 Could I ask people to find a seat please? Okay, we're going to leave the coffee and everything in the back so you should all feel free to go back and help yourself during the event. I would ask people to, if you've got a cell phone, put it to silent stun. I don't want to hear any bells ringing in here. I mean, you may have paid big money for that chime tone, but I don't need to hear it. Okay, let it vibrate or something. But we don't want to interrupt the flow of what will be a very interesting and good afternoon. So I want to say thank you very much for coming. My role is entirely ornamental, which has usually caused laughter when my wife is in the room. But it's just to say thank you to all of you for coming. I appreciate very much for being here and want to say words of thanks for our speakers who are here. Especially want to thank Gary Ruffett for being here. Jim Marshall, who is the new head of USIP. And I told him when I met him last summer, I thought it was courageous for him to do it. This is a man that didn't need to take on the challenges of running USIP, but it's his personal conviction that this is an important service of the day that's needed. And I think it's really very grateful that he was willing to do that. And it's really part of the reason we've asked him to be involved here today. We're going to start with Admiral Ruffett for very important reasons. We're really trying to shine a light on an important dimension that's... They're not going to spend a great deal of time in the Pentagon on this, and they shouldn't. I understand that. We've got major things we have to do right now, especially with the sequester. I can't believe we're in this, but we're in this. And the services have to make hard choices, meaningful choices. The Navy's facing very serious challenges. You've already seen that they've been canceling what we call availabilities, maintenance availabilities, they've been canceling deployments. We're canceling spare parts orders. It's going to be a tough time. We're going to see some very serious issues with readiness coming in not too far away because of these choices the Navy has to make. I don't know when this is going to get fixed, because I'm afraid that the pathology that gave us the sequester is still there, and it's still a backdrop that we have. So the purpose for our meeting today, and wanting to put a light on this, is to say that there is still an enormously important dimension to the role that the military plays that was pioneered very much by Admiral Ruffett. I use the term medical diplomacy, although I think it's an awkward term. This was when we had the Aceh earthquake, and Gary reached out, and where's my friend John Howe back here with Project Hope, mobilized volunteer doctors and nurses, and then the Navy mobilized the infrastructure of support for those doctors. It was a beautiful, brilliant solution to a complicated problem, and you saw what happened around the world. America's standing was just dramatically changed because we responded from our hearts in a way that the locals needed, and it was that dimension that we can't afford to lose now when we're in the middle of recessions, or not to say but sequesters. There's so much power in the inspirational side of America's power. We've got two dimensions of power. Powers of intimidation, powers of inspiration. Our powers of intimidation are strong, and obviously we're going to do a lot to protect those of our hard military power. But we didn't win the Cold War from our powers of intimidation. We won them from the powers of inspiration. And now that we're heading into a period of sequesters, tough budgets, we cannot lose this focus. This has to be part of the domain that we insist and preserve because I personally believe the power of those inspirational powers have so much more vitality and lift with average citizens than we realize. Of course America's always going to have to have a strong and competent military for fighting wars when we have to do that. But that's the last thing a military wants to do. It's have to fight wars. It's far better to shape the environment in the positive ways. And that's what we're doing with this program. So Gary has been, forgive me, the informality. He's now a friend as well. Admiral Ruffett has been working with us for several years on this. He worked when he was carrying over from his mission when he was, you know. And he's done a number of projects with us and still is. And so with that in mind, we asked if he would lead the way today. Would I ask you to come up? Would you all please welcome him and thank him for doing this today? Well, thanks John for the introduction. And it really is great to be here at CSIS and particularly to be here to talk about the project that has been a little bit less than a year in the making. I'd like to thank Steve Morrison for the work that he's done. Tom Cullison, retired rear Admiral Tom Cullison. And whenever you look at a group of people that produce something, I always look for the youngest person on the team because that's the individual that's likely done all the work. And that's been the case with Seth Gannon. So Seth, thanks for your work in keeping us on a true course. As John mentioned, my interest and involvement in humanitarian assistance, medical diplomacy, the various terms that are used, really came as a result of the tsunami of 2004. In my career in the Navy, we had always been involved in disaster response of one form or another. But in the aftermath of the tsunami that swept through south and southeast Asia, it was clear that with the disaster of that magnitude that we could have done better. I'm extraordinarily proud of the work that our people did. I mean, the stories are absolutely extraordinary. But it became apparent that we could have done better in response and coordination if we had habitual relationships among the various militaries in the region, even among our own militaries within the United States, our own services within the United States, and particularly with the non-governmental organizations, the NGOs. And so that was the genesis of moving forward with what we referred to as proactive humanitarian assistance. We did the first one in southeast Asia, revisiting the places where we had been for the tsunami using the hospital ship Mercy. We then picked up a similar operation in Central and South America. Had some things going on in Africa at the same time. And what it did was allow the teams to build, allow people to get to know one another. And we knew at the time that we were having an effect on relationships, on access, on cooperation. And we also knew that it was of great benefit to our medical professionals as well because they were in areas where they had not been. They were standing next to doctors and medical professionals from the countries where we were operating, learning from them in ways that they would not have learned in any other way to be on scene with the local medical folks. And so our skills also were enhanced. I would also say that from a planning perspective, my experience in having dealt with military operations of many different dimensions, these proactive humanitarian missions are some of the most complex from a planning perspective that anyone can engage in because it involves so many different facets and the complexities of operating in remote areas really require some extraordinary planning skills and capabilities. The other thing that also comes across are the young people who participate in these missions. My sense is that their lives are changed forever when they have an opportunity to experience and really make a difference in people's lives. So there are a lot of benefits for that and the work that has been done by the team from CSIS has kind of revisited that, reaffirmed it. And in addition to meetings here, it was important that the team go out. They visited the Pacific Command and the Pacific Fleet, Southern Command and then had the opportunity to visit Vietnam in the aftermath of the visit of the hospital ship Mercy. So they were able to get a sense of what the mission really means and what some of the aspects to the missions that need to be accounted for. But as we looked at this and as John mentioned, it's a different time. There'll be questions about the resources. There'll be questions about whether these operations and these missions are worth the effort and the expense. And I think you will see that they are. And the question then becomes how can they be continued? What can be done to make them better? And there are some things that the report points out that clearly address the importance of a different planning process. The integration of these missions into a whole of government approach. I know that's an often worn out term to be used. But how do these Navy based humanitarian missions fit into what the other services may be doing? How do they fit into what CDC is doing, USAID? And how are they coordinated so it becomes part of the whole and not standalone events? How do we plan within our government and with the country teams to make sure that they complement and emphasize and reinforce one another? Which I think is just part of how we do the planning. What are the resources that we devote to that process? There are points in the report that talk about that. And then the sharpest question of the day is how can you afford to do this? And there's no question that money will be tight. But as we look at strategies and where we want to be and how we want to be able to partner and cooperate with other countries, with other militaries, with non-governmental organizations, this has to fit into that fabric of the strategy. And so that is part of where you have to place your money and your budgets. Now we've also found, as we expected, that the budgetary process that supports these operations, it would probably be kind to refer to it as Byzantine. Because there are so many different restraints and constraints on the money. There are so many different places from which you can draw the money. And the way that we have to deal with that, one, occupies a lot of time on the part of the people that are trying to pull this together. But moreover, it really doesn't, in many cases, pass the common sense test. For example, we can have money to go build a clinic, but we can't use that money to outfit the clinic. And so, oftentimes, some people will say, well, that's the law. And my experience has been that that's a very easy cop-out because in most cases you'll find that it's policy and regulation and not law. And so some recommendations that we have deal with how decision makers need to approach perhaps making some changes in that process. But I believe, again, that the work that has been done points to the value, the worth, and the importance these missions have in bringing together a very, very diverse group who are all focused on improving the lives of others. And in our case, in the United States, for providing new opportunities and continuing opportunities for cooperation, for access, and for partnership as we go into the future. So, again, I'd like to thank the team that did all of the hard work for the recommendations that they have developed. And I am hopeful that this will inform some of the very, very hard decision-making that's going to have to take place, particularly in the Pentagon in the coming months and years. So thank you very much. And with that, I'll turn it over to Steve. Thank you, Admiral Ruffhead. Good afternoon. I'm Steve Morrison from CSIS. I have the honor of introducing Congressman Jim Marshall. When we pulled together this panel today at the launch of our report, we wanted to bring in at least one significant voice, additional voice here in Washington who could help fill out the discussion. And we were very, very fortunate that Jim Marshall was willing to come and be with us today. And fortunate for a couple of reasons. First of all, he comes having been a very distinguished ranger in the U.S. military, left Princeton University in the middle of his undergraduate career in the late 60s, served, returned, became part of the Ranger Hall of Fame, went on to become a businessman in practicing lawyer and law professor. Educated Boston University came back to Georgia, served as mayor of Macon, and then joined Congress from 2003 through 2011 where he served on armed services, agriculture and financial services. And so he brings here today a background as a veteran, as someone who's served in the House Armed Services Committee and seen the big picture in terms of policy and priorities. And now, as of September, he is the president and CEO of the U.S. Institute of Peace, which as many of you know, is a very unusual organization created with a charter from Congress, as he can say more about, back in the mid-80s, to fill a gap in bringing forward skills and creativity from multiple disciplines that could really begin to address issues around conflict and transitions and making use of new instruments of power, much in some ways, much like what we're addressing here today. So we're very grateful to Jim for coming and helping us open this up. He'll deliver some prepared remarks and then we will transition into a, after that we'll all, along with Admiral Cullison, who is part of our team. I'll introduce him in a moment when we get seated. We'll then have a roundtable discussion for the balance of our time and welcome many of you to, for your comments and remarks during that period. So please join me in welcoming Jim Marshall. I thought that was a very generous and kind introduction. There have been plenty of very bad things said about me and you skipped all of those. Steve invited me to, you know, describe a little bit of the background of the United States Institute of Peace. We've got a 15-member board. It's the Secretary of Defense, Secretary of State, or their designees. The President of the National Defense University and then 12 appointed by the President, confirmed by the Senate. So it's 15 members. No more than eight can be from the same political party. Our operating funds must come from the federal government. We get a base budget and then we get pass-through funds from defense, from state, et cetera. Steve's quite right. We're pretty good at convening people, sort of working in the direction of this whole of government stuff. I want to thank John Hamry for those very kind remarks and, you know, his reference to intimidation, inspiration. My board chair, Robin West, talks about the battle for moral legitimacy and that we have going on globally right now and that the United States has an awful lot to offer that the world should be attracted by and so to the extent that the Institute of Peace is assisting, it's assisting in the direction of trying to win that battle for moral, legitimately, globally. I want to thank also Steve Morrison and Seth. Admiral Tom Cullison is here. He's a fellow Vietnam vet except he spent his time in Vietnam just swimming around. A slight exaggeration. He was with the Riverine forces and actually doing salvage work and wound up as Deputy Navy Surgeon General and to the extent that you were responsible for the attending physician's office, I thank you because I use their services regularly. And I must say, I thought this long ago, too bad Gary Ruffhead wasn't born a few centuries ago. We wouldn't necessarily be stuck with a mundane name like John Paul Jones. Horatio Hornblower. Don't you think Gary Ruffhead would be much better than... I'm going to be fairly provocative here. I'm not sure, Admiral Ruffhead, when you were CNO, whether you were the one that said grace over the Navy saying a global force for good. If you were, congratulations. It made the rest of the services kind of wonder what their role was if the Navy was a global force for good. Army guy like me, what are we? I often refer to the Institute of Pieces Building, which most of you have seen down the corner of 23rd and Constitution, as a lens or prism through which we would like the world to see the United States and the United States to see the world. It's very open. It's very inviting. It's extremely friendly. I mean, in the battle for moral legitimacy, that's the image. That's the image that we want to portray. And for today's remarks, what I'd like to do is take this concept of a global force for good and use that as the lens through which to take a look at the report and the general effort to reach out to the globe with soft power to reach out in the fight for moral legitimacy. Now, I'll start by saying that politically in the United States, particularly when times are a little hard, it's very difficult to persuade Americans that much, if any, money should be put behind a global force for good. Now, think about that. You know, many, many Americans think generally that foreign aid is ineffective, unsustainable, fundamentally corrupt, and corrupting, taking one great quote, I don't agree with, but taking from the poor in America to give to the rich in other countries uncoordinated, duplicative of immeasurable value in a negative sense, not a positive sense. And I could go on and on and on. I mean, you've seen it. After World War II, we had the Marshall Plan. There was a real commitment by this country to spending huge dollars, relatively speaking, huge dollars on aid that we thought was important to shape the world. You don't see that commitment so much these days. If you think about the pre-911 history, just in the, say, two decades that precede 911, what you'd see in Congress would be an increasingly hostile notion toward aid programs, toward soft power kind of work efforts, and budgets being cut, cut, cut, cut, cut. Then came 911. And with 911, things changed. We knew we needed the military. We knew we were going to respond. But we also thought, well, gosh, you know, maybe we've been withdrawn from the world too much. We don't understand the world as well as we'd like to. We don't have the kind of contacts we would like to have, the relationships we would like to have to really understand what's going on out there. Something that's very important to us if we're going to understand how to address the problems that are out there. And so we were both thinking we needed the military and that perhaps we needed to reach out with soft power. Joe Nye came out with his book. There were actually quite a few articles along those lines. There was a hunk of people that thought that we were the hegemon now, the Soviet Union had fallen, and we could just sort of bend the world to our will. But I didn't share that view. I thought for sure this battle for moral legitimacy, not a term that I had in mind back then, but I think a term that captures well what the objective is, that this battle for moral legitimacy was going to take more than the military. There's just no question about that. So we get involved in Afghanistan. I've been running for Congress at the time. I had already been beaten running for Congress, and so this is my second go-round. And I would say from time to time to people, you know, you've got two choices here. You can either put me in Congress or from my perspective, you can put me into Afghanistan, just drop me with a special forces A team, something like that. But I'm going to need probably six months' worth of cholesterol and blood pressure medication. Then we do Iraq. Again, we sort of have the hegemon view of this. You know, if our allies can't get their act together, there's a kind of coalition that you'd like to see. Let's just go ahead and do it. You know, the reality is where military operations, at least conventional military operations, concern an awful lot of the allies might just get in the way. They just don't have our command and control capabilities. We can do this. We can take care of them. I remember having a conversation with somebody, I won't name, but in a think tank here in Washington, who was very much of that view, and then I would talk about, well, okay, so after we do this, there's going to be a brief lull, and then there's going to be chaos, and a long-term counterinsurgency. That's what we're going to face. And if we've got international allies in tow, they'll be very helpful for that phase of this conflict. Their guys can get shot on street corners, just as well as our guys can get shot on street corners. It turned out to be a lot harder than we thought. Very few of us predicted how difficult this would be. And then came Bob Gates' Kansas State Speech, and I'm going to just quote part of that, that if we are to meet the myriad challenges around the world in the coming decades, this country must strengthen other important elements of national power, both institutionally and financially, and create the capability to integrate and apply all of the elements of national power to problems and challenges abroad. In short, based on my experience serving seven presidents and as former director of the CIA, now as Secretary of Defense, I'm here to make the case for strengthening our capacity to use soft power and for better integrating it with hard power. Well, everybody in this room knows that turned out to be very difficult also. Very hard to do. There were lots of starts in the example, in the direction that just sort of fell flat. There was a spirit, and there still is, a spirit that recognizes this whole of government approach to things, but the actual coordination proves to be very difficult. Part of the fault lies with Congress and its structure and its inflexibility. A lot of the fault lies with budgeting authorities. A lot of the fault lies inherently with who has the money, has the power. I'm going to be looking after my folks first and be generous second, or maybe fourth or fifth. I'll probably think of some other things to do in the meantime. And in that regard, just a current example to me is pretty significant. Look at Afghanistan and our planned reduction of forces going into 2014 and the argument that you see over troop numbers. And let me ask you this question. Do you think it really makes a difference what size force? Let's say the choice between 12,000 and 20,000. Let's say that's the choice. Do you think that choice really makes any difference ultimately in the long run and the result that we obtain? If the political transition in Afghanistan goes poorly, the elections are viewed as illegitimate and the government that's elected viewed as illegitimate. Just how long do you think Afghan forces are going to stay together? And there's a real concern in Afghanistan right now that that's exactly what's going to occur if those elections aren't viewed as legitimate. So about a year ago, roughly less than a year, I'd say six months ago, a recommendation was made that $100 million be spent. This was the UN recommendation and the recommendation came up as a result of UN work with the Afghan Elections Commission. $100 million be spent and that would take care of the problem with legitimacy of the Afghan elections. For us to keep 1,000, roughly 1,000 troops in Afghanistan is over a billion dollars a year, substantially over a billion dollars a year. The difference between 14,000 or 12,000 and 20,000 is probably six, seven, eight billion dollars a year and that difference probably won't make any difference if in fact there's not a good political transition and yet we quibble over the $100 million. Now, on the military side, there might be a recognition that these things are exactly right and a willingness to come up with $100 million, but good luck making that kind of transition to the soft side from the military budget. It's very hard to do, even if the military is willing to do it. So we had the 1207 authority. We now have the Global Security Contingency Fund. We really need to use that on the Afghan elections. We have to focus on the Afghan elections as being very important to security efforts. At this point, we're sort of facing fiscal constraints, war worryness, worryness generally, a fair amount of instability politically and it's very difficult to see the congressional or public support for simply doing good globally. There's got to be something more to it if you're going to sustain funding in an environment like the one that we're heading into. So that prompts me to first say that today's report is timely and I thought it was extremely well done. I got an advance copy, so I actually had time to read this. You all haven't. I thought it was extremely well done and I had two just general thoughts where the report is concerned. First, what I'd like to do is get you to turn to page 8 if you would open your report. Turn to page 8 and at the bottom of page 8, you'll see a reference to measurement and evaluation. At the Institute of Peace, we talk about monitoring and evaluation. I've just eliminated the Chief of Staff position and created a new position called Vice President for Program Management and Evaluation because in this era, perhaps more so than other eras, it really should be in all eras, whether you're swimming in money or not, you want to spend that money as well as you possibly can. So it really shouldn't matter era to era, but in an era of fiscal constraints, you expect more and more attacks. It's clear that you've got to be able to explain the value added for your programs or those programs are not going to get funded. So if you would look at the bottom of page 8, there's a list of what are perceived to be the strategic reasons for the United States engaging in these mercy comfort medical missions generally by the Navy. And it's enhancing U.S. strategic engagement, blah, blah, blah, maintaining peace and reducing the likelihood of conflict, training U.S. military personnel and preparing the Navy for future crises, building partner government capacity particularly for natural disasters. And to those first four, I'll add the one that Admiral Roth had mentioned, and that is there really is a terrific boost to personal morale when you have an opportunity to do something like this. As a young Navy guy, soldier doesn't matter. It's a big boost to morale, to your commitment to how you feel about what you do. And then look at the last one. It's delivering medical services and other humanitarian assistance. Okay. If you turn the page, take a look at the first paragraph at the top of the page. In recent years, it has become widely recognized that the Navy has many measures of performance, parent, patients seen, surgeries performed, clinics constructed, et cetera, close parent, and few measures of effectiveness. Parent, improvement in population health measures, more capable health system, and the like. Accordingly, the Navy has made a serious commitment. You can go ahead and read the mounts of that paragraph. I'd like you to flip back to the list of five. What's referenced in that paragraph on page nine explaining that the Navy is actually doing this to try and determine effectiveness, value added, these kinds of evaluations. As far as I can tell, that only applies to the last one, delivering medical services and other humanitarian assistance. Well, that's the one that talks about doing good globally. And that's the one that in a difficult financial environment, like the one that we're in right now, is politically very difficult to sustain. It's necessary, and it's not just for this particular effort by the Navy, but it's necessary for the State Department, USAID, USIP, et cetera, to be able to explain how the strategic objectives that are listed, the first four strategic objectives that are listed, are actually furthered as a result of this effort. As distinguished from perhaps using the same funds to do some other effort that would maybe better further those strategic objectives. And it's really hard to do. That is really hard to do. We work on it day by day to the extent that I don't know whether or not there's going to be more work here on CSIS on these subjects, but we'd be happy, Steve, to collaborate with you a little bit, because your thinking about it can help our thinking about it, because this is what we need to explain regularly. And in order to continue to support the mission that the Navy has engaged in these medical missions, it really can't just be seen as humanitarian assistance to the world. Got a lot of people here in the United States have trouble accessing healthcare. I'd be remiss if I didn't digress and say that I published something last year on the general subject of healthcare reform. Healthcare reform is the largest explanation for our current financial woes, or our healthcare system is the largest part of the explanation for our current financial woes. And I'd ask you, if you were curious about my views concerning this and what we can do to fix it, to take a look at just Google Marshall real healthcare reform. I published something a couple of years ago. It's only 2,000 words. It's much shorter than this report. And it explains why we're in such trouble where the healthcare system is concerned, and then it gives some suggestions for how to get out of the problem. The second thing having to do with the report that I found really pretty fascinating was this whole discussion of whether we use the white ships, the mercy and the comfort that are painted white, and under international law enjoy some security against attack. I question whether or not against a capable, really committed adversary. That would mean anything. To me, a really committed adversary that was capable of doing it would consider knocking those two ships out if only to just clog the battlefield with wounded problems, people that need to be taken care of, which drain resources, diminish capability. But forget that for the moment. Just this choice between the big white ships and the Navy graywater ships. In the report, there's a discussion of the white ships not being sufficiently Navy, and so Navy doesn't necessarily get the credit that it wants to get as a result of providing the services. That the white ships can be mistaken as, you know, let's just hope, or it's any number of other things. This blurring of the distinction between military efforts, humanitarian efforts, NGO-like efforts, state department-like efforts, USIP, you know, United States Institute of Peace-like efforts. This blurring of the distinction is a big problem. I vote for the graywater ships. They're more adaptable. They're smaller. The mission is cheaper. You probably get the exact same strategic benefit as far as publicity and et cetera, et cetera is concerned. Be easier to do the missions as a result of the fact that it's smaller, quicker, less expensive, et cetera. And then the clear message that this is Navy is something that's pretty important. We ask that you all have a chance to get a copy of, here it is, guidelines that, yeah, these guidelines that were published in 2007. The United States Institute of Peace worked with a couple of other organizations, including DOD, to come up with these guidelines. The blurring, the difference between aid workers and military, or heaven's forbid, you know, the intelligence community, is a real problem for actually projecting the soft power that you want to project. The battle for moral legitimacy takes lots of different actors. Your audience is pretty important. You don't get to pick your audience. In fact, the audience is the one that's voting on who it decides. It's American Idol, but on a global stage. Who it wants to listen to, who it will listen to, who it will give credibility to. And if it's not going to be a DOD, hopefully maybe it's the Institute of Peace, or it's the State Department, or it's USAID, or it's this NGO, that NGO, it will never be our intelligence operatives. That's just not going to happen, so when we put that one out there. But to the extent that it all gets blurred, then who do you believe? And that becomes very difficult for aid organizations, for NGOs generally, for State Department, for working in an insecure security environment is tough enough without those you're trying to help and persuade being convinced that you're part of the defense establishment or the intelligence establishment. So I don't witness all the polio vaccine workers being killed in Pakistan as a most recent example of the problem associated with that. So I'm for great ships for a number of different reasons. Finally, I would say that there are a number of lessons here. First, trying to tackle how you prove value added on the first four strategic regions and probably a few others. The ones, frankly, that will get people to sign checks. How you prove that's tough to do. It requires telling your story and telling it a lot. It requires partnerships with real credible voices. They're willing to stand up and say, this is really good. Everybody talking in favor of it. Defense Department is hugely helpful to the Institute of Peace when it talks well about what we're able to do in support of it. That's true of State in other words, but the Defense Department has a really credible voice. And that's helpful to us. We can be helpful generally to the Defense Department with engaging these kinds of efforts and kind of help people be persuaded that the strategic needs that are listed in this order and hard to show are being met. Lots of other things that can be done and I guess I'll just end with it really is a global American idol out there. The audience gets to choose. We should have various actors out trying to do various things and we ought to be pretty clear in our divisions actor to actor. And with that I'll stop. While we're getting settled in, I'm going to ask Tom Cullison to kick this off. I want to say just a few words of thanks and a few special words. First of all, Chris Decker, who many of you knew, he passed away in early November suddenly and unexpectedly he was with the National Intelligence Council. He was a very close friend of many of us and a very admired and respected professional colleague who had made very substantial contributions around the question of health and how health figures in U.S. foreign policy and in national security calculations and he made quite a contribution to the effort that's represented here in terms of the hospital shifts and raised some really hard questions. And Jim Marshall, I think if you had been at the last meeting that he attended, he was particularly tough-minded and your comments reminded me of his line of argument but I think we need to make a special mention and special tribute to Chris Decker and the work that he's done. Admiral Cullison, we're very grateful to you both for the amount of time and energy and commitment that you've made to this effort and this would never have gone where it has gone were it not for that commitment. And on behalf of everyone, Seth Gannon in particular, myself, John Hammering, I want to thank you both for that commitment. We've been blessed throughout this effort by the generosity and the professional expertise and guidance that we've received from many, many parties from within government and outside government. Admiral Nathan, Admiral Middleman, Admiral Bono, the Surgeon General at Paycom, all of them have given us considerable amount of time and energy in this effort and have been very open and receptive to the tougher issues, some of which both Admiral Ruffhead and Jim Marshall have touched upon as the ones that defy quick and easy answers. Allison Vernon from the Center for Naval Analysis went out of her way to bring forward for our purposes many of the internal studies done by CNA, which proved to be very valuable and those are reflected in the report that we put together. Chris Daniel, colleague here, Captain Daniel, retired Navy physician who's with us here during a major effort looking at the strategic rebalance and how the military's humanitarian engagement writ large figures within that potentially. Chris has been a major partner and contributor as has Lindsay Hammergren who staffs that work here at CSIS. Josh Michele, I don't know if Josh is with us here today from Kaiser Family Foundation, produced in the period of this study an encyclopedic analysis. I think we shared this with you earlier yesterday on Friday, Jim, when we spoke cataloging the Defense Department's multitudinous programs that touch on health. I know we have Boche Anderson here today who works in that area. Our partner NGOs like Kaiser Family Foundation have made enormous contributions in this area. On the NGO side of things, we're joined here today by John Howe. We've been from Project Hope, to the success of these missions. Fred Gerber, his colleague, has also been very generous with us, Surge Dust from the International Medical Corps. I'm not sure if Surge is with us here today, but he too was very, very important. So with that, what I'd like to do right now is shift for a moment and ask Tom Cullison to share with us some of his reflections as a member of this group. Tom, as Jim pointed out, it was a career Navy physician. He served in many leadership and command positions. Over the course of his career, we first met when he came with us to China in the mid-naught decade when he was Surgeon General in the Pacific Command, and we were off to China looking at CSIS, looking at HIV-AIDS issues. He's been a terrific friend and colleague since then served as a Deputy Surgeon General for the Navy most recently before he retired and is now generously helping us in. I thought that it would be very good to hear from Tom his reflections, particularly on some of the operational matters, the complexities that both Admiral Ruffhead and Jim Marshall have pointed to as those that everyone struggles with, but also Tom and Seth and I had a chance with Lindsay to visit Pacific Command and Pact Fleet in Hawaii in the summer and also to visit Vietnam shortly after the mercy had visited, and that was an eye-opening experience in many, many ways for us. Tom, if you could kick things off and add your remarks and we'll come back for a bit more circulation among our members and then we'll open the floor for your comments and questions, so thank you. Steve, thanks a lot. Congressman Marshall, thank you very much because I was going to end with monitoring and evaluation, but I thank you for your comments because there must be echoes in this room. This is a topic that comes up over and over and over. So let me start with it. The issues that you raised, how do you get from the very tactical questions of what type of medicine do we do during a specific health engagement? How do we know if we're delivering good care or not? So in the best of all worlds, we've done some good for a health system in a very small area. How do you link that to the question of did we meet the U.S. strategic goals of a better relationship with a country that we happen to be operating in? And there's a huge air gap between the tactical and operational questions of a specific infant and the larger strategic questions and in the medical community, which is where most of my comments will be coming from, we've been wrestling with the comment what are the metrics that the medical community should use or the engineering community in the case of the CBs when it comes to the tactical things that we do, the medical things that we do, and who should be answering the questions and asking the questions and making the link back to those specific events. I think this brings up a larger question and Steve and I have talked about the exact thing that you brought up of sponsoring groups to look at this in a holistic way. Who should be involved? How should we approach this? So thank you very much for bringing that up in a minute. Many of the people in the room here have been involved in health engagement events in permissive environments, which is what we're really talking about here. And we can look at this on several levels. Admiral Ruff had talked about the first response of the mercy to the tsunami in Ache Province in Indonesia in 2004. Many of the people in the room were there and we know that the mission that we did in Haiti with the hospital ship a few years ago on many levels went much better because over several years we'd practiced. We'd done exercises by doing these types of missions. So from strictly an operational military standpoint, by doing what any other part of the military does, practice in a controlled environment what you expect to execute in an uncontrolled environment, that's what we did. We took the comfort, we took the mercy, we found large tech gray halls and did medical missions in foreign countries in strange environments where we needed translators and we were working with NGOs and we were working with folks from other militaries to do good to use the same equipment we would use in a disaster response. So from the strictly military standpoint that's one way to look at it. The question of health and engineering to some degree is unlike in a lot of other ways the rest of the military. The spillover between military health care of most countries and the civilian health care program and the countries we work in are very integrated. So you can't really go to a country that we would go to in say Southeast Asia and only work with the military health system because there isn't one. So we have to work with the entire country health department. So if we go there we're probably going to be working with the same people that you talked about in the pamphlet. The NGOs, the UN organizations, the host nation ministry of health, the host station ministry of defense all together to take care of patients and whatever their health system is. And getting to know each other has been a learning event over the last five to six to seven years. The Institute of Peace has really been helpful in that in sponsoring meetings between NGOs and the Navy in your building on several times. So Fred Gerber and others here today have been involved in those meetings and we've really tried to progress over the last several years of working better together understanding each other's differences and we've made progress in that direction. That's an ongoing process. Let me speak a little bit though about the experience that we had since Steve brought it up in Southeast Asia during this last trip. We went to Vietnam. Steve, Seth, myself, Lindsay to our embassy to many of the ministries in Hanoi and just got their perspectives on how did this go when the mercy came to town? How was it perceived? And we got various feedbacks from the government of Vietnam and their ministry of defense, ministry of health, ministry of foreign affairs which compared to the times that I was there seven or eight years ago prior to that were very open, very straightforward and very tactfully and well delivered to us giving their points of view on the welcoming and sometimes not so welcoming reasons that the ship came to town. From our own embassy, from Ambassador Shear particularly and from the DATS office, the Defense Office Office the mission was very well received. Ambassador Shear did many other ambassadors saw this as a valuable tool that they're able to use to advance the United States strategic interest in that country and we heard this in Vietnam we've heard this in other countries we've heard this here from ambassadors at CSIS who've talked to us so in-house in the United States house is a very valuable tool. The most telling part though is when we went to Vinh which if you don't know where Vinh Vietnam is don't feel bad, I didn't either until we went there it happens to be the provincial capital of Ho Chi Minh's birthplace strange place to send a hospital ship maybe but that's where we went and I don't think that was an accidental problem with open arms. Both the ship when it was there we were there about six weeks later the People's Committee, the town council and the president of the People's Committee the mayor went out of their way to talk about the very positive reception that they gave the ship the response from the U.S. sailors, the foreign sailors from other militaries and the NGOs that were there but the telling thing to us was they said you know we really want to know because we want to help that town get ready so they don't have the same problems that we had when the ship came here we want to get over some of the bumps in the road because this went so well. Part of the reason for that was that we had changed our approach over the last several years from less doing coming in and doing major surgeries for example and more teaching subject matter expert exchanges and opportunities to work with local host nation physicians and there's a lot of planning which in any other military exercise you would expect a lot of learning about what is the status of the local health system what could they most benefit from western medicine what would they like to teach us and how do we act peer to peer in their system to help them develop if we go in open in that regard we were very well received and the reception we received from the local provincial government the clinics that we visited where we helped individuals was just outstanding we had no pushback whatsoever so this is all good let me come back to monitoring and evaluation you say so what you did great stuff in Vietnam in a country that nobody here in the room could probably find that town on a map if I ask more it was how do you relate that back to our relationship with Vietnam and you have to tell the story over and over and over you're exactly right and Steve will cringe when I start to do this because I've told this story over and over an hour in Vietnam in 1968 and 1972 under very different circumstances I'm assuming you've been back at several times and once okay I've been back several times and it's a totally different relationship and the first time we were getting shot at and the second time we're trying to do health in their system and you're doing whatever you were doing in your way of going my first experience of talking to the Vietnamese surgeon general in Hanoi was very uncomfortable the next time was a little easier the next time was easier yet and this last visit we were welcomed with open arms so somehow we have to get back to monitoring and evaluation look at the U.S. strategic relationship with Vietnam today vis-a-vis other actors in the age of the Pacific region and somehow be able to relate each of these incremental steps we've taken each of these areas we've approached engineering health police rule of law whatever and be able to link it and somehow it should cause an effect and I'm with you we need to figure out how to do that and I would challenge Steve to help us go along that line and I've just taken a job in the other organization we'll help you do that so that's it from here from there but it comes back to monitoring and evaluation how can you make the case today that this is money well spent and telling the story will get you part way there but it comes down to prove it and well that's my challenge today guys just I think the list of strategic objectives is a good one the one toward the end is not as complete as the one toward the front of the report so there's more to be said in fact toward the front of the report there's a specific mention of what good this does for the troops themselves I think the thing to do though is to focus on each one of those strategic objectives and then put a lot of thought into how do we show that this has been met or not great and it certainly helps to have the local ambassador American ambassador and others saying that this is making their relationships but then offer specific examples of that you know how did this help you out very hard to measure yes sir pre and post public opinion polls believe it or not that's something that you need to think about those sorts of things in order to be able to say to a funder we're not just doing good globally we are doing something that's strategically important to the United States beyond being nice if I could also add to that I think it's important particularly as we in the United States look at metrics you know we as people tend to be pretty impatient we want to know right now and I think it's helpful as you look at the objectives that you're pursuing or the effects that you may potentially observe that you're also able to articulate when you will likely begin to see some of these effects it won't all happen at the front end as all of you know and I often cite the case of the young boy who is treated during one of these missions who has a life altering outcome and that young person then finds their way into public life a decade, two, three later and I would submit that their view of the world is going to be very different because of what happened to them and I think being able to try to put that in context as we talk about the expected outcomes is something that needs to be done in this measurement process because we want to know what the effect is the day the ship comes back and it's going to take a little bit of time in some areas to do that. Let me add a few thoughts from the Vietnam visit it was very clear from that visit as well as the prior stop in Hawaii that the planning cycle was a rushed cycle it was one where the teams that were putting these operations together which became rather complicated the more you focused on partnerships versus just delivery the more complicated they became and the ship was moving through three or four visits in rapid succession so the planning cycle didn't allow for a whole lot of careful early thought and after thought and this is one of the things that we talk about is the need for a much longer planning cycle. There were a couple of other things that we highlighted as enduring challenges that if improved upon will make it easier to sustain these operations measure their impacts and make the case to Congress and to the American people one is that they really are very episodic but they don't necessarily need to be as episodic as they are they could be more recurrent there could be a greater selectivity of let's pick a few places build the relationships in a more consistent and recurrent way which if you're episodic it's hard to know what the lasting impacts are going to be there was very little integration on shore with very large health programs done by CDC, AID the president's emergency plan for NIH research programs and when you looked around the landscape was full of capacity on the civilian side that reached back into our U.S. civilian agencies in partnering with Vietnamese entities but it just wasn't something that had happened yet and in short missions like this it's difficult to do that but again with a longer planning cycle with perhaps a more recurrent requirements that window becomes open as well we saw language was a problem there in terms of many of the health professionals in Vietnam had a bit of trouble in the language instruction and it was hard to find good Vietnamese proficient instructors as well on our side so those were important things too in understanding how much was being learned and how much was being gained in that period the NGO issue was one that I hope we can get a little bit more discussion on too because there's a huge capacity in the American society in terms of NGOs and the ability to deliver a very high level of expertise across a spectrum of of activities and it's my feeling that much more could be done in partnering with American NGOs particularly those with a considerable depth and I know the Navy's done a lot to try and build up that dialogue get an MOU try to engage much more systematically and USIP as you point out with the guidelines and principles that you've developed but these are things that are all require more attention and effort which will make it easier to measure impact and make the case it seems to me in Hawaii one last point in Hawaii we were trying to test the proposition then and more recently when Chris Daniel and Lindsay and Tom were in Hawaii test the proposition of how high up in the hierarchy of leadership is the humanitarian mission are the medical missions embraced and the answer was quite a bit that this had become internalized and it had become institutionalized and very clear and identifiable planning exercises doctrines, guidance and the like and that was a big revelation for me and a testimony I think Colonel Admiral Ruff had to your leadership in moving this forward that it has taken on that level of becoming embedded at the leadership level now in a period of budgetary constraint the question I wanted to put back is that going to be sufficient in your mind to make the case and defend because at the end of the day making the case for impact and value is going to be most important at the leadership level where these programs really matter and I think we saw some very promising evidence that this was beginning to happen and I'd like to hear from both of you a little more on that okay yep my sense is that there will still continue to be strong advocacy for the missions and and in very thoughtful ways of trying to get a handle on the resources to be able to do it because these missions make such a huge difference in the types of relationships that the US military enjoys in whatever region it may be and of course my experience is mainly in the Asia-Pacific region but there are relationships that that developed and solidified solely on the basis of what we did with these humanitarian missions we could not have developed those relationships in any other way in my opinion because for many of the countries you can argue whether it should be this way or not the idea of going into an area together with other militaries with NGOs and doing humanitarian work is something that can be very easily agreed to but to go in and say let's go ashore and we're going to shoot up a bunch of stuff that's a completely different kettle of fish and there are relationships that have been developed that again I can't say it emphatically enough are a direct result of the humanitarian efforts and people realize that I believe that there will be a pull from countries in the region to continue these and I also believe that countries in the region will use this as a meter as to whether or not the U.S. engagement is going to remain or not remain and when you look at the scheme of things the cost of these missions not that significant and if they're factored into the overall approach that the Department of Defense is taking it's a pretty easy calculus in my opinion Well I thought the two were these two but from my perspective my trip to Vietnam the one trip I did take was a congressional delegation and I was with two other members going to see the premiers of Vietnam and Cambodia to talk about POW, MIA stuff but then I took personal time after that and when I wound up I found myself in Saigon Ho Chi Minh City and I did a fundraiser for Project Smile and then got fairly actively involved in Project Smile and I know that there's been an awful lot of support for Project Smile as part of the Navy's effort so I as I think about how do you show the kind of thing that you would describe as something that I wouldn't know as a member of Congress my past background I'd listen to that makes sense to me build the relationship doing good things and then when you got to do something that's hard maybe you got the relationship you need in order to actually go do the hard thing from my perspective though just trying to sell this generally to members of Congress that makes some sense and then need to again think about the strategic objectives and how you again having a sufficient advanced planning so that you've taken into account very appropriately maximizing the public relations part of this in as effective a way as possible building partnerships in as effective a way as possible having the appropriate NGOs very comfortable with this and then singing praises of the operation I mean it's just a series of things like that that can persuade members of Congress have to get re-elected those that have difficult seats do certain things in order to try to get re-elected I find myself wondering right now if you couldn't look at what members of Congress do to win hearts and minds where do they spend their money to try and do that and then mimic that a little bit because they understand it they do it themselves is that sort of thinking that needs to be done here is not in doing global good it's going to be difficult to sustain let me pick up on the ship question a little bit Allison Vernon Allen Brown Maria Kingsley in the CNA paper write about something that we found and that was that the ship was extremely important visibly it was very much an icon the question came up of can't you do these a lot cheaper by just going out and doing some health and the thought was it'll get lost particularly in Vietnam to have a large U.S. ship show up off their coast which they're now responsible for the safety was a huge deal and it's that way in many ports in some ports when you send a grey hull in which can be viewed as either a warship or a health ship depending on what use it's being taken for the time you can send different messages that way so to have different options for the types of ships that we send, large, small, whatever but the fact that our Navy sends a ship to their country to do good is a huge deal and the fact that we happen to do some medicine is almost coincidental I don't know if you've experienced that ever before absolutely, I mean the often times when you talk about the humanitarian assistance and the role of the ship it some become concerned that we're diminishing some of the other great work that the other services do but there is something to be said for that physical demonstration of U.S. commitment on the part of the ship and I'm drawn back to a story that was shared to me by John Howe we were in Holo in the southern Philippines and one of the families that was being treated, or children can recall all the particulars brought something that had been hanging on their walls since the 60s and it was a picture of the SS Hope which was a hospital ship that had come there had done humanitarian work and decades later that was the image in their mind of the United States and what the United States meant so not to diminish the work that goes on in perhaps smaller units and remote areas that image is something that stays in the mind of people I believe for a long time on the choice of ships I've had my say I would say it can be tested whether or not the larger white ship has this fundamentally different reception than a smaller gray ship is something that's testable I guess as an aside during the Haiti earthquake we had the mercy there and we also had a large deck amphib which has six operating rooms and a lot better medical capacity in some ways in terms of the ease of getting people on and off the ship and there was a whole lot more attention paid to the big white ship and I don't think anybody knew we had a helicopter carrier down there except for the Navy in some regards at least my office at Dumed I kept asking are we sending anybody over there and the answer was not very many so that captured the headline because it was different maybe because of the mission but just interesting aside from living the Haiti dream here in the DC why don't we move to some comments and questions we have two mics here set up and what we'll do is ask you to step forward identify yourself be very brief in your remarks and comments and we'll bundle together we'll do three and then we'll move back to our speakers and we'll do another round so please come on forward yes please my name is Dr. Rebecca I'm from the office of naval research Hi what occurs to me as you look at this is the is this one? it is is the role of information sharing and information gathering and the need for innovation in these areas the old style paper and pen surveys they're very old pat have you guys considered the problems and promises of innovative information sharing technologies innovative novel survey methods we have a lot of those things that are being funded here and there but they need some connectivity they need to be moving forward we need to put all of that we have done on social media monitoring humanitarian assistance disaster relief crisis mapping and monitoring these projects exist in the Navy have you thought about those problems and possibilities and the need for more connection there? Thank you, please hold it we'll take a couple more, yes ma'am I'm Mitzi Wertheim with the Naval Postgraduate School I have a few suggestions first of all I think we need a 21st century definition of national security which I think you're absolutely at the top of that but it needs to be made known to the American public as well as the rest of the world it would be useful when you go in and do the kinds of things you were talking about the rules and regulations that are inhibitors when you did these studies you identified those rules and regulations I once did an analysis of buying $100,000 worth of computer equipment for the Navy and I had to hire a lawyer who'd worked on the hill for many years but it took her three months to pull out that stuff if that was a general body of knowledge that was eventually built up by some of the think tanks that would be really important and I think the other thing that I think is so important what I heard was the word relationship keeps coming up over and over and over again I can assure you that's not a word that is used when they teach international relations in schools and you might somehow get the word out that they need to teach that they have very mechanistic models when they teach international relations which don't give you the kinds of insights I'll stop there Thank you Mr. Joe Bosco with the Southeast Asia program which is formally with OSD where I worked on HADR I was there during the period Admiral Ruff had described the tsunami all the way through Cyclone Argus and Burma and so I can attest to the complexities of working with other agencies that you described particularly with OFTA which within AID is by statute the lead federal agency so you had that constant tension with the resources with OFTA and AID coming to Mr. Marshall's point about white ships versus gray ships one of the criticisms or tensions there was with the NGO community was the military played such a large role that they were concerned with the militarization of humanitarian assistance and we had a constant tension on that matter we had to kind of be in the background and yet our role was indispensable particularly you got kind of a pushback from some in the military who worried about the humanitarianization of the military that we were shifting our focus from the main mission to that of HADR so be interested in your comments on those Great thank you If I could ask you both just to pause for a moment take a seat we'll come back to our speakers here we have questions around information sharing, survey methods, social media questions around redefining national security if I could I'll just take your question as a suggestion and I think you're absolutely right there are lots of different techniques that can be used these days they're getting more and more sophisticated for measuring impact and part of the planning process for these missions should be to max out on utilization of these kinds of techniques in order to demonstrate impact I would also say to that that I think as you look at the integration and the assessment process that it will be important for the various entities or activities to get over the rice bowl lightness and to be able to open up information to one another because I think that can be a huge breakthrough and I think that will be harder because people are going to be very protective but it really should go just the opposite way if we want to do better integration the other point I would make is to not leave out some of the local entities who are polling their population and how do we reach into those and make use of their information which may be more relevant they may have a better way of tailoring it to that particular population but I think I agree with you this is an area that really needs to be worked and it can't be worked with a green eye shade on it has to have some common sense applied to it and the books need to be much more open than they currently are one of the sensitivities that always comes up and coming back to Dr. Goldsby's comment about using some of the techniques you approached and discussed is the question of what's the difference between an assessment of a health engagement and an intelligence assessment done by a military organization and once the term intelligence comes into it then our relationship with other parts of the government and the NGOs is at risk so we have to be very sensitive to the terms we use and the techniques we use although the information that comes out of that may be the same it can scuttle a lot of work by a lot of people to try to work together over a period of time I just I see that as a very sensitive area that we need to pay attention to I agree with you completely that the techniques that are there need to be figured out at the tactical, operational and the strategic level but how we go about that and how open we are about what we're doing needs to be very clear as we go forward in this area particularly. If I could get back to Joe's point about what I took to mean well if you're talking about this militarization problem we've been talking about this for years and years the dilemma in the kind of conflicts that we've been in with the exception of the initial stages of the conflict is that in order to move forward effectively you've got to win hearts and minds because it's a counterinsurgency in essence even if you're not calling it that and in order to do that there are an awful lot of humanitarian things nation building things what have you that you would like to see done and there's nobody that can do it except the military because the environment is too hostile so the military being a can-do operation steps in and tries to do what it's not familiar with and then as the situation becomes less hostile and NGOs it's permissive and consequently NGOs and others are available it gets very awkward typically they're more talented at doing what the military has been doing but what's the handoff what's the so you can see the military saying look this isn't what we do we've got civil affairs for days but that's not really what we do it would be nice if we could figure out how to have that kind of capacity available to us in impermissive environments insecure security environments and we haven't been able to figure that out as a nation we just haven't been able to do that we can't direct order USAID State Department employees into these impermissible environments if anything we've headed in the opposite direction if you look at our embassies they're fortresses and it's understandable historically it used to be that your ambassador was invited if your ambassador couldn't be protected by the host nation then your ambassador just didn't go there and sometimes there were problems and ambassadors got killed but now we're in an environment in which the host nation watch there but can't protect you so we have these fortresses that make it very difficult for State Department USAID and everybody else to work from Mr. Ruffhead can you say a few words about the dialogue with NGOs as it's evolved over this period you know if you go back and look at the relationship particularly that the Navy had with NGOs in 2004 and you look at it today I would submit it's very very different for a couple reasons one the population has grown in the number of relationships that we have to some of the NGOs that were apprehensive or reluctant to work with the military I think that has changed I would say that at the very beginning there were several NGOs that were there and have been continuous partners with us you talked about Operation Smile John Howe here from Hope who's been so much a part of the missions but it's also a two way street we learned about NGOs and to your point NGOs have a function they have expectations they have stakeholders and it was important that we learned about that as well and to best judge where the lines are where the responsibilities are where the strengths and weaknesses are how the entities can cooperate with one another and we have come a long way and I believe that we need to continue down that path because it's when you bring all of it together that it really can make a difference I referenced earlier in my remarks that the United States Institute of Peace was pleased to work with you in particular on that subject and we've got a civilian military working group that's ongoing that works on trying to better coordinate better understand etc why don't we have another round sir gentlemen in the back kindly been patient to my question my name is John Rothenberg I was with USAID on a Navy PRT in Pactica province the I was there for two years and there were four different PRTs and three different brigades in charge of the battle space each because of the need to close out your SERP projects and because of various other things people were concentrating on very short term projects and in most of these situations to me the more long term you can do the more impact you're going to have with the ships to me it's the structure of the intervention is such that you have the exact opposite you have multiple visits you have the same people on the ship well longer period of time than nine months but I would think that the impact would be deeper and broader and I was wondering if that's the case and if it is how could you take those lessons and apply them to other naval humanitarian interventions yes we're going to collect a number of comments hi my name is Charles McRafress retired Navy SEAL Mr. Cullison, Admiral Cullison I haven't seen you in about 15 years so congratulations on the admiral in retirement I could set up a round table and talk to you guys for hours about this from experience and things because I was also a medic and as they say in the SEAL teams the one thing that hasn't been addressed the image that we get saved my life I can tell you five different times over in Iraq as well as many of my team members so the image that we get from this is unmeasurable please keep saying that yes ma'am hi I'm Allison Vernon from CNA it's nice to see all of you I just want to offer one clarification and then some of our thoughts and analysis on the objectives issue the clarification on the Great Hall and White Hall is that that was from the point of view of the host nation and while there were some logistical differences on the White Hall and Great Hall in terms of getting to port etc the big difference for countries especially that had a previously antagonistic relationship with the US was the cognitive dissonance that happened when a warship pulled in and off of that ship instead of gunners and combat fighters came doctors and nurses and engineers and that that created a profoundly different impression in them on their entire opinion of the US military and also our country as a whole so that's sort of where that preference comes in what I wanted to touch on was your discussion about the objectives as well as the measurement of those objectives and fiscal constraints so what we have found is that strategic objectives are hard to measure but they are hard to measure in part because of how they are currently written so you have strategic objectives that are very appropriate at combat and command level but when they are translated to operational or even tactical objectives they remain virtually the same so it's strengthened partnership and alliances at a strategic level and down to the commodore of the mission he needs to work with allies and partners to strengthen our relationships because they are unable to target their activities effectively so it's a lot of throwing stuff out hoping they achieve something but I think if those objectives were rewritten in a more concise way they could figure out who it is they need to affect and what they need to do to affect them in sort of a more streamlined way thank you very much sir why don't we collect some very quick closing comments and thoughts so yes sir yes sir thank you for your time I'm commander Rich Gustafson from OSD policy and I'm at the health affairs disaster relief and global health and I've been shrouded with this cumbersome title of global health engagement coordinator and I started off as an E2 pormin 30 years ago and I've always taken great pride in what the navy medicine has done I spent time at NAMRI and saw the pictures of malaria research and things like that but it's only six weeks ago when I reported on board at OSD policy that I found out that the navy wasn't authorized to do all that and I say that tongue in cheek but I've been informed I never feel that the navy seems to have a disconnect about what its authority is and going out there and interacting with host nations whether it's their military or civilians so I just wondering if you want to touch on that thank you and let's just very rapidly Hi, I'm James Tetlow with Washington Corp thank you for speaking today since this is a two year anniversary of the 311 disaster in Japan I was wondering if you could talk a little about lessons learned from US assistance during that disaster and how it's informed proactive work since that Thank you Closers, thanks for your service One of the key strategies you said was about moral legitimacy winning that battle can you define moral legitimacy? I'm pretty sure our enemies can so the question is can we is it democracy promotion is it free market capitalism is it Judeo-Christian values is it all of them, is it none of them because if we can't define it how will we project that? Thank you My name is Kezia Edmondson I'm a graduate student at the Uniform Services University where my thesis I guess there is on the difference between white holes and gray holes and I'm glad that Ms. Allison Vernon came up here and spoke about the cognitive dissonance because that was one of the things that I was going to speak to along with several other things such as polling results that have showed that the gray holes are the preferred capability to bring to the host nations and then also one of my biggest things is their ability to blend both soft and hard power which of course the white holes cannot do so my question is why when there is such this perception in the host nation that they are more willing to see these and as well as force projection etc why are our own leaders not seeing them as much or more of capability to send out than the white hole shit? Thank you 30 seconds please Olivia Bosch Five Years Security Council and some time in Iraq I also do a national with the United Kingdom I had a different perspective on the white gray hole from the country's point of view many developing countries see the military as a good asset coming to the aid of the community so elaborate on this MOU between the state and the department in terms of aid to defense as an article in foreign policy last year the degree to which state department knowledge of a country in terms of the people's perception of the military might be a contributing factor to whether you bring a white or a gray hole to bear Thank you very much I didn't realize that the white gray you've really put us onto this this has ignited quite a bit quite a bit more discussion than I had anticipated Admiral Ruffin I may kind of burst some bubbles here on the white gray hole debate a lot of it was driven for budgetary reasons and scheduling reasons as to what assets we had and what we could use at the time the sense and one of the reasons why I think it was so important to do this project and some of the follow on work clearly that many people here have an interest in is to determine what is the best way ahead because in the early days of the missions when we first started this out the request often as I would travel around through the Asia Pacific region was when is mercy ship coming back it had taken on almost this you know mythological aura and there was great interest in the white hole because it was benign and it was easy to break in maybe after you pass through a period of developing relationships and people truly understand the good that can come from the mission then maybe the white gray becomes a little less important but I think that clearly without question this is something that the Department of Defense is going to have to sort out because there are two hospital ships and the numbers of amphibious ships could decrease based on the budgetary environment and so how do they get a portion around to do the missions so I think that the work that has been done and will continue to be done is going to be very very important if you want the missions to continue and what's the right model for them Tom I'll stay away from the white and gray thing the question about Japan we can have a whole session on that there were a lot of sensibilities around that the Japanese basically responded to their own disaster we provided some very strong technical capability in certain areas and there's somebody here in the audience I can introduce you to maybe you can answer some other questions for you but it's nice to say that was two first world countries and probably the most complicated scenario we went to dream up in fact to the place I worked at the time we were sitting around dreaming up scenarios and we said how about a 9 foot 9 foot or earthquake with a 45 foot tidal wave that knocks over a nuclear reactor and somebody said nobody will buy that so no kidding three weeks before the event that came up as a scenario that was deemed too hard so that with all the fallout was probably something that should be studied for many many reasons you've seen me afterwards I can point you to somebody that can answer some more specific questions and just as a short aside on that I was really struck having done the scenario four and then still being on active duty when Fukushima hit I was really struck that here you had Japan highly developed country that one would assume that any sort of natural disaster would be easily handled until you injected in the nuclear dimension of something that only happens at a developed country and it really changed the dynamic it was a completely different problem on many many levels but I would offer that it's something that we need to think about because I think there's a fundamental shift coming in the nuclear world if you look at nuclear power with something that was a purview of developed countries developed countries are now walking away from it and developing countries are bringing it on developing countries are more prone to many of the natural disasters whether it's Pakistan or Southeast Asia so this is not something I think we should take Fukushima and say hey this is a one off and it will never happen again I think that we may be entering a period where nuclear problems could be more on our scope than we would like them to be I think you're absolutely right when you look at the existing 450 plants worldwide many of them aging and we've got another 60 under construction largely in emerging economies so this whole question of security and low level low dose radiation exposure very important on the response to Tohoku the US military was remarkably fast and effective at clearing ports but they took a very low profile and the Japanese took credit for the most part in what happened and they were within the space of a week were able to mobilize over 100,000 troops which of course was constitutionally unprecedented since the end of the war which was also a remarkable development so the interface was I mean we were there shortly thereafter and repeatedly and it was a remarkable interface over a very complicated quick moving and dramatic situation where I think the US made enormously profound contributions on a very end that were deeply appreciated the polling data interestingly that showed a collapse of confidence in the government in Tokyo showed a rise of confidence in the United States military which was also very unusual survey work in Japan you know there are a lot of observations and questions that I'd love to be able to comment on if I could remember them all the PRT question is near and dear to me since I think it's a ill-conceived word very well thought a good program that was very poorly executed but that's for another day let me tackle the moral legitimacy question that's pretty presumptuous it's the intimidation versus inspiration question we in the United States enjoy a country that has very low transaction costs associated with doing business hence there's a lot of interdependence we trust one another we generate a lot of wealth in many countries transactions costs associated with doing deals with just trying to get together and figure out how to maximize by individually specializing very, very costly very difficult to do in the United States we're pluralistic society we have many flaws no question about it but we're a society that gives rights to minorities, gives rights to religious groups we very strongly feel that the government ought not to be driven by one tribe by one family or by one religion we allow people to freely express themselves and people have a responsibility at the same time to not go overboard and frankly we don't do very much as far as policing them is concerned because we protect the right to speak and to express and to protest and we value that so highly so the moral legitimacy and lots of studies have been done of this that is more likely if it were global to lead to peace and prosperity that's our belief we think there's a moral imperative behind that we think that in this battle inspiration, moral legitimacy that we're more attractive and the battle here is to persuade the globe that in fact we are that jihadists and others are not we're at the end of our hour I want to ask and knock out three questions in about a minute here one, John Rothenberg you asked about the issue of the duration as you were talking it really hit me that even though the people on the ships may change the image in the entity is really the ship and so I think that's where you get a sense of continuity that does not exist where you're dealing with the individual on a person to person level on the softening of the military that some have accused these HA missions of being indicative of that my sense is you just weather the storm and you work with those who are being critical and show the benefits that are being derived from the relationships from the complexity the operation and the experiences and then what they have led to over time and to the commander on the Navy Authority I'll confess I never got the memo on that note please join me in thanking our presenters thanks