1. Case Studies in Afghanistan Health & Related Lessons Observed in EUCOM and PACOM 30 Jan 2012 Col John Mitchell The MHS: Healthcare to Health Defense Institute for Medical Operations; Former CSTC-A SG

2. Has no real or apparent conflicts of interest to report. Conflict of Interest Disclosure John Mitchell, MD

3. MSO: Objectives  Discuss direct medical stability operations efforts to include cooperation plans in past or ongoing CENTCOM operations.  Evaluate specific cases of successes and failures related to USG efforts in Afghanistan  Evaluate specific cases in EUCOM and PACOM

4. Agenda & Key Points  Medical Stability Operations (MSO) –Worth Doing –Steep learning curve (MHS, DoD, USG, PN) –Goals are elusive (whose MoE, AMoE, MoP) –Getting Smarter (PN Civ/NGO/Mil linkages; USG) Origins of Health (Water, Food)  Challenges of direction

5. MSO: Worth Doing  “(The AFMS is involved in) GHE initiatives because health equates to security. When the people are healthy and prospering, economies grow, which furthers the goal of spreading democracy.” Major General (Dr.) Byron C. Hepburn, Commander, 59 th Medical Wing, Wilford Hall Ambulatory Surgical Center, Lackland AFB, TX

6. MSO: Worth Doing  For Agile Combat Support (AGS),“GHE –Establishes “US access and influence with partner nations by building their health capabilities” –“Can serve as a model for success within the other ACS elements (airfield operations, logistics, security forces, maintenance, civil engineering, air traffic control, weather).” from pg 19 of Global Partnerships Strategy signed out Dec 2011 by CSAF and SECAF)

7. MSO: Worth Doing  For Agile Combat Support (AGS),“GHE –“Without the various and specialized resources provided by the ACS community, sustained and successful air domain operations would not be possible….to achieve Joint effects.”

8. MSO: Steep Learning Curve  Outset: Infrequently well versed in MSO –POCs, funding, documents, PN relationships?  Stovepiped (MHS, DoD, USG, PN)  Failures teach faster than successes; $ invested?  Employment Training—MSOC (DMRTI), Non-Medical Cultural Orientations Crs, etc.  Resources to teach PN—DIMO, DMRTI, Svc- specific

9. MSO: Goals Are Elusive  Line Command MoEs—from GEF to IMO to PN (e.g., Access, Influence, Visibility; O,T,E)  Health MoEs—World Bank, WHO –CDHAM/CoE (DMHA) project (next lecture) –BUMED, other Svcs, DIMO (29) measures –Planned synchronization –Require lots $, skill/time, focus; not easy  “AMoEs”—”(Aligned MoEs)” Projects with direct alignment to Health MoE

10. MSO: Goals Are Elusive  “AMoEs”—”(Aligned MoEs)” Projects with direct alignment to Health MoE –Procurement with Regional/Local importance Facility, Equipment, Personnel contract, etc –Training/Education with portability, flexibility DIMO (101: 26 Human med capabilities, 4 Policy, 5 Protocols, 66 Vet outcomes)  MoPs  “You get what you pay ($, time, etc) for!”

11. MSO: Goals Are Elusive  Success in Sustainable New Capability: –CENTCOM wanted aerial capability for AFG, Iraq –Health Ldrshp pushed Air Evac Rotary wing (espec.) Fixed wing

12. MSO: AFG Success 12  CSTC-A Line MoE  Trnd w/ANA Mi-17, 2007-8  Independent Rotary, 2008  Independent Fixed, w/cardioversion 2009  Not a World Bank MoE, but is AMoE

13. MSO: Iraq Success 13  MNF-I then USF-I MoE  Trnd w/Iraqi Mi-17, & C-130 ( DIMO AE course 2008 )  Iraqi trnd Iraqis in 2009  Wks later saved 78 lives by fixed wing from Basrah to Baghdad  Not a World Bank MoE, but is AMoE

14. Students From Country Course In-Country Both Global Reach 2002-11: 212 msns, 124 countries, educated 7,346 students Defense Institute for Medical Operations (DIMO)

15. MSO: AFG, Goals Are Elusive  AFG Mil-Mil –Facilities (clin, 50-100 bed hosp, impr 400 bed) for direct care, trng, warehouses –Ambulances, AFAK, myriad equipment/supply –Education, trng, policies developed –Myriad of capabilities –Not WB MoE; AMoEs? or MoPs?

16. MSO: AFG, Goals Are Elusive  AFG Mil-Civ (HA funds) w/o NGOs –CSTC-A Direct Care Facilities, inpatient equipment/supply Trng Facilities, equipment/supply –PRT’s x 12, ISAF units Same +, educ/trng, policies developed  AFG Civ-Civ—USAID, DHHS/CDC, other USGs, orgs  Not WB MoE; AMoEs? or MoPs?

17. MSO: AFG, Dental Outreach  PRT Identified Real need & Constraints  PRT Developed to build capacity  Equiped, Trained, Practiced  Turned over to the Afghans  Still running for yrs  AMoE, MoP? 17

18. MSO: AFG, “Successes”  CSTC-A, now NTM-A CSTC-A integrated approach –Vertical Ministerial Development Institutional Development Healthcare Provision Training –Horizontal 17 ofcr & enlisted specialties mentored

19. MSO: AFG, Failures  Some AFG leaders  Some AFG construction  Some equipment (voltage, size, instructions, maintenance, etc.)  Lost trainee ouput (espec. hundreds of combat medics)  Less than full synchrony with CDC, ISAF, MoH, PRT, Univ, USAID

20. MSO: Getting Smarter  Health NGOs partnering –Have been doing this well before MHS health ramped up role from DoS/USAID –Business model; sustainability-minded –In non-kinetic locales, partnering has benefits NGO/Civ/Mil is even better  USG experience and interoperability growing

21. MSO: AFG, Getting Smarter  AFG Mil-Civ (HA funds) with NGOs –Contributed to some MoEs (vs. AMoE’s) –CSTC-A--Direct Care Facilities (trauma clin, amputee/rehab clinic, maternity hosp ED), inpatient equipment/ supply MoEs: Life expectancy, maternal/child mortality –PRTs with USAID, USDA, etc– Sewers, Agri- culture, Roads to Healthcare, Vaccines, etc. MoEs: Mortality, Prenatal Care, Malnutrition, Clean Water

22. MSO: AFG, Getting … Strong Food  PRT Identified –Real need, Constraints –Sustainable supply line  PRT Developed, Tested & Implemented project  Turned over to Afghans, NGOs  Child wgts incr.  Now MoE in 5 provinces 22

23. MSO: AFG, Getting … Clean Water  PRT Identified –Real need & Constraints –Sustainable supply line  PRT Developed, Tested & Implemented project  Turned over to Afghans, NGOs  Provided jobs  MoE, AMoE? 23

24. MSO: EUCOM, Goals are….. Moldova Hospital School Croatia Incubators Georgia Nursing School  Mil funded Successes of local/regional construction, renovation, equiping  AMoE or MoP?  Mil & USAID funded for trng output….  Govt goes pvt

25. EUCOM  Croatia Hospital new incubators (x2) purchased with agreement to train both doctors and nurses on them and to use these as a teaching platform for future medical education which built intellectual capacity 25  Moldova Burn Hospital renovations, donated equipment, trained local staff saving local lives  Moldova public school sustainable, functional renovation to "No Water" toilet system since water supply unreliable

26. EUCOM with NGO  Mil-Mil: BPC in ISAF amputee care, Georgia (impt PN)  Working with Georgia MoD and NGOs, WReed DoD Amputee SMEs, to treat their ISAF-WIA they cannot manage  MoE: POTUS discussing it with PoG on 30 Jan at White House 26

27. EUCOM Integrated Approach  Mil-Civ/Mil: BPC with National Amputee Care Ctr, Estonia (impt PN)  With civ med ldrshp  Line MoE  Future, "simple" hospital renovation long-term med capacity (logic model) 27

28. PACOM Agri-business, Surveilance  Mil-Civ/Mil/NGO: Mongolia, focus on survivability, economic growth (meat, wool, cashmere), animal health…  Human health, proper nutrition, decreased parasite loads  Surveillance of diseases  MoE’s many 28

29. PACOM Agri-business, Health  Mil-Civ/Mil: Timor Leste, (gold std?) is paying for TDYs & penning pigs  Pigs increased litter size, weaned weights, # live pigs at weaning  Goats and cattle production  MoEs many 29

30. PACOM  Training –Gray Hull activities (NAVPAC) –Disease Surveil. (CDC, DoD, Lao, USAID) –Blast Injury Survival (DMRTI, CoE (DMHA)) –Infection Control Workshop (DIMO Vietnam) –Asia Pacific Military Nursing Symposium (12 countries)  Lives Saved = MoEs –Nepal events (DIMO trauma & Disaster crs)

31. MSO: COCOMs Lsns Observed  Linking COCOM medical efforts to Strategy  Minimizing Random Acts of Engagement  Ensure all Component medical activities support a common goal/objective  Med may only be OPR for 1 of 50 Lines of Activities/ IMOs for PN, including mil deployability 31

32. Denial Depression Bargaining Anger Acceptance Avg Emotions of GHE Deployer AFG Arrival Thriving?

33. Agenda & Key Points  Medical Stability Operations (MSO) –Worth Doing –Steep learning curve (MHS, DoD, USG, PN) –Goals are elusive (whose MoE, AMoE, MoP) –Getting Smarter (PN Civ/NGO/Mil linkages, USG) Origins of Health (Water, Food)  Challenges of direction remain

34. Questions? 34

35. The MHS Quadruple Aim Readiness Ensuring that the families and individuals that make up the total military force is medically ready to deploy and that the medical force is ready to deliver health care anytime, anywhere in support of the full range of military operations, including humanitarian missions. Population Health Reducing the generators of ill health by encouraging healthy behaviors and decreasing the likelihood of illness through focused prevention, chronic care management and the development of increased resilience. Experience of Care Providing a care experience that is patient- and family- centered, compassionate, convenient, equitable, safe, and always of the highest quality. Per Capita Cost Creating value by focusing on quality, eliminating waste, and reducing unwarranted variation; considering the total cost of care over time, not just the cost of an individual health care activity.

36. Videos 36

37. How to Embed Videos  Open the slide where you want to place the video  On the INSERT menu, point to MOVIES AND SOUNDS and then click MOVIE FROM FILE  Locate the file and click OK  A box will pop up to ask “How do you want the movie to start in the slide show?” Click on the “when clicked” option. Your video is now embedded.  To test the video, go to SLIDE SHOW > VIEW SHOW and locate to the slide where the video is placed. Click on the video. Note: A separate copy of the video must be submitted with the presentation.

38.  Locate the slide containing the video and right click on it.  Click on EDIT MOVIE OBJECT  Click on the “SOUND VOLUME” button and adjust as necessary  Click OK when finished How to Change Video Volume

39.  Select the movie in the slide and then drag the sizing handles (sizing handle: One of the small circles or squares that appears at the corners and sides of a selected object. You drag these handles to change the size of the object.) that are displayed around the video. –To maintain the video’s original proportions, drag one of the corner sizing handles. –To change the original proportions, drag one of the sizing handles in the center of a border. –To change the video’s size without displacing the center of the image (that is, to resize it symmetrically about the center), press CTRL while you drag a sizing handle. –To move the video, drag it to a new location. How to Change Video Size