Category Archives: Duke in DC Program Blog Posts

But Isn’t Diplomacy the Opposite of National Defense?

Before embarking on my summer internship, I received a few puzzled looks. “Why are you interning at the State Department if you are interested in National Security? Shouldn’t you be going to the Pentagon?” Well, considering that I just left the active duty military, going back to where I just came seemed too safe for a summer internship. I wanted another perspective into our country’s national security apparatus, so I picked the State Department.

Political-Military Affairs, the bureau where I worked during my internship, just happened to be the interagency link between the Department of Defense (DoD) and the Department of State (DoS). As stated in their mission statement, “The Mission of the Political-Military Affairs Bureau (PM) is to build enduring security partnerships to advance U.S. national security objectives.” PM specifically provides policy guidance on areas of international security, security assistance, military operations, defense strategy and plans, and defense trade.

Taking a lunch break in front of the Harry S Truman building
Taking a lunch break in front of the Harry S Truman building

While I did not travel overseas to negotiate grand foreign policy agreements, my scope was within the office of foreign policy advisors (POLAD) in Washington, DC. The POLAD office manages a large group of Foreign Service Officers (FSO) embedded within major military commands, all over the world, to provide foreign policy expertise; true influencers within the interagency continuum. My summer internship corresponded with the timing of provocative topics about the relationship between DoD and DoS, so it was insightful and a unique privilege to discuss these issues with senior staff members like the Principal Deputy Assistant Secretary for Political-Military Affairs Ambassador, Tina Kaidanow, and Under Secretary for Arms Control and International Security Affairs, Rose Gottemoeller.

Throughout the summer, I worked on office policy and procedures, redesigned the office website, and coordinated one of the big events of the office, the POLAD Orientation. This is where we prepare FSOs for their new posts by giving a brief introduction to internal processes to the military such as military planning and briefing. Everyone that has been around the military knows our affinity towards PowerPoint. While many of these FSOs have worked alongside the military, this posting requires a true internal perspective and understanding of what the DoD does. POLAD Orientation is not, however, military charm school!

So, in some ways I could relate. While I did not work here in an official military capacity, my perspective going into this internship was similar. I saw DoS in action while in Iraq and thought I had a pretty good grasp on what “the people in civilian clothes” were doing over there. Yet, actually working inside State gave me a true appreciation for the vast, political scope that State must examine when dealing with security issues.

Additionally, when operating in areas of conflict abroad, there are more than just state actors to keep in mind. That is why, in addition to my State Department internship, I took the opportunity to engage in a one-week intensive course on Humanitarian Action in Geneva, Switzerland. We discussed humanitarian principles and the provocative issue of neutrality. I was afforded the ability to re-evaluate my stance on these issues when engaging with major leaders of the global, international governmental organization (IGO) and non-governmental organization (NGO) communities.

A warm Geneva welcome to the Sanford School by the International Committee of the Red Cross!
A warm Geneva welcome to the Sanford School by the International Committee of the Red Cross!
About to head into UNICEF with my HA cohort
About to head into UNICEF with my HA cohort

Foreign policy is not easy. It is not black and white. Sometimes we overcomplicate things and forget that it is ultimately about relationships with people that come from different places, so of course perspectives on policy will differ. While we can’t and shouldn’t control what others bring to the table abroad, shouldn’t we have a better understanding of our own institutional culture and motivations before we reach across the pond?

Disclaimer: The Department of Defense and the Department of State does not necessarily endorse, support, sanction, encourage, verify or agree with the comments, opinions, or statements posted on this post. Any information or material placed online, including advice and opinions, are the views and responsibility of those making the comments and do not necessarily represent the views of the Department of Defense, Department of State, or the United States Government or its third party service providers.


Summing Up The Modules: NIH vs. Health Care Policy

By Stephanie Colorado & Simone Serat

While NIH and health care policy have the same goal of improving the health of Americans, they occupy two very different political spaces. We decided to address the similarities and differences between the two, hoping to shed some light on the root causes behind the  contentiousness of health policy and the relative bipartisanship over support for biomedical research.

We began by identifying four key themes that interact with health care reform and NIH policy: interest groups, partisanship, American ideology and political framing. We separated the class into two groups, one speaking for health policy and one speaking for biomedical research policy, and asked them to identify how each theme related to their assigned area. The table below sums up their responses:

Biomedical Research Policy Health Policy
Interest groups Universities lobby for patents and grants Interests groups create and exaggerate policy traps
Partisanship 21st Century Cures (Republican) vs. Precision Medicine Initiative (Democratic) The target is not to create effective reform but to have a power play and defend one’s party’s stance
American ideology Competitiveness: US is #1 in biomedical research Health care is an individual responsibility
Political framing Lack of common knowledge, nobody wants to say they are “against science” Timing and salience, fulfilling campaign promises

We noticed the descriptions provided for the NIH and biomedical research policy section revealed it to be more of a bipartisan issue. In contrast, the examples provided for health care policy showed revealed it as more politically partisan and the contentious.

We then moved onto a full-class discussion guided by questions we created to further our understanding of the key issues concerning differences between health policy and biomedical research policy. We started with questions about the current status of NIH and health reform:

If you were a Congressional Representative, how would you merge initiatives from the NIH to those of health care reform? If you would not, then why?

The overall impression from the class was that it would be really difficult to merge initiatives, even if there was a desire to, and merging initiatives may slow the research progress and innovation derived from the NIH as it tries to be responsible for a chaotic issue like health care reform. The bureaucratic elements within health care reform may be to the detriment of the NIH’s continual search for innovation. Students in the class seemed to come to terms that both entities, despite answering to the health of Americans, are just too different to work closely together.

The conversation then shifted to talking about institutions that served as the bridge between NIH and health care reform. Health service research came up, which led to the next question:

The entity that seems to fulfill the gap between NIH and health care is health service research. Why is there such a focus on NIH compared to health service research when it seems like the state of health care in the U.S seems to be in peril?

While students did emphasize the importance of health service research in their explanations, they referred back to what was discussed during the opening activity in regards to the NIH’s role in providing innovation. The NIH’s biomedical research is more bipartisan, and appeals to American desire for competitiveness. While health service research is essential, it is also closely associated with health care and reform, which is tied to disputing normative beliefs about access to health care. As Americans differ in their beliefs about whether everyone is entitled to health care and who should provide it, issues that revolve around it, such as health service research, get bundled into the heated arguments and muddles support for it.

This led to the next question: In regards to policy, which is more powerful: having more support or having a lack of opposition?

Some students answered that a lack of opposition is more powerful than having support. They explained that if the public does not understand an issue well, such as those concerning NIH biomedical research, they are less likely to oppose and promote barriers that hinder progress. Other students answered that a balance of both is necessary- support is necessary to get ideas through and a lack of opposition allows those ideas to more smoothly drive by.

We then shifted our focus to the future of health reform. We first asked, what do you think will happen if the Supreme Court rules in favor of the plaintiff in King v. Burwell? “Millions of Americans would lose health insurance coverage,”one student said, “which would basically nullify the individual mandate, a very important part of the ACA. The potential political moves on either side are hard to predict, but we wanted to know what our classmates thought.”

Later, we asked, now that the individual mandate is a liberal policy tool, what potential options do you see as good choices for Republicans as they create a plan to replace the ACA? Do they even need to create a replacement plan? What is the effect on all of this in 2016? A student piped up that both parties will need to do something to address health care reform, not just Republicans. While Democrats have a variety of fallback options–single payer, the employer mandate, and Medicaid expansion for example–the individual mandate was the only strongly voiced Republican policy tool in health reform until the Affordable Care Act, so we were interested in our classmates’ suggestions for Republican alternatives to the individual mandate. Dr. Cook-Deegan expressed an opinion that the GOP might not create an alternative plan at all. The class jumped on that, generally agreeing that they would call a “you touched it last” on health care reform. Given the perceived lack of Republican alternatives to the individual mandate, the class believed, the best option for Republicans was to emphasize the failure of Democrats in health reform.

The final question asked the class was which of the four themes do you think was the most important in regards to NIH and health care policy? The conversation became heated as various students stood by different ideas that supported all four themes as the most important. One student pointed out that the framework we provided was missing another key theme–economic framing, or how each policy is framed in regards to the economy. There was absolutely no consensus about which theme was the most important, but we agreed that they all provided a good lens for discussing the key similarities and differences between NIH and health care policy.



By Tierney Bishop & Summer Xing

Our reading for week 6 focused on Part II of Paul Starr’s Remedy and Reaction. This chapter pertained to the demise of Clinton administration’s healthcare plan during the early 1990s. We discussed the missteps taken by Clinton’s task force that caused a vertiable implosion when the proposed act was initially introduced to Congress and the public. We then explored how Clinton Care influenced Obama’s approach to healthcare reform in terms of the Affordable Care Act.

Certain themes emerged from the reaction blogs regarding why health care reform has been such a struggle in U.S. recent history and what the Clintons did wrong in pushing the act. A primary example of this were policy traps: “a costly, extraordinarily complicated system which nonetheless protected enough of the public to make the system resistant to change.” Interest groups, ideology groups, and political institutions constantly find new reason to oppose reform against the new promoters of that reform.

Students also highlighted the striking similarities between Hillarycare and Obamacare, as well as the role of transparency, which was grossly overlooked by Hillary’s taskforce at the time.

In our classroom discussion, we talked about the role of narrative and American ideology, especially the role of anti-socialist ideology and the idea of “raising oneself up by one’s bootstraps”. This excited much debate about whether or not this was an influential factor in HillaryCare’s demise, though everyone agreed it is pervasive in American culture and thus the political environment.

We also opened up the floor regarding the role of interest groups, which played a large part in ClintonCare as, as Ernie stated, Clinton attempted to “please everybody” with compromises that were largely deemed “too little too late”. What I found interesting was that everybody agreed how poorly Clintoncare was developed and, and everyone agreed that ClintonCare and ObamaCare were very similar, yet no one attempted to find the similarities between the political failure of ObamaCare and that of ClintonCare.

The class discussion revolving this week’s reading was very interactive and engaging. We not only covered the reading’s main themes, but were able to apply and engage with broader themes that have been introduced and explored throughout the semester.


Obamacare and Bipartisanship

By Ryan Burns & Kristen Shortley

For the past few weeks, Professor Cook-Deegan’s Health and Science Policy class, based out of Duke in Washington, focused on Obamacare – the roots of universal health care, the struggles to pass universal health care, the final passage of Obamacare, etc.. This week, the class read “Part III: Frustrated Ambitions, Liberal and Conservative” from Paul Starr’s book Remedy and Reaction: The Peculiar American Struggle over Health Care Reform. The class was most struck by the bipartisan origins of universal health care in the United States and the policy traps of the Obamacare.

As the class went through the plethora of questions, the discussion reflected this bipartisan origin by how varied the topics of discussion were. From the basic consideration of healthcare as a privilege versus a right to the economic costs and benefits of various plans, the class discussed the end result of the health care reform movement and the ultimate swing from bipartisanship to ultra-partisanship that the reform eventually took. If nothing else, it quickly became clear that the multi-faceted nature of health care reform makes the confusion of policy and the divisiveness of politics understandable.  Now we will continue to watch as the intertwined nature of policy and politics tests the endurance and effectiveness of Obamacare.



ClintonCare vs. Obamacare

by Noah Triplett & Ernest Britt

Continuing our examination of healthcare reform and the implementation of universal healthcare in the United States, this week we looked at the ClintonCare proposal. Our readings came from part 2 of Paul Starr’s book, Remedy and Reaction. While reading, Professor Cook-Deegan asked the class to consider the following questions: Why is the US the only OECD country that does not have universal health insurance? What is the role of history and policy traps? Why does the US spend so much more on health care than other countries? Why are its public health and health status indicators so mediocre?

We began the discussion with a look at Clinton’s political strategy. From a PR standpoint, the planning of ClintonCare was a nightmare. Although Clinton attempted to associate Hillary with the plan as a way of establishing a personal connection and garnering support, this plan backfired. When polled, most Americans supported the provisions of ClintonCare when suggested alone but did not support ClintonCare. We then segued into a comparison of the political atmospheres during the Clinton administration and Obama administration, attempting to determine why ObamaCare was able to pass and ClintonCare was not. We contrasted partisanship during both administrations and determined possible reasons for ClintonCare’s demise, which included: negative public perception, disapproval associated with the Clinton name and reverse lobbying by the Republicans in Congress. We came to the conclusion that ClintonCare’s inability to pass was a politics problem and not a policy problem.

We then redirected our discussion to focus on the questions Professor Cook-Deegan had posed earlier in the week. We discussed the individual mandates that often accompany universal health care and how many Americans view mandates as an imposition on individual rights. American’s beginnings of “liberty and justice for all” make it hard to impose mandates without significant backlash. Moving to America’s public health and health status indicators, we found it odd that our indicators did such a poor job of measuring health outcomes. We found that Americans desire data. We need proof to back up our opinions, so the lack of reliable and valid health status measures seemed to undermine this desire. However, this could also underlie the reluctance for health care reform because we do not have reliable health status measures to prove to Americans that we need reform.


1.22 – Health Research Beyond the NIH

Each week in Professor Cook-Deegan’s Health and Science Policy class we read several primary articles pertaining to a unique topic.  This week our topic was “Health Research beyond NIH”, and our readings included an article from Francis Collins – the director of the National Institutes of Health – two from Professor Cook-Deegan and as well as a variety from other medical and policy professionals.

We started off our class with a conference call with one of the authors from this week, Hamilton Moses, who was gracious enough to volunteer nearly an hour of his time. Throughout the call, Dr. Moses gave us a background of his career path.  He took us through his study of psychiatry and neurology and his entrance into medical school.  He told us he was chief physician of John Hopkins University, when he was only in his thirties!  Now he works as a senior advisor with the Boston Consulting Group.

In his article, The Anatomy of Medical Research – US and International Comparisons, he talks about the United States’ declining investment in health and science research.  While the US is spending less on science and technology, other countries – especially in Asia – will soon surpass us as number one in the biomedical field. But why does this matter? As our class and Dr. Moses discussed, there is a return on investment in terms of knowledge production, increased health of citizens and intellectual property.

 After spending time hashing out the complex world of medical research we turned our class discussion to whether or not the investment in medical research meets American citizens’ expectations of public health. We discussed the dichotomy between “health services research” and “biomedical research,” and if there is a way to better integrate the both. Many students addressed the need to restore public faith in government-sponsored health initiatives. With the announcement of “precision medicine” in the State of the Union Address this week,  we are looking forward to where this semester take us in light of health and public policy debate!

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Jamie, Jenny and Professor Cook-Deegan taking notes during conference call with Dr. Moses