Historically, international agencies and nongovernmental organizations (NGOs) have been the primary responders to people overwhelmed by natural disasters. In the recent past, combined civilian and military operations have become more common. The increased involvement of the U.S. military in these combined operations is due largely to Department of Defense Directive 3000.05 "Military Support for Stability, Security, Transition, and Reconstruction Operations" put forth in November 2005. The goal of this new policy was to expand the role of the U.S. Armed Services to include a greater role in humanitarian assistance and disaster relief (HA/DR). This increased emphasis on Support for Stability, security, Transition, and Reconstruction operations has been extremely effective at improving the status and acceptance of the United States and its military worldwide. Polls conducted by the Pew Research Center after the military tsunami relief efforts in 2005 showed that Indonesians had an increased favorable opinion of the United States, up from 13% in 2003 to 38%; a Terror-Free Tomorrow poll over a year after the start of tsunami relief efforts showed persistent and further improving goodwill feelings (up to 44%) toward the United States among the Indonesian people. Similarly, following the military response to the Pakistani earthquake in October 2005, favorability among the local people toward the United States doubled from 23% to 46%. With more frequent involvement in worldwide natural disaster responses, commanding officers have developed ongoing relationships within country agencies such as the U.S. Agency for International Development, Office of Foreign Disaster Relief (USAED/OFDA) and local embassies which have made recent relief operations run more smoothly.
At the time of the Yogyakarta earthquake, the United States and Indonesia had a Memorandum of Understanding that allowed the U.S. military to provide aid when requested by the Indonesian government. The government of Indonesia did request military support within hours of the earthquake on May 27, 2006. The U.S. military deployed medical and support personnel-dubbed by the participants as "Operation Aftershock"-to the severely damaged Bantul district, with the first forces arriving within 72 hours of the disaster. The unit consisted of members of the 3rd Marine Expeditionary Brigade (MEB) from Okinawa, Japan, the U.S. hospital ship U.S.N.S. Mercy, and nearby U.S. naval vessel U.S.S. Essex for a combined total of 286 U.S. military personnel including support personnel based in Okinawa and Singapore.
Of note, since the December 2004 Indian Ocean tsunami, components of the 3rd MEB unit have provided assistance by responding to a series of natural disasters in Asia: the South Asia earthquake (October 2005), the Southern Leyte Philippines mudslide (February 2006), and this May 2006 Java earthquake. At the time of the earthquake, the 10,00-bed hospital ship U.S.N.S. Mercy was on a 5-month deployment to Southeast Asia on a goodwill humanitarian assistance voyage. The U.S.N.S. Mercy was tasked to assist in the earthquake response and sent an internist, pediatrician, family practitioner, and a preventive medicine officer to augment the medical team from the 3rd MEB. The U.S.S. Essex supported Operation Aftershock with a shock trauma platoon (a complete surgical team). A total of 37 medical providers were involved in the disaster response during the mission. The group had access to basic laboratory equipment which allowed them to evaluate blood cell counts, blood gases, and urinalyses. Most importantly, the 3rd MEB brought a portable digital x-ray machine (Fig. 1) which allowed plain film evaluation of the many extremity injuries that were treated. A "World Health Organization" New Emergency Health Kit, designed to medically support 10,000 people for 3 months in a displaced persons camp, provided the majority of the medicine for the operation. It contained a variety of antibiotics, antipyretics, antiseptics, antimalarials, anesthetics, antiallergics, and cardiovascular, respiratory, and gastrointestinal medications. The 3rd MEB fielded a one-bed operating room and a four-person recovery room. The medical component was supported by 178 members of a Marine headquarters battalion. These additional personnel were planners, logisticians, and communications experts. All medical and support personnel arrived by air and conducted activities out of the Sewon soccer stadium in Bantul, 12 kilometers southeast of Mount Merapi.
The initial team was on-site approximately 72 hours after the earthquake and was treating patients a little over 24 hours later (Fig. 2). The medical personnel initially helped in existing hospital facilities that were intact in the city of Yogyakarta while the military surgical suite (Fig. 3) was being set up. The team provided surgical and medical assistance during a 16-day action period and then redeployed back to their component commands when they were no longer seeing injuries due to or related to the earthquake.
What Did the Team Do at the Disaster?
Overall, 4,627 earthquake victims were seen and cared for at the stadium facility and at the outreach sites. Figure 4 shows the number of patients seen by date and category.
As the 3rd MEB medical staff was augmented by the additional personnel from the U.S.N.S. Mercy and U.S.S. Essex, the unit elected to improve local services by using outreach mobile medical teams supplemented with an Indonesian volunteer nurse and physician. These mobile medical teams saw patients in villages too far removed from the stadium clinic to avail themselves of that health care. Each team (usually consisting of two doctors, a nurse, several medical assistants, translators, and military support from the Indonesian military) set up clinic in the middle of small villages (Figs. 5 and 6). Physicians made house calls to provide assistance for those too injured by pelvic, leg, or back fractures to seek care. Education on wound management, dressing changes, fracture care, use of simple physical therapy measures to prevent pneumonia and blood clots, and home treatment for dehydration were given to families and patients in case future disasters necessitated self care. In addition to these mobile medical teams, the preventive medicine officer worked with the existing Puskesmas (Indonesian village clinics) to give tetanus and measles immunizations to any interested villager. At least 30 water treatment interventions were performed by the preventive medicine technician during this evolution.
What Were the Strengths?
The military was able to deploy rapidly with mobile medical technology such as digital radiography (x-ray) which was used extensively in the evaluation of disaster-associated trauma. The 3rd MEB used this x-ray capability to diagnose extremity injuries that could be treated with simple splinting vice casting, given the rapid depletion of casting supplies within the country. Also, based on the ease with which this machine could be broken down, moved, and set up, it can be an invaluable asset when trying to reach remotely injured people. The group also arrived with an established working relationship with USAID/OFDA. USAID was the major U.S. government agency that helped in the procurement of equipment, supplies, and logistic needs, such as transportation and translation capabilities. Additionally, USAID had situational awareness and communication networks in place to help in the organization and planning of each day's mission. The in-country embassy team helped the military unit establish relationships with a few civilian Indonesian physicians and nurses which greatly eased the anxiety of many patients. These NGO health care providers helped procure locally available immunizations to add to the supply brought in by the 3rd MEB. The operational logistics were strong components of the military response allowing access to the remote countryside and easy ability to resupply. A robust communication system allowed flexibility among the mobile teams by rapidly disseminating plan changes even from a distance. This allowed situational awareness and medical intelligence to be available among members of the widespread unit. A global positioning satellite was used to map the location of mobile medical teams. These teams used intelligence gathered from the local village in which they were working to identify other nearby villages in need of assistance.
The military used a novel method for record-keeping and documenting services provided. Each patient seen was given a card documenting the care rendered. The intent was that if the same patient was seen by another mobile medical team or by another military or NGO group, the patient would not receive duplicate immunizations, antibiotics, or pain medications which could have had dire consequences and also helped conserve limited resources. Each patient interaction was categorized into one of four categories as noted above. Category 1 and 2 patients were those who had suffered injury or illness directly or indirectly attributable to the earthquake. Category 3 patients were those with acute or chronic illnesses not associated with the recent disaster. Category 4 patients were those seen in follow-up after previously being seen by 3rd MEB medical providers or another local, NGO, or foreign military medical group. It was made clear to the local populace, government officials, and local health care providers that the military intended to leave once category 1 and 2 injuries were on the decline and when category 3 illnesses were the majority of what was being seen and treated by the 3rd MEB. It was not the military's intent to provide routine long-term health care to the population since this would have interfered with the livelihood of the local health care providers and likely led to hostile feelings that the U.S. military was trying to establish a more permanent presence.
Limitations and Barriers to Success
Only medical assistance was requested by the host nation although the 3rd MEB had much more to offer in terms of disaster response. Assistance not requested but available through the brigade included road clearance equipment, tactical airlift, search and rescue, and other forms of logistical support. The expectations of the host nation and of the assisting NGOs were not well-delineated at the outset. The capability of the U.S. military was also not well-defined initially, leading local hospitals to believe the military had greater medical capability than it had, particularly with respect to providing subspecialty surgical care, inpatient care, and follow-up chronic care.
Do not plan too much, as any preconceived plan will be quickly overcome by the fog and confusion of the evolving disaster. Team training and cross-training should be done extensively during interdisaster periods. Leaders should know where to seek information related to the socioeconomic and health background of the people in the affected area. They should have rapid access to current updates regarding the local situation and how it is affecting the vulnerable populations. Leaders should know who to find and who to listen to, because it is imperative that the most severely affected and least self-sufficient people receive the assistance they need. Response teams should learn how to take advantage of any local available human resources and how to rapidly set up effective communication within and outside the organization. Deployable military medical units need rapid assessment tools to use in disaster scenarios. These should be developed as aids for identifying requirements and for measuring effectiveness of the relief efforts.
When at home, access to easily available resources, such as the U.S. Army Medical Research and Material Command/ Armed Forces Medical Intelligence Center, was inaccessible due to damaged satellite towers and the subsequent lack of Internet access. A valuable lesson learned was that selfcontained media such as compact discs or flash drives with medical intelligence related to local host nation endemic diseases, vector-borne disease, and medical assets should be brought with any deploying unit.
Develop redundant communications strategies in case the primary means of communication becomes ineffectual. Attempt to find common means of communication with host nation responders. Develop a host nation marketing strategy to give realistic expectations for what is available in terms of medical and ancillary care and determine how best to disseminate this information broadly using host nation and NGO assets. Community leaders, medical societies, and political leadership should be sought out early to determine their expectations and to be given realistic expectations of the military time line and capabilities. Anticipate language barriers and problems with translation services (both quality and personal biases). Communication should be consistently open with local leaders to share situational facts as well as to help develop a trusting relationship.
Host Nation and NGO Interactions Lessons
Know the country and any regional resources for utilization in the response. Use the U.S. Embassy "country team" and other local resources for on-site situational awareness. Get to know both medical and governmental points of contact and important persons. Use local resources such as medical schools and universities for community outreach as it is here that education on topics such as breastfeeding, home treatment of dehydration, sanitation, water control, and hygiene can leave a lasting impression on the population. Service groups and medical societies can be helpful in terms of identifying vulnerable populations in greatest need of assistance, but be attentive to regional or social biases so as to not miss under-represented segments of the population. Understand that fiscal concerns may limit the local health care provider's assistance and cooperation in marketing "free-ofcharge" Western medical care. Have only one leader for each medical event, but develop a mentorship program to provide skill-building for further events. Know the skill sets of all individuals and adapt and augment their skill sets by other team members and cross-training.
Put an early emphasis on public education as it is durable after the disaster relief efforts are over. These educational efforts also provide an opportunity to assess the needs of local populations. Make at least one daily outreach mission to a more remote site. Use psychological outreach and surveys as tools to address social issues. Ask about local expectations and tailor the follow-on response to both the perceived and the observed needs.
Frequently, HA/DR missions are lumped together as a similar entity. They are not. Training up for a disaster response mission will do well in coordinating a humanitarian assistance mission, but not vice versa. In a disaster response, one must plan for chaos and a chaotic environment. Team and site leadership need to be able to make on-site decisions without the need for further command or distant leadership input. Cross-training and developing "fall back" plans and having the ability to provide augmentation teams to assist if needed are critical for disaster relief missions. Previous experience in HA/DR missions will lead to already existing relationships with nearby NGO groups, in-country agencies, and embassy teams allowing more rapid and extensive initial assistance.
We acknowledge that what we have described as novel methods to the military have in fact been used historically by many NGO groups well-versed in HA/DR missions. Unlike NGO groups that tend to have stable leadership with a wealth of personal experiences to draw upon, the U.S. military does have more flux within its ranks as members transfer to different jobs and commands. This continuous turnover does limit the ability to maintain firsthand knowledge from similar previous experiences and frequently means that units waste valuable time, energy, and resources "reinventing the wheel." Fortunately, the onsite medical commander for "Operation Aftershock" had recently been in command of the unit deployed to the October 2005 Pakistani earthquake relief operations. We drew heavily upon his experiences, which is why we feel this operation was so successful in terms of integrating with USAID/OFDA, local embassies, and other volunteer NGO groups.
It is clear that the U.S. military fully intends to continue these missions of goodwill based on the 2007 humanitarian missions aboard the U.S.S. Pellileu to Southeast Asia and the U.S.N.S. Comfort to South America. The Chief of Naval Operations, Admiral M. Mullen, noted in a speech on June 18, 2007 that these humanitarian missions encourage the development of relationships that can build trust and help prevent the spread of terrorism. Additionally, the financial cost of these missions is felt to be substantially less than an extended military campaign, and this, along with the abovereferenced nonpartisan research centers, generates a significant improvement in public sentiment toward the United States.
Lessons from "Operation Aftershock" should be used to plan and train for further Department of Defense disaster response operations. If experienced medical personnel are in leadership positions and are allowed to lead, we believe the U.S. military can be rapidly deployed and be immediately effective in DR situations. We also recommend that HA/DR relevant training be given to all U.S. military medical contingents and personnel. We found that the use of standardized and widely distributed medical supplies such as the World Health Organization New Emergency Health Kit facilitated rapid delivery of care in a humanitarian crisis and led to a seamless transfer of care between other aide and host nation organizations. In summary, the Department of Defense should develop and vigorously support a specific and robust HA/DR planning and implementation program using experienced and knowledgeable personnel to further the goal of "medical diplomacy."
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Source: Military Medicine