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By Matt Pueschel,
FHP&R Staff Writer
DoD has become increasingly involved with other U.S. government agencies and nongovernmental organizations (NGOs) since it was directed in late 2005 to give international health capacity building missions the same priority in planning as combat operations, and to be prepared to work closely with its interagency and civilian partners on such missions.
As a result, FHP&R's International Health Division (IHD) has been attempting to foster these collaborations since it was formed to develop the new policy about 19 months ago.
The relationship between DoD and NGOs is not without precedent. Rand Walton, Director of Strategic Communications for the NGO, Project HOPE, said HOPE's involvement with DoD actually goes back to 1958, when the USS Consolation naval ship was given to the NGO by President Eisenhower and transformed into Project HOPE's main vehicle for providing humanitarian assistance and health education around the world. The ship conducted 11 year-long missions to such regions as Indonesia, Africa, and the South Pacific. "Hope's founder, Dr. William B. Walsh, had been in the military and saw a great need to provide basic help and care to poor countries' children and families," Walton said. "We provided care, education to doctors and nurses at each site, and we were staffed by volunteer doctors and nurses. In the '70s, the ship was decommissioned and we became land-based."
However, that changed in late 2004-early 2005 after the tsunami struck Indonesia. Then-Chief of Naval Operations Adm. Vernon Clark contacted current Project HOPE president Dr. John Howe and asked if he could provide doctors and nurses to staff the U.S. Navy hospital ship Mercy, which was heading to provide relief in the devastated region. "Dr. Howe agreed and had 3,000 volunteers gathered over the weekend for 215 spots," Walton said. "That kind of reinvigorated our relationship with DoD."
When that mission concluded, the Navy saw a tremendous value in continuing these types of hospital ship missions around the world. "We provided great care to Indonesia and (helped) change perceptions of the West toward the U.S. in a favorable way," Walton advised. "The Navy sent the Mercy back in '06 to Indonesia again, Bangladesh, the Philippines, and set up clinics onshore. The Navy has tremendous logistical capabilities, helicopters, and can get us to places where we couldn't reach easily on our own."
In fact, HOPE has been involved with every Navy hospital ship mission since the tsunami. The Navy's new Maritime Strategy includes humanitarian assistance as an important component, and since 2006 the Navy has been leading two annual 4-month interagency hospital ship humanitarian health care outreach and disaster response training missions to multiple countries in the Southern and Pacific Command regions. The Navy also supports standing humanitarian civic assistance missions to West Africa and the Global Maritime Partnership. Walton said there may be a Navy gray hull ship sent to East Africa soon, as well. DoD Africa Command Surgeon Col. Schuyler Geller, USAF, MC, said it has been discussed and could take place in early 2011 if approved. "We plan to have our volunteers support them," Walton advised. "This partnership HOPE has with the Navy and DoD is something we are committed to and we plan on continuing to do in the future. We direct health care-oriented volunteers and this provides an excellent platform to tap into and help build health care capacity in these countries. There are not a lot of NGOs willing to do this. Operation Smile is another. They've been involved in nearly all of them. Smile does cleft lip (and cleft palate repair in children). They set up in 2-3 ports, and they work very closely with the Navy to bring people out to the clinics. The Church of (Jesus Christ of) Latter-day Saints Charities (LDS) sent volunteers aboard the (recently concluded Comfort hospital) ship (mission this April-July to Latin America). Other NGOs provided medical supplies. The Navy reached out to a lot (of NGOs). A small group said yes. (But) more NGOs are beginning to see the value of this program to work with DoD."
The recent increase of DoD involvement in global public health may have caused some NGOs to be hesitant, even though the Department of State has the U.S. government lead in international health development. "There is a concern in our community, among a lot of our peers, that DoD will take over and the NGO won't have the autonomy when they go in and do the work," Walton said. "We look at it differently. We don't have to worry about fuel and can focus on care. The Navy does the logistical (side) and that helps us. It makes it easier for us to get in and educate heath care workers in their communities. To us, we think it's been a really good combination of our volunteers' skills-many are from the best hospitals like Massachusetts General, Vanderbilt, the Mayo Clinic-so it's great because they get to work with the military and share skills and improve everyone's abilities. A lot of them never see these infections and injuries. Maybe in the U.S. they have been eradicated, but they are prominent in the developing world. So, it's a very good partnership we have with the military doctors."
Nate Leishman, manager of humanitarian emergency response activities for LDS, said the hospital ship is a great vehicle and symbol of hope, and DoD's ability to reach out to the Ministry of Health in each country opens doors for NGOs. "It's a new type of mission for people and I think for a lot of NGOs, their budgets are tight. I think there is some hesitation to jump in and go to work with the military (and understand the) motives, (but) I think as more NGOs hear about this, more and more (will get involved)," he said. "I think it's great DoD is doing this type of mission. We think the goodwill created not just for the U.S., but the whole perception that people can come together to help people and providing services to so many people at a bigger scale than we have participated before on, I do feel a real impact is made. It may be a small percentage of the population, but thousands of people are served during a few weeks. You can't meet all the needs, but you will make an impact in many people's lives. The need is so great throughout the whole world. It's (also) a good vehicle to bring other nations together. That was one of the things we liked. It was not just U.S., it was a multi-national response. This is good preparation for an actual emergency."
Conversely, NGOs can also open doors for DoD. IHD Senior Health Stability and Humanitarian Assistance Specialist Dr. Lynn Lawry, who previously worked for NGOs for 16 years and now serves as a liaison to that community for DoD, recently utilized her contacts to pave the way for a DoD-NGO collaborative health care project in Africa between DoD's Africa Command and the NGO, International Medical Corps (IMC). Dr. Lawry conducted a 2008 study that found high rates of depression, PTSD, and TBI among ex-combatants who had participated in the civil war in Liberia. The study further showed worse mental health outcomes among both male and female former combatants who had experienced sexual violence. As follow-up, Dr. Lawry is now working with Africa Command Surgeon Dr. Geller and IMC to set up a joint DoD-NGO program to train TBI-competent physicians in Lofa County, Liberia, which was the center of the rebellion. The proposed plan is to set up a clinic at an IMC-supported hospital there in Voinjama close to the Sierra Leone border. Dr. Lawry said about a third of Liberia's population, or 1 million people, have reported serving with the nation's fighting forces-many recruited by abduction and kidnapping. About 270,000 of them have possible head trauma. "This, to me, is a stability issue," she said. "If you have this many people that are upset, sad, willing to commit suicide, you have to deal with it."
Dr. Lawry will soon conduct a similar study in the Democratic Republic of the Congo with a focus on gender-based violence, at the request of Dr. Geller. It will be supported by Africa Command in cooperation with IMC. Dr. Geller said areas for future collaboration between NGOs and Africa Command include direct surgical, medical and mental health support and advocacy to victims of sexual gender-based violence (SGBV) and war-related injuries in still unstable post-conflict areas. "To assist in the return of stability and security by bringing hope and caring in uniforms to those who have lost all faith in them," he said. "This is especially true if we can teach our partner nations to do as we do. This will help to restore confidence in civil governments by showing the right way for officers and enlisted to join together with long-term sustainable resources in unstable areas to secure the underpinning of society by the restoration of essential services, such as safe water and food, lines of communication (roads, bridges, and airfields), building materials and health care."
In a growing effort to reach out to more NGOs, IHD exhibited in the annual InterAction Forum in Arlington, Va., this July for the first time and plans to be involved in it regularly. InterAction includes 181 U.S.-based international NGOs as members who are focused on aiding the world's most poor and vulnerable people, and this year's forum drew 65 exhibitors and over 700 attendees. IHD itself has convened several forums over the last year that have brought together U.S. government interagency and international health leaders to discuss collaborative efforts and challenges in rebuilding the medical systems of stressed regions such as Iraq, Africa and Afghanistan.
This September, Project HOPE will also play a small role partnering with the 13th Air Force and a U.S.-sponsored international NGO, the East Meets West Foundation (EMW), on a health care mission to Vietnam called "Pacific Angel." A KC-135 transporting 25 U.S. military medical personnel and others will fly into Vietnam to conduct Joint Total Force Combined humanitarian assistance and civil-military medical, dental, optometry, general practice/primary care and engineering operations. "They'll fly into a town, set up an on the ground clinic for (about a week) providing care and supplies and looking at opportunities to extend beyond that, to train locals or continuing to provide volunteers at the clinic after it is established and after the mission is over," Walton said.
The MEDCAP (medical civic action project) portion of the mission will partner with Vietnamese civilian medical professionals and Vietnamese Army medics at a clinic set up in an elementary school, while the dental component will partner with EMW (which is focused on creating sustainable solutions for disadvantaged people in Southeast Asia). Another 15 U.S. military engineering personnel will conduct repairs on a rural medical clinic that serves four townships and is the primary care site for area motor bike and vehicle accident victims, despite having limited health care capacity and capability.
A further example of a successful DoD-NGO health project can be found in Iraq. Walton said HOPE has been involved with the Army Corps of Engineers to develop a children's hospital in Basra to treat cancer. "In southern Iraq, there is a high incidence of childhood cancers-8 to 10 times higher than the U.S.," Walton said. "Leukemia is very treatable if you catch it early. The Army is building it with local contractors. HOPE has been equipping the facility with devices it would need to care for kids, radiology, x-ray machines and training 60-70 Iraqi doctors and 100 nurses to work there. This fall, it will start accepting patients. It's been a great partnership and we've brought both of our own strengths together to address a health care need."
Making A Joint Impact
Among the goals through the direct care and education provided to countries from the Navy-led interagency hospital ship missions is sustainability and medical capacity building. "We spend 2-3 weeks in each port and the education HOPE provides to the local health care workers lasts beyond that, and raises the capabilities of doctors, nurses, EMTs and midwives so they can provide better care long-term," Walton advised. "The Comfort mission just finished. We had volunteer doctors and nurses working with Navy doctors and nurses onboard, and the Navy reached out to militaries in other countries and they provided doctors and nurses. Unfortunately the tsunami triggered all of this, but a lot of great humanitarian assistance has been provided since then."
When asked how follow-up care is provided in the host countries after the hospital ship departs each port stop after only a couple weeks" stay, Walton said mission personnel provide mostly primary care, minor surgeries, cleft palate/lip repair, hernia repair, bone resets, cancerous mole or tumor removals, or things that do not require a lot of follow-up. Leishman said volunteers provided mostly public health, vision, neonatal, dental and hygiene care on the Comfort mission, and added that if patients received major surgeries they could get follow-up care with local doctors. "But we're looking at how can we partner with local NGOs on the ground (in the countries) to maybe plan ahead," Walton advised. "We're trying to work with the Navy to have a say on where we go because if we already have a presence there, there can still be some follow-up. We're making progress. We're not where we want it yet."
For instance, Project HOPE has two clinics in the Dominican Republic. "When the (Comfort) ship came in (earlier this year), we were able to talk to patients to encourage them to receive care and (have) an opportunity to do some follow-up at Project HOPE clinics after the ship left," Walton said. "An older woman had cataracts, she went and was screened, (had the surgery) and was able to see for the first time in 30 years. That's the direction we're working towards."
Walton said the Navy receives a lot of requests from different countries for the hospital ships. "It's a decision based on the tremendous needs, not necessarily because the NGO is already there," he advised. "We operate in 35 countries around the world, so there are a lot of places (where we have a presence)--Indonesia, Central and South America--and other NGOs have a presence in those countries, too. These (pre-existing clinics) are separate from the ship clinics (that are set up temporarily onshore)."
The concern with the clinics set up by ship personnel is sustainability. "Maybe there aren't people to continue operating them," Walton said. "We're talking to the Navy about leaving NGO volunteers there after the ship leaves, and make sure local health care workers know how to use (the clinics and equipment)."
The change in the number of Latin American countries visited by the Comfort this year to seven from the previous 12 in the 2007 Comfort mission to the region also allowed for longer stays at each stop. "That was another great lessons learned," Walton advised. "How can we make them more effective and (to stay for) as many as 15 days. That's still not ideal. It's not a year-long presence, but the Combatant Commands are doing a great job."
NGOs have some involvement in the planning process for the missions. The Department of State (DoS), through the embassies, will reach out to local health officials in each country to let them know the ship is coming. Where there is an NGO presence, they can promote the mission locally. "For Project HOPE, we work very closely with the (country's) Ministry of Health (MoH)," Walton advised. "There is a lot of communication from all three-DoS, DoD and NGOs-about these missions to the MoH. In February, Southern Command brought together all the key players from the DoD perspective, and DoS and representatives from the embassies for a 2-3 day seminar in Miami that brought everybody up to speed to talk about locally what was going to happen (on this year's Comfort mission)."
Although a Navy captain oversees medical activities for each hospital ship mission, each day a group run by the Navy reviews the day's events and plans for the next day, and HOPE has a chief medical officer who attends those meetings. "They look to us to help determine what needs to be done," Walton advised, adding that HOPE also works with the Navy to develop a formulary for the missions and has provided $33 million in medication donations since 2005. For the first time, the military is also helping to transport some of the NGO volunteers to the hospital ships.
Leishman said that volunteers from LDS, which does no proselytizing in its humanitarian efforts, also attended the Navy-run daily briefings during the Comfort mission and were asked for their input, as well. He said their suggestions were heeded, and they were very impressed with the professionalism and graciousness of the military.
Building for Future Collaborations
Leishman said DoD had previously provided transportation for LDS medical and food donations to Zimbabwe and Ethiopia, but the NGO's first major partnership with DoD was the recent Comfort mission. LDS has a partner, Islamic Relief, that helped connect them with Southern Command last year. "This January, I went to a conference to learn about this in Norfolk (Va.)," Leishman said. "We were late in getting involved. Originally (DoD) asked for 10 container loads, but they had some shortfalls in staffing and nurses and asked organizations if they can fill the needs. I raised my hand and said I could help with nurses and translation."
Through a memorandum of understanding with Southern Command, LDS provided about $1 million, or 18 container loads of clinical supplies, hygiene materials, blankets and wheelchairs, to the host countries, as well as 40 nurses and 10 general volunteers over four rotations. HOPE also sent four rotations of 25-30 volunteers each to the ship.
"Most of the (LDS volunteer) nurses stayed on the ship, some went in as needed," Leishman said. "We also provided translation services through members of the church in the countries. Some were brought on the boat or stayed with the dental and eye screening clinics (onshore). We also had some general volunteers at various sites helping with distribution and crowd management."
Leishman said this year's Comfort mission and NGO partnership with DoD was successful. "I think it worked quite well," he said. "Reports from the Navy and Southern Command have all been very good. This is a great mission. By so many groups coming together, we can make good things happen. The Navy couldn't do it alone and vise versa, so we get a lot of synergy. We feel like it was a success and we're going to proceed to do something next year (with DoD, too). Probably next year we'll be looking at the (Navy hospital ship) Mercy with the Pacific Partnership and getting involved earlier in the pre-planning."