Conflict, war and medicine (catch all).

**Madhu** · 05-20-2012

I had wanted to put together a small article for SWJ on the topic but quickly realized that much of what I know from my civilian experience is not helpful in understanding what I am reading. I thought instead to post various things that I've found, in hopes that it might be of use to somebody.

It is also interesting to note that modernization theory rears its head again and again. From the Neel paper (Military Medicine-August 1967:605-608):

"Most emerging nations share the fundamental problem of a significant degree of medical deprivation. The modernization process of each such nation can be markedly inhibited by its health deficiencies. An essential objective, then, is to increase the level of medical self-sufficiency in emerging nations."

The following on experiences in distance learning in Afghanistan is a bit sobering, and yet, might prove useful in the current context if approached in the correct way:

I worked on a UNESCO project for four months in Afghanistan in 1977 to build an educational radio system. However, the President of Afghanistan at the time wanted a news television station instead, which was built by Japanese loan money, so the education radio network never got built. Within days of the TV station opening, the Soviet Union invaded and they took over the TV network."

http://www.tonybates.ca/2011/01/11/d...in-afghanistan

The reason I posted the above in this starter thread is that I am interested in distance medical education and curriculum development. Such tools may not work in all settings, but it is nice to have a variety of tools to use if needed:

"TUSK is being used as a platform for curriculum co-development and global sharing across institutions. An export-import tool allows easy movement of content across institutions."

http://www.ucel.ad.uk/oer12/abstracts/326.html

Schools in Ghana, Uganda, Tanzania, Democratic Republic of the Congo, and India use such tools already, and other African countries are to follow according to the above link.

And there is the Aga Khan network and cell phone distance education curriculum in a variety of places, including Afghanistan. I found a program on oral radio education in Somalia:

"We use local stories, poems, and music. While it essentially provides reading and math instruction, lessons also address drought, health, malaria prevention, water filtration, and conflict resolution. Parents find this extremely useful. Many adults are listening, and that wasn't anticipated."

http://www.edc.org/newsroom/articles/teaching_radio

I am surprised how many distance medical education tools are already available online, including medical "flashcards" in a variety of Afghan languages. I think this is key. There is much already available, online, open source, and using host nation infrastructures.

First Ask, First Do No Harm, would be my motto.

I have more papers in this area that I've dug up and will post accordingly.

Update: How all of this connects up with "vital" security interests--whatever those are--I really have no idea. But if people in charge think medical operations are useful, it's useful to think about what might be sustainable, less intrusive, and less expensive. Training the medical trainers and all that....

**Surferbeetle** · 05-20-2012

Interesting thread Madhu and i like your stone soup approach

This link might be of interest. I am told (and believe) that it is a worthwhile experience and it seems that there are many commanalities when comparing the experience (and outcomes) to that of some of our 'non-lethal' efforts.

Stop Transmission of Polio (STOP) Program

The global effort to eradicate polio is the largest public health initiative in history. The initiative was established in 1988 by the World Health Assembly (WHA) with the goal of eradicating polio by the year 2000 while strengthening capacity to control other major childhood diseases. At the 130th Session of the Executive Board (EB) of the World Health Assembly (WHA) in January 2012, delegates recognized the progress made to date on the three-year Program of Work on polio eradication initiative and called for additional human resources to assist with country level efforts. To fill the request for more staff for the field, the STOP program has expanded its assignments from 3 to 5 month assignments starting with the team being trained in June 2012. To obtain more information and to get updates about the progress of the initiative worldwide, please visit the Global Polio Eradication Initiative website.

To meet the target date of polio eradication, the global partners are looking for ways to supplement human resources at the field level. The U.S. Centers for Disease Control and Prevention (CDC) is therefore seeking short-term, highly qualified, health professionals to join our Stop Transmission of Polio (STOP) teams for 5½ month non-salaried field assignments (travel and per diem for food and lodging provided.)

**ganulv** · 05-20-2012

It would be interesting to see a content of analysis of the sort of literature you are looking at to see whether the modernization talk subsides in any way post-Cold War.

How much do you know about Partners In Health? Personally, I feel that worthwhile attempts at real improvement in public health must be framed at the level of grand strategy.

**Dayuhan** · 05-22-2012

Originally Posted by ganulv

Personally, I feel that worthwhile attempts at real improvement in public health must be framed at the level of grand strategy.

I wonder about that. A small vignette to illustrate why...

Every municipality in the Philippines has a government-run health center, or Rural Health Unit (RHU). Many of these are barely functional. The staff are underpaid and often lethargic to the point of being comatose. Medicines and equipment are routinely sold. Statistics are invented. Little or nothing gets done.

The town I now live in has the most effective RHU I've seen in this country. Same pay, same equipment, same supplies, totally different result. The staff are incredibly proactive: if a pregnant woman hasn't showed up for a checkup or a kid has missed a vaccination, they go out and find them, even if that means chasing them down in the fields or home visits after working hours. Home visits are routine, someone comes by quarterly checking blood pressure, making sure the salt is iodized (we're far from the ocean and goiter is common), checking on sanitary facilities, talking over health and nutrition issues.

Overall the system works extremely well, despite being the same system that works so poorly in so many places. That's partly because this is a tribal community, all the staff are local people, and there's a strong sense of looking after their own. It's also because the doctor in charge is a rather formidable woman of enormous competence and integrity, who tolerates no slacking and takes no scheisse from man or beast.

The lesson of the tale, to me, as that at the end of the day it's about the people. With the right people, even a flawed system can work. If the people on the implementing end aren't motivated or capable, all the grand strategy on earth will get you nowhere.

**ganulv** · 05-22-2012

Originally Posted by Dayuhan

I wonder about that. A small vignette to illustrate why...

Every municipality in the Philippines has a government-run health center, or Rural Health Unit (RHU).

What you are describing sounds not unlike how health care works in rural Cuba, except that there all the docs and nurses stay on top of things. Yeah, one clinic with one good doc can make a world of difference (if sufficiently and consistently provisioned) but to make a real dent in public health issues you have to go regional and beyond. The eradication of malaria in the U.S. is an example of the scale I am talking about. The wartime Office of Malaria Control in War Areas was established in 1942 and morphed into the contemporary CDC; the National Malaria Eradication Program was an interagency effort cross-cutting jurisdictions which ran from 1947 into the early 1950s.

**Dayuhan** · 05-22-2012

True, for major disease eradication programs you need the grand strategy approach... though even there the effort hinges on effective local implementation. Actually delivering effective health care at the local level requires more than that. If the Cubans can do it, and if individuals can do it in other places, it can be done, and if it can be done with limited resources in some places, it can be replicated.

Sometimes the priorities get skewed. HIV gets more attention than malaria or TB, both of which are arguably bigger problems. Even those get more attention than the combination of invisible combination of malnutrition and parasitism... invisible because it shows up in the data as death from respiratory or GI infections. Grand strategy could be useful in dealing with these problems, especially if it focused on clean water and sanitation (less sexy, alas, than eradication of dreaded diseases), but again effective local primary health care will always be the most cost-effective response.

**Uboat509** · 05-24-2012

Dayuhan hit the point exactly. The most well thought out strategy in the world will still fail if it is not properly executed at the regional/local level. There are a lot of great ideas out there that do not seem to take that into account. This is a big part of my problem when people start talking about the West and the US in particular not doing enough to "fix" this problem or that in developing world states. The solutions to many or most of these problems are at the micro, not macro level. Few states have the resources, never mind the national will, to devote to that kind of work. None that I have seen have shown any particular talent for it in any case. The idea that a Western power can come into a developing world state or region and implement a "grand strategy" that will fix their problems for them is, to borrow a phrase, a fatal conceit.

**Uboat509** · 05-24-2012

Originally Posted by Dayuhan

I wonder about that. A small vignette to illustrate why...

This vignette also illustrates why the phrase "government-run" is often at the root of a problem, regardless of the government. Correct me if I am wrong Dayuhan, but I suspect that the reason that these RHU's fail more than they succeed is that, like most large scale government programs, there is little incentive for them to succeed and virtually no consequences for failure. The fact that they are Rural suggests that oversight is weak or non-existent. It clearly does not pay well enough to attract the best staff. The fact that the problem is so widespread also suggests that either there is no system for locals to redress problems with the government or that the system is extremely poor. If I was to hazard a guess, I bet that there are occasional (say, around election season) high profile cases where one of these RHU's is investigated and perhaps someone is fired or goes to jail but overall little changes because there is either a lack of incentive or a lack of resources to change things, or a combination of both. When the system is broken that leaves it up to individuals to fix things locally. Dayuhan is fortunate that the head of his local RHU is not only competent and strong willed enough to run an effective clinic but is also willing to do so for a paycheck that does not seem to have attracted the best of her peers to other clinics. That is an extremely rare thing.
This is not meant to be a dig at the government of the Philippines or developing world states specifically. It applies to rich-world states as well. Governments, no matter how well intentioned, tend to be poor stewards of large scale social programs (surprise).

**Dayuhan** · 05-24-2012

Originally Posted by Uboat509

This vignette also illustrates why the phrase "government-run" is often at the root of a problem, regardless of the government. Correct me if I am wrong Dayuhan, but I suspect that the reason that these RHU's fail more than they succeed is that, like most large scale government programs, there is little incentive for them to succeed and virtually no consequences for failure. The fact that they are Rural suggests that oversight is weak or non-existent. It clearly does not pay well enough to attract the best staff. The fact that the problem is so widespread also suggests that either there is no system for locals to redress problems with the government or that the system is extremely poor. If I was to hazard a guess, I bet that there are occasional (say, around election season) high profile cases where one of these RHU's is investigated and perhaps someone is fired or goes to jail but overall little changes because there is either a lack of incentive or a lack of resources to change things, or a combination of both. When the system is broken that leaves it up to individuals to fix things locally. Dayuhan is fortunate that the head of his local RHU is not only competent and strong willed enough to run an effective clinic but is also willing to do so for a paycheck that does not seem to have attracted the best of her peers to other clinics. That is an extremely rare thing.
This is not meant to be a dig at the government of the Philippines or developing world states specifically. It applies to rich-world states as well. Governments, no matter how well intentioned, tend to be poor stewards of large scale social programs (surprise).

All of this is true, but in many cases there are few alternatives to government management of rural health, especially in developing countries. There's little money in it, and few health care professionals are willing to stick with providing GP and primary health care services out in the countryside when the "good life" in the city beckons. It's not only a problem in the developing world; even in modern countries there's real shortage of physicians in many rural communities. In the absence of material incentive (or the presence of much greater incentives elsewhere) it's difficult to find a fully private sector solution.

Of course there are systems here for oversight, but the systems, like most systems in the Philippine government, often aren't implemented with any great vigor. In much of this country there's an established culture of complacency, self-service, and corruption in government service, and those who actually want to do something find themselves slogging through a morass of bureaucratic inertia.

**Madhu** · 05-22-2012

Originally Posted by Surferbeetle

Interesting thread Madhu and i like your stone soup approach

This link might be of interest. I am told (and believe) that it is a worthwhile experience and it seems that there are many commanalities when comparing the experience (and outcomes) to that of some of our 'non-lethal' efforts.

Stop Transmission of Polio (STOP) Program

That link is of interest. I had to look up what "stone soup" was, though

@ ganulv: Honestly, a lot of the current papers I am reading seem to use the same language of modernization theory, but maybe I am seeing what I want to see?

Stuff like this:

Afghanistan has the highest perinatal mortality rate in the entire world. One Afghani woman dies every 30 minutes from perinatal- related event. One of eight Afghani women will die from perinatal events. Maternal mortality is (use percentage, not fractions) 1600/100,000 vs 13 /100,000 in the United States. Afghanistan is one of the only countries in the world in which the average woman?s life expectancy is shorter than a males- despite the active, nationwide combat fought primarily by Afghani males. Meaning, women in Afghanistan are not routinely involved in combat, yet are more likely to die than a man of the same age. This article presents an alternative model Medical Seminar (MEDSEM) for a successful Special Forces (SF) medical counterinsurgency (COIN) plan that can obtain real results by addressing the mission of the Afghan Ministry of Health versus clinging to old notions. This model forms around the medical capabilities of the SF Operational Detachment (ODA)- Alpha (A) and preventinmaternal-infant complications.

http://www.researchgate.net/publicat...or_Afghanistan

Medical programs are valuable tools when they properly align with operational objectives. In counterinsurgency operations, the medical program should promote the capacity of the host nation government and lead to greater self-sufficiency. The Medical Civic Action Program (MEDCAP) often fails to fully integrate host nation providers and officials which may undermine local medical infrastructure and rarely provides sustainable improvement. The Medical Seminar (MEDSEM) was developed during Operation Enduring Freedom- Philippines to address the shortcomings of the traditional MEDCAP. The MEDSEM greatly enhanced the MEDCAP by adding education to the venue, thereby promoting self reliance and improving the sustainability of medical interventions. Furthermore, the MEDSEM forged relationships and promoted interoperability through collaboration between local medical providers, governmental leaders, host nation forces, and U.S. Special Operations Forces.

http://www.ncbi.nlm.nih.gov/pubmed/20306411

Which is quite laudable, I just don't know how it fits in with our military goals in Afghanistan. (The Philippines program seems to make more sense to me, but I don't really know about that part of the world so maybe not).

But I think at this point I am so turned around on all of this stuff that I will keep focusing on the e-learning stuff. I had not heard about Partners in Health, thanks for that link!