with circumstances such as loneliness, availability of sexual temptations, and the stressful conditions of war and peacekeeping that determine individual vulnerability to risky behavior leading to HIV infection. Figure 1 illustrates the social context of military personnel, with the military individual as the central focus. In the immediate circle are families and sex partners, representing the closest relationships. The outer circle is composed of the institutional The military and civilian sectors civilian elements with which the individual and his/her immediate circle are related in both the causes interact, including government programs, commercial enterprises, and and the effects of HIV/AIDS. NGO leaders in religious, social and proThey are stakeholders in one fessional organizations. The interaction at the various levels between civil and anotherâ&#x20AC;&#x2122;s success in combating military entities demonstrates the integral role of military personnel in a sociHIV/AIDS. ety and the need for civil-military collaboration in the fight against HIV/AIDS. Military and Civilian Populations: One Society

MILITARY AND CIVILIAN POPULATIONS: ONE SOCIETY

Figure 1

Both the civilian and military sectors suffer the economic effects of HIV/AIDS. HIV/AIDS burdens and retards a countryâ&#x20AC;&#x2122;s economic development and limits the resources available to all sectors, impacting both the civilian and military populations. It strikes most severely the age group of young adults who are in or are entering their most productive years, the stage of life at which society hopes to recoup its investment in its youth. It can inhibit foreign investment as it increases workforce absenteeism and turnover, reduces productivity and increases costs of training. It overburdens hospitals and health budgets and hurts families that lose income while acquiring costs of care and funerals. HIV/AIDS negatively impacts the tax base, reducing funds available for schools, infrastructure, health care and the military. Thus, the military and civilian sectors are related in both the causes and the effects of HIV/AIDS. They are stakeholders in one anotherâ&#x20AC;&#x2122;s success in combating the pandemic.

Civil-Military Collaboration

As indicated by the case studies presented in this booklet, various types of civil-military collaboration are occurring. It is not yet a widely-implemented technical strategy, but countries are beginning to see its advantages and benefits. Most, however, are at the stage of exploring very basic questions: What substantive concerns might the two sectors have in common? What can collaboration accomplish? How can it happen? What can we learn about the scope and design of existing collaborations? What has been done that we may consider a best practice? Elements of a Common Agenda As the HIV/AIDS pandemic affects both the civilian and military sectors, the first step in developing collaboration between the two is the defining of common areas of interest. Listed below are topics pertaining to and concerning both sectors: a national strategy for fighting HIV/AIDS, based on a national assessment of problems and needs the impact of HIV/AIDS on economic development, tax revenue, and support for services in health and health education cultural influences, including religion, which affect behavior and the design of the response to the HIV/AIDS problem civilian employees of the military women in the military and in the community, wives and military families military widows and orphans commercial sex workers the health of recruits demobilization hosting of foreign troops blood safety testing and sentinel surveillance epidemiology and research care in hospitals and home care medical, nursing and counselor training Toward Civil-Military Collaboration

TOWARD CIVIL-MILITARY COLLABORATION

T O WA R D C I V I L - M I L I TA R Y COLLABORATION

training of trainers for preventive education education programs and materials media campaigns condom social marketing human rights: confidentiality and discrimination program monitoring and evaluation models from other countries A focus on women is emerging as a leading topic for civil-military collaboration. Women are increasingly becoming infected with HIV, and reports indicate approximately half of newly infected adults worldwide are women. This is an issue which will have a profound Women are increasingly impact on the military. Women are serving in the armed forces in increasing becoming infected with HIV, numbers. Military men interact with civilian women who are wives, girlfriends, casual sex partners, or commerand reports indicate approxicial sex workers. mately half of newly infected Thus, women are emerging as a natural bridge for civil-military collaboration adults worldwide are women. due to the positions they hold within the military, within military families, and Women are emerging as a within the civilian community supporting the military. International organizanatural bridge for civil-military tions, such as the Commission of the European Union, USAID, UNAIDS, the collaboration due to the Pan American Health Organization positions they hold within the (PAHO),AIDSCAP/Family Health International,The Latin American Union military, within military families, Against Sexually Transmitted Diseases (ULACETS) and the Ford Foundation, and within the civilian have recommended that women become a special focus and vehicle for community supporting and CMC. serving the military.

Programmatically, discussions about focusing on women have included sugCivil-Military Collaboration

gestions to create civil-military women’s organizations; design gender-sensitive training programs within the military; improve STI diagnosis and treatment of women, including provision of counseling and support services; and train both male and female military recruits to work in community HIV-prevention programs. Mutual Benefits The benefits to civil-military collaboration can be summarized as follows: Setting Policy: Creating working coalitions of civil, military and private agencies has the potential to elevate HIV/AIDS to the national policy level and to make HIV/AIDS a national priority. Convening Power: In many countries, the status of the military is such that it can focus the attention of the government on a particular subject; in other words, it has “convening power”. The joint interest of military and civilian agencies can lead to policy attention at the highest levels. Expanding Reach: Due to the fact that military bases are spread across a country’s regions, the military can complement and reinforce civilian programs, potentially reaching large numbers of people who otherwise may not easily or effectively be served. Thus, nation-wide program implementation becomes a possibility. Exchanging Information and Know-how: Opportunities exist for both sectors to learn from each other, particularly in the areas of epidemiology, program development, achievements and constraints, and best practices. In many countries, HIV prevention, care and counseling have been slower to develop for military men and women than for civilians. However, some of the militaries that have tested their personnel have epidemiological data that could be mutually beneficial in identifying concentrations of HIV transmission, needs for surveillance and other research, and possible areas of collaboration. Sharing resources: In order to improve efficiency and costeffectiveness, and in light of decreasing budgets and increasing Toward Civil-Military Collaboration

costs associated with HIV/AIDS, resource-sharing becomes a major advantage. Practical possibilities for cooperation include: distribution of materials for the civilian sector by military airplanes and vehicles design of joint prevention programs in targeted communities development of programs whereby demobilized soldiers are trained and utilized in HIV-prevention campaigns in their home communities joint resource centers providing telephone and computer access for individuals to obtain information on treatment sharing of hospitals for AIDS patients use of civilian counselors for military personnel and families use of civilian trainers and trainers of trainers for military programs; civilian certification of military trainers nationwide testing and counseling centers for both civilian and military use military use of civilian educational materials joint special training programs for nurses civilian training of home care providers serving military personnel

Benefits of CMC: Elevation of HIV/AIDS to national policy level Power to convene groups at highest level Expanded geographic reach Exchange of information and expertise Resource-sharing

Potential Partners Perhaps the most logical partners for the military are the Ministries of Health and Education. In virtually every country, the Ministry of Health (MOH) plays a leading role in technical leadership and in the provision of preventive as well as healthcare services. Furthermore, the MOH typically hosts the National AIDS Control Program (NACP). The Ministry of Education also seems a likely partner in that it is responsible for the education of the country; a joint activity might be the development of a sexual health curriculum with an HIV/AIDS/STI component. The Civil-Military Collaboration

Ministry of Defense is already an implicit partner since we are discussing military collaboration. The National AIDS Control and Prevention Commissions are toplevel, multi-sectoral political entities charged with setting policies, advocating for HIV/AIDS prevention programs, and generating resources for interventions. These may serve as potential partners for CMC, depending upon their level of effectiveness in the country. Generally speaking, non-governmental organizations have had limited resources and often represented too many interests to be of use to the military, but this situation is changing. NGOs are growing in size and expertise, focusing on women, forming national and regional networks, receiving increased international funding and technical support, and helping to place HIV/AIDS on the national agenda. Two private voluntary organizations (PVOs) with which military partnerships currently exist are The Red Cross, in training trainers to conduct educational sessions, and Population Services International (PSI), in condom social marketing. The strongest cultural force in many countries is the church, whose influence encompasses both its civilian and military members. Thus, religious organizations present another unique opportunity for collaboration. In Italy, for example, the military chaplain joins the medical doctor and commanding officer in leading HIV preventive education; these three people are the most authoritative figures in the lives of the soldiers. In the civilian sector, many religiously-based service agencies provide HIV/AIDS counseling, care and hospice. Therefore, religious-based organizations are also potential partners for CMC. Possible Processes Civil-military collaboration may involve the following processes: convening meetings to discuss shared problems, objectives and possible topics for cost-effective collaboration designing joint activities Toward Civil-Military Collaboration

developing joint pilot projects, for example, in garrison communities where military and civilian personnel interact integrating joint activities into the framework of national planning Joint civil-military seminars have occurred in the African and Latin American regions, sponsored by combinations of international organizations. Joint conferences within countries have also been held and are becoming more frequent. In 1996 in Chile, for example, military officials invited representatives of schools and the Red Cross to conferences in both the northern and southern regions, thereby beginning local-level discussions in which both civilian and military sectors participated. The Dominican Republic brought its civilian and military sectors together in a national conference,â&#x20AC;&#x153;HIV/AIDS: A Challenge to Developmentâ&#x20AC;?, in July 1996. The combined theme of health and economic issues, in both of which the two sectors are stakeholders, underscored the commonality of military and civilian interests. A current set of linked processes suggests how a multi-level approach may be used to maximize effectiveness in advancing CMC. Three process models are connected: 1. The first model is one of inclusion-at-the-creation. In forming its Central American Regional Chapter during the Regional Seminar in Honduras in July 1997, the Civil-Military Alliance involved leaders of ULACETS and PASCA (the USAID-funded Central American AIDS Action Project), as well as representatives of the Congress of Military Health for Central America and Mexico. This process enabled all present to discuss common areas of interest in CMC. A follow-up meeting is scheduled for October 1997, at which time the Congress will consider ways to make HIV/AIDS and CMC prominent aspects of the broader regional concern for military health. NGOs will also be invited to participate in the Congress.

Civil-Military Collaboration

2. The second is a two-step process model involving countries selected because of their potential for regional and sub-regional leadership in program development. Representatives from five countries — Bolivia, Brazil, the Dominican Republic, Honduras, and Peru — presented epidemiological data at the Regional Seminar in Honduras and discussed program development in their countries, with special attention on the aspect of CMC. A second phase will occur at the XI Latin American Congress on STI and V Pan-American Conference on AIDS to be held in Lima, Peru, in December 1997. These same countries will provide follow-up reports on developments in national planning, including civil-military collaboration.

The Dominican Republic brought its civilian and military sectors together in a national conference, “HIV/AIDS: A Challenge to Development”, in July 1996. The combined

3. The conference in Lima itself provides a third process model: hemispheric feedback to the civilian sector. As military participants will be included in panels throughout the conference program, this sends a signal to civilian HIV/AIDS/STI professionals across the hemisphere that CMC is an emerging technical strategy in partnership development and program implementation that should be incorporated in all Latin American countries.

theme of health and economic issues, in both of which the two sectors are stakeholders, underscored the commonality of military and civilian interests.

Toward Civil-Military Collaboration

As stated previously, although civil-military collaboration is not a widespread technical strategy, it is occurring within countries and amongst countries and regions. In fact, the majority of the 63 countries responding to the Civil-Military Alliance’s 1995 global survey,“HIV/AIDS Prevention,Testing and Care in Military Medical Practice”15, indicated the military use civilian trainers for preventive education to supplement inadequate numbers of military trainers, to complement military trainers on special topics, and/or to rely entirely on civilian trainers of trainers. As Figure 2 illustrates, HIV/AIDS prevention and control efforts are taking place in three realms. The first occurs within the military itself, the second within the civilian population, and the third is an intermingling of the two sectors. Figure 2

CMC in Progress

CMC IN PROGRESS

The following five vignettes present examples of the third realm, current CMC. Three are based on policy decisions at the national level involving the military and the Ministry of Health, and the other two are collaborations between the military and PVOs. These are not the only models that exist, but they are included to demonstrate the types of activities that are possible as well as to stimulate thinking for future collaborations. Integrated Planning: Peru Peru has created a national planning and administrative system for its campaign against HIV/AIDS. The civilian and military sectors are independent but coordinated. The overarching crosssectoral framework is PROCETSS (Program for the Control of STIs and AIDS/Programa de Control de Enfermedades de Transmisión Sexual y SIDA), a three-tier administrative system operating at the national, regional and local levels. It is based on the premise that “coordination establishes a relationship between independent collaborators and respects the autonomy of the parts”.16 PROCETSS’ macro objectives are to achieve: integrated attention to HIV/AIDS/STI; interventions to change behavior; nationwide epidemiological surveillance; and the strengthening of institutional capabilities across the country. There are seven points of common operational guidance for all three implementing levels: 1. Health services should be accessible, acceptable, and of quality. Accessibility in part means “the guarantee of autonomy, privacy, confidentiality, and no discrimination”. 2. The control of STIs is the basic strategy for the control of HIV/AIDS. 3. Counseling is to occur before and after testing. 4. Sentinel surveillance is to be developed. 5. The World Health Organization’s Prevention Indicators will be used as measures for evaluation. 6. Urban areas are to have priority. 7. Management, human resources and equipment will be improved at all levels. 18

Civil-Military Collaboration

PROCETSS links the three levels of implementation functionally. The responsibility of the national level is to national, regional and provide regulations and standards; assure fulfillment of objectives by coorlocal level HIV/AIDS planning dination and supervision, consistent with the protection of human rights; and administrative system is provide technical assistance; design, implement and evaluate a sequential based on the premise sexual education program in the school curriculum with the education sector; that “coordination establishes undertake a public campaign reaching politicians, the media, representatives a relationship between of churches and places of employment; and evaluate program cost-effectiveness independent collaborators and socio-economic impact. The regional level designs and proposes regional responses congruent with the and respects the autonomy national framework, and submits opera16 tional reports and epidemiological data of the parts.” to the national level. The local level designs and proposes local programs that are consistent with the national framework and are sensitive to local culture, coordinates with community organizations, and submits operational reports and epidemiological data to the regional level. Peru’s integrated civil-military

Within this overall framework, the armed forces and national police have developed their own integrated planning system, COPRECOS (Committee for the Prevention and Control of HIV/AIDS in the Armed Forces and National Police/Comité de Prevención y Control del SIDA de las Fuerzas Armadas y Policía Nacional de Perú). It operates within the PROCETSS system and integrates planning for Peru’s armed forces and national police. It has a common set of objectives for all the armed and national police forces: securing of safe blood supplies; arranging for the availability of testing; improving the epidemiological information system and laboratory procedures; providing psycho-social care and family counseling; and developing preventive education proCMC in Progress

grams. The plan designates lead hospitals and calls for education programs within the military schools and training centers. It defines the projects to be implemented toward achieving each objective and specifies organizational responsibility, indicators of success, documentation requirements and budget requirements. It operates in parallel to the three PROCETSS levels, coordinates with and provides reports at all three levels, and participates in the national outreach campaign. Peru shared this planning model with military representatives from 11 Latin American countries in Lima in May 1995. Subsequently, five additional countries have adopted or adapted the COPRECOS model: Bolivia, Brazil, Chile, the Dominican Republic and Honduras. Beginning Multiple Activities: Brazil Brazil is in the early stages of implementing a variety of activities. A Commission for the Prevention and Control of HIV/AIDS in the Armed Forces (COPRECOS/Brazil) has been created. A “Protocol of Intentions” frames cooperation between each of the three military services and the Ministry of Health, and a Permanent Interministerial Council has been established to address health problems. The original protocols have been expanded to include regional and functional activities, focusing primarily on the Amazon and frontier regions; service to indigenous populations; sanitation, surveillance, equipment and plasma needs; and the production of medications in pharmaceutical laboratories. A 1995 agreement between the Ministry of the Army and the Ministry of Health instituted a “permanent program of mutual cooperation to prevent the spreading of HIV”. The Army, in cooperation with the Ministry of Health, is beginning an HIV prevention program for indigenous, frontier and Amazon region populations. The Ministries of Health and the Army initiated a General HIV/AIDS/STI Coordination Program in 1996 directed toward the 18-year olds presenting for military service. This CMC is enabling a statistical sample of over a million male youths.17 20

Civil-Military Collaboration

Training of Trainers: The United States Another example of a civil-military joint effort is the collaboration between The American Red Cross and the U.S. Navy. Beginning in 1991,The Red Cross assisted the Navy in preparing a comprehensive prevention program for its 6,000 Navy and 4,000 Marine Corps units, with the potential to reach an estimated 900,000 personnel. A training of trainers component was also included, and to date, more than 1,600 Navy Instructor-Trainers have been trained. Instructors receive dual certification from the Navy and The Red Cross. Many Navy personnel have subsequently volunteered to serve as instructors for Red Cross civilian groups. The Navy utilized existing manuals, booklets and other training materials from The Red Cross as well as Navy-specific materials. The American Red Cross materials are available in Spanish and are being utilized in seven Latin American countries. Social Marketing: Africa Most militaries promote condom use and distribute condoms for free to their personnel. An alternative to free distribution for the military is the social marketing of condoms, whereby low-cost mass quantities of condoms are purchased from a private organization and sold at a subsidized cost to the consumer. This approach has the benefit of reducing costs to the military. Studies have indicated that people are more likely to use condoms they pay for than those they receive for free, for the simple reason they perceive the condoms purchased to be of superior quality.18 The leading organization in this field, Population Services International (PSI), has offices in Latin America but has not yet begun to work with the military sector. It is working with the military in Africa (Rwanda, Mozambique and Zambia), and the examples of Rwanda and Mozambique are presented here. In Rwanda, funds for condom purchase under a World Bank loan have been used to buy the socially-marketed brand,â&#x20AC;&#x153;Prudence Plusâ&#x20AC;?, which has good name recognition and is the preferred brand of the soldiers. The military now buys 100,000 condoms per month. To promote condom usage, the project began a mobile video unit campaign at seven military bases in 1996. New CMC in Progress

“…one can apply to the defense of life the concepts used in defense of the country” and “the health of Bolivian families can be improved if all

radio spots were produced, and the project devoted its “Prudence Time”, a 15minute Sunday radio show, to themes specific to the military. The project also published three articles in the military newspaper in January 1997, including an interview with the project director regarding the sale of condoms to the military. The project is scheduled to visit five bases in 1997 and to sponsor a week-long sporting event.

soldiers, upon returning to PSI/Mozambique has undertaken communications activities targeting military personnel and police. Communitythat they learn.” 9 based peer educators trained by the project have visited military bases to educate audiences on HIV/AIDS/STIs and the importance of consistent and correct condom use. The educators have effectively used music and drama to communicate their messages. A play,“So A Vida Ofrece Flores” (Only Life Offers Flowers), is used to elicit an emotional response in the audiences, increase their awareness of AIDS as a disease which could alter their lives, and motivate them toward safer sexual behavior. Other skits focus on STIs and are used in conjunction with condom demonstrations.

their community, teach all

Community Empowerment: Bolivia Initiated in 1989, Bolivia’s Sentinels of Health program is a community-integrated, civil-military national system with the potential for long-term impact. Its underlying principles are that “one can apply to the defense of life the concepts used in defense of the country” and that “the health of Bolivian families can be improved if all soldiers, upon returning to their community, teach all that they learn”.9 Figure 3, a Swiss military poster, provides an example of this protective service of the military. A sentinel,“el centinela”, is a sentry or person who is on guard. In Bolivia,“sentinels” guard the people’s health as an essential ele22

Civil-Military Collaboration

ment of the nation’s defense. During the first three months of military service, recruits complete a course on health and become certified “Sentinels of Health”. Within a few years, as many as 400,000 young men will have completed the health training.

The health instruction for Bolivia’s Sentinels of Health uses military analogies, such as sentinels are to “fight the enemies of health”, “protect the frontiers of the body”, and to think in terms of using intelligence, strategy, tactics and techniques to defend the body. HIV is a “powerful, mortal enemy that directly attacks our defenses; it is a specialist in the art of camouflage”. As part of the system of defense, soldiers are taught how to fight this health “microwar”.

CMC in Progress

In this cooperative program, the military provides the instructors. The National Health Secretariat does the strategic planning, establishes the standards, and performs the project evaluation. Certification of the sentinels is jointly issued by the Ministry of Defense and the Ministry of Housing and Social Development, and the certificate also bears the emblems of UNICEF, WHO, and PAHO. During the training, each sentinel receives a 140-page booklet, Para la Vida, which has been adapted from NICEF/WHO/UNESCO publications. Soldiers learn about common diseases and their causes, including malaria, yellow fever, tuberculosis, diarrhea, alcoholism, HIV/AIDS/STIs, among others. Additional topics are covered, such as hygiene, nutrition, safe water, construction of latrines, hazards of rubbish dumps, oral rehydration, and maternal and child health. The instruction uses military analogies, such as sentinels are to “fight the enemies of health”,“protect the frontiers of the body”, and to think in terms of using intelligence, strategy, tactics and techniques to defend the body. HIV is a “powerful, mortal enemy that directly attacks our defenses; it is a specialist in 23

Figure 3 the art of camouflage”. As part of the system of defense, soldiers are taught how to fight this health “microwar”. The sentinels are to have multiple effects when they return to their home communities upon completion of military service. They are not only to become a generation of educated fathers who will know how to take care of their families, but also community educators who know how to apply their knowledge to motivate others in the community and to direct their activities as agents of change. Source: Civil-Military Alliance to Combat HIV and AIDS

The sentinel is registered within the community and works with local authorities as a member of a health team. The communities keep records on how the sentinels are utilized and report monthly on the sentinel’s activities, such as conducting educational sessions or organizing the clean-up of dumps. At periodic meetings, district health directors evaluate the utilization and impact of the sentinel program. In some districts the local health authorities undertake community projects in collaboration with military units in order to optimize the use of existing resources. For the Bolivian people, the military and civilian sectors have agreed on a joint mission and collaborative effort to improve the quality of life.

Civil-Military Collaboration

Civil-military collaboration has been relatively slow to develop for a number of reasons. Initially, the military focused on the problem internally, and military medical systems in many countries were slow to launch HIV/AIDS prevention and care programs. Unlike civilian systems, the military specialize in dealing with immediate threats to unit readiness and generally are not well-prepared to address long-term illnesses. Military commanders are more concerned with medical problems that can incapacitate their forces in the immediate future. Thus, HIV/AIDS posed a unique challenge for the military. As the problem became more compelling, particularly between 1985 and 1992 in most countries, each separate military service became busy and concerned with its own growing and increasingly complex HIV/AIDS agenda. They focused on three areas: 1) problem assessment, testing and blood safety; 2) prevention programs emphasizing education and condom promotion; and 3) care of personnel, including counseling and provision for survivors. These activities forced each of the services to simultaneously face issues of staff development, budget and cost effectiveness, human rights and entitlements. By 1990, most countries were developing national AIDS agencies whose functions were national planning and program development. Typically, the military were not included or were included only marginally. In some countries, collaboration was further inhibited by civilian animosity toward the military stemming from civil wars, political differences and/or military dictators as government leaders. The military, however, has been a missing link in cross-sectoral planning. The conditions for civil-military collaboration are improving, however, particularly as both sectors recognize they are one population with a common enemy, HIV/AIDS. Commonalities between the sectors are becoming better understood. NGOs have improved their capacity for effective partnerships. International CMC: A Belated Development

CMC: A BELATED DEVELOPMENT

donor agencies are encouraging the next step of developing cross-sectoral approaches. Precedence of CMC already exists in building roads, bridges and even housing. Program experience from both sectors are forming the basis of discussions and assisting in the development of collaborative efforts. Regional meetings on HIV/AIDS are concluding that civil-military collaboration is essential to combat the pandemic.

Civil-Military Collaboration

1. Just as the HIV/AIDS pandemic is not exclusive and impacts all of society, the response to it must not exclude any sectors. Thus, a coordinated, multi-sectoral approach is required, one that includes the military sector. 2. Civil-military collaboration has been slow to develop due to initial internal focusing on its HIV/AIDS problem by the military as well as the militaryâ&#x20AC;&#x2122;s exclusion from national planning efforts. 3. Civil-military collaboration builds on both functional complementarities and commonalities among the sectors and makes more effective use of resources. 4. The military sector is unlike any other, particularly in Latin America, in its ability or power to convene large military and civilian population segments. It typically has a presence in all geographic areas of a country, including the small towns; thus, it has the potential to reach millions of individuals. 5. The mission of the military is to protect the population and the country as a whole. This social service of protection must also include the health of the individual and the collective health of the countryâ&#x20AC;&#x2122;s population. Therefore, the military must participate in HIV/AIDS prevention and control programs through civil-military collaborations. 6. Regional approaches are effective because they attract civilian and military leaders at the highest levels and provide a forum for cross-national sharing of programs, initiatives, policies and problems. They can lead to mutual assistance across countries and, ultimately, to regional utilization of expertise. 7. International financial and logistical support is crucial to convening regional meetings, developing the agenda, and promoting civil-military collaboration as a viable technical strategy. Lessons Learned

LESSONS LEARNED

Furthermore, a brokering and/or coordinating body is essential to bringing together the international organizations, donors, experts, and civilian and military sectors from various countries. This brokering agent must plan the agenda, stimulate strategic thinking, raise funds, serve as the liaison between all parties, coordinate the logistics, and prepare reports for dissemination. 8. Cultural affinity facilitates regional approaches. In Africa, four common languages â&#x20AC;&#x201D; English, French, Portuguese and Swahili â&#x20AC;&#x201D; help enormously with communications. In Latin America, the Spanish language, the similar Portuguese language, and shared cultural institutions and mores contribute to mutual understanding and interest in collaboration. In contrast, the cultural separation of the English-speaking Caribbean has been a barrier to joint programming with Central America. 9. Program development must be sensitive to cultural issues. At one level, culture is a major determinant of individual sexual behavior; behavioral intervention strategies must be sensitive to an individualâ&#x20AC;&#x2122;s culture and to cultural differences. At another level, failure to consider cultural context can lead to political trouble. Indeed, cultural issues can contribute to avoidance of HIV/AIDS issues at the highest levels, where leaders can face political risk by addressing homosexuality, bisexuality, the use of condoms, church doctrine, sex education, the sexual behavior of military personnel and sex-based politics. 10.Partners of the military sector can include NGOs and PVOs as well as Ministries of Health and Education. It is possible to develop a civil-military agenda in collaboration with regional military health organizations, such as the Central American Congress for Military Health, and to introduce CMC into the agendas of largely civilian professional medical associations.

Civil-Military Collaboration

Recommendations to further advance civil-military collaboration include: Dissemination of information on CMC, such as the rationale for collaboration, agenda possibilities, processes leading to collaborations, models for replication, and results from existing collaborations Advancement of the brokering role in bringing the parties together Expansion of the focus on the military to include peacekeeping troops, police, prison guards and maritime personnel Utilization of leaders of well-developed programs to assist in developing programs in other countries Development of policy frameworks that will facilitate collaborations and that will ensure international and local military personnel receive mandatory training on the UN Conventions on the Rights of the Child and education on HIV/AIDS/STI prevention Development of joint projects with potential for replication or adaptation beyond the immediate site Evaluation of policies and programs in order to determine the most effective approaches Civil-military collaboration is a nascent strategy in HIV/AIDS prevention and control with the potential for expansion and replication. The process of developing civil-military collaborations will create dialogue on policy issues, promote new approaches to problem-solving, and stimulate new partnerships and capabilities within communities, countries and society as a whole. We may expect the impetus for CMC to vary with the Recommendations

RECOMMENDATIONS

extent of the HIV/AIDS problem. In countries where the epidemic is advanced and seroprevalence is high, there is an urgent need for CMC. However, even in countries with low HIV prevalence, this may be the moment to achieve the greatest impact with a comprehensive and integrated civil-military program.

Civil-Military Collaboration

REFERENCES

REFERENCES 1. Development Associates, Inc. Management Review of the AIDSCAP Project. Washington: Development Associates, 1995. 2. Family Health International/AIDSCAP. Making Prevention Work: Global Lessons Learned from the AIDSCAP Project 1991-1997. Washington: Family Health International/AIDSCAP, 1997. 3. “Holography.” Colliers Encyclopedia. 1996 ed. 4. “Holography.” Encyclopedia Americana. 1997 ed. 5. Babbie, Earl. The Practice of Social Research. 6th ed. Belmont, CA: Wadsworth Publishing Co., 1992. 6. Kingma, Stuart J. “AIDS Prevention,Testing and Care in Current Military Practice.” International Conference on AIDS, July 7-12, 1996, 11 (1): 47. Abstract No. Mo.D.350. 7. Temoshok, L.R., and Stuart J. Kingma. “HIV Exposure Risk in Military Populations: An Uncharted Prevention Frontier.” International Conference on AIDS, July 7-12, 1996, 11 (1): 48. Abstract No. Mo.D.354. 8. “The Impact of AIDS on Military Institutions.” Civil-Military Alliance Newsletter. July 1995. 9. Ministerio de Desarrollo Humano, Secretaria Nacional de la Salud. Centinela de la Salud. La Paz, Bolivia: Ministerio de Desarrollo Humano, Secretaria Nacional de la Salud, 1995. 10. Piot, Peter. Keynote Address. NATO Medical Committee Symposium on HIV Prevention. 23 Feb. 1996. 11. Smallman-Raynor, M.R. and A.D. Cliff. “Civil War and the Spread of AIDS in Central Africa.” Epidemiology and Infection. 1991 Aug; 107 (1):69-80. 12. “HIV as a Weapon of War.” Civil-Military Alliance Newsletter. April 1995. References

13. Elliott, L. “Child Prostitution: A Case Study in Military Camps in Liberia.” International Conference on AIDS, July 7-12, 1996, 11 (1): 254. Abstract No. Tu.D.136. 14. Yeager, Rodger. “Military HIV/AIDS Policy in Eastern and Southern Africa: A Seven Country Comparison.” Civil-Military Alliance Occasional Paper Series. 1996. 15. Yeager, Rodger and Craig W. Hendrix. “Global Survey of Military HIV/AIDS Policies and Programs.” Civil-Military Alliance Newsletter. January 1997. 16. Ministerio de Salud. Doctrinas, Normas y Procedimientos para el Control de las ETS y el SIDA en el Perú. Lima, Perú: Ministerio de Salud, 1996. 17. Ministerio da Saúde. Relatorio de Atividades 1996, Perspectivas para 1997. Vol. I. Brasilia, Brasil: Ministerio da Saúde, Secretaria Executiva/Gabinete do Ministerio,Assessoria Especial, 1997. 18. Lewis, Maureen A. “Do Contraceptive Prices Affect Demand.” Studies in Family Planning. 17:3. May/June 1986.

Civil-Military Collaboration