Military medicine has often driven advancements in the provision of medical care in austere environments. Military medicine encompasses all aspects of health care required to keep the fighting force healthy and deployed. The result is a diverse requirement, including response to complex polytrauma, management of large numbers of patients in a short period of time, care for patients during prolonged transports, and the prevention, recognition, and management of endemic communicable diseases. These attributes are shared with the characteristics of clinical care for patients following a humanitarian crisis or disaster situation. Though the fields are drawing ever closer together, humanitarian assistance (HA) and disaster response (DR) remain somewhat distinct in practice and scope. This chapter focuses on the U.S. military experience and relevant lessons learned for domestic DR and international HA/DR missions.
The U.S. Department of Defense (DoD) has a long history of applying the unique capabilities of the individual armed services to HA and DR efforts following both natural and human-made disasters. In 1882 the U.S. Army Corps of Engineers provided support to the Army Quartermaster Corps’ efforts to rescue people and property during flooding of the Mississippi River. In 1899 the U.S. Army Medical Department’s role in the response to a severe hurricane in Puerto Rico was guided by the military governor’s chief surgeon and involved the disbursement of more than 60 tons of medical supplies. DoD elements executed Operation Damayan in November 2013 as part of a broad multinational response to the devastation wrought upon the Philippines by Typhoon Yolanda or Haiyan.
The U.S. military’s medical system has long played a part in response efforts, treating local populations abroad during and after complex emergencies, providing logistical support for governmental and private aid organizations, and ensuring secure operating space for humanitarian actors. Despite this long history of participation in HA/DR to natural disasters and complex emergencies, the role of the DoD and its impact on the practice of HA/DR has been questioned both internally and by civilian agencies. Historically the HA community has argued against military involvement in HA/DR operations, citing the Geneva Convention and International Humanitarian Law (IHL), which emphasize neutrality, impartiality, and independence. This philosophy has many valid supporting arguments, but practically has resulted in distinct professional approaches to HA/DR. In addition, the increased prevalence of intrastate conflict and the proliferation of nonstate actors utilizing service-restriction tactics (e.g., destroying health care facilities, restricting water and food deliveries, and gender-based violence) have worsened the “dilemma of neutrality” and are challenging the historic concepts fundamental to IHL.
Traditionally the civilian medical intervention in fragile regions was divided into DR, HA, and international development (ID). Each sphere defined their role vis-à-vis crisis response in somewhat narrow terms. DR was largely short-term, high-intensity interventions meant to stabilize populations in the post-event phase. The DR field was dominated by government organizations, such as the Department of Health and Human Service’s (DHHS) Disaster Medical Assistance Teams (DMATs), the U.S. Agency for International Development (USAID) Disaster Assistance Response Teams (DARTs), and the Office of the United Nations Disaster Relief Coordinator (UNDRC), now part of the U.N. Office for the Coordination of Humanitarian Affairs (OCHA). Emergency medicine professionals (e.g., physicians, paramedics, and emergency department [ED] nurses) dominated the dynamic DR field. HA developed in response to longer-term “creeping crises,” such as droughts, famines, and large-scale population migrations. The U.N. Department of Humanitarian Affairs (DHA) ultimately merged with the UNDRC to form OCHA, which covers HA and DR missions. The HA industry largely defined and developed the principles of IHL and applied these principles across decades of global response. The HA professionals tended to have stronger interests in public health, primary care, and infectious diseases. ID as a generality is comprised of policy experts, public health specialists, and health economists approaching broad issues via activities that will span years and require decades to achieve the desired effects.
Multiple factors are driving the evolution of the military medical system’s role in HA and DR. The most significant shaping factor has been the engagement of the United States in the broadly defined Global War on Terrorism (GWOT) since 2001. In addition to large-scale conventional operations in Afghanistan and Iraq, the U.S. military has engaged in counterinsurgency (COIN) engagements and stability operations across the Middle East, Africa, and Southeast Asia. Each mission profile adds unique contributions to the development of medical systems, mission planning, and logistical support for medical operations.
Operation Iraqi Freedom began on March 19, 2003, and major combat operations lasted less than 2 months, ending with President George W. Bush’s now infamous declaration of “mission accomplished” on May 1, 2003. The initial stage of Operation Enduring Freedom was similar in length. The first Pentagon-acknowledged ground action occurred on October 19, 2001, the Taliban lost Kabul on December 7, 2001, and the birth of the U.N.-authorized International Security Assistance Force and swearing in of Hamid Karzai marked the birth of the new transitional central government before the end of December 2001. The exceedingly short period of time required for domination of the battlefield contrasts starkly with the more than 10 years of irregular warfare, including COIN, counterterrorism, foreign internal defense activities, and the peacekeeping and stability operations that have followed. The persistent, long-term execution of these missions has resulted in changes in practice and procedure through trial-and-error discovery of best practices. Lessons derived from COIN and stability operations, including the establishment of tiered treatment facilities, development of streamlined patient transport systems, utilization of electronic patient tracking, forward deployment of mobile critical care capabilities, emphasis on local capacity-building partnerships, and interagency coordination, often have applicability to HA and DR efforts.
The second factor driving the convergence of military and DR medicine is current U.S. National Security Strategy (NSS). The U.S. NSS outlines the nation’s major security concerns and the authoring presidential administration’s goals and preferred methods for addressing those challenges. The current NSS is built upon the three pillars of defense, diplomacy, and development. DR is represented in all three key pillars. After the conclusion of the Cold War, the 1999 NSS authored by President Bill Clinton’s administration referenced DR and disaster relief efforts multiple times, placing them in the context of affecting both the important national interests and humanitarian interests of the United States. President George W. Bush’s 2002 document focused primarily on response to the September 11, 2001, attacks and gave little mention to DR. However, in President Bush’s 2006 update to the NSS, reference is again made to DR, most notably recognizing that coordinated disaster relief efforts have contributed to improvements in regional conflicts in Indonesia and between India and Pakistan. An NSS published by the Obama administration in 2010 references disaster relief efforts several times, but often commenting on the need to focus inward on the domestic preparedness of the United States. In practice, however, the U.S. government (USG) has used DR as a tool of diplomacy and soft-power exertion in multiple high-profile events since 2010, including responses to the Haiti earthquake, Japan earthquake, and 2014 Philippines hurricane.
The current U.S. foreign affairs policy articulates a “whole of government” approach to development and DR, closely aligning subordinate components of the Department of State (DoS), USAID, and DoD. Department of Defense Directive (DoDD) 3000.5 (November 28, 2005) is the guiding directive that articulates the importance of integration of civilian and military efforts to achieve successful stability operations. DoDD 3000.5 also outlines the manner in which the DoD will interact with foreign governments and security forces, global and regional international organizations (IOs), nongovernmental organizations (NGOs), private sector individuals, and for-profit companies. Title 10, US Code, Section 401 governs U.S. military involvement in international HA/DR and articulates the manner in which the DoD may be activated to support operations and the technical assistance that the DoD may lawfully provide during HA/DR missions. This “whole of government” strategy drives funding requirements and therefore programmatic development. The result has been increased DoD engagement in the HA/DR space. According to Dr. Stewart Patrick, the DoD is now the major provider of official development assistance (ODA). Between 1998 and 2005 the Pentagon’s share of total U.S. ODA rose from 4% to 22%, or to $5.5 billion, with the majority spent in Iraq and Afghanistan. This percentage has since declined to 18%.
Third, intrastate conflict has emerged as one of the most significant challenges in modern DR (e.g., conflict as either an initiating factor or consequence of disaster). A brief survey of major humanitarian crisis and disaster zones from 2013 to 2014 includes civil wars and massive population displacements in Syria, the Central African Republic, the Democratic Republic of Congo, South Sudan, and Somalia. In 2013-2014 infectious disease outbreaks, such as cholera in Nigeria, polio in Syria, and measles in the Sahel, can also be directly linked to ongoing violence. With human conflict an impetus for, or a direct consequence of, many modern disasters, the world’s militaries are increasingly working side by side with civilian HA/DR and development organizations.
Finally, beyond these geopolitical realities, military medicine and DR share a variety of similar operational challenges and often demand overlapping skill sets. Both combat and DR present multimodal challenges to the delivery of care, including, but not limited to, logistics, security, multiagency coordination, data collection, rapid modification of medical care protocols, and disciplined adherence to the mission at hand. However, perhaps the most unifying challenge is the “tyranny of distance” that affects all aspects of combat and DR.
Domestic Response Systems
Military medicine has had a fundamental role in the development of domestic DR strategies, especially in the United States. The military’s influence on civilian disaster management can be broadly categorized into operational systems and clinical care. Key among the systems contributions are the Incident Command System (ICS) and principles of high-reliability organizations (HROs). The ICS is an all-hazards incident management approach for the command, control, and coordination of emergency responses. The ICS is based upon limited span of control and is a fundamental tenet of DR. The ICS concept, initially proposed in 1970 by California fire chiefs as a strategy for coordinated battling of forest fires, was based on the U.S. Navy hierarchical chain of command. In the past 45 years the ICS emerged as the key operational paradigm for prehospital, health care facility, and governmental response to crisis. Both in the prehospital environment and in health care facilities (e.g., hospital ICS) the ICS system is used to standardize the management of complex, interagency, or interdepartmental responses. Briefly, the ICS system creates flexibility of action, clear accountability, and clear operational span of control. ICS mirrors the military command system by identifying and empowering an incident command (e.g., commanding officer), operations officer (e.g., staff 3 [S3]), planning officer (e.g., staff 5 [S5]), logistics officer (e.g., staff 4 [S4]), finance and administration officer (e.g., staff 1 [S1]), and information officer (e.g., staff 6 [S6]). The ICS principles are discussed at length in Chapter 38 .
During the past 5 years, disaster management practitioners have gained increased awareness of the principles of HROs. The theory of HROs began in the 1970s but gained traction with the study of the aircraft carrier USS Carl Vinson and Capt. Thomas Mercer. The study examined the notion that “accidents” in high-risk environments were considered normal. Capt. Mercer and his team faced highly complex operational environments, uncertain threats, frequent turnover of staff, and catastrophic consequences for failure. Their approach embodied the principles of HROs, leading to fewer significant adverse outcomes and improved safety. An in-depth discussion of HROs is beyond the scope of this chapter; however, the five core concepts of HROs include the following :
Sensitivity to operations: Constant awareness by leaders, practitioners, and staff about the state of the systems and key processes that affect patient care. Accidents are rarely the result of a single error by a single person, but rather errors “latent in the system.”
Reluctance to simplify: Clinical and response operations are inherently complex. Development of simple processes can reduce error, but oversimplification of the root cause of errors is dangerous. Categorizing challenges is unavoidable, but should not constrain skepticism or investigations.
Preoccupation with failure: Constant vigilance about viewing near misses within the system as early signs of failure. This is not a preoccupation with avoiding failure. Rather, this acknowledges that errors will happen and focuses attention on avoiding complacency and limiting adverse outcomes.
Deference to expertise: Willingness of leaders and managers to listen and respond to the expertise of front-line staff. Expertise is not based on position, but rather knowledge, experience, and credibility.
Commitment to resilience: Organizations must maintain function during periods of high demand or system failures and grow from prior episodes.
These HRO principles are applied in intensive care units (ICUs), emergency medical service (EMS) agencies, EDs, and DR. They have also become a component of the Agency for Healthcare Research and Quality (AHRQ) standards for achieving clinical quality, safety, and efficiency.
Clinical Care Advances
The practice of military medicine has advanced tremendously in the past decade. The GWOT has provided a generation of military medical providers with expeditionary experience. During this period, the military often looked to civilian HA/DR providers for lessons learned, best practices, and gap analysis. However, where civilian practice is frequently limited by lack of funding, the GWOT provided the unique opportunity to align defense funding and training requirements with these identified gaps, therefore accelerating the advancement of medical care delivery in austere or high threat environments, both military and civilian.
In the prehospital environment the influential example is the creation of the Tactical Combat Casualty Care (TCCC) guidelines. TCCC stems from efforts by U.S. Special Operations units in the 1990s to adapt prehospital care techniques to the battlefield environment where disciplined adherence to tactics often determines mission success versus failure. The TCCC guidelines were the first modern medical guidelines to align medical care and operational constraints—in this case the tactical combat scenario—to address potentially preventable causes of death. The tiered application of TCCC guidelines to nonmedical personnel, medics, and physicians resulted in the lowest case fatality rate in modern combat history. Over the past decade the TCCC Guidelines expanded beyond point-of-injury care to address issues related to standardized field surgical care, analgesia, damage control resuscitation, and tiered hemorrhage control. The CoTCCC also drove initiatives, such as the DoD implementation of tourniquets, hypothermia prevention, expanded use of tranexamic acid (TXA), and utilization of intranasal ketamine for analgesia.
The military experience has clear and direct application to mass casualty incidents (MCIs), acts of terrorism, and management of complex polytrauma in the civilian setting. The civilian Committee for Tactical Emergency Casualty Care (C-TECC) was established in the United States to serve as a best practice development group for translating combat lessons learned to civilian response to high threat prehospital care. The C-TECC guidelines emphasize an integrated, threat-based response to prehospital care with emphasis on threat mitigation, early hemorrhage control (e.g., aggressive tourniquet application), rapid extraction, and tiered initiation of damage control resuscitation principles. The TECC guidelines represent a critical paradigm shift in civilian care, especially in regards to aggressive tourniquet use, which had been considered an anathema in trauma care. Multiple studies have demonstrated the efficacy and safety of properly applied tourniquets, leading to more widespread adoption as part of MCI plans. Since, organizations such as the American College of Surgeons have looked with increasing frequency to the military to provide lessons learned on management of traumatic MCI events. The 2013 Boston Marathon Bombing illustrated the critical importance of proper, aggressive tourniquet application—a key lesson learned from combat experience and articulated in TECC.
One of the other critical military care advancements with direct application in the civilian DR community is the conceptualization and development of damage control resuscitation (DCR) strategies. DCR emerged in the early years of the U.S. conflict in Afghanistan as forward-deployed surgical units began to manage large volumes of complex, polytrauma patients in resource-poor environments. The principles of DCR include early hemorrhage control, permissive hypotension, prevention of acidosis and hypothermia, and early damage control surgery (DCS). The apparent reductions in mortality noted by implementation of DCR and DCS principles in combat led to the widespread adoption of these techniques in civilian trauma centers, especially as part of MCI and disaster plans. Though DCR principles continue to be fine tuned, they certainly have a role in the provision of high-quality care in austere, resource-challenged, and crisis situations.
The U.S. DoD has a long history of conducting and supporting HA missions. The DoD provides much of its routine humanitarian aid through the Overseas Humanitarian, Disaster and Civic Action (OHDACA) account. Outside of overt war zones, these DoD operations are generally conducted in “semi-permissive” environments defined by elevated threat scenarios but not outright combat operations. Academic, operational, and policy stakeholders actively debate the impact, consequences, and implications of the “militarization” of HA missions. However, there are clear lessons learned from military operations that inform modern and future civilian HA missions.
Operations Management and System Design
The DoD is a clear global leader in logistics and mission support. Frequently, components of the U.S. military must work with other branches of the U.S. Armed Forces, USG civilian agencies, foreign governments, nonstate responders, and IOs to achieve mission success. In response, the DoD creates various interagency task forces and provides guidance on roles, responsibilities, and operational span of control. Clear chains of command, effective communication, and cooperation are critical to success. This mission profile mirrors that of the HA community during large-scale response operations. The largely ineffective U.N. cluster system was and is an attempt to provide a similar coordination infrastructure by identifying key stakeholders within each sector and identifying sector “leads.” Limitations to the U.N. cluster system include a lack of regulatory and command authority. In Jordan the U.N. High Commissioner for Refugees (UNHCR) has begun to implement, with some success, issue-specific task forces, innovation and problem solving teams (similar to Red Cell teams in the military), and contracted lead agencies with execution authority within specific areas of operation.
The U.S. military is also an expert at the development and deployment of trauma systems in crisis zones. In Iraq and Afghanistan the U.S. military has created an integrated, tiered trauma system that provides exceptional care from point of wounding through evacuation to the United States. The DoD system combined trauma training for nonmedical personnel, rapid evacuation using various modalities (e.g., trucks, helicopters, and fixed-wing aircraft), far-forward deployment of surgeons and critical care staff, mobile ICUs, modern information management systems, and a properly resourced logistics and support system to reduce combat mortality to the lowest rate in modern combat history. The system design focused around the critical issues of prolonged evacuation time and resource limitation. In particular the ability to provide critical care in austere environments was a major advance in combat, and thus HA medicine. These principles focused on diligent resource management, aggressive infection control, practiced interdisciplinary team care, and leveraging of air-evacuation platforms. In disaster zones from postearthquake Haiti to posttyphoon Philippines these lessons are critical for success and should be closely studied by HA leaders.
Innovation and Technology
Plato wrote, “Necessity, the mother of invention.” Jonathan Schattke expanded on Plato, writing that “Necessity, it is true, but its father is creativity, and knowledge is the midwife.” The September 11, 2001, attacks drew into the military some of the most creative, knowledgeable, and motivated individuals in the United States. The subsequent decade of complex urban operations, counterinsurgency, and mixed national policy goals demanded from leaders at all levels the rapid development of expertise and application of creativity in order to both achieve mission success and to survive.
Reliable energy is critical to effective HA mission execution. Often-times HA/DR operations occur in remote regions or areas where the energy infrastructure has been destroyed. The U.S. military faced a similar challenge in Afghanistan, where the logistical system required to provide power to forward-operating bases was expensive, deadly, and unreliable. In 2009 the Pentagon estimated the average cost to provide one gallon of fuel to a vehicle in Afghanistan was $400/gallon. The officials also estimated that one casualty was sustained every 24 missions. So pressing is the issue that the Defense Advanced Research Projects Agency (DARPA) is developing a mobile integrated sustainable energy recovery (MISER) system. The applications in HA missions is direct and obvious. Unfortunately, the cost of large-scale solar projects and antiquated funding mechanisms have prevented the large-scale deployment of renewable energy solutions beyond solar lamps, solar water heaters, and the occasional solar street lamp. For example, during 2014, UNHCR spent an estimated $700,000 USD on electricity for the Za’atari refugee camp in northern Jordan. Jordan has an abundance of solar energy with average annual daily solar irradiance ranges from 5 to 7 kWh/m 2 . The scenario is primed for widespread application of clean energy technology, such as solar and wind. The increased interest from the U.S. military is driving research and development, creating a private sector market for mobile renewable energy and providing case studies for application in austere environments.
In HA/DR missions one of the most significant challenges is tracking refugees, casualties, and at-risk populations. In Haiti the Operational Medicine Institute (OMI) identified a critical gap in the interagency/U.N. cluster system capacity to track volunteers, patients, and displaced populations. As a result, the OMI developed an iPhone-based tracking application that gained widespread utilization. However, the issue of accountability repeated itself in the Philippines, South Sudan, and countries responding to the massive Syrian refugee crisis. In 2013 the HA community again looked to the military for a solution. During the conflicts in Iraq and Afghanistan, the U.S. military deployed portable biometric identification devices to identify criminals, track insurgents, and vet potential political allies. Again this drove development and technology transfer to the civilian sector. In Jordan the UNHCR contracted with Iris Guard to provide biometric registration of refugees, allowing greater situational awareness, the efficient deployment of cash and food voucher systems, and the identification of potential security threats from insurgents posing as refugees.