By: Christopher Bryant and James Markman
Warehouses full of undistributed goods and mounds of rotten food are often reported in the wake of large-scale disasters such as Hurricane Katrina and the Haitian earthquake. Superficially, these stories stir up sadness and frustration among those who could have benefitted, but more deeply these accounts sow the seeds of futility and lack of appreciation among those who contribute. Even when such high-profile disasters are backed by a fully staffed and integrated Humanitarian Military Operations Center (HuMOC) based on the UN OCHA Cluster System, Humanitarian Assistance (HA) missions are fraught with waste and inefficiency. Yet smaller scale efforts lacking HuMOC infrastructure suffer from operational limitations such as austere environments and low visibility, and very little in the way of basic organization systems, guidelines, and effective use of personnel. This article highlights lessons learned by Active Duty Civil Affairs (CA) and the U.S. Army Reserve operating in rural West Africa as part of a multinational effort with the Host Nation (HN), other African Partner Nations (APNs), and a single NGO to deliver much needed medical supplies and services and counter the influence of Violent Extremist Organizations (VEOs).
Leave it to the NGOs?
For many outside the CA world, the question is: “Why not just leave the small stuff to the NGOs?” Unfortunately the answer is difficult to articulate. NGOs typically execute their activities unilaterally. They have a niche that they fill, they may have a very small staff, and they may not be able to effectively liaison with a larger effort. Often they are working to avoid the innate inefficiency of larger efforts operating in that same theater.
CA recognized that small low-friction units could serve as a vital link. It is a win-win with NGOs benefitting from the security and resources CA can arrange, and then CA benefitting from the relationships and information gained from such experiences. CA brings the unique ability to work in conjunction with the US military, State Department, USAID, NATO, UN and other Intergovernmental organizations (IOs). Additionally, CA can introduce third parties to further extend the mission, such as providing unique training for HN military personnel and indigenous populations and institutions (IPI). This serves to strengthen military-population relationships, bolster Host Nation (HN) legitimacy, acquire valuable civil information, and execute the designated mission. Thus, contrary to entertaining lore, the goal of the Civil Affairs operator conducting medical HA is not to drop like a comet into a village and cure as many ailments as possible. Instead, the mission is far more complex: improving access and influence and bolstering the capacity of the HN government, all while still addressing that humanitarian need. In the end CA does not seek to replace or supplant NGOs, but to magnify its effect.
Don’t we already have a plan for that?
Historically, efforts to deliver medical assistance after disasters were ad hoc, primarily relying upon boots-on-ground improvisation to deliver medical supplies and render aid. These efforts reinvent the wheel with each iteration – providing little opportunity for the conveyance of ‘lessons learned’ or for the carrying forward of ‘best practices’.
In response, a variety of on-ground medical delivery models have been devised. Military manuals are littered with protocols for distributing pharmaceuticals and medical supplies, performing dental treatments, delivering medical care, organizing mass vaccinations, and triaging casualties.
Perhaps the most significant criticism for existing protocols is that they are not adaptable for the unique missions the U.S. military encounters. Rigid protocols prove unwieldy when there are a few providers caring for hundreds of sick. These protocols look and function better on paper than in practice. A second significant criticism of existing protocols is the inefficient use of available clinicians, reflecting a paucity of clinician participation during the engineering of protocols. As with so many similar situations, superimposing western expectations of healthcare delivery leads to inefficiency.
Needless to say, we propose a flexible framework for medical delivery. In the following vignette, we adequately address the above concerns. This is no academic or theoretical proposal. Instead, we devised and executed this plan in theater. We did so under austere and fairly hostile circumstances. Examination of the by-line reveals that we include a seasoned trauma surgeon and experienced SOCAMS medic who implemented a structure that permits latitude for ground improvisation.
The mission was timed to occur during a multinational training exercise, during which thirty-two African and Western nations converged. The authors were tasked with the distribution of pharmaceuticals aggregated by an NGO explicitly requesting Army CA assistance in distribution to isolated populations vulnerable to VEO exploitation. The U.S. effort consisted of a four-person U.S. Army Civil Affairs Team and a U.S. Army Reserve medical team led by a Trauma Surgeon.
To accomplish the HA mission the following had to be taken into consideration:
How to effectively treat hundreds of villagers utilizing only a single HN military physician?
How to safely and efficiently distribute pharmaceutical interventions for those diagnosed?
How to best engage the untapped potential of a hundred HN and APN military personnel, none with even rudimentary first-aid training?
How to leverage this opportunity to train HN and APN soldiers on a versatile strategy for coordinating mass triage and resource distribution.
Training and Execution
From the onset, it was apparent that our western notions of basic first-aid training were vastly presumptuous. Medical training was simply not emphasized in the training of our partner force tourniquets and splints seemed as unfamiliar as ventilators. Recognizing we were starting so far behind the blocks required a great deal of innovation in itself, but does effectively demonstrate exactly how flexible our model really is. Establishing time for basic medical training proved quite a challenge but we established a three-day window during the two-week exercise. Each day was as deliberate and carefully choreographed as anything on Broadway – basic-first-aid transitioned to effective triage, medical evacuation yielded to humanitarian response. Didactics alternated with practical exercises hourly. HN and APN troops were divided into chalks and each rotated through synchronous training iterations. All were taught the basics, and competence merited further education.
Medical concerns around the village were previously obtained through civil reconnaissance. A handful of common complaints emerged, and from this a series of complaint-specific stations designated (Malaria, Diarrhea, Pneumonia, Hypertension, and Childhood Ailments) with remaining patients were sent to a sixth station (Other Complaints). Our surgeon and the HN physician devised a series of high-yield questions for each complaint-specific station. A sheet with these questions was prepared and translated into French (Figure 1).
Figure 1: Example of complaint-specific questions for the Malaria station (English, French)
On the day of the event, groups of five patients are greeted by the external security cordon maintained by APN soldiers. Demographic and language information was obtained, and vitals were taken by local nurses and documented on a sheet carried by the patient (Figure 2). The patient was subsequently escorted to the appropriate station based on their primary complaint. At each station one of three medically untrained HN soldiers talked through a list of specific questions. Herein is one of the key features of our proposed model: it permits a great deal of patient history to be obtained by non medical personnel and is then to identify the patient’s illness. The HN soldier then presents the patient's paperwork to the local physician. Often, this information alone is enough to secure a diagnosis for more straightforward maladies such as malaria or childhood parasites. Other diagnoses prove more elusive and require further examination. In such cases, the local physician either instructs the HN soldier to obtain further specific details, or directs the HN soldier to retrieve the patient for a direct interview.
Although perhaps falling short of the standard for direct physician interview expected in Western healthcare, the reality is that for most common complaints the objective data gleaned from the targeted questionnaires is sufficient to secure a diagnosis accurately. With the diagnosis confirmed, the appropriate intervention is prescribed. The HN soldier escorts the patient over to the ad hoc pharmacy assembled with the NGO donated pharmaceuticals. Here, the written prescription is handed over to another medically untrained HN soldier who fills the order from previously categorized boxes.
Figure 2: Structure of triage as executed.
a) Questionnaires: Proper design and completion of the vitals sheet and complaint-specific questionnaires are extremely beneficial, the malaria station in particular. After reviewing the vital sheet and the complaint-specific questionnaire, only 8% of patients required further inquiry or examination by the HN physician prior to confirming the diagnosis and prescribing treatment.
b) Parental consent: We assumed children would be accompanied by parents and our initial CR confirmed this. However, we executed this mission on a weekday encountering groups of schoolchildren brought in by their teachers. This introduced challenges of consent and incomplete history of illness. We found the teachers here to be intimately familiar with both their young charges and the associated families, allowing us to work through these challenges.
c) Language: Comprehensive CR/CE did anticipate a challenge with tribal language. Fortunately, utilization of HN soldiers permitted us to translate from local tribal dialect into French. We did, however, encounter some patients from local villages who spoke their own unique dialect. This required careful pairing of HN soldiers with dialect familiarity.
d) Dental: Dental complaints represented a larger portion of complaints than anticipated. We did not have the resources to treat dental ailments other than antibiotics for abscess. With appropriate clinicians, our model could easily accommodate additional services including dental care, prenatal care, and the performance of minor procedures. Given the fact we had only a single HN general practitioner, we chose to forgo such offerings.
e) Common complaints: Although we were sincerely impressed by the resilience of the patients we encountered, chronic pain (particularly arthritic pain) emerged time and again as a very legitimate primary complaint. We suggest that this issue of non-acute pain be introduced early in the planning of a medical exercise, and a consistent protocol be established for addressing the issue.
f) Out of time: Despite our efficiency, we simply could not accommodate every single patient who presented. This is the reality of the situation, and simply cannot be avoided. That said, we anticipated this and effectively set (and subsequently revised) expectations as the day wore on. Patients sense when the exercise is coming to an end. We stopped admitting patients well in advance of the termination. We strongly encourage rehearsal on dealing with desperate and frustrated patients – notably including de-escalation and crown control challenges – as that has the potential to severely undermine the goodwill built during the exercise.
g) Embracing the Partner Force: We found civil engagements with tribal elders to be a very fulfilling process. We facilitated the discussions, but took a back seat during the CE allowing our HN partner force to lead. Time and again, our efforts spent preparing the HN soldiers for such conversations were validated as the HN soldiers gained the trust of the local tribal leaders and leveraged their influence to facilitate the mission. Secondarily, we noticed that subordinate HN and APN soldiers were both impressed with, and proud of, the efficacy of their sergeants.
This is a model for delivering high-quality medical care utilizing very limited medical resources. We provided medical care to 421 patients in 9 hours, a feat given that we did so with only a single HN physician and an entirely new medically-trained cohort of HN and APN soldiers. The backbone of our model includes comprehensive CR/CE, establishing complaint-specific stations reflecting local disease prevalence, devising complaint-specific questionnaires in conjunction with the physician, and using lay soldiers to obtain objective data.
Our model is versatile and equally adaptable to triage after disaster, distribution of humanitarian resources, or administration of vaccines. In fact, it can be adapted to virtually any scenario in which a large local population requires a very limited resource. In the spirit of “by, with, and through”, CA elements often are the first called upon to assist NGO efforts or facilitate distribution of organic resources. They are often among the first US elements to arrive and are particularly well suited to such challenges. As they do so, we believe they will find our framework particularly useful in their efforts.
About the Authors:
Christopher Bryant is assigned as a Special Operations Civil Affairs Medical Sergeant (SOCAMS) on CAT 121, Bravo Company, 91st Civil Affairs Battalion, Special Operations (SO) Airborne (A). He holds a Tier 1 certificate in DoD International Affairs, is a credentialed Special Operations Combat Medic (SOCM), and is pursuing a Bachelor of Science in Health Science. Before joining Civil Affairs, he was a Detainee Operations Specialist. He has deployed in support of Flintlock19 and as the Medic for a Civil-Military Support Element.
James Markman, MD is a Surgeon in the Michigan Army National Guard. He is a practicing general and trauma surgeon at Mount Carmel Health System in Columbus, Ohio. Dr. Markman began his Army career as an active-duty Field Artilleryman in the 18th Fires Brigade (Airborne) in 2005 subsequently earning a Purple Heart for wound sustained in Iraq. He transitioned to the USAR Psychological Operations in 2012 and has been a Medical Corps officer in the Michigan National Guard since 2015, activated in support of both Flintlock19 and Flintlock20.
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implied above are those of the authors and do not reflect the views of any organization
or any entity of the U.S. government.