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Newsletter 10-64
September 2010

Chapter 2. Afghan Culture and Mass Casualty Operations

Section I: Afghan Mass Casualty Operations

Section II: Conclusion

The initial call of a major avalanche in Parwan Province was received at 0328 hours on 9 February 2010 by the Task Force Medical (TF MED)-East Tactical Operations Center, Bagram Airfield. At that time, approximately 150 Afghans were trapped at a high mountain pass blocking a major route between Kabul and northern Afghanistan. Helicopter evacuation was the only means of removing victims from the avalanche site. By 1250 hours, 60 to 70 casualties were inbound to Bagram Airfield.

While hospitals and medical personnel are expected to respond to such mass casualty events, this disaster involved primarily a U.S. military hospital, staffed with U.S. medical personnel, and Afghan casualties. What were the cultural implications?

Fortunately a group of Afghan medical professionals with varying backgrounds, from internal medicine to an orthopedic surgeon, were participating in a trauma mentorship program at the hospital. The Afghan providers played a vital role in the medical care given to their own people. It was evident the local-national patients were more comfortable being treated by their fellow countrymen. In addition to assisting with medical treatment of the injured, these Afghan medical personnel worked as interpreters and liaisons to the patients in a cultural capacity.

"For some of the patients coming from remote areas of Afghanistan, this may be their first and only interaction with coalition forces," TF-MED Medical Readiness Officer CPT James McDaniel said. "The importance lies in the fact that we are professional and sensitive to their cultural needs. The assistance we receive from the Afghans helps to convey the respect and professionalism these people need and deserve."

-Staff Sergeant Richard Williams,
455th Air Expeditionary Wing Public Affairs Office
Medical Teams Render Assistance after Afghanistan Avalanches,
10 February 2010, Air Force News Service

Catastrophic events caused by environmental conditions can occur anytime and anyplace, and they are never predictable. Unfortunately they can and often do produce mass casualties. Afghanistan has two such environmental conditions-earthquakes and avalanches-the size and timing of which can significantly affect counterinsurgency (COIN) operations. U.S. forces could become victims, but will almost always be relief providers. In either case, U.S. forces must be sensitive to the culture of the Afghan victims and their families.

Section I: Afghan Mass Casualty Operations

When employing military forces to provide assistance during mass casualty operations involving the Afghans, U.S. personnel must consider these key points:

  • Afghanistan, in urban areas, has hospitals and medical personnel. However, these areas lack the numbers of hospitals and medical personnel as well as medical supplies and equipment to provide what Westerners would consider adequate and timely treatment.
  • Victims in the rural and mountainous areas, in all likelihood, are without other than rudimentary medical care.
  • Afghanistan lacks the organizational capabilities to respond to mass casualty events.
  • U.S. military medical personnel who do not routinely come into contact with Afghans in the performance of their medical duties must have knowledge and understanding of the Afghan culture, as well as the language.
  • Afghan victims and family members who escort them for medical care may be experiencing their first contact with U.S. military personnel, their first helicopter flight, their first contact with other than family or clan members, their first Western food, and their first experience with doctors and nurses.
  • U.S. military medical personnel must consider Afghan cultural needs. For example, can the Afghans eat the food provided based on their religious beliefs? Do provisions need to be made in the event male doctors cannot treat female patients or male patients cannot be treated by female nurses? In some instances injured female Afghans may not even be allowed in the same area with men who are not family members.
  • Afghan medical personnel, if available, need to be incorporated into mass casualty operations that involve Afghans. Their involvement shows them how to prepare for and respond to mass casualty emergencies. They can serve as interpreters and liaisons between coalition medical personnel and Afghan casualties. Additionally, Afghans may be more comfortable being treated by their fellow countrymen if they feel they are medically competent.
  • U.S. military personnel may be working with individuals from nongovernmental organizations or individuals who may or may not have a high opinion of the military. In all likelihood, these individuals are there to assist in caring for the casualties. Casualty care is the reason for everyone being there. Put the casualty first.
  • A single command authority does not exist in a humanitarian mass casualty event. Because one aspect of U.S. forces in Afghanistan is to enhance the creditability of the Government of the Islamic Republic of Afghanistan (GIRoA), seek every opportunity to show the Afghan National Security Forces (ANSF) are working to provide timely and positive responses.
  • Legal limitations apply in humanitarian mass casualty response operations. The staff judge advocate is trained and resourced to identify the legal, fiscal, and political limitations. Some humanitarian mass casualty response may have to be almost instantaneous. Therefore, it is advisable to have this staffed and rehearsed in the event such a response is required.

Section II: Conclusion

Being prepared for mass casualty events in the Afghan diverse cultural environment is an absolute must as your unit could go from conducting or preparing to conduct COIN operations to humanitarian mass casualty operations in a very short period of time. Afghans and U.S. personnel who do not normally come into contact with each other are not prepared for the cultural differences they will experience. It is important that all U.S. military personnel prepare themselves in the event they become involved in such operations. Preplanning and rehearsal exercises are thus very important.


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