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Sustainability Key in New Global Civil Affairs Medical Approaches

May 02, 2012

By Matt Pueschel,

FHP&R Staff Writer

CONTACT US: FHPR.Communications@tma.osd.mil

 [pictured left-right: Col. James Wolff and Dr. Warner Anderson in front of International Health educational outreach exhibit at recent Friends of Civil Affairs Conference in North Carolina.]

In an attempt to strengthen medical capabilities in Tanzania during a recent relationship-building mission, a U.S. military Civil Affairs (CA) team taught microscopic disease detection techniques to 50 local providers and researchers. The top 10 students then taught the class to another group of local providers, so that the project is having a sustaining impact in enhancing the country’s health surveillance and response capacity.

The key to the project’s success was that the CA team stayed behind the scenes, mentoring and empowering local epidemiologists. More often CA providers are undertaking such forward-thinking approaches to stability-building outreach missions in underdeveloped, stressed areas of the world that are enhancing DoD’s international partnerships and regional security cooperation efforts. “This is an area where we’ve made tremendous progress, although we’re still scratching the surface,” said Col. James J. Wolff, USA, the 95th Civil Affairs Brigade (Airborne) Commander. “There is still a ways to go, but the medical and veterinary side is getting a lot better the last couple years. Our medics are much more advanced.”

DoD has often conducted medical civic action projects (MEDCAPs) that provide direct care to foreign populations in unstable or at-risk settings for very brief periods of time, but it is taking steps to change that and pursue more comprehensively planned capacity building missions focused on mentoring that enhance host country providers’ own capabilities to deliver and sustain medical services. Such DoD medical stability operations (MSOs) can include international assistance such as establishing or reconstructing health sector infrastructure, public health education, humanitarian care and relief, or medical training of local military providers.

CA medics say they often face the challenge of achieving health sector and security improvements simultaneously, but are now approaching MSOs with enhanced planning that allows them to meet both objectives in a more focused, goal-oriented way. “When you plan your tactical medical operations, you should plan them with a strategic focus,” said Dr. Warner Anderson, Director of FHP&R’s International Health Division (IHD) during the annual Friends of Civil Affairs Conference this February in Pinehurst, North Carolina. Sometimes that can be as simple as placing the local government’s providers out front as the project lead, which demonstrates support toward the population, he added. DoD providers must also be ethically sensitive to ensure any training or infrastructure improvements they provide are sustainable and compatible with local standards of care.

Dr. Anderson recommends that DoD plan the medical component of stability missions thoroughly in advance and maximize resources by consulting with interagency partners that may already have a presence in the area. Often military providers have gone into rural areas with good intentions and conducted primary care, dental and minor surgical operations on hundreds of patients over just a few days that may pass on some individual benefits, but Dr. Anderson stressed that if they are not working with local doctors it can carry the potential of undermining the area’s own health care practices and leaving patients who may require follow-up without a place to go. “There is no way to measure if that was the right thing to do,” he said. “We don’t do a very good job sometimes of analyzing on these medical-related projects. We can positively or badly influence people’s health.”

CA Assuming Growing Role in MSOs

While DoD looks to gain efficiencies in a tight budget era, the 95th CA Brigade is growing and extending support to the military’s general purpose force while continuing its Special Forces role. The brigade is forming a fifth battalion and adding two companies to each battalion by 2017. CA teams include medical, veterinary and dental health providers that support DoD’s five Geographic Combatant Commands, Special Operations Command task forces and U.S. ambassadors by helping host countries that request assistance conduct area needs assessments, disaster recovery and prevention, and civil infrastructure improvements such as building clinics, schools, roads and wells.

CA teams bring together local and international resources to improve stability and reduce the influence of violent groups, working with U.S. embassy country teams, the U.S. Agency for International Development (USAID), foreign military, agricultural and health ministries, and nongovernmental organizations (NGOs). They are trained to adapt in foreign environments, from remote villages to large urban centers, while keeping a low profile and command structure that allows them to develop local relationships and programs that address the root causes of instability.

Lt. Col. John Maza, USA, DO, MPH, the 95th Brigade Surgeon, said the brigade began to take steps to enhance MSOs when it formed a working group over a year ago to address challenges in the field and better combine the respective strengths of its medics, physicians, dentists and veterinarians to develop more effective projects. Working closely with host country providers, civilian aid agencies and NGOs in planning projects also helps CA teams understand local health issues and existing host nation capabilities and needs. “We advise and assist Host Nation national agencies on medical, veterinary and public health activities,” he said. “The WHO and OIE (World Organization for Animal Health) can provide baseline (country) assessments that we can work from. We already do baseline assessments in other CA activities, so why not in medical? DoD humanitarian activities are important in winning hearts and minds, but we can do capacity building that accomplishes both (achieving improved partnerships and good health care).”

Dr. Anderson added that CA veterinarians and medics complement each other well. “They know more about food crops, and there are opportunities to marry the vet and medic in these missions,” he said.

Furthermore CA medics recently started receiving compulsory four-month language training prior to deploying on international stability missions, which helps them assimilate in other countries and better identify areas they can assist in a more value-added way.

New MSO Approaches from the Field

While one-week MEDCAPS have been geared to achieving instant results and are still requested by line commanders at times, the CA brigade has conducted several recent capacity building projects that can potentially serve as new MSO models. Lt. Col. Maza said they are making a conscious effort to take more sustainable approaches that maximize civil-military partnerships whenever possible. He cited a May 2011 project in Sri Lanka in which a CA team first obtained a baseline assessment outlining the basic level of medical service capabilities in the area they planned to assist. The team then trained rural health workers how to conduct health assessments and determine whether any residents need follow-up care at the nearest government clinic. “Instead of a MEDCAP, we designed a Medical Seminar (see related story at Medical Seminars show early success) in partnership with the host nation and an NGO to provide first responder training, first aid and public health classes to enhance local providers’ capabilities,” he said. “The planning identifies public health needs and promotes interoperability. The host nation medical officials remained in the forefront of the project, and the Sri Lankan students conducted their own medical operations in a village. Not providing direct care trains them to do it and frees our own resources.”

Another recent project, a veterinary seminar, was conducted by the 98th CA battalion in Colombia. The team worked closely with local veterinarians to drive what was needed and build from within the existing infrastructure. Local leaders were engaged and high school youth were a key target to raise interest in a vocational veterinary training program. The team worked with Colombian police and military personnel, a university and NGO to train farmers, veterinary and high school students on agricultural techniques they can employ to enhance livestock health and crop production. “The goal is not to immunize animals and leave (after a short time), like a VETCAP (veterinary civic action program),” Lt. Col. Maza advised. “We steer away from individual animal medicine, and use an impact assessment model to ensure inputs, outcomes and MoEs (Measures of Effectiveness) are in sync. In a conventional MEDCAP or VETCAP, we consider the numbers of patients and animals treated, but as we move from the short-term to long-term, capacity building becomes the priority.”

The hope is that the project produces positive, sustainable results and influences farmers in the region to refrain from growing for the drug trade. “Short-term care doesn’t affect that. With a VETCAP, we may get temporary access, but this model leads to sustainment and improvement in the human infrastructure,” Lt. Col. Maza said, adding that it is imperative to evaluate and work from a country’s current capability level instead of separately from it.

Capt. Rick Tucker, DVM, a 91st CA Battalion veterinarian, spoke of a collaborative project his team is undertaking in rural Mauritania to increase food security and enhance local veterinary care. Together with civilian and Mauritania government partners, the team is setting up a program to deworm livestock herds, build corrals and conduct clinics while showing local veterinarians nuances in detecting disease and selecting special veterinary products that can make or break the health of the herd. The CA team went into rural regions with an NGO, local herdsmen and Mauritania government personnel to increase the health of the animals and train a local CA team, including a veterinarian, to help the Mauritania army reach areas they could not get to previously. “It is an ongoing project and is joint between the CA Team in Mauritania, an NGO, the Mauritania Ministry of Rural Development and the Mauritania Central Veterinary Laboratory,” Capt. Tucker said. “The goal is to have it all complete, and up and running before the rainy season that usually begins in July.”

The 91st also conducted a project in Mali in June 2011, in which they assessed an area and coordinated a veterinary project with a CA Malian officer. Capacity building plans were made, but initially only supplies for a short-term project arrived to deworm as many animals as possible. “This may cause harm to local veterinarians and it doesn’t impact anything long-term,” Lt. Col. Maza cautioned. “Deworming ignored the most important disease of camels in this area. We provided improved modifications to the project, so instead we train and work with farmers to detect disease and obtain effective medicines. We work with the Mali central laboratory on sustainability so that our inputs are aligned to measures of effectiveness and outputs are measured not against sheer numbers of cows dewormed or vitamins dispersed.”

A one-day MEDCAP conducted in Mali in the fall was also discussed by conference participants in which high end expensive medical supplies were provided that were not appropriate for the area and could not be sustained by the local health system. A CA member said more basic, less expensive items were needed that could be purchased in the local market. The project has improved over time with CA providers mentoring Mali medics, who are training their personnel. “You need locally procured stuff,” Lt. Col. Maza said. “We are trying to get Brigade mission planners with the docs together to plan ahead of time.”

Dr. Anderson said similar MSO challenges have arisen previously, where CT machines were donated in Iraq, for example, with no locally trained personnel to operate them. He said it is crucial to determine whether there is a local chain of medical supplies and pharmaceuticals that can sustain any health assistance that is provided. “Our planners don’t always look at that,” he said. “They look at quantity moved or dollars moved, not necessarily quality. We try to take our high-tech 100 percent standard downrange and it doesn’t work.”

Dr. Anderson said it is important to recognize cultural norms and unique local health issues and standards of practice so that any care provided or clinic that is built can be sustained by local medical personnel. A CA medic said that approach also allows them to learn what occupational hazards local farmers and other workers encounter that impact their health. “We need to learn from them, too, what their issues are and the environment, and what unique approaches they may have to care,” Dr. Anderson said. “We should always take the opportunity to learn from the host nation. It also removes the perception that we are coming in with an attitude of we knew what’s best for everyone.”

Other CA members said often host countries lack providers in remote areas and do not have public health systems that reach the whole community. Training host country community health workers to send into rural zones can be a great way to contribute to building local medical capacity. Assisting with setting up a vaccination program to help kids avoid preventable illnesses and stay in school, or training workers to identify what is causing a certain health problem and administer preventive medicine are other measurable ways they can assist. They added that DoD can be very good at accessing dangerous areas and kick-starting projects or assisting an NGO with gaining access to a community that needs help.

CA providers suggested that instead of measuring project outcomes by the number of teeth pulled, patients treated or animals vaccinated, tracking whether stability has increased over time such as by drops in insurgent attacks or crime would be beneficial in areas where MSOs have been done.

Lt. Col. Maza said another concern with traditional MEDCAPS arises when they are conducted in isolation from other agencies and DoD medics are forced to learn by trial and error, missing out on crucial project guidance and advice. Working closely with USAID and the host country’s relevant ministries early on in the mission planning stages helps DoD identify gaps in care and produce better project results.

Dr. Lynn Lawry, IHD’s Senior Humanitarian Assistance Analyst, told attendees at a recent Military Health System conference in Maryland that when planning MSOs, DoD providers should work with the U.S. embassy and USAID team in the country they are deploying to. She advised focusing on military-to-military capacity building. She recommends limiting direct care of civilians to emergent humanitarian relief situations when local or civilian resources are unavailable and when directed by USAID’s Office of Foreign Disaster Assistance, to avoid performing parallel care or undermining services provided by the host nation or international relief organizations. (please see Military Guide to Working with NGOs)

Placing the focus on building capacity also allows DoD to hand off responsibilities to the host government. This is occurring in Afghanistan, where U.S. military medical personnel are helping the Afghan National Army and Police develop their health system. The goal is not to develop a U.S.-style system, but focus on mentoring in preventive health and lifesaving trauma care, first responder aid, ground medical evacuation and some rehabilitation services. Leaders say it is important to ensure project continuity with each successive group of medics that rotate in.

U.S. Special Forces medical groups are also taking longer-term approaches to rural village medical operations in Afghanistan, with the hope of reducing Taliban influence. At the annual Special Operations Medical Association Conference in December in Tampa, SF providers said it is important to gain trust and work with Afghan Army and village shura leaders. A difference from previous approaches is that some SF providers are now living in the villages to build trust and gain acceptance as valued guests in an environment that has endured 30 years of conflict. With local buy-in they can build security and governance and undertake small-scale economic development projects of $5,000 or less that utilize local labor and address food preservation and other sources of instability, and then transition support to government district centers and civilian agencies. They are trying to avoid traditional MEDCAPS, although sometimes they are useful to gain initial access and support. Since women are not allowed to be treated by male providers, DoD female engagement teams are also making progress in female community health worker training and care programs. With thousands of villages across the country, it is a monumental task. Challenges include lack of available education for children in southern Afghanistan, insufficient numbers of female Afghan providers, and low salaries for health professionals in rural areas.