To Render Assistance

Emergency humanitarian assistance is likely to remain a continuing—even if not a principal—mission of the U.S. armed forces. Operational commanders should under­stand the strengths and weaknesses of mili­tary forces—here, a medical team arrives in Bangladesh during Operation Sea Angel—when they are used for this purpose.

The U.S. military has a long tradition of providing emergency humanitarian assistance to civilian pop­ulations stricken by natural or man-made disasters. The multitude of armed conflicts and the potential for dev­astating natural disasters in the post-Cold War era strongly suggest that the Navy and Marine Corps will continue to be tasked with humanitarian assistance missions abroad, perhaps even more often than before. Both “. . . From the Sea” and The Navy Policy Book mention these operations specifically as an important role for deployed naval forces in the 21st century, and “Forward . . . from the Sea” strongly implies involvement in these missions.

Because the major goal of humanitarian assistance is to provide lifesaving medical and human services, opera­tional commanders should understand the strengths and limitations of U.S. military forces when used for this pur­pose. Our forces can make critical contributions to emer­gency relief efforts, but operational medicine is designed to provide medical support to troops in combat opera­tions—not refugees or disaster victims. Recent missions in Kurdistan, Bangladesh, and Somalia illustrate funda­mental principles and problems and suggest practical mea­sures to improve the effectiveness of future missions.

Historical Background

The U.S. military often has been called upon to render assistance after natural disasters, including earthquakes in Peru (1972) and Nicaragua (1972), flooding in the Sudan (1988), volcanic eruption in the Philippines (1990), and tropical cyclones in East Bengal (1970) and Sri Lanka (1978). More recently, during Operation Sea Angel (1991), naval forces provided emergency relief in Bangladesh after a devastating typhoon killed more than 100,000 per­sons and left a million more homeless. Many believe that expanding populations in disaster-prone regions of the developing world face rising risks from natural calami­ties because of the increasingly fragile infrastructures of these nations.

In addition, in the past decade, myriad armed con­frontations around the world have displaced more than 43 million persons, and most observers believe that more such conflicts will continue to occur.¹ In the past few years, military forces have been called upon to intervene in some of these intractable disputes, either to provide direct as­sistance to victims or security for international relief efforts. Operations Provide Comfort in Kurdistan (1990) and Restore Hope in Somalia (1992) illustrate the U.S. military’s growing role in multinational emergency relief efforts. Recent relief efforts in Rwanda and the deploy­ment of a naval field hospital to Zagreb, Croatia, also reflect this trend.

Strengths of Military Forces

Events in Kurdistan and Somalia clearly demonstrate that an important capability of the military is the use of force to establish and maintain security. The safe haven in northern Iraq enabled relief efforts to proceed safely and encouraged the vast majority of displaced Kurds to return home. In Somalia, protection of relief supplies and transportation systems substantially reduced the threat of violence. Effective relief efforts were not possible in either situation without armed intervention. Operations in Kurdistan, Bangladesh, and Somalia show other in­herent strengths of U.S. military forces that can be applied to humanitarian assistance.

Transportation and Logistics. Some relief organizations, such as the World Food Program, routinely transport large quantities of relief supplies to disaster sites. However, they sometimes are unable to reach remote or damaged areas or to organize and distribute the often overwhelming quan­tity of supplies effectively in the immediate aftermath of a natural disaster or conflict. U.S. armed forces, by con­trast, have enormous capacity to transport supplies and personnel on short notice to and within distant and dev­astated locations. Furthermore, sophisticated military logistics systems enable effective management and distribution of relief supplies under adverse conditions.

In Operation Sea Angel, C-130 aircraft, heavy-lift helicopters, and air-cushion landing craft rapidly trans­ported thousands of tons of food, medicine, and building materials, as well as relief workers, into devastated and flooded areas that were otherwise inaccessible. After the safe haven was established for the Kurds in northern Iraq, most internationally donated relief supplies were managed in a large military field warehouse, where military logis­ticians cataloged, prioritized, stored, and distributed goods. In Somalia, where few serviceable vehicles were available, the U.S. military not only provided trucks but also organized and protected convoys from Mogadishu for re­lief operations throughout much of the country’s interior.

Self-Sufficiency and Reconstruction. Many international relief efforts have been burdened by well-intentioned vol­unteers who arrive with no means to provide for them­selves, much less render aid to disaster victims. In addi­tion, few relief organizations have the personnel, equipment, or resources to rebuild key infrastructure on an emergency basis. U.S. military forces, on the other hand, are organized, equipped, and trained to be self-sus­taining in the field. Furthermore, engineering and con­struction teams, such as Navy Mobile Construction Bat­talions, can build or repair essential infrastructure rapidly in hostile environments.

In Mogadishu, military units made the seaport, airport, main roads, and key buildings in and around the city operational. Engineers rebuilt many of the country’s major highways. Teams also repaired schools, clinics, water sources, and power supplies. Without such basic ac­tivities, relief efforts would have been significantly more complicated.

Command, Control, and Communications. International relief efforts, many of which have involved more than 100 relief agencies from around the world, often lack organi­zation, coordination, and communication. U.S. military forces, by contrast, have a clearly defined organizational structure with extensive, highly capable communications systems. The task-organization concept allows diverse spe­cialized units to be assembled under unified commands to succeed in a common endeavor.

Military forces were the de facto coordinating relief agency in northern Iraq. This allowed central planning of a medical care system, immunization programs, and sup­ply distribution. Such direction also enabled the unprece­dented movement of almost one-half million Kurds back to their homes over a two-week period, with minimal adverse impact.

Rapidly Deployable Medical Assets. Many relief orga­nizations, such as Physicians without Borders and the International Committee of the Red Cross, routinely deploy acute-care medical facilities in support of hu­manitarian relief efforts; however, their facilities can be overwhelmed by a large-scale disaster. Fur­thermore, few are capable of providing sophisticated medical care in the field or during evacuation, which can be critical after certain types of disasters. The U.S. military has a wide array of medical teams, field hospitals, hospital ships, and medical evacu­ation systems designed to deploy rapidly and provide medical care in the most adverse conditions. When used appropriately, these assets can contribute greatly to emergency relief efforts.

Military medical teams in northern Iraq and Bangladesh treated thousands of disaster victims in field conditions. In Somalia, field and shipboard medical personnel not only treated the indigenous population but also provided emer­gency care to seriously ill and injured relief workers and journalists.

Preventive Medicine Teams. Most relief agencies focus on providing acute medical care and have limited preventive medicine capabilities. Disease prevention, how­ever, now is regarded by many as much more important in minimizing deaths after disasters.² Relief measures must include supplying sufficient potable water, adequate food, appropriate immunizations, and a health information sys­tem based on timely disease surveillance. Few relief organizations can meet these needs or deploy the kind of field medical laboratories needed to define the infectious disease pathogens that can ravage refugees. Operational medicine, on the other hand, emphasizes these measures to minimize illness in deployed forces.

Military preventive medicine teams in northern Iraq and Bangladesh performed critical rapid-assessment surveys, conducted disease surveillance, provided insect control, investigated disease outbreaks, and improved water and sanitation for refugees.³ Field infectious-disease laborato­ries were used in Bangladesh and Somalia to determine the causes of fever and diarrhea among refugees and which antibiotics would be most effective.

Specialized Units. Elite units such as the U.S. Army Special Forces have unique training in foreign languages and intercultural interaction that make them well suited to work with victims of natural disasters or conflicts abroad. Special Forces “A-teams” in northern Iraq established relationships with Kurdish military and civilian leaders prior to the start of ground-based relief efforts. This was essential for establishing security, assessing medical care requirements, and ensuring that relief supplies were dis­tributed fairly. Civil affairs units, which are particularly skilled in dealing with refugee populations, managed the mass relocation of Kurds out of the mountains and the construction and management of state-of-the-art resettle­ment camps. No civilian relief organizations can mobilize such skilled personnel on such a large scale.

Limitations of Military Forces

The cost of using the military for humanitarian assis­tance can be very high; Operation Restore Hope cost approximately $80 million per month. Also, some have wondered whether prolonged involvement in humanitar­ian assistance will degrade our operational readiness. Operations in Kurdistan, Bangladesh, and Somalia also demonstrate that military forces have significant limita­tions in meeting many of the essential needs of refugees and disaster victims.

Potential Medical Care Mismatch. Measles, diarrhea, and acute upper respiratory infections are the three most common causes of death among refugees and displaced persons.⁴ In addition, illness and death after dis­asters are disproportionately high among children and women, who make up the majority of many pop­ulations overseas. Operational medi­cine, however, is designed to con­serve fighting strength and is directed primarily toward stabilizing troops wounded in battle. Other acute-care capabilities are limited and focus on medical problems usually found in young, healthy American adults. Ill or injured troops who cannot be returned to full duty promptly are evacuated.

Medical units attempting to pro­vide emergency medical care to dis­aster victims have minimal quantities of the medications and supplies rec­ommended by the World Health Or­ganization, including oral rehydration salts, basic antibiotics, pediatric sup­plies, and obstetrical equipment. Nor do they normally include the types of physicians—such as obstetricians, pe­diatricians, and family practitioners—needed to deal with the medical prob­lems of women and children. In addition, few military health-care providers have training in the care of large groups with epidemic diarrhea or starvation or in the diagnosis and treatment of tropical medical problems.

During the early months of Operation Provide Comfort, children with diarrheal disease, dehydration, and malnu­trition accounted for more than 75% of all deaths.⁵ Mili­tary medical personnel experienced great difficulty caring for children at the trauma-oriented field clinics and hos­pitals that initially were established. Inexpensive but critical supplies, such as oral rehydration salts, were un­available. In addition, medical teams were not prepared to establish community-based oral rehydration and emer­gency feeding programs.

Limited Preventive Medicine Assets. Military preven­tive medicine teams also can have substantial constraints. Immunizations usually are administered to military personnel prior to deployment. Medical teams take mini­mal amounts of vaccine to the field and take none appropriate for children. Few in the military have experi­ence managing large immunization campaigns in the field or developing emergency sanitation and water systems. In addition, preventive medicine personnel typically have limited transportation, communications, and other critical capabilities.

In northern Iraq, delays were experienced in obtaining vaccine even after a measles vaccination program was identified as a high priority. Inadequate personnel and equipment were available to improve water and sanitation. Military public-health teams attempting to conduct basic assessments and surveillance in northern Iraq and Bangladesh frequently were unable to obtain essential airlift, vehicles, and communications equipment. In Somalia, even though measles and dysentery were causing most of the deaths, military preven­tive medicine teams had neither means nor mission to support needed public-health measures.

Limited Focus on Redevelopment. Restoring indigenous medical capa­bilities is a priority in emergency relief operations. Nevertheless, mil­itary medical teams seldom are well prepared to develop sustainable com­munity medical care systems. Local physicians in northern Iraq warned that our high-technology medical re­sponse might undermine indigenous physicians and slow the Kurds in im­plementing their own solutions. Fur­thermore, with very few exceptions, well-trained local physicians and nurses in northern Iraq were not brought into relief efforts.

Inappropriate Use of Supplies. Some readily available supplies may be unnecessary and even detrimen­tal. For example, even starving peo­ple prefer familiar food and will not consume the prepackaged military meals (MREs). Most important, highly caloric meals with a high con­centration of salt can be hazardous to dehydrated or malnourished persons, particularly chil­dren. The U.S. armed forces do not have readily available supplies of oil, flour, rice, and other basic commodities recommended by the World Health Organization for emer­gency food relief.

In Kurdistan, the provision of powdered infant formula that subsequently was mixed in inappropriate concentra­tions or used with contaminated water may have con­tributed to the extensive childhood diarrheal disease and dehydration. Some supplies such as canned fruit, cloth­ing, and blankets were shipped in large quantities, but they were not necessary and occupied valuable airlift space.

Relations with Civilian Re­lief Organizations. Emer­gency medical relief is best provided with coordinated policies. Myriad relief orga­nizations, each with its own mission and agenda, make such coordination difficult. Some military commanders in northern Iraq initially did not understand the very dif­ferent roles of major relief or­ganizations. And civilian re­lief personnel had minimal experience with the complex hierarchical structure of the military. The confusion over command and control de­layed implementation of high-priority oral rehydration and measles vaccine cam­paigns and slowed transfer of medical operations to relief organizations as U.S. forces withdrew.

In addition, the military is easily perceived as having interests other than humani­tarian relief, particularly in situations that involve armed conflict. An adversarial relationship that interferes with both the military’s and relief organizations’ ability to pro­vide medical assistance may result. In Bangladesh, some local leaders did not want to be perceived as receiving aid from the U.S. military. In Somalia, many relief workers were tom between reliance on the military for security and their mandate to be neutral parties.

Inadequate Training for Humanitarian Assistance Mis­sions. Few officers (including the medical corps) receive training in humanitarian assistance. There is only mini­mal guidance on appropriate principles and procedures in current operations orders, contingency plans, doctrinal publications, and training manuals.

U.S. military medical providers may be further con­strained by a lack of training in the languages, customs, and medical practices of other populations. In Kurdistan, military-style latrines built to improve sanitary conditions were not culturally acceptable and therefore were not used. In addition, in all three operations, many medical per­sonnel faced widespread suffering and death for the first time. Nor were they prepared to cope with the variety of ethical and medical-legal dilemmas that resulted from attempting to apply a highly developed medical care system to a poverty-stricken population in extreme circumstances—such as determining who should be med­ically evacuated. Also, the responsibilities of medical personnel under international humanitarian law is an evolv­ing and complex issue.

Recommendations

Emergency humanitarian assistance should not be viewed as a principal mission of the U.S. armed forces. However, given that U.S. forces are likely to continue per­forming these missions, we should strive to improve the assistance we render.

Define the Mission Appropriately. The goals of the mis­sion statement should reflect how military forces are most appropriately used after a disaster. The military is best suited for providing rapid transportation to remote loca­tions, restoring a functioning infrastructure in a devastated area, providing armed intervention in unstable situations to establish and maintain security for relief operations, and supplying certain initial medical care and evacuation for disaster victims. In addition, whenever possible the mission statement should specifically support medical interventions that will minimize loss of life. Line com­manders must have the mandate to implement the major lifesaving priorities, including providing adequate shelter, potable water, sanitation, immunizations, vector control, and nutrition.

The limitations of military medical care must be kept in mind; simply sending combat casualty oriented hospi­tals or implementing a sophisticated medical system may not be the best course. Civilian relief organizations often are better prepared to provide many medical relief services, particularly as the focus shifts to redeveloping sustainable medical care.

Improve Preparation within the Military. Humanitarian assistance operations are usually joint-service operations. Unified doctrinal guidance covering all the armed services is therefore essential. Joint, Navy, and Marine Corps doc­trinal publications currently being prepared to cover op­erations other than war or other expeditionary operations need to address the unique challenges and demands of hu­manitarian assistance operations.

Theater commanders-in-chief and Navy component commanders should expand their guidance on humani­tarian assistance operations in Annex C (Operations) or Annex D (Logistics) of operations orders. Humanitarian assistance should be addressed in appropriate operations plans, including those prepared for noncombatant evacu­ation operations. Operational commands likely to partic­ipate in relief operations, such as amphibious ready groups and construction battalions, need to consider humanitar­ian assistance in deployment plans and orders.

A potentially cost-effective method of providing oper­ational forces with the specialized expertise needed for humanitarian assistance missions is to establish a cadre of experts capable of rapid mobilization and deployment to augment regular operational and medical units. Health­care providers, logisticians, and communicators with experience or specialized training in humanitarian relief are candidates. Active-duty personnel are possible, but specialized reserve units, particularly civil affairs units, would be especially valuable.

Collateral training in humanitarian assistance operations should be provided to active forces to improve their abil­ity to work with augmentation teams. Along with medical officers, appropriate Navy and Marine Corps officers need training in joint and naval humanitarian assistance doc­trine. Candidates include amphibious group, amphibious squadron, and Marine expeditionary unit commanders, operations and logistics officers; Civil Engineering Corps officers assigned to SeaBee units; and unified and com­ponent command operations and logistics officers. The Uniformed University of the Health Sciences, the war col­leges, and the command and staff colleges would be excellent resources.⁶

Humanitarian assistance simulations (war games) should be conducted to practice joint and naval doctrine. Exist­ing facilities at the staff colleges and other locations can be used to simulate large-scale humanitarian relief oper­ations to refine joint and naval doctrine and to provide fundamental training. Command post exercises for deploying units should focus on planning and command- and-control procedures, and would entail mobilization and field deployment of command elements only, rather than entire units. More complex joint field exercises, in which regular military units augmented by humanitarian relief specialists actually deploy under field conditions, also should be held.

The Joint Staff, Army, and Marine Corps have begun conducting simulations and field exercises addressing op­erations other than war. These simulations should include a humanitarian assistance dimension. In addition, com­manders-in-chief should identify training priorities based on anticipated operations and supplement central train­ing with area-specific instruction and training. Some important exercises in this arena recently have been con­ducted, such as the I MEF-sponsored Emerald Express⁷ at Camp Pendleton and simulations at the Joint Readiness Training Command in Fort Polk, Louisiana. At the Com­mander-in-Chief, Pacific, headquarters, specific plans and training have been developed for disaster scenarios unique to the Pacific Rim, and the Defense Appropriations Com­mittee recently allocated $1 million to establish disaster management training in conjunction with Tripler Army Medical Center and the University of Hawaii.

Develop Relations with Major Relief Organizations. Navy and Marine Corps humanitarian assistance experts should develop and maintain liaison with the major civil­ian organizations likely to be involved in relief operations. Most important, we should expand recent efforts to coor­dinate the U.S. government response to disasters overseas through regular interactions with the Office of Foreign Disaster Assistance of the U.S. Agency for International Development.

Configure Forces Appropriately for Humanitarian As­sistance Missions. Most relief missions require additional preventive medicine, logistics, civil affairs, and line per­sonnel, as well as adequate transportation, communica­tions, and other resources. The assignment of physicians to treatment facilities may need to be modified to in­clude more pediatric, obstetric, infectious disease, and tropical medicine specialists. Appropriate emergency re­lief materials—including familiar foods, medical supplies, shelter, and construction materials for potable water and sanitation facilities—must be readily available. Some crit­ical supplies, such as oral rehydration salts and measles vaccine, may have to be obtained outside the military pro­curement system. The Bureau of Medicine and Surgery recently revised the emergency relief authorized medical allowance list to include many of these supplies. Doctrine has just been published for a rapidly deployable public health laboratory, which could be of immense value in hu­manitarian assistance missions.⁸

1 M. J. Toole and R. J. Waldman, “Refugees and Displaced Persons: War, Hunger, and Public Health,” Journal of the American Medical Association, vol. 270, no. 5 (4 August 1993): 600-606.

2 M. J. Toole and R. J. Waldman, “Prevention of Excess Mortality in Refugee and Displaced Populations in Developing Countries,” Journal of the American Med­ical Association, vol. 263, no. 24 (27 June 1990): 3296-302; Centers for Disease Control, “Famine Affected, Refugee, and Displaced Populations: Recommenda­tions for Public Health Issues,” Morbidity and Mortality Weekly Report, vol. 41, no. RR-13 (24 July 1992): 1-3, 26-27.

3 Ray Yip and Trueman W. Sharp, “Acute Malnutrition and Diarrhea: Lessons Learned from the Kurdish Relief Effort,” Journal of the American Medical Asso­ciation, vol. 270, no. 5 (5 August 1993): 587-90; Centers for Disease Control, “Famine Affected, Refugee, and Displaced Populations,” pp. 1-3, 26-27.

4 Toole and Waldman, pp. 3296-302; Centers for Disease Control, “Famine Af­fected, Refugee, and Displaced Populations,” pp. 1 -3, 26-27; Yip and Sharp, “Acute Malnutrition and Diarrhea: Lessons Learned from the Kurdish Relief Effort,” pp. 587-90.

5 Yip and Sharp, “Acute Malnutrition and Diarrhea: Lessons Learned from the Kur­dish Relief Effort,” pp. 587-90.

6 S. R. Lillibridge, F. M. Burke, and E. K. Noji, “Disaster Mitigation and Human­itarian Assistance Training for Uniformed Service Medical Personnel,” Military Medicine (forthcoming); J. C. Gaydos and G. A. Luz, “Military Participation in Emergency Humanitarian Assistance,” Disasters, vol. 18, no. 1 (March 1994): 48-57.

7 F. M. Burkle, et al., “Complex Humanitarian Emergencies: I. Concepts and Par­ticipants, II. Medical Liaison and Training, III. Measures of Effectiveness,” Prehospital and Disaster Medicine, vol. 10, no. 1 (January-March 1995): 36-56.

8 Naval Doctrine Command, “Forward Deployable Laboratory (NWP 4-02.4 Part C),” Naval Doctrine Command, Health Service Support Division, Quantico, VA (April 1995).

Commander Sharp is a preventive medicine officer assigned to Head­quarters, U.S. Marine Corps. He served in Operations Sharp Edge in Liberia, Desert Shield and Desert Storm in Saudi Arabia, Provide Comfort in Iraq, and Restore Hope in Somalia.

Captain Malone is head of the Infectious Disease Division, National Naval Medical Center, Bethesda, Maryland, and specialty advisor to the Chief of the Bureau of Medicine and Surgery for infectious diseases. He served in Operation Safe Harbor in Guantanamo Bay, Cuba.

Commander Bouchard is branch head, Strategy and Concepts Branch, in the Office of the Chief of Naval Operations. A surface warfare officer, he was commanding officer of the USS Oldendorf (DD-972).