Case Studies in Afghanistan Health & Related Lessons Observed in EUCOM and PACOM

30 Jan 2012

Col John Mitchell

The MHS: Healthcare to Health

Defense Institute for Medical Operations; Former CSTC-A SG

Has no real or apparent

conflicts of interest to report.

Conflict of Interest DisclosureJohn Mitchell, MD

MSO: Objectives

Discuss direct medical stability operations efforts to include cooperation plans in past or ongoing CENTCOM operations.

Evaluate specific cases of successes and failures related to USG efforts in Afghanistan

Evaluate specific cases in EUCOM and PACOM

Agenda & Key Points

Medical Stability Operations (MSO)– Worth Doing – Steep learning curve (MHS, DoD, USG, PN)– Goals are elusive (whose MoE, AMoE, MoP)– Getting Smarter

• (PN Civ/NGO/Mil linkages; USG)• Origins of Health (Water, Food)

Challenges of direction

MSO: Worth Doing

For Agile Combat Support (AGS),“GHE – Establishes “US access and influence with

partner nations by building their health capabilities”

– “Can serve as a model for success within the other ACS elements (airfield operations, logistics, security forces, maintenance, civil engineering, air traffic control, weather).” • from pg 19 of Global Partnerships Strategy signed

out Dec 2011 by CSAF and SECAF)

MSO: Worth Doing

For Agile Combat Support (AGS),“GHE – “Without the various and specialized

resources provided by the ACS community, sustained and successful air domain operations would not be possible….to achieve Joint effects.”

MSO: Steep Learning Curve

Outset: Infrequently well versed in MSO – POCs, funding, documents, PN relationships?

Stovepiped (MHS, DoD, USG, PN) Failures teach faster than successes; $

invested? Employment Training—MSOC (DMRTI), Non-

Medical Cultural Orientations Crs, etc. Resources to teach PN—DIMO, DMRTI, Svc-

specific

MSO: Goals Are Elusive

Line Command MoEs—from GEF to IMO to PN (e.g., Access, Influence, Visibility; O,T,E)

Health MoEs—World Bank, WHO– CDHAM/CoE (DMHA) project (next lecture)– BUMED, other Svcs, DIMO (29) measures– Planned synchronization– Require lots $, skill/time, focus; not easy

“AMoEs”—”(Aligned MoEs)” Projects with direct alignment to Health MoE

MSO: Goals Are Elusive

“AMoEs”—”(Aligned MoEs)” Projects with direct alignment to Health MoE– Procurement with Regional/Local importance

• Facility, Equipment, Personnel contract, etc

– Training/Education with portability, flexibility• DIMO (101: 26 Human med capabilities, 4 Policy,

5 Protocols, 66 Vet outcomes)

MoPs “You get what you pay ($, time, etc) for!”

MSO: Goals Are Elusive

Success in Sustainable New Capability:– CENTCOM wanted aerial capability for AFG,

Iraq– Health Ldrshp pushed Air Evac

• Rotary wing (espec.)• Fixed wing

MSO: AFG Success

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CSTC-A Line MoE Trnd w/ANA Mi-17,

2007-8 Independent Rotary,

2008 Independent Fixed,

w/cardioversion 2009 Not a World Bank

MoE, but is AMoE

MSO: Iraq Success

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MNF-I then USF-I MoE Trnd w/Iraqi Mi-17, &

C-130 (DIMO AE course 2008 )

Iraqi trnd Iraqis in 2009 Wks later saved 78

lives by fixed wing from Basrah to Baghdad

Not a World Bank MoE, but is AMoE

Students From Country Course In-Country Both

Global Reach 2002-11: 212 msns, 124 countries, educated 7,346 students

Defense Institute for Medical Operations (DIMO)

MSO: AFG, Goals Are Elusive

AFG Mil-Mil– Facilities (clin, 50-100 bed hosp, impr 400

bed) for direct care, trng, warehouses– Ambulances, AFAK, myriad equipment/supply– Education, trng, policies developed– Myriad of capabilities– Not WB MoE; AMoEs? or MoPs?

MSO: AFG, Goals Are Elusive

AFG Mil-Civ (HA funds) w/o NGOs– CSTC-A

• Direct Care Facilities, inpatient equipment/supply• Trng Facilities, equipment/supply

– PRT’s x 12, ISAF units• Same +, educ/trng, policies developed

AFG Civ-Civ—USAID, DHHS/CDC, other USGs, orgs

Not WB MoE; AMoEs? or MoPs?

MSO: AFG, Dental Outreach

PRT Identified Real need & Constraints

PRT Developed to build capacity

Equiped, Trained, Practiced

Turned over to the Afghans

Still running for yrs AMoE, MoP?

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MSO: AFG, “Successes”

CSTC-A, now NTM-A CSTC-A integrated approach– Vertical

• Ministerial Development• Institutional Development• Healthcare Provision • Training

– Horizontal• 17 ofcr & enlisted specialties mentored

MSO: AFG, Failures

Some AFG leaders Some AFG construction Some equipment (voltage, size, instructions,

maintenance, etc.) Lost trainee ouput (espec. hundreds of combat

medics)

Less than full synchrony with CDC, ISAF, MoH, PRT, Univ, USAID

MSO: Getting Smarter

Health NGOs partnering– Have been doing this well before MHS health

ramped up role from DoS/USAID– Business model; sustainability-minded– In non-kinetic locales, partnering has benefits

• NGO/Civ/Mil is even better

USG experience and interoperability growing

MSO: AFG, Getting Smarter

AFG Mil-Civ (HA funds) with NGOs– Contributed to some MoEs (vs. AMoE’s)– CSTC-A--Direct Care Facilities (trauma clin,

amputee/rehab clinic, maternity hosp ED), inpatient equipment/ supply• MoEs: Life expectancy, maternal/child mortality

– PRTs with USAID, USDA, etc– Sewers, Agri-culture, Roads to Healthcare, Vaccines, etc.• MoEs: Mortality, Prenatal Care, Malnutrition, Clean

Water

MSO: AFG, Getting … Strong Food

PRT Identified– Real need, Constraints– Sustainable supply line

PRT Developed, Tested & Implemented project

Turned over to

Afghans, NGOs Child wgts incr. Now MoE in 5

provinces

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MSO: AFG, Getting … Clean Water

PRT Identified– Real need &

Constraints– Sustainable supply line

PRT Developed, Tested & Implemented project

Turned over to Afghans, NGOs

Provided jobs MoE, AMoE?

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MSO: EUCOM, Goals are….

.• Moldova Hospital School

• Croatia Incubators

• Georgia Nursing School

Mil funded Successes of local/regional construction, renovation, equipingAMoE or MoP?

Mil & USAID funded for trng output….

Govt goes pvt

EUCOM with NGO

Mil-Mil: BPC in ISAF amputee care, Georgia (impt PN)

Working with Georgia MoD and NGOs, WReed DoD Amputee SMEs, to treat their ISAF-WIA they cannot manage

MoE: POTUS discussing it with PoG on 30 Jan at White House

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EUCOM Integrated Approach

Mil-Civ/Mil: BPC with National Amputee Care Ctr, Estonia (impt PN)

With civ med ldrshp Line MoE Future, "simple" hospital

renovation long-term med capacity (logic model)

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PACOM Agri-business, Surveilance

Mil-Civ/Mil/NGO: Mongolia, focus on survivability, economic growth (meat, wool, cashmere), animal health…

Human health, proper nutrition, decreased parasite loads

Surveillance of diseases MoE’s many

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PACOM Agri-business, Health

Mil-Civ/Mil: Timor Leste, (gold std?) is paying for TDYs & penning pigs

Pigs increased litter size, weaned weights, # live pigs at weaning

Goats and cattle production

MoEs many

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PACOM

Training – Gray Hull activities (NAVPAC)– Disease Surveil. (CDC, DoD, Lao, USAID)– Blast Injury Survival (DMRTI, CoE (DMHA))– Infection Control Workshop (DIMO Vietnam)– Asia Pacific Military Nursing Symposium (12

countries) Lives Saved = MoEs

– Nepal events (DIMO trauma & Disaster crs)

MSO: COCOMs Lsns Observed

Linking COCOM medical efforts to Strategy

Minimizing Random Acts of Engagement

Ensure all Component medical activities support a common goal/objective

Med may only be OPR for 1 of 50 Lines of Activities/ IMOs for PN, including mil deployability

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Denial

Depression

Bargaining

Anger Acceptance

Avg Emotions of GHE Deployer AFG

Arrival

Thriving?

Agenda & Key Points

Medical Stability Operations (MSO)– Worth Doing – Steep learning curve (MHS, DoD, USG, PN)– Goals are elusive (whose MoE, AMoE, MoP)– Getting Smarter

• (PN Civ/NGO/Mil linkages, USG)• Origins of Health (Water, Food)

Challenges of direction remain

Questions?

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The MHS Quadruple Aim

ReadinessEnsuring that the families and

individuals that make up the total military force is medically ready to deploy and that the medical force is ready to deliver health

care anytime, anywhere in support of the full range of

military operations, including humanitarian missions.

Population HealthReducing the generators of ill health by encouraging healthy behaviors and decreasing the

likelihood of illness through focused prevention, chronic care

management and the development of increased

resilience.

Experience of CareProviding a care experience that is

patient- and family- centered, compassionate, convenient,

equitable, safe, and always of the highest quality.

Per Capita CostCreating value by focusing on quality, eliminating waste, and

reducing unwarranted variation; considering the total cost of care over time, not just the cost of an individual health

care activity.

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