Sunday, September 9, 2007

Health Diplomacy - Tales from the USNHS COMFORT

The MH60 Knighthawk describes a graceful anti-clockwise arc, suddenly to our left a huge red cross looms out of the grey sea. The aircraft turns its nose to the cross, levels up, utters a long shudder as it bleeds away airspeed and lowers itself to the ships deck. The moment the wheels are firm, a host of ground crew in colored jackets descend on the helicopter, in seconds it is secured to the deck, doors opened and we are ushered through the roaring wind of the blades, to the sanctuary of ‘Flight Ops’. As I remove my life-vest and helmet the Knighthawk’s engine tone becomes more urgent and it slowly lifts away, headed back to the shore to collect patients. I am home from teaching at the local medical school.

Home is a white-painted leviathan known as the USNHS T-AH 20 COMFORT; its official title is a hospital ship but its actual presence beggars description. It is almost one thousand feet long, eight floors high and weighs 69,000tons. It has a complement of over 800 souls and carries enough food and water to feed them for a month. It has twelve operating rooms, an enormous ER known as CASREC, cutting edge ICU and post-op capability, state-of-the-art laboratories and a radiology department that would be the envy of any mid-sized American hospital. It has the capacity to manage up to one thousand patients and bring them on and off by air or sea. It is a fully capable trauma hospital at sea, and it is huge!

The COMFORT has been my home for over two months. We have sailed together from Norfolk Virginia to Belize, Guatemala, and Panama, through the Canal, Nicaragua, El Salvador and most recently Peru. As I write, we are heading north again towards the coast of Ecuador, the seventh country in a planned twelve nation tour that began in early June and will finish in October in Suriname.

Health Diplomacy
I am part of an experiment. The brain-child of the Under Secretary of State for Public Diplomacy and Public Affairs, Karen Hughes, it’s called ‘health diplomacy’, the use of national healthcare assets, military and civilian volunteers, to ‘win the hearts and minds’ in strategically important parts of the world, in our case, Central and Latin America. The US Navy has long held it has a vital global role in providing humanitarian relief in natural and man-made disasters and has used assets, including the COMFORT’s west-coast sister-ship the MERCY, in previous operations. The MERCY responded to the Asian Tsunami and the COMFORT to Hurricane Katrina. Recently the US Navy has sought to expand this role to more deliberate, planned humanitarian operations, specifically the provision of healthcare support in under-served areas of the world. In 2007, there are two such missions underway, the COMFORT is operating in Latin America and the USS Peleliu, a helicopter carrier, is working in Southeast Asia. This congruency of international policy and US Navy doctrine has produced a new and fascinating turn of events.

The experiment is novel not only because it is a new role for the Navy and particularly Navy medicine, but also because it deliberately includes contingents from the US Public Health Service and, more contentiously, civilian Non Government Organizations (NGOs) two in particular. Operation Smile, an NGO specializing in reconstructive surgery for cleft lips and pallets, and Project HOPE, a Virginia-based NGO with a long history of working aboard ships to deliver healthcare to under-served areas of the world. Both NGOs feature volunteers, individual doctors, nurses and other healthcare specialists who give their time and expertise for weeks at a time to serve on the ship and ashore in various countries.

Some will raise their eyebrows at the concept of NGOs working so closely with the military. I reserve my judgment; it is too early in the experiment to draw definitive conclusions. I view the Mission as a form of ‘armed reconnaissance’, the Navy is using its reach and power to identify needs in various countries, addressing the immediate needs where it can. The NGOs in turn use their expertise to determine the numbers and types of long-term capacity building projects that are feasible and begin work with the host countries to establish them. One thing is for certain; at the end of this Mission I will have a more informed position than most of my NGO friends. I will most definitely let them know.

Project HOPE

As a HOPE volunteer, I am the COMFORT mission medical director and will serve on the ship for four months. I manage the Volunteers during their stay on the ship. They come aboard in four waves, each of about 20 Volunteers and stay three missions each time. The twelve missions will see almost 100 Volunteers serve on the ship. They provide general surgery, primary healthcare and education, with a heavy emphasis on the latter. HOPE seeks volunteers with specific expertise, experience working in austere environments, good education skills and a strong streak of independence. The independence is an essential attribute for balanced living in a powerful Navy culture but it can cause the odd headache. I describe my job as ‘Manager of the La Scala Opera House’ I have more than one Diva to deal with daily. I nevertheless am in awe of the experience and sheer dedication of the average HOPE Volunteer.

In addition to the Volunteers, HOPE provides what it calls ‘Gifts in Kind’. The HOPE Regional Director for Latin America gathers from the country MOHs, ‘shopping lists’ of medical equipment and medications which individual countries need and find difficult to acquire. HOPE HQ approaches the US manufacturers and businesses in general to donate or buy these resources. They are delivered to their final destinations aboard the COMFORT and presented to the MOH for distribution. This huge generosity of US businesses amounts to millions of dollars annually and is another example of the private face of American altruism.

Tales to Tell
Each country we have visited has presented a uniquely different environment, cultural and working. Advanced teams visited each country months ago and plans were instituted by the US Embassies and the Governments, particularly the MOHs. On arrival the COMFORT either anchors off the coast or [preferably] comes alongside in a port. Up to three teams deploy to undertake primary healthcare missions in separate locations, a fourth to teach. In addition the surgeons deploy in the first few days to triage patients for surgery on board the ship. There is a substantial complement of SEABEES aboard; these redoubtable engineers turn their hand to any construction and repairs that they can accomplish within the ships stay in the country.

There are sufficient tales to tell from the journey so far, to fill this magazine and I will save them for a future date. They range from bouncing down the Guatemalan coast in a storm, the ship is a converted oil tanker and too light for its size so rolls around in a disconcerting [and sickly] fashion, to passing through the Panama Canal (a modern Wonder of the World), through ending up in Nicaragua at the same time as President Hugo Chavez and on Sandinista Day, to the trials of the Crossing the Equator Ceremony. We have seen all manner of people and all manner of illness, fixed some and not others but made many friends.

Emerging Themes
We are now in the second half of our Odyssey and though it is too early to draw absolute conclusions I have some pretty firm ideas about both the good and the not-so-good of the Mission to date. The first point I think it vital to make is that this is a training mission. We set off on the 15th of June over 800 souls from the US Navy, Army, Air Force, US Public Health Service, Canadian Defense Forces and NGO volunteers. Few if any had ever seen each other before let alone worked together. Most, including the majority of the Navy medical staffs had never been to sea before. It was only to be expected that the learning curve for all would be vertical and life would be difficult. It was, and at times painfully so. It is hard to reconcile learning a task and practicing for real at the same time. But this is the reality of the modern Navy, constant turbulence.

We learned quickly and by Panama had grasped the main lessons and were beginning to work together. Peru has witnessed that truly military phenomenon, ‘the Team’, forming in almost every department of the ship. These tight little groups have cultures developed around shared experience and a vernacular that is impenetrable to the outsider. Though we may not appreciate it now, the often painful learning process we went through in each hot and dusty medical site, every frustrating encounter with a creaky communications system, was necessary to produce this very essence of the military culture, the ‘Band of Brothers’.

Competing Imperatives
We have learned too that it is difficult to reconcile two competing imperatives, to visit our ‘medical diplomacy’ on a large number of countries in a relatively short period, and provide substantive medical care in each target country. The latter takes time and the former does not allow it. The result at times has been the disappointment of unmet expectations, frustration amongst clinicians who felt their medical abilities constrained by time and resentment from indigenous medical staffs who felt excluded from events. It could be argued that no matter how long we stayed we would only be ‘scratching the surface’ and that is true, but longer would have been better. We are learning to compensate by making our procedures slicker, using our advance teams to set tighter, more achievable schedules and focusing in on what we do best. Still, the lines at the main primary care site in Trujillo Peru would have put a football match to shame. I contend that future missions would benefit from a more targeted approach, less countries and longer stays.

Trojan Horses
At the tactical level we have learned valuable lessons which we will continue to expand and exploit. The first and by far and away my favorite is what I have nicknamed ‘the Trojan Horse’ approach. The countries we have visited and will visit are overwhelmingly agricultural; animals are an essential element of Everyman’s wealth. It therefore follows that healthy animals mean wealthy owners and wealthy people are healthy people. Yet we did not grasp the full import of this until Nicaragua. Given the current political environment of the Country, we not surprisingly met resentment and disinterest in our offers of primary healthcare. A decision was made at one site, to lead with the USPHS Veterinary Medicine team offering healthcare to animals, principally horses, Nicaragua abounds in horses and they are an essential part of society. The effect was a sudden huge interest in all we were doing including human health. The ‘Vets’ had provided the catalyst to our primary care program. I believe this approach, combining animal and human healthcare in coordinated teams at the community level is a vital lesson learned and key model for future humanitarian operations.

Cabbage Patch Dolls
The second lesson concerns training and education, which should underpin our capacity building in every target country. We must expand our education initiatives and include them in every aspect of our healthcare delivery, from surgery to health promotion, dental care to veterinary care. The first tenet is that all training and education should be through the MOH and the medical teaching institutions and should include host nation teachers and interpreters. This takes a great deal of preparation and planning.

Training and education should be both culturally relevant and shaped to suit the needs and technology of the recipients. To this end we have instituted what I have called ‘come-as-you-are’ first aid at the community level. Rather than teach using the sophisticated technology of the US military, we have shown the Navy Corpsmen how use materials commonly found around households and workplaces as first aid appliances. Even more innovatively, the HOPE midwives teach the management of obstetric emergencies using a cardboard MRE box, Cabbage-Patch doll and a length of parachute cord. With these simple tools they can teach an array of techniques to manage deliveries. The local health workers are enthralled, both with its simplicity and the fact that ‘if it’s good enough for Americans, it’s good enough for us’.

The COMFORT of Home
The COMFORT is the center of our World and though we often complain about the food, the smells, the noise and lack of privacy (I like most ‘officers’ share a small cabin with seven other men) we know it is our safe haven, cool in the tropical heat, with familiar routines and friendly faces and the best hot showers I have experienced in my life. It also houses some wonderful technology and great people. I am fascinated by the Radiology Department which houses a CAT-Scan and is so sophisticated I view it as the modern Anatomists Laboratory. We no longer cut up bodies to see how they work, we map them from top to bottom, inside and out and travel their three dimensional digital images like modern explorers.

I am in awe too of our helicopters and their crew, who never seem to stop working. They fly tirelessly from dawn to dusk and whilst the rest of us are snoring they lovingly take their machines apart and reassemble them under the night sky. Without them and the redoubtable ‘pirates’ of the Military Sealift Command who ferry us faithfully to and from the ship like modern Charons, in almost all weather, we would most times be able to do little more than stare at distant shores.

So here I am for another two months. Some days I feel a little like the character that shot the albatross in the Rime of the Ancient Mariner. Others I am as excited as a latter-day Walter Raleigh. I have already learned much, seen a great deal and met some wonderful people, on both ship and ashore. I look forward to writing more tales and thoughts from our medical Odyssey.