Monday, March 24, 2008

Bloody Hands and Bleeding Hearts

“[h]umanitarian agencies don’t mind coordinating with the military but they don’t like being coordinated by the military” ….Hugo Slim
Medical Diplomacy
It is almost a year ago today that I rather foolishly volunteered, without a second thought, to join a Project HOPE mission as the leader of a contingent of medical volunteers aboard the USNS COMFORT. The plan was for the hospital ship to visit twelve countries in Latin America and the Caribbean. Project HOPE would provide a group of about twenty five volunteers at any one time.
During this Odyssey, I wrote a couple or articles. In one I described the mission as an exercise in what had become known as ‘Medical Diplomacy’ and promised I would examine the issue in depth at a later date. The key issues, it seemed to me, centered around the relationship between NGOs, in this case Project HOPE, and the US military and the US Navy in particular. Is this a good model for future humanitarian operations? What does the US Navy get from it? What do NGOs like Project HOPE get from it? Is this a flag waving exercise or does it provide long-term good for the recipient countries and their people? I have procrastinated for almost four months since the end of the COMFORT mission; herewith my observations.
Nothing New
My first contention is that what Project HOPE did on the COMFORT was neither new nor innovative. They and a number of other NGOs had deployed on the USNS MERCY the previous year, on a similar mission in SE Asia. Whilst the COMFORT was sailing noisily around the Panama Canal, the USS Peleleu, with a contingent of HOPE volunteers, was quietly reprising the MERCY mission in SE Asia. Currently, a group of HOPE volunteers is aboard a USN ‘grey-hull’ off the coast of West Africa and the USNS MERCY prepares to sail, with HOPE volunteers and other NGOs for SE Asia in June.
Moreover, whilst relationships between the military and civilian humanitarians have certainly intensified over the last two decades, they are by no means new. As Hugo Slim notes in a series of excellent articles The Stretcher and the Drum: Civil—Military Relations in Peace Support Operations. The ICRC was born in 1863 out of the Battle of Solferino, the Save the Children Fund (SCF) in 1919 out of the First World War, and OXFAM and the US Committee for Aid and Relief Everywhere (CARE) out of the Second World War in 1942 and 1945 respectively. He points out that, to a large degree, “Militarism and humanitarianism have represented two sides of the same coin – humankind’s inability to manage conflict peacefully”.

The Birth of CIMIC
Perhaps the defining moment in recent NGO/military relationships was Operation PROVIDE COMFORT in northern Iraq in 1991. I think even the most hardened critics of civil/military cooperation (CIMIC) would agree that a great deal of good was done and many lessons learned. It’s a shame they were not remembered in the frequent man-made and natural disasters of the following decade; Bosnia, Rwanda, Kosovo to name but three, saw the CIMIC relationship as exercises in re-inventing the wheel. To misquote Santayana, ‘History repeats itself. It has to because nobody listens.”
More recently, conflict in Afghanistan, Iraq, the Tsunami and the Pakistan Earthquake have seen ever-increasing cooperation between INGOs (UN etc), NGOs and the military. With each experience the relationship has improved and the results too. But it has been a fraught and imperfect gestation.
New Tools
My second contention is that like it or not, the CIMIC approach to disasters either man-made or natural; is the model of the future, particularly and most contentiously with the aftermath of conflict known as Peace Support Operations Why? Because there is a growing revolution in thinking amongst the militaries of the world, that questions the utility of force. It argues that most modern conflict is so complex; militaries have only a limited role in their resolution, creating the conditions for a political solution. In other words creating and enforcing a secure environment.
The problem is, to butcher a quote from Maslow, ‘If the only tool you have in your toolbox is a hammer, all the world’s problems are nails’. The argument goes that the military needs new tools, new methods, new training to meet the demands of modern conflict. Like Colossus it moves and changes slowly, but the change is inexorable. We can already seeing US Army Artillery Regiments putting away their field guns and learning about peace support, civil affairs and COIN. But the military has so much to learn and little time to learn it in. Moreover, there are skills and expertise it finds difficult to obtain and impossible to retain; skills essential to Disaster Relief and Peace Support Operations. For example how many veterinary officers does the Navy have? It must therefore form alliances with the UN and with NGOs of every shape and size, local and international, to provide this expertise in order to achieve what it calls, ‘winning the battle for hearts and minds’..
So the first point I would make about Medical Diplomacy, I have in part, made before; it is an experiment, an honest attempt to explore ideas old and new to meet demands that appear to be inescapable. The people of America and indeed the world, want conflicts, where they are inevitable, to be resolved in ways other than bombing cities until the rubble bounces. This will require the military and civilian humanitarian agencies to work in very close concert from the outset. This in turn will require them to think, plan and train together.
Pre-Planned Humanitarian Missions
You might ask why this discussion has focused so far, on disasters and conflict, when the organization at the center of my argument, Project HOPE, has historically not been involved with the military post-conflict, in what are fashionably called Peace Support Operations. In fact it has only been involved with the military on one recent Disaster Relief operation, the Tsunami. All of HOPE’s other sojourns with the military were and are to date, archetypal preplanned ‘cold’ Humanitarian Assistance operations.
So I must return to the original questions. Why would HOPE want to be involved in these sorts of missions? What does it get from them? What does it contribute? How does it justify such a close working relationship with the military?
The answer to the first question is pragmatic and banal. HOPE used to have its own ship. In fact it started using it 50 years ago this year, beginning in SE Asia and then moving along the Pacific coast of Central and South America. It got too old and expensive; HOPE let it go and became land-lubbers with long-term capacity building programs. There are many such HOPE programs around the world, some conventional healthcare and development programs; others very out of the ordinary. HOPE is currently completing the building and staffing of a Children’s Hospital in Basrah, Iraq. It has even taken on the training of nurses and other clinical staff, in what I consider to be a model method; the subject of a future article.
Project HOPE has always had a hankering to return to its seaborne roots and the US Navy has provided the means and much more. They provide what an NGO needs to survive and work in a hostile environment, security, logistics and communications. Much the same as the military provides NGOs in CIMIC operations the world over.
Given the essential political/military nature of these missions, NGOs like HOPE don’t get much of a voice at the table when it comes to deciding where to go or for how long to stay. But that need not be a deterrent to joining. With planning and forethought, NGOs with long-term interests in a specific geographic area can capitalize on the Navy’s presence. Operation SMILE used the COMFORT mission in Latin America to obtain logistic support, communications and clinical resources for surgery and post operative care in a number of countries. The US Navy shared in the kudos of this unique service and a number of Navy medical staff both learned and taught local healthcare workers.
Project HOPE used the journey for similar purposes; to conform to military argot, I called it ‘armed reconnaissance’. We deployed teams of healthcare Volunteers who undertook an array of clinical and teaching roles in concert with their Navy counterparts. At the same time we used this work to create relationships with the MOHs, local NGOs and civil society and to identify new long-term capacity building training and education projects for HOPE. We have potential new projects in Panama and a number of other Latin American countries at this time.
The preplanned, ‘cold’ Humanitarian Affairs mission of the COMFORT/MERCY type, also provides a medium for the thousands of volunteers from all over the US and beyond, who want contribute their time and there expertise but only have a little of the first. Many are willing to give a few weeks of their time to provide what HOPE is looking for, expert teaching and training of healthcare skills in under-served regions of the world. The HOPE/US Navy partnership provides a relatively uncomplicated means for these individuals to serve. Vitally, in an era of the All-Volunteer Military, it also offers a chance for civilians to experience and perhaps understand a little of military life.
Experience as Value-Added
The case for HOPE’s contribution to this aspect of CIMIC is a little more complex and I need to tread carefully for fear of sounding like the archetypal arrogant NGO. Military medicine in general and Navy medicine in particular have much to learn about Humanitarian Assistance and Disaster Relief. The average Navy doctor, nurse and medic is a very busy person working in a peacetime facility. Their customers are fit health young men and women with mainly fit healthy families, who leave before they get old and sick. Moreover, many of the navy medics are young and inexperienced and have been trained according to rigid protocols with state of the art, resources. When they are suddenly thrust into an environment where every affliction known to man is common-place, resources are minimal and people ‘wing’ the protocols, it is a chastening experience and a tight learning curve.
It is in this environment that the HOPE volunteers provide the value-added. Most are experienced in working in austere environments; HOPE deliberately seeks and selects those with previous NGO, volunteer, missionary experience. The Volunteers become the teachers and trainers, often at the behest of the Navy medics. It is this role, of education, training and expertise that HOPE promotes as its contribution to these missions. Whether the ‘student’ is an indigenous, doctor, nurse, community midwife, or a US Navy corpsman or nurse, really is not the issue. It is about capacity building through education and training. That is HOPE’s contribution
Continuity Factor
There is another aspect, the continuity factor. When the COMFORT sailed on her 12 country mission last year, she had a complement of about 850 souls, from the Navy, AF, Army, USHPS, Coast Guard, Canadian Defense Forces and NGO volunteers. Most had never previously met and many had never been to sea before. It is not hard to imagine what the first few weeks were like. If we had been called upon to deal with a DR mission before week 4, I think we would have had real problems. The first month was a training exercise for all on board.
By the time the COMFORT sails on a future mission, almost everyone who sailed last year will be dispersed to the four winds, The CO and the leadership will be starting almost from scratch. The Mercy when she leaves for SE Asia in June will have exactly the same issues. These are the facts of life in the modern US Navy. Here again there is a role for NGOs who have access to experienced people who have ‘been there and got the tee shirt’.
Underpinning CIMIC
Finally, I want to try and bridge the gap between preplanned ‘cold Humanitarian Assistance missions and Peace Support Operations or whatever term the jargoneers in the five-cornered building are using this week.
Every, mission involving UN/NGOs/military (US and Coalition) I have served in or analyzed has labored at the beginning. It’s to be expected, it is the fog of war. But there are some deeper intrinsic reasons for this initial dysfunctional relationship. They might best be examined under the general rubric of communications. This is not a reference to ITC or radio communications, though they are always a bone of contention. The key is how to forge a working relationship, CIMIC, rapidly and efficiently, in a time of great stress. How to weld together a number of organizations often multi-national and multi-cultural in nature and with deeply differing views as to how to achieve a successful outcome.
Creating Understanding and Trust
The key principals of humanitarian agencies are impartiality and independence, luxuries rarely afforded the military – Bob Leitch
From 1991 in northern Iraq through to today in Helmand Province, the secret of a successful CIMIC operation has been how well the players worked as a team. The military generally knows what it has to do, the Commander’s Intent. How they get there is always a dynamic process, depending on the changing political environment and the actions of those who would thwart them. INGOs and NGOs too, normally have a pretty clear idea of what they intend to do and although they aim at impartiality, neutrality and independence their very presence shapes day to day events and the endgame. To achieve a common goal, the end of conflict, suffering and a return to normalcy, all parties have to know each other, know what that endgame is and how each team member intends to contribute. They have to know each others strengths and weaknesses, cultures and customs. Above all they have to trust each other, more often than not with their lives.
If, through projects such as the routine HA missions of the MERCY,COMFORT and ‘grey-hulls’, and focused interagency training courses, like the Army’s at Ft Polk, we could begin this process of understanding and building trust, this might shorten the time and ease the difficulties in establishing future CIMIC structures. We might, in turn, go into the next crisis better prepared and more rapidly produce a favorable outcome
This is my most defensible justification for ‘Health Diplomacy’ missions; in the manner Project HOPE and other NGOs are conducting them with the military, particularly the Navy. Both are developing and encouraging an ever closer relationship. The aim: to build a bridge, intellectual, institutional and above all cultural, between two organizations which as Hugo Slim says ‘represent two sides of the same coin.

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