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DoD Medical Outreach Efforts in Central America Building Partnerships, Stability

July 10, 2013
  1. Army Maj. Charles Boggs, MST surgeon and Honduran Dr. Carolina Velez, third year surgery resident, perform surgery on a patient during a Surgical Medical Readiness Training exercise at Hospital Escuela in Tegucigalpa, in April, 2013.
    Air Force photo by Staff Sgt. Eric Donner

 

By Matt Pueschel,

FHP&R Staff Writer

From providing surgical assistance to overburdened hospitals in Honduras, to supporting medical responses to area disasters, and building local health capacity through training host country providers, Joint Task Force-Bravo (JTF-B) is helping fill health gaps across Central America with the hope of contributing to enhancing stability in a region where poverty and violence have been commonplace.

Based at Soto Cano Air Base in Honduras, JTF-B serves under U.S. Southern Command and carries out joint medical readiness training exercises (MEDRETEs) with partner country militaries in underserved areas, as well as counter narcotics-terrorism, humanitarian assistance, disaster relief and capacity building activities that promote enduring security cooperation. JTF-B’s medical outreach activities include public health education, disease screenings, deworming and vitamin programs, disaster preparedness training, dental, primary and pharmacy care for underserved populations in Panama, Honduras, El Salvador, Nicaragua, the Dominican Republic, Belize, Guatemala and Costa Rica. JTF-B also sponsors specialty MEDRETEs to the region focused on plastic surgery, pediatric orthopedics, urology, and eye, ear, nose and throat care.

 “The U.S. presence working in conjunction with the Ministry of Health, host nation armed forces and other host nation government institutions helps not only improve the image of these institutions but also provides recognition in the presence of the population,” said Guillermo Saenz, MD, a Honduran doctor who serves as Host Nation Liaison Medical Officer for JTF-B’s Medical Element, in a June interview.

The capacity building aspects of the missions are crucial in a region where crime is rampant. According to a report by the United Nations Office on Drugs and Crime (UNODC), the global homicide rate per 100,000 population in 2011 was highest in Honduras at 91.6 with El Salvador second at 69.2 and Guatemala measuring 38.5. Comparatively the U.S. rate was 4.8 in 2010, while England’s was 1.2 and Japan’s 0.4 in 2009. Cocaine produced in Colombia, Peru and Bolivia destined for North America and Europe travels through the region and gangs are common. The report showed a link between crime and development, suggesting that countries with wide income disparities are four times more likely to be afflicted by violent crime than more equitable societies. Economic growth seems to help reverse the trend. “Chronic crime is both a major cause and result of poverty, insecurity and under-development,” according to a UNODC release.

JTF-B’s security cooperation activities with militaries and government health ministries in the region are tackling these roots of instability. “Most if not all of the general MEDRETEs are focused in areas that have illicit drug and human trafficking and at the same time are areas that are underserved by the Ministry of Health – not only in Honduras or in El Salvador, but the same applies to the rest of the countries in Central America where JTF-Bravo goes,” said Dr. Saenz.

JTF-B has been engaged in humanitarian medical activities in Honduras since the early 1980s and regionally the last five years. “What has evolved through the years is that it has become more organized with more clear objectives,” said Dr. Saenz. “It also has diversified into not only general and specialty MEDRETEs, but into other fields like research projects and training.”

Among JTF-B’s key initiatives is a monthly partnership between its Mobile Surgical Team (MST) and Hospital Escuela, a Honduran training hospital in Tegucigalpa, where the MST travels to help fill a gap in surgical services. The MST also supports a hospital at Comayagua twice a week, and another in La Paz weekly. “We work in conjunction with the Honduran surgeons doing all that’s in the scope of general surgery,” Dr. Saenz said. “The support is seen as excellent by the host nation. The Ministry of Health doesn’t have enough operating room (OR) personnel to do all the surgeries that they have booked. It helps a lot due to the scarcity of supplies and personnel that the Ministry of Health has. Most of the time these hospitals just have one OR team and several times the elective surgeries are cancelled due to emergencies like C-Sections.”

The MST has become a valued asset to the Honduran hospitals. “(Honduran doctors) are very skilled but often need more manpower for the large patient load and emergency cases,” said Maj. Charles Boggs, USA, MD, MST Surgeon and Commander. “MST has a significant positive impact on staff and some on resources and materials.”

Each MST team, comprised of a surgeon, certified registered nurse anesthetist, two OR nurses and technicians, and occasionally other medical specialists, stays at the Honduran hospitals for 1-2 days. “The MST handles acute trauma (gunshot, knife wounds, motor vehicle accidents), as well as emergent surgical cases (bowel perforation, appendicitis, strangulated hernias) and elective cases (gall bladder, hernias, breast surgeries),” Dr. Boggs said. “The MST off-loads cases from the Honduran teams and expedites patient care, often saving lives.”

The MST’s regular presence has built a mutual trust. “The partnership (with Honduras) has been greatly improved through our consistent MST outreach activities and MEDRETEs,” Dr. Boggs said. “The hospitals gain additional surgical resources to provide quality care to patients, which is very appreciated by the Honduran surgical teams and public.”

The U.S. and Honduran doctors work closely together and learn from each other. “The Honduran and U.S. physicians/surgeons are always collaborating on current therapies and surgical techniques,” Dr. Boggs said. “When resources are limited, the Hondurans have tremendous insight on use of alternative techniques and treatment regimens appropriate for Honduras (which U.S. physicians can apply in other low-resource settings).”

The medical capacity of the Honduran hospitals has also grown. “The local surgeons have  learned to treat patients that otherwise would have been referred to the capital city in Tegucigalpa, where many times patients don’t get the surgery done in a timely manner because of the huge load of patients at the top of the pyramid of the referral system in Honduras,” said Dr. Saenz. “Host nation OR techs learn appropriate OR techniques, and Honduran anesthesia techs learn of the new anesthesia drugs used. MST has helped to train Honduran surgeons in laparoscopic surgeries.”

JTF-B’s approaches reflect efforts by the U.S. Defense Department Office of Force Health Protection & Readiness (FHP&R) to develop Military Health System policies that promote international assistance focused on building host country health sector capacity that is compatible and sustainable with local resources. “This is a great example of DoD helping a region in need fill a health care gap and assist the host nation military and civilian health agencies in a positive, meaningful and lasting way,” said Dr. Warner Anderson, Director of FHP&R’s International Health Division. “We also learn from our host country medical counterparts so it is a mutually beneficial exchange that contributes to building our partnerships and stability in the region.”

The MST additionally travels via helicopter to remote Honduran hospitals every few months, setting up an OR tent to provide primary care and surgeries with host country Ministry of Health personnel, and conducts out of country MEDRETEs for 5-7 days at a time. These missions also build the disaster response readiness of both the MST and Honduran providers. “All these activities really contribute to not only enhancing the good U.S.-Honduran relations, but also in building national capacity through the training and support they receive from the MST,” said Dr. Saenz.

The MST further supports actual disaster relief operations, and provided urgent care in the aftermath of earthquakes in Peru in 2007 and Haiti in 2010. “In Haiti at the beginning the MST was even helping to deliver babies, general medicine, because it was one of the first medical teams that arrived,” Dr. Saenz said. “They were doing all types of medical emergencies like wound debridement, open fracture stabilization and cleanup, crush injuries, cleanup and suture of contaminated wounds.”

JTF-B’s logistical capabilities also often help the region’s militaries, Ministries of Health (MOH) and nongovernmental organizations (NGOs) reach remote areas by helicopter to serve populations they otherwise wouldn’t be able to reach. “We have helped the MOH to increase their immunizations coverage by more than 90 percent in remote areas in just a two-week period that would have normally taken them two months to complete,” Dr. Saenz said. “As other examples, we helped transport micronutrients to a remote area in the Darien jungle (large rainforest in Panama), and provide transportation for MOH nurses in the remote Mosquito Coast in Honduras. We have also supported USAID (U.S. Agency for International Development) to transport supplies to remote areas.”

JTF-B has increased its interagency partnerships in recent years. “We work closely whenever possible with NGOs, USAID and other U.S. government agencies,” Dr. Saenz advised. “For example, in Nicaragua USAID helped us with project promotion to patients in a remote area where we were going to be working and they also put us in contact with an NGO that was doing a nutritional study in the area. Both teams complemented each other because the weights they were taking of the children helped us for the medical consultations we did. We had the support of several NGOs in Panama and Nicaragua that were distributing school supplies and furniture.”
Local Peace Corps offices and bilingual schools have also provided translators.

Working closely with U.S. civilian agencies, foreign governments and militaries, and NGOs to help reestablish host countries’ health sector capacity when needed and increase effectiveness has been a key policy theme of FHP&R’s International Health Division. “There is space for more collaboration,” Dr. Saenz added. “Whenever there is an NGO working in the area where we will be doing a MEDRETE, we try to coordinate with these institutions.”

A traditional strength of DoD’s international health efforts is teaching partner country militaries techniques in logistics, casualty care, disease surveillance and health prevention. JTF-B focuses its MEDRETEs on both military-to-military training and military-to-civilian medical exchanges. “We also have just military to military medical personnel training like a First Aid Combat Lifesaver course that has been given in Honduras and El Salvador,” Dr. Saenz said.

 JTF-B further participates when invited with larger annual Southern Command civic engineering, medical and disaster readiness missions to the region. “We have also supported research projects from Southern Command, such as the Febrile Disease Research Program, and HIV/AIDS prevention,” Dr. Saenz said.

Through other Southern Command programs, JTF-B helps research and monitor regional diseases like malaria, dengue, yellow fever, encephalitis and typhoid, and develop HIV prevention and treatment strategies for militaries. 

Health Security Results Measured Over Time

Although the impact of these collective efforts is difficult to quantify and often cannot be measured simply by the number of medications dispersed or patients seen, there are some tangible results. “General MEDRETE impact results are sometimes difficult to measure,” Dr. Saenz acknowledged. “In a specific timeframe some results can be measured instantly like immunization coverage, pathologies resolved with the medications or more complex diseases that were referred to the appropriate host nation care levels. Other health problems like malnutrition, diarrheas or upper respiratory diseases can be measured over the years of going back to the same places and getting information from the Ministry of Health.”

Both pre-mission planning and periodic follow-up between each host nation and JTF-B is pivotal. This also helps ensure timely arrival of supplies and sufficient mission promotion to appropriate patients who will benefit from the treatment offered. Dr. Anderson said local doctors and NGOs will also have localized medical expertise and awareness of unique regional health issues at play that are crucial to mission success.

Dr. Saenz’s main role is working with the U.S. military in planning, coordinating and executing the medical aspects of JTF-B’s MEDRETEs, and he has been involved with medical activities to all the countries in Central America. “At the end, the greatest reward for a physician is that no matter how many problems or barriers we had to overcome from both sides the results of your persistence and patience is seen when you see the first patients smiling and even showing genuine gratefulness because we have solved their health problems,” he said.