Brigade Combat Team Health Service
Figure 8-1. The very young and elderly have a higher mortality and morbidity rate from the consumption of nonpotable water.
As described by the World Health Organization (WHO), "The quality of drinking water is a powerful environmental determinant of health. Assurance of drinking-water safety is a foundation for the prevention and control of waterborne diseases."12 "Lack of drinking water and sanitation kills about 4,500 children a day and sentences their siblings, parents, and neighbors to sickness, squalor, and enduring poverty. Improvements bring immediate and lasting benefits in health, dignity, education, productivity, and income generation."13 The military commander has the capability to have a significant impact in this arena of essential services with the BCT's organic equipment, preventive medicine expertise, and distribution capability. The water purification equipment of the BCT must deploy with the unit.
Preventing Disease Outbreaks Through an Immunization Program
Like providing potable water, implementing a vaccination campaign for a displaced persons camp or a refugee camp will decrease human morbidity or mortality. "It is one of the most important public health interventions," according to the WHO.14 "Vaccines are a cost-effective method of further reducing human suffering and death."15 It is not a question of eliminating diseases spread by poor sanitation, but rather a matter of putting practices in place that limit their spread. Vaccinations against Hepatitis A, Hepatitis B, and diarrheal diseases are a cost effective method to curb the spread.16
The command's determination of which vaccines to administer should be based on the diseases endemic in the area and the WHO's recommendations. The commander can effectively utilize Commander's Emergency Response Program (CERP) funds in this endeavor. Immunizing individuals residing in displaced persons camps or refugee camps creates a refrigeration requirement for the transport and storage of the vaccines. In any immunization campaign, an adverse vaccine event will most likely occur. The commander must ensure appropriate personnel are available on site to manage this occurrence and have a prescribed plan for transportation, hospitalization, and acute follow-up.17 Army Regulation (AR) 40-562, Immunizations and Chemoprophylaxis, details the minimal requirements for the U.S. Army.
Proper Disposal of Medical Waste
Medical operations generate waste that must be disposed of using proper medical waste disposal procedures. "Waste generated by health care activities includes a broad range of materials, from used needles and syringes" used in immunization campaigns, "soiled dressings, diagnostics samples, medical devices, pharmaceuticals..."18 "Poor management of health care waste potentially exposes health care workers, waste handlers, patients, and the community at large to infection, toxic effects, injuries, and risk polluting the environment."19
Improper waste disposal will create a sensational media story when identified by any reporter and negate the positive effects of the humanitarian mission. Waste generated by military forces must be disposed of properly.20 Detailed guidance is located in the Medical Command Regulation 40-3, Management of Regulated Medical Waste. Safeguarding medical waste is just as important as properly disposing of it. An individual or group rummaging through medical waste can become a medical casualty, generate an infectious disease outbreak, and/or inadvertently distribute or utilize objects that can spread disease directly or indirectly.
Utilization of the BCT's Field Sanitation and Preventive Medicine Teams
The brigade support medical company has subject matter experts on field sanitation and preventive medicine.21 In addition, per U.S. Army doctrine, at the company level there are at least two Soldiers trained in unit and field sanitation.22 Brigade, battalion, and company commanders can utilize these individuals to conduct camp assessments in support of humanitarian operations.
The field sanitation and preventive medicine teams provide valuable assessments in creating and monitoring IDP camps or refugee camps. This assessment should identify the potable water requirements, the quantity and location of latrine facilities, and human waste disposal requirements. The field sanitation team will also be able to develop a food safety inspection program as well as insect and rodent control measures. These duties are identical to the functions they provide to their parent organization, and minimal additional funding and support is required. Field sanitation is another area in which the commander's utilization of CERP funds will proportionally relieve human suffering.23
Managing Expectations, Operating, and Supporting Health Care Clinics
In planning ad hoc clinics or contributing to the support of the health clinics in an IDP or refugee camp, it is important that medical units become the supported element. It is not unusual for hundreds of IDPs or refugees to seek medical care on a single day.
Augmentation for crowd control is a requirement. If the medical staff is part of the crowd control force, it cannot focus its attention on providing medical care. Crowd control includes the flow of patients into the patient care areas, establishing security and a plan to deal with disruptions, plus a carefully executed plan for departure at the conclusion of the day's activities.24 Individuals waiting in line will get upset or initiate a riot when a humanitarian clinic closes or if they believe they cannot be seen before the clinic closes.25 Managing expectations is also important. A triage system must be put into place, and the focus should be on acute illness and, if the resources are available, some chronic care.
An individual who shows up for a second opinion for a cancer diagnosis or treatment will be disappointed. A process to screen these folks before they enter the clinic will allow the health care providers to concentrate their limited time on the medical issues they can treat. A method is to have a staff member screen each person in order to direct them to the patient care area or issue a supply of vitamins and conclude their visit. The medical element of Joint Task Force Bravo, based at Soto Cano Airbase, successfully uses this methodology. This organization has years of experience in conducting medical missions consisting of health clinics in the remote areas of Central and South America.
Figure 8-2. In 2009, El Salvador experienced torrential rains that resulted in flash floods and mudslides. Joint Task Force Bravo (SOUTHCOM) responded to the natural disaster by delivering humanitarian aid and conducting ad hoc clinics. On an average day the health care professionals provided medical care to more than 500 people. The staff comprised members of the DOD, nongovernmental organizations (NGOs), and the host nation.
Often, the host nation population travels for hours to seek the medical care provided as a joint venture with host nation professionals, NGOs, and interagency partners. A member of the humanitarian team starts with a lecture on preventive medicine and sanitation. Children are given a single dose of anti-helminthic (de-worming) medication due to the ubiquitous infestation of the population. Each person requesting a consultation with a provider is screened by an allied health professional in order to direct them to the patient care area or is informed that the services requested are beyond the scope of the care provided and are issued a supply of vitamins. This methodology generates the feeling that everybody received something for their visit, whether they saw a physician or not.
Providing Quality and Culturally Aware Medical Care
The situational understanding and awareness of the IDPs and refugees goes beyond their immediate predicament. It is important to understand the varied cultures that exist in the population and their respective language. It may not be appropriate for a male physician to interview and evaluate a female patient without a female chaperone. Similarly, it may not be appropriate to use a male translator for a female patient consultation. Members of the humanitarian mission who speak the language are invaluable. The use of an interpreter increases the time requirement per patient and adds an additional element that can lead to a medical error. It is not always possible to have a native speaking health professional or native- speaking translator who has a mastery of medical terminology. Despite the focus to get the most patients seen, the ultimate benchmark should be on the quality of care, minimizing the number of medical errors and adverse events. This understanding must be incorporated into the commander's intent.
This article provides members of the BCT planning staff and brigade commander a starting point for humanitarian missions for IDPs camps and refugee camps. By directing the limited and valuable resources organic to a BCT, the BCT commander can have a positive effect on winning the hearts and minds of the population by reducing the level of human suffering.
1. An internal medicine physician traditionally focuses his or her scope of practice to an adolescent-age (18 years) population and higher. http://www.certificationmatters.org/abms-member-boards/internal-medicine.aspx. Accessed 8 May 2012.
2. Depending on the core training of the PA and/or additional training beyond the core curriculum a PA can specialize in pediatrics, orthopedics, emergency medicine... expanding their capability. It is a common practice for PAs in the AMEDD not to request credentials to treat and evaluate children under the age of two. Physician Assistant's Scope of Practice; Professional Issues, Issue Brief, published by the American Academy of Physician Assistants, October 2011. Available for review at this link. Accessed 8 May 2012.
3. Unlike PAs, nurse practitioners can be credentialed to work independently and traditionally have no pediatric limitations in their scope of practice unless they specialize. Scope of Practice for Nurse Practitioners, published by the American Academy of Nurse Practitioners, Revised 2010 Edition. Available for review at http://www.aanp.org/NR/rdonlyres/FCA07860-3DA1-46F9-80E6-E93A0972FB0D/0/2010ScopeOfPractice.pdf. Accessed 8 May 2012.
4. Paramedic, Requirements for National EMS Certification, brochure. Available for review at www.nremt.org or https://www.nremt.org/nremt/downloads/Paramedic_Brochure.pdf. Accessed 8 May 2012.
5. EMT-Basic, Requirements for National EMS Certification, brochure. Available for review at www.nremt.org or https://www.nremt.org/nremt/downloads/EMT-Basic_Brochure.pdf. Accessed 8 May 2012.
6. Depending on the core training of the PA and/or additional training beyond the core curriculum, a PA can specialize in pediatrics, orthopedics, emergency medicine... expanding their capability. It is a common practice for PAs in the AMEDD not to request credentials to treat and evaluate children under the age of two. Physician Assistant's Scope of Practice; Professional Issues, Issue Brief, published by the American Academy of Physician Assistants, October 2011. Available for review at this link. Accessed 8 May 2012.
7. Unlike PAs, nurse practitioners can be credentialed to work independently and traditionally have no pediatric limitations in their scope of practice unless they specialize. Scope of Practice for Nurse Practitioners published by the American Academy of Nurse Practitioners, Revised 2010 Edition. Available for review at http://www.aanp.org/NR/rdonlyres/FCA07860-3DA1-46F9-80E6-E93A0972FB0D/0/2010ScopeOfPractice.pdf. Accessed 8 May 2012.
8. "Primary care provider" is defined as a physician, nurse practitioner, or PA whose scope of practice is focused on ambulatory care medicine that is not in a specialty field. Examples include: pediatrician, family medicine, and internal medicine.
9. WHO. Water for Life, Making it Happen. Available for review at http://www.who.int/water_sanitation_health/monitoring/jmp2005/en/index.html. Accessed 8 May 2012.
12. WHO. Water Sanitation Health. http://www.who.int/water_sanitation_health/dwq/en/. Accessed 8 May 2012.
13. WHO. Water for Life, Making it Happen. Available for review at http://www.who.int/water_sanitation_health/monitoring/jmp2005/en/index.html. Accessed 8 May 2012.
14. WHO. Immunization Safety, http://www.who.int/immunization_safety/en/. Accessed 9 May 2012.
15. WHO, Immunization, http://www.who.int/topics/immunization/en/. Accessed 9 May 2012.
17. U.S. Department of the Army. AR 40-562, Immunizations and Chemoprophylaxis, Washington, DC: Government Printing Office, 29 September 2006, paragraph 2-9.
18. WHO, Medical Waste, http://www.who.int/topics/medical_waste/en/index.html. Accessed 9 May 2012.
19. Ibid. and WHO, Waste from Health-Care Activities, November 2011, http://www.who.int/mediacentre/factsheets/fs253/en/index.html. Accessed May 2012.
20. U.S. Department of the Army. Medical Command Regulation 40-3, Management of Medical Regulated Waste, 29 April 2008.
21. U.S. Department of the Army, Field Manual (FM) 4-90, Brigade Support Battalion, Washington, DC: Government Printing Office, 31 Aug 2010, page 5-3.
22. U.S. Department of the Army, FM 21-10, Field Hygiene and Sanitation, Washington, DC: Government Printing Office, 2000, page 2-4.
23. It stands to reason; the more money available to implement the facilities and services required, the more the quality of life would improve. The assumption is that the money is being utilized properly and not diverted.
24. U.S. Department of Defense, Joint Publication 3-29, Foreign Humanitarian Assistance, Washington, DC: Government Printing Office, 17 March 2009, page A-7.
25. This is often an informal lesson learned from organizations that conduct humanitarian health clinics in areas with great need. An appropriate amount of security should be present as the clinic closes to ensure the safety of the staff at the clinic and to prevent a riot.