Military-Civilian Surgical Diplomacy: An Emerging Role for Amphibious Assault
By Commander David S. Plurad and Captain Scott D. Flinn, Medical Corps, U.S. Navy
The Navy and nongovernmental organizations (NGOs) engage in volunteerism worldwide. However, extensive interagency cooperation in planned, non-disaster-related, humanitarian assistance is less common. The DOD and large charitable groups face declining resources, making combined efforts more attractive. NGOs can meet their doctrinal goals with expanded logistic support, while the Navy can facilitate foreign policy objectives as well as providing essential services. Also due to limited resources, both agencies must reevaluate priorities and use existing assets with efficiency and innovation.
Former Health and Human Services secretary Tommy G. Thompson described medical diplomacy as a foreign policy that aggressively prioritizes medical assistance and the expansion of a healthcare infrastructure.1 In regions that are contested because of current terrorism, such engagements are also relevant to U.S. security concerns. Medical diplomacy has the potential to undermine terrorist ideology. It has measurably improved our image around the globe.2
Surgical Diplomacy
In the same spirit, the concept of surgical diplomacy might be of great use. It could be a critical component of planned, non-disaster-related, charitable operations. Surgical diplomacy would be especially effective in the wake of combined tri-service and international military-civilian humanitarian assistance, and it could be provided using a traditional combatant platform. To demonstrate how this could work, we collected data on surgical services planning, operations, and output.
The USS Peleliu (LHA-5), an amphibious assault ship, deployed 23 May to 20 September 2007 (the Peleliu Pacific Partnership) to underserved regions in the Philippines, Vietnam, Papua New Guinea, and the Marshall and Solomon Islands. The ship assisted governments with medical, dental, veterinarian, and engineering projects. Such a mission from an amphibious assault platform represents an important new role for this asset.
Preparations to use the Peleliu in this non-traditional humanitarian-assistance role began shortly after the Navy hospital ship USNS Mercy (T-AH-19) had deployed successfully to Southeast Asia.
Amphibious assault ships do not have designated surgical personnel, but the platform can be configured for up to 6 operating rooms (ORs), 16 intensive care unit beds, and 40 ward beds that can be expanded to about 600 if needed. Surgical services while under way are typically provided by an embarked Fleet Surgical Team and one fully functional OR. This can be expanded as combat requirements dictate.
But supplementing these capabilities was necessary to provide safe elective surgical services to a large number of patients. Most of the necessary hardware was stored on board the ship, and minimal physical reconfiguration was required. Other equipment was loaned from the major local naval hospital and the Mercy. We needed to lease equipment capable of thyroid function tests, at a total cost of approximately $9,000. Because we had anticipated a large number of referrals for symptomatic thyroid goiter, funding for this highly specific capability was approved. Plain X-ray and ultrasound alone, normally available on both general-purpose and multipurpose amphibious assault ships (LHA/Ds), sufficed for the vast majority of other cases.
Troop berthing adjacent to the medical department was slightly modified, which facilitated patient and escort accommodations and messing. These were relatively minor adjustments, but safely providing major elective surgical services to a large, varied population necessitated a sizable manpower augmentation. Among the professional resources we tapped were those of the Department of Defense, NGOs, foreign militaries, and host nations.
Logistics of Care
Ship-to-shore movement is central to the LHA/D wartime mission. The Marine Corps' H-53E, a heavy-lift helicopter, and the landing craft utility (LCU) were ideal for moving large numbers of patients and staff. The main logistical complexity was arranging for patients and escorts to be at predetermined locations at specific times. This meant that local agencies had to coordinate with military personnel, a complicated process, particularly when patients were not taken directly from screening into pre-surgical care.
Local participating surgeons had already prescreened most potential patients before we arrived. Then the final screening took place ashore. Those patients who were selected were transported to the ship for preoperative evaluation, which helped to reduce the cost that the local system had already incurred.
After surgery and recovery, patients were discharged once their surgeons had cleared them. This usually occurred the next day. Local referring surgeons or physicians saw them for follow-up evaluation.
We offered general, plastic, and ophthalmologic surgical services. Over the course of the 120-day deployment, 28 days included surgical operations, with 6 days committed to screening. Two hundred sixty-two procedures were performed on 251 foreign nationals. The most common case was hernia repair (64), followed by cataract surgery (50) and subtotal thyroidectomy (42). We had detailed screening data for 214 patients, of which 140 (65.4 percent) underwent at least one procedure. The most common reason for rejection was referral for a nonsurgical diagnosis (40.3 percent).
Positive Medical and Military Results
The importance of military-civilian collaboration was underscored by the success of humanitarian assistance to Indonesia after the 26 December 2004 tsunami. The Mercy provided critical medical services in cooperation with multiple NGOs. Follow-on combined efforts in the region in 2006 were an overall success. In a poll of citizens in the first and third most populous Muslim countries, 85 percent of Indonesians and 95 percent of Bangladeshis who had heard of the U.S. Navy mission held a positive view of the United States.3
Navy leaders understood the importance of medical diplomacy in accomplishing an objective that involved foreign policy. Using the USS Peleliu in efforts such as these alleviates the Mercy's operational tempo; demonstrates the flexibility of the LHA/D platform; illustrates interoperability between the U.S. military, NGOs, and multiple other partner nation militaries; and contributes to a favorable image of the U.S. military thoughout the world.
But medical diplomacy is not needed only during disaster relief. It is also necessary for prolonged or recurrent humanitarian assistance.4 This includes infrastructure improvements, as well as educational opportunities to provide sustained advancement for local populaces. At the same time, such efforts can facilitate U.S. security goals, through mitigating terrorist influence over the long term.
In short, among the many positive results could be a sustained reduction in anti-U.S. sentiment, with a potential decrease of violent acts. Unfortunately, at this time charitable endeavors tend to emphasize primary care and preventative medicine services, because of the widespread belief that those provide a better return on expenditures, and that the initiation and sustainment cost is less.
Partnering to Move Surgery to the Fore
During the early phases of the Peleliu's mission planning, surgical support was, indeed, to be minimal. Primary-care objectives were prioritized, and full-scale, large-volume elective surgery could not be supported with the typical physical and staff configuration of an amphibious assault ship's medical department.
However, after further investigation into the surgical needs of the proposed target populations, accompanied by manpower commitments from key partner NGOs, plans were formulated to offer a wide variety of surgical services to large numbers of patients.
NGO involvement provides "corporate knowledge" in specific regions and in the intricacies of worldwide medical volunteerism that may not be readily available within the military, while the armed forces provide logistical and personnel support that NGOs do not normally have. The partnership is most effective.
Surgery can provide high-profile, immediate results. Therefore, it is vastly different from the primary care and preventative services that usually dominate non-disaster-related humanitarian-assistance operations. Surgical diplomacy is a distinct, important component of any well-conceived and -executed humanitarian undertaking.
However, it should encompass not only these relatively brief humanitarian-assistance deployments. Surgical leadership of developed nations can bring about improvements in the infrastructure of developing nations at relatively low cost compared with the potential gain.
Many large charitable groups have financial problems similar to those of developing nations. Investment in surgically oriented objectives may be too costly compared with expanding preventative medicine and an infrastructure oriented toward primary care. Regrettably, this unbalanced expenditure can lead to numerous deaths that could be avoided with relatively simple surgery.5
Training of well-rounded surgeons and support staff can be accomplished via traveling scholarships, access to hard-copy or electronic literature, visiting lectureships, and regional training programs. Ground level surgeon-to-surgeon interaction is required to assess need and formulate plans, with subsequent assistance from local governments and/or U.S. NGOs or the Department of Defense. Integrating NGOs into this assistance package also addresses the frequently encountered need for the host nation's government to remain independent from a foreign military.
The amphibious assault ships' inherent capability for movement of materials and personnel in the littoral environment also gives this platform the capacity to sustain large-scale surgical support of humanitarian missions. Addition of needed equipment is minimal, but a Fleet surgical team alone would be inadequate to make a significant contribution in a comprehensive charitable effort.
The close association between the military and NGOs is mutually beneficial, and we should expand it. Leadership must commit the needed medical and surgical subspecialists and personnel to augment the humanitarian-assistance package, ensure patient safety, and engage in meaningful surgical diplomacy.
Current global operational priorities make this obligation of resources difficult. However, worldwide humanitarian assistance led by agencies and the U.S. government represents an increasingly important front against extremist ideologies.
1. T. G. Thompson, "Advocating for Medical Diplomacy: A Conversation with Tommy G. Thompson," Health Affairs (Project Hope, http://www.projecthope.org/), January-June 2004, Supplemental Web Exclusives, W4-262-8.
2. "Unprecedented Poll: World's Largest Muslim Countries Welcome U.S. Navy," Washington, D.C.: Terror Free Tomorrow, 2006. Accessed 4 August 2007 through http://www.terrorfreetomorrow.org/index.php.
3. Ibid.
4. Thompson, "Advocating for Medical Diplomacy."
5. "Unprecedented Poll: World's Largest Muslim Countries Welcome U.S. Navy."
6. R. J. W. Blanchard, R. C. Merrell, G. W. Geelhoed, et al., "Training to Serve Unmet Surgical Needs Worldwide," Journal of American College of Surgeons 193 (2001): 417-27.
Navy Air Mobility: The Fleet's Yellow School Bus
By Commander Jeff Kennedy, U.S. Navy
When the school bus shows up on a wintry day and picks up your kids, you may be momentarily grateful for the effort expended. Anyone who takes more time to wonder about this appreciates the work behind the scenes that gets children to school. Similarly, Navy Air Mobility is the Fleet's yellow school bus. Often overlooked in operational planning, the Fleet Logistics Support (VR) community remains the Fleet commander's premiere tool for fast, flexible, reactive medium airlift.
VR's recent contributions to the Navy's operational and contingency needs include Operation Shining Light 2003, Tsunami 2004, and Hurricane Katrina 2005. It has remained relevant throughout its 65-year history and continues to provide immediate on-call air mobility for the Fleet commander.
But even though they know of its existence, many staffs are simply unaware of VR's potential and capabilities. The strike fighter, helicopter, and antisubmarine aviation communities have reserve squadrons and wings, which keep them connected to their active-duty warfare cultures and Fleet staffs. But the VR community has no active-duty aviation partnership and is 100 percent manned and operated by the reserve component.
The VR community comprises 60-plus aircraft, 15 squadrons, 2 executive transport detachments, 1,200 aircrew, and 3,000 Sailors. The Navy's largest air wing flies C-9s (Skytrain II), C-12s (King Air), C-20/37s (Gulfstream), C-40s (B737), and C-130s (Hercules).
The VR Structure
Title 10 of the United States Code authorizes air transportation that is essential to the Navy's unique operational requirements. Specifically, this airlift is chartered to satisfy unpredictable high-priority, short-notice airlift of people, cargo, and mail. These are lifts that are not compatible with Air Mobility Command Channel and Special Assignments Airlift Missions, or with commercial routes. Navy Unique Fleet Essential Airlift (NUFEA) is designed to provide wartime movement of personnel and material from Air Mobility Command inter-theater storage and distribution locations to carrier and vertical onboard delivery sites called airheads. Airheads are strategically located to provide Fleet customers with priority cargo from shore-based airfields to ships in a matter of hours.
Manned and equipped by Commander Fleet Logistics Support Wing and tasked primarily by the Naval Air Logistics Office (NALO), the aircraft have in the past been provided mostly with National Guard/Reserve Equipment funding. However, the Navy has sustained them. Both Commander Fleet Logistics Support Wing and NALO report to Commander, Naval Air Forces Reserve.
The Problem
Unfortunately, the Navy's airlift request protocol has become confusing for the Fleet customer. The Joint Operational Support Airlift Center (JOSAC) at Scott Air Force Base, Illinois, currently schedules the Navy's domestic airlift requests (using C-9s and C-12s only), while NALO schedules Navy international airlift requests for C-40s and C-130s. Under the present structure, one possible scenario is that a Navy C-9 can be scheduled via the Joint Operational Support Airlift Center—but that aircraft is at the moment fulfilling another service priority, perhaps for the Army. Meanwhile, Sailors wait at Naval Air Station Fallon in Nevada.
Confusing matters further, Commander Task Force 63 (6th Fleet), Commander Fleet Air Western Pacific (7th Fleet), and Commander Task Force 53 (5th Fleet) also schedule dedicated VR assets that are temporarily assigned in Fleet commanders' areas of responsibility. Detachment sites include Atsugi, Japan; Sigonella, Sicily; and Bahrain International Airport.
Too many scheduling agencies make aircraft availability inefficient. For instance, 7th Fleet may require immediate maximum air mobility for a tsunami, while aircraft sit idle on the deck in Sigonella. This scheduling mess was officially documented by the Navy Warfare Developmental Command after Hurricane Katrina.
Rightfully so, Navy personnel are perplexed as to how they should task and maximize the capability of their Navy Unique Fleet Essential Airlift. The frustration of scheduling NUFEA assets has led to decisions that squander potential airlift, not to mention wasting taxpayers' money. One result is that some air training squadrons now opt to fly commercial airlines to their weapons detachments in El Centro, California.
Proposed Solution
We need to create a worldwide NALO, with missions prioritized by the Navy Operational Logistics Support Center in Norfolk. This center's Transportation and Distribution department provides support to unit supply and transportation officers and liaises with air and water terminal operations. Additionally, the center develops, coordinates, and publishes Navy transportation policy and plans on issues involving worldwide cargo movement by airlift, sealift, and inland transportation.
The Navy Operational Logistics Support Center monitors transport effectiveness of Navy cargo and passengers. It also provides support to joint deployment operations, exercises, and Navy logistics war games. Under this proposed change, the Navy would continue to support the Joint Operational Support Airlift Center with excess NUFEA aircraft—but only after all Navy requests had been satisfied.
We also need an innovative approach that will maximize VR's capabilities. Noncombatant evacuation operations, C-130 carrier air wing tanking, special operations, air medical evacuation, and humanitarian contingencies are a few scenarios that should include VR in Fleet planning.
Integrating the carrier onboard delivery capability with VR would streamline airlift and expedite delivery of critical parts and Fleet personnel from origination to destination. Also, restructuring the chain of command by placing NALO under Fleet Forces Command or creating a NUFEA office within the U.S. Transportation Command would help to distribute assets effectively, as well as arbitrating distribution of aircraft in real time as situations and environments changed.
The capabilities of VR belong to Fleet commanders. If we do not use our tools efficiently, another service's competing priority will borrow our yellow bus. Then our kids will remain in the snow and be late for school.
Operations Analysis Guides LCS Employment.
By Lieutenant Ben Abbott, U.S. Navy
The highly capable littoral combat ship (LCS) promises to lead the Navy into the 21st century by providing access to the littorals, releasing multi-mission surface combatants for more appropriate tasking, and leveraging the technology of unmanned vehicles. The flexibility inherent in LCS allows it to operate independently, as part of an employed squadron, or as part of a carrier or expeditionary strike group.
The ship's heavy reliance on technology and bold approach to manning has driven numerous studies to determine procedures, develop operational concepts, and identify the best practices for the LCS. What has not been done thoroughly is an examination of squadron composition and tactics.
Across all studies, the mission of the LCS is to ensure joint force access to the littorals. The ship is a focused mission platform, which means that a single LCS is largely incapable of handling simultaneous tasks by itself. However, when operating in a squadron, the LCS can be configured by the combatant commander to ensure operational success across a broad range of challenges associated with littoral warfare.
My analysis of an LCS squadron was guided by the three questions below. The purpose of the study was to provide insight into the capabilities of an LCS squadron in a stressful operational environment.
- How many LCSs should there be in a squadron
- What combination of mission packages is needed in the squadron to complete the mission when the possibility of multiple threats exists
- How effective are sensors and weapon systems with regard to enabling the LCS to complete its focused mission
These questions were addressed using simulation and data analysis. In addition to providing insights, the research serves as a foundation for the use of these techniques to investigate similar or related topics. The study provides quantitative, analytic support for the best configuration of an LCS squadron to complete a mission in waters complicated by multiple threats.
Modeling the Problem
Three scenarios were created based on the current mission packages for LCS: surface warfare (SUW), antisubmarine warfare (ASW), and mine interdiction warfare (MIW). In each one, an employed LCS squadron is deployed to neutralize a primary threat, but it faces the possibility of a secondary threat in a different warfare area.
For example in the SUW scenario, an LCS squadron is given a mission to neutralize a missile boat threat, but a submarine threat may also exist in the same waters. An agent-based combat modeling environment called Map Aware Non-Uniform Automata is used to implement these scenarios.
This simulation uses a technique called data farming, which produces many data points through high-performance computing. Data farming allows for numerous variables (such as number of SUW LCS and/or missile boats, and probabilities of kill and detection for sensors and weapon systems) to be analyzed over broad ranges. Thus, a large number of possible outcomes can be studied. For this research, 41,195 littoral combat operations were simulated, 23,130 of which were used to produce the data. These simulated operations were conducted in short order. To carry out such a study using real ships would have been extraordinarily costly and time-consuming, even if proxies for the not-yet-built LCS could have been used.
Interpreting the Results
Analysis of the simulation results yielded firm answers to the questions posed, along with additional insights. With regard to the size of the employed LCS squadron, six to ten ships produce relatively low friendly casualties and high enemy casualties in all three warfare areas. As to the composition of the squadron, analysis shows low friendly and high enemy casualties using the following numbers and types of ships:
- SUW scenario: five SUW LCSs and two ASWs
- LCS ASW scenario: five ASW LCSs and one SUW
- LCS MIW scenario: six MIW LCSs and one SUW LCS
Five LCSs configured for the primary threat and two for the secondary threat serves as a compositional rule of thumb.
Regarding the effects of sensors and weapon systems, analysis shows that in the SUW scenario, the number of LCSs is more significant than sensors and weapon systems in the SUW scenario.
In the ASW scenario, Hellfire probability of kill (Pk), rolling airframe missile Pk, SUW MH-60R probability of detection (Pd), ASW unmanned surface vehicle Pd, and Blue Torpedo Pd are identified as playing significant roles.
Finally, Pk of the bow-mounted 57mm is identified as playing a significant role in the MIW scenario, due to its being the predominant SUW weapon on a MIW LCS.
One limitation of this study is that it cannot show precise thresholds for most of the sensors and weapon systems identified as significant. However, it shows which systems play significant roles in LCS mission effectiveness.
Further Recommendations
Additional insights point to the following recommendations:
- When considering the use of an employed LCS squadron for an ASW mission, additional Fleet assets should be provided to support the squadron when the number of enemy submarines is anticipated to be ten or more.
- For a SUW mission that may contain a submarine threat, the squadron should use tactics that maximize ASW sensors and weapon systems—especially a low speed of advance.
- Due to the inherent risks entailed by littoral combat, the Navy should effect a paradigm shift so that casualties of both ships and personnel are expected and accepted.
- For an asset that is not yet built or deployable, simulation and data farming provides valuable knowledge rapidly. These techniques should be used in future Navy research to guide the development and deployment of new technologies.
This study provides analytic support for the size and composition of an LCS squadron based on a region and threat set, and identifies significant sensors and weapon systems for each warfare area. The result is sound analysis that can be used to assist the Navy in its continuing development of policies, concepts of operation, and tactics for LCS and its mission packages.