Conflict, war and medicine (catch all).

[davidbfpo]

Moderator at work

I have merged a small number of threads into one, retitling it 'Conflict, war and medicene' (catch all).

The old threads were: "The Medical Role In Army Stability Operations": COL Neel, Military Medicine
and 'Military Medical Assets as Counterinsurgency Force Multipliers: A Call to Action'.(ends)

I know there are few threads on medical matters, including RFIs, but there appears to be no thread on the developments made in recent wars on frontline medical care. IIRC posts exist about the changes in training combat troops on initial care, by JMA and others.

This thread thought was prompted by watching a BBC 2 TV documentary 'Frontline Medicine':

Michael Mosley travels from the frontline of war to the frontline of research to uncover the medical breakthroughs that are coming out of current conflicts.

Part One (today):

the medical advances driven by the conflict in Afghanistan

and Part Two (next week):

how medicine and technology can help to rebuild shattered lives.

Link:http://www.bbc.co.uk/programmes/b017ld7n

Yes, I know BBC TV is often not available beyond the UK, but I know some here can find a way!

A summary of the first part:http://www.bbc.co.uk/news/health-15771688

UK Defence Medical Services website:http://www.mod.uk/DefenceInternet/MicroSite/DMS/

BBC summary on:

Clinical trials are under way in the UK of new blood transfusion procedures for patients with traumatic injuries

Link:http://www.bbc.co.uk/news/health-15741800

Note the hospital at Camp Bastion was shown to be a multi-national facility, with US, UK, Danish and New Zealand flags.

[ganulv]

Originally Posted by davidbfpo

Yes, I know BBC TV is often not available beyond the UK, but I know some here can find a way!

Surely an officer of the law is not suborning digital piracy???

[davidbfpo]

Originally Posted by ganulv

Surely an officer of the law is not suborning digital piracy???

No, just acknowledging my IT skills are poor compared to many here and who have time to locate a TV segment far beyond the UK. I am sure the BBC have resources to decide whether such an acquisition is 'digital piracy'. Finally I am a retired 'officer of the law' and feel no obligation to guard corporations digital resources.

[Madhu]

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]

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]

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.

[Madhu]

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!

[Dayuhan]

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]

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]

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]

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.

[ganulv]

Originally Posted by Uboat509

The most well thought out strategy in the world will still fail if it is not properly executed at the regional/local level. […] The solutions to many or most of these problems are at the micro, not macro level.

With the sad reversal of the effective eradication of cholera in Haiti we can see that, yes, you have to get things right at the lower levels if you want a regional or national public health initiative to succeed. But the notion that many or most public health issues is a micro issue is just incorrect. For example, what can be done about MDR–TB at the local level besides treat and isolate infected individuals?

Originally Posted by Uboat509

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.

I don’t disagree, but I nowhere said that the West had to be involved at all.

Originally Posted by Uboat509

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 Musevini-lead anti-HIV/AIDS campaign in Uganda is an example of success at that kind of work, and one which the West (unless you count Cuba, whose role was minor in any case, as the West) did little to formulate or execute.

[Uboat509]

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).

[Uboat509]

Originally Posted by ganulv

With the sad reversal of the effective eradication of cholera in Haiti we can see that, yes, you have to get things right at the lower levels if you want a regional or national public health initiative to succeed. But the notion that many or most public health issues is a micro issue is just incorrect. For example, what can be done about MDR–TB at the local level besides treat and isolate infected individuals?

The government can provide the drugs or the vaccines or the treated insect nets but it is up to the local providers to implement protocols, treat patients and distribute medical supplies. Dayuhan's vignette is a perfect example of that. If the local provider is simply selling the supplies and equipment that the government provides then the plan fails. Please do not misunderstand me. I am not saying that these problems are only at the micro level. I am simply saying that you cannot ignore the micro level.

Originally Posted by ganulv

I don’t disagree, but I nowhere said that the West had to be involved at all.

Sorry. That was not aimed at you. I was speaking generally because there are a lot of people who do make that complaint. I did not mean to imply that you had.

[ganulv]

Originally Posted by Uboat509

The government can provide the drugs or the vaccines or the treated insect nets but it is up to the local providers to implement protocols, treat patients and distribute medical supplies.

True, and though increased oversight is no magic bullet (I say that mostly because I do not believe in magic bullets) you (by which I mean “me”) have to wonder if the government isn’t somehow willfully part of the fraud if no reasonable effort in the area of oversight is being made.

I would feel remiss if I did not mention that this sort of thing comes in an American flavor that most of us are unaware of.

[Uboat509]

Originally Posted by ganulv

True, and though increased oversight is no magic bullet (I say that mostly because I do not believe in magic bullets) you (by which I mean “me”) have to wonder if the government isn’t somehow willfully part of the fraud if no reasonable effort in the area of oversight is being made.

It is never out of the realm of possibility but Ken White has a great quote that I cannot find now that says something to the effect of "Never attribute to malice what can be easily attributed to incompetence." Lack of oversight can be caused by a number of different things. It can be a regulator who is complicit with illegal activities at the local level. It can be a lazy and/or overworked regulator. It can be a regulator that lacks an effective regulatory mandate to actually be effective. It can also be an incompetent regulator. It can also be a lack of funding to have enough regulators to cover all the locations. It can also be a combination of several of these things together.

Originally Posted by ganulv

I would feel remiss if I did not mention that this sort of thing comes in an American flavor that most of us are unaware of.

There is absolutely no doubt that our bloated social programs have problems.

[ganulv]

Originally Posted by Uboat509

It is never out of the realm of possibility but Ken White has a great quote that I cannot find now that says something to the effect of "Never attribute to malice what can be easily attributed to incompetence."

I don’t know about malicious, but when your job is to stem fraud and the best you (as an institution, and the higher-ups within it) can do is throw up your hands and say, “What else can we do?!?” I kind of think you yourself are acting fraudulently. But that’s a discussion for a dedicated Ethics thread.

[Dayuhan]

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.

[Ken White]

Originally Posted by ganulv

I would feel remiss if I did not mention that this sort of thing comes in an American flavor that most of us are unaware of.

Only to have the Health Insurance bureaucracy come down on me like a ton of bricks, in essence telling me to sue, bring criminal charges or shut up in order for them to justify their over priced premiums...

Calling the Guvmint's Fraud Waste and Abuse hotline resulted in more of the same. No one flat said "we know and we like it that way..." but it was rather apparent that was the attitude.

One complaint was over an orthotic brace for my wife, an item that can be purchased for about $50.00 in most Medical Supply Stores or on the internet-- we paid about $85, the insurance company over $300...

Hanlon's razor, "Never attribute to malice that which is adequately explained by stupidity" doesn't apply -- the health care industry isn't stupid and, while not truly malicious, they sure aren't straight arrows...

[davidbfpo]

Medicine is not a speciality I am familiar with, but reading this thread and mindful of the history that supplying medical care in COIN is often described as a "win, win" option two thoughts came to mind:

a) traditionally IIRC medical care was given on an individual basis, with the host community being aware of what that meant and with very rarely was care given beyond the "village" or local community

b) today there is an emphasis on public health, e.g. clean water and on somewhat sophisticated medical care, way beyond local comprehension, local affordability and out of community sight, e.g. helicopter evacuation to Camp bastion's hospital for an IED injured child

It seems to me that in 'stability operations' we have adapted the traditional approach, which was kept small and in view, added the far more effective public health option - which may not be locally seen as benign and offered medical care that is simply too much.

This issue also appears in civil / NGO provision in medical emergencies, notably after disasters and natural failures, drought comes to mind.

Now back to my "armchair".