- Email: [email protected]
Humanitarian military medical mission in a postconflict environment: lessons from Cambodia
Public Health (2004) 118, 421–425
Humanitarian military medical mission in a postconflict environment: lessons from Cambodia M.E. Hubnera, Thomas F. Ditzlerb,* a
USAF Medical Corps, International Health Specialist, Medical Public Health Unit, Center of Excellence in Disaster Management and Humanitarian Assistance, Postconflict Tripler AMC, Honolulu HI 96859-5000, USA b Director of Research, Department of Psychiatry, Tripler Army Medical Center Adjunct Faculty, Center of Excellence in Disaster Management and Humanitarain Assistance Honolulu HI 96859-5000, USA Received 1 May 2003; accepted 4 December 2003 Available online 28 March 2004
KEYWORDS Civil–military collaboration; Nongovernment organization
Summary In the aftermath of a genocidal civil war, the Government of Cambodia is left with major deficiencies in its healthcare system. This article recounts a military medical mission to Cambodia; the authors describe the objectives of the mission and provide a summary of the lessons learned. Specific areas of concern include healthcare infrastructure, logistics, standards of care, social traditions, organizational issues and potential problems in civil –military collaboration. This report is offered as a heuristic device to illuminate some of the issues that can mediate the success of military medical missions in postconflict environments. Published by Elsevier Ltd on behalf of The Royal Institute of Public Health.
Recent history of Cambodia Cambodia is a poor but developing nation governed by a parliamentary democracy with a constitutional monarch. Much of the current poverty and deprivation in the country finds its roots in the 1975 revolution in which communist Khmer Rouge forces took over the government and pursued a policy of strict agrarian Maoism. In 1978, an invasion by Vietnamese forces drove the Khmer Rouge into the countryside and initiated another 13 years of fighting. Following national elections in July 1998, the two major political parties formed a coalition government that brought renewed political stability. *Corresponding author. Tel.: þ 1-808337035; fax: þ 18084331757. E-mail address: [email protected]
Overview of public health issues in Cambodia As Cambodia addresses the ravages of armed conflict that plagued the country for the last 25 years, the most pressing medical concerns are lack of public health infrastructure, inadequate primary care, public safety risks, communicable disease, and a fledgling medical and nursing education system. Medical facilities and primary healthcare outside the capital of Phnom Penn are very limited; some areas are virtually devoid of medical resources. Specific problems involve a range of issues related to lack of resources, endemic diseases and environmental risks. In addition, the nation also suffers from problems attendant to the nation’s recovery efforts themselves. For example, improved roads and increased traffic flow have led to an alarming increase in motor-vehicle-related
0033-3506/$ - see front matter Published by Elsevier Ltd on behalf of The Royal Institute of Public Health. doi:10.1016/j.puhe.2003.12.007
422
injuries. Increased commerce and tourism have brought much needed income, while simultaneously fostering a dramatic increase in prostitution and associated sexually transmitted infections (STIs) including HIV/AIDS.1 Another interesting and somewhat unexpected result of the protracted conflict is a high prevalence of Down’s syndrome. The war left many widows who are now approaching 40 years of age. It has become a social custom for younger men to marry these older women who then continue to have children into their 40s.2 Commonly presenting tropical diseases, as well as those traditionally associated with poverty, continue to be a problem. The infant mortality rate remains the highest in Asia due primarily to diarrhoeal, respiratory and vaccine-preventable diseases. Infant mortality rates range from a low of 58/10003 to a high of 103/1000.4 Anecdotal evidence from non-government organization (NGO) sources places the rate at 115/1000 in more remote areas. Malaria is endemic with 500 000 active cases and 5000 deaths annually, and the prevalence of active tuberculosis, currently 4.5/1000, is on the rise due to the rise in HIV. In addition, mental health issues associated with human rights abuses under the Khmer Rouge remain largely unaddressed. Many rural parts of the country lack adequate police, and some areas are subject to banditry. Although demining activities have been successful in reducing the threat of landmines and unexploded ordnance, surviving landmine victims are a disturbingly common site; over 40 000 Cambodians have suffered landmine-related amputations.5
Mission activities This mission was authorized and co-ordinated by the United States Pacific Command Surgeon’s Office, the Pacific Air Force Surgeon’s Office and the US Embassy, Phnom Penh. The team was composed of 15 personnel, representing orthopaedic and plastic surgery, primary care, preventive medicine, physiatry† and physical therapy, anaesthesiology, dentistry, operating theatre staff, and equipment repair. Manning was provided primarily by the US Air Force, with support from Tripler Army Medical Center. The focus of the mission was primarily surgical, but all services evolved in the context of a postconflict environment in which mission success was greatly influenced by a depleted host country economy, limited public health infrastructure, socio-cultural issues and civil– military relations. †
The speciality of physical medicine and rehabilitation.
M.E. Hubner, T.F. Ditzler
Team members responded to a range of pathology typically seen in US, as well as less commonly presenting problems including tuberculosis, HIV, malaria, dengue fever, meningitis, polio, typhus, fungal infections, Hansen’s disease, amebiasis, protozoal infections, skin lesions and worm infestations, as well as congenital deformity not typically seen in the primary-care setting in US.
Surgical care The team performed more than 90 surgeries and related medical services for children and adults at five hospitals in three locations. Surgical activities focused on orthopaedic and trauma care. The plastic surgeon brought additional value by virtue of the highly visible and dramatic impact of reconstruction of cleft palates, burns and similar psychosocially debilitating conditions. The team’s operating room nurses provided significant training in the fundamentals of instrument and equipment sterilization, principles of infection control, creation of a central supply system, and OR support and flow in three of the mission’s locations. The team also provided much-needed equipment service support through the work of its equipment repair technician. After action, staffing analysis determined that future missions would benefit from the addition of a general surgeon.
Rehabilitation Rehabilitation is in its infancy in Cambodia; services and resources are minimal. The team’s two rehabilitation specialists taught classes and saw patients in all locations, and were instrumental in bringing an emphasis on rehabilitation to the Cambodian healthcare facilities. The medical staffs at various hospitals were eager to learn about and incorporate rehabilitation principles into patient treatment. Staff teaching worked best with hands-on demonstration and interaction. Pictures and drawings were helpful in augmenting besides teaching. The physical therapist was of greatest service at the hospital level in teaching the local staff and direct patient care; the physiatrist focused on programme development, co-ordination and planning with the Ministry of Health.
Dental care At the suggestion of US Embassy, the team included a general dentist. The logistical requirements for dental services were minimal in relation to services provided. In general, dental services are discrete, well defined and reduce pain; recipients are
Humanitarian military medical mission in a postconflict environment: lessons from Cambodia
typically very appreciative. The dental component was highly successful clinically and had a significant effect on the goodwill impact of the mission.
Issues in clinical performance Training and professional development Our Cambodian colleagues were eager to share their expertise and participate in teaching rounds, but were constrained by resources and limited training in preclinical sciences imposed by the protracted conflict. This provided team members with a natural laboratory in which to develop more refined skills in cross-cultural aspects of care. Our team learned to be careful not to usurp the local medical hierarchy and leadership. When interacting with local physicians, our personnel learned to explore the possible reasons for strategies or techniques that appeared at odds with Western standards. Local providers were often masters of innovation and improvisation in their utilization of available resources. This provided a unique opportunity for our team members to develop highly useful practical techniques for operating in austere or depleted environments.
Anaesthesia resources Our team faced the problem of limited anaesthesia capacity, particularly in the delivery of paediatric care. Locally available anaesthesia resources were varied and inconsistent. In cases presenting unacceptable risk, we found it necessary to establish clear operational parameters. One benchmark we developed was to operate only on children weighing more than 20 kg, with exceptions made on a case-by-case basis. This is a good example of a technology-driven clinical problem typical of postconflict environments, and points to the need for military planners to develop standards of practice policies prior to deployments. Such clinical parameters provide a foundation for patient selection while allowing for appropriate adjustments in special cases.
Issues in civil – military collaboration The Cambodian Ministry of Health recognizes the pressing need for outside assistance as it develops its healthcare system, and accepts virtually all offers of aid. Since the national elections of 1998, Cambodia has benefited from a dramatic increase in the number of NGOs who provide a broad range of
423
aid. By 2000, there were over 200 international and 600 local NGOs registered with the government. Individual organizations range in size and complexity from large-scale, internationally funded NGOs focused on infrastructure development and reconstruction to small, community-based social service organizations.6 The Ministry of Health has crafted an ad-hoc style of management to accept and integrate this patchwork assistance; a strategy influenced by Cambodia’s long-standing Buddhist tradition. It was the government’s view that although the system created some short-term discontinuity, it afforded more broadbased development in the long term. Within this system, the Ministry sought to provide appropriate oversight and quality control of the activities of the various donor agencies active in the country. For people accustomed to working in highly organized environments focused on efficient and cost-effective service, this can be vexing. Our team members found it useful to view their contribution as part of the greater patchwork. Not surprisingly, patience and a sense of humour were also helpful. During the mission, the team had an opportunity to work with several NGOs. All were internationally funded health organizations that supplemented their respective teams to varying degrees with local caregivers. Our team members became acquainted with the structure, philosophy and capabilities of our NGO partners, and worked in a supporting role within the parameters of the particular NGO’s mission. Civil and military organizations have their respective cultures, missions and operational styles. Our team worked in an environment characterized by chronic material shortages, infrastructure deficiencies, inconsistent governmental oversight, and lack of medical and nursing professionals. These limitations are characteristic of many postconflict environments, and provided the team with valuable real-world experience in civil–military collaboration.
Goodwill and NGO resources Although a few of the larger NGOS are well funded, many struggle for funding and supplies. As a result, those providing direct healthcare may often operate with limited resources. Our team learned of a previous instance in which a US medical team deployed to a remote area completed many procedures and then departed, leaving the rural hospital’s supplies depleted. This inadvertently limited the hospital’s ability to deliver care over the following months while it built up its hospital stores. We determined that future missions should
424
take more than 100% of predicted needs in order to prevent depletion of the local supplies.
Language ability Our team was very fortunate to have a surgeon who was fluent in Khmer; this had a dramatic impact on mission function, relationship building and establishment of goodwill. The presence of a native speaker carried a strong behavioural message of respect for the culture, and exerted a significant impact on the team’s ability to forge important relationships.
Lessons learned Be aware of the financial and social impact of the mission on indigenous providers During the mission, our team faced several awkward situations regarding the financial impact of our services on the developing local medical service sector. In one situation, local physicians appeared reluctant to operate or round on patients in the afternoons. This was initially confusing until we learned the local system for physician compensation. The Government hospitals pay approximately 10% of the average physician’s salary; the remaining 90% is derived from fees for service consultation, typically in the afternoons. One dentist confided that while he felt our visit provided him with beneficial training, the time away from his practice cost him an entire weeks’ earnings, imposing considerable financial hardship. In a related issue, team members provided medical lectures to a group of local staff physicians. At the completion of the training, the team was informed that it was customary for the teaching party to pay the attendees a modest amount of money to compensate for wages lost while attending the lecture. Following guidance from the Embassy, the team declined to pay the student ‘retainer’ fees. Future missions should be aware of local methods for provider remuneration to include both ‘official’ and ‘unofficial’ economies.
Be prepared for body fluid exposure in the OR During the mission, one team member was cut with a bloody instrument during a surgical procedure. Since the patient had an undetermined HIV status, the team member was immediately started on antiHIV medication while the patient’s blood sample was sent for HIV testing at a reputable laboratory.
M.E. Hubner, T.F. Ditzler
After the test came back negative, the medication was stopped. The team member had appropriate follow-up upon return to the USA. This incident illuminates the risks and raises a number of thorny questions regarding surgical intervention in an austere or sub-optimal environment with a high prevalence of HIV in a largely untested patient population. It was very helpful to have up-to-date information on reputable laboratories in the area in addition to US-made antiretroviral medication. Teams must anticipate operative mishaps and have laboratory and medical assets in place to care for team members while preserving patient confidentiality and dignity.
Understand that competition for resources and patients can disrupt the civil– military collaborative process In some environments, there is competition between various organizations for both medical providers and patients. In one underserved area, several hospitals had been built by foreign NGOs motivated to demonstrate the value of their respective organizations to the community. Hospital administrators later found it necessary to provide increased financial incentives to attract and retain both patients and hospital personnel. On occasion, groups have aggressively pursued public collaboration with visiting military assets in an effort to imply ‘endorsement by association’ for their organization or services. When establishing civil– military collaboration, it is important for military personnel to understand the role of funding and visibility needs for many NGOs. Future missions should be mindful of the local social and economic issues affecting relationships among the various indigenous and external donor agencies before crafting civil–military agreements.
Understand local resource procurement and allocation The impact of the stunted economy was often reflected in the management of material donation. In some instances, facilities accepted whatever medical supplies were offered, even if not needed, in the hope that the supplies could be traded or sold at some later date. One facility asked the team’s equipment technician to repair three of its six electrocardiogram (EKG) machines, although it never used any of them. Discussions revealed that the facility was planning to trade them for equipment with other hospitals. Care providers unfamiliar with contingency or postconflict environments could view these situations in disparaging terms. In the context of
Humanitarian military medical mission in a postconflict environment: lessons from Cambodia
the existing resource limitations, however, they demonstrate a high degree of resourcefulness developed from living and working in an uncertain and depleted environment. These adaptive strategies may become barriers to maximizing mission objectives. Teams need to be aware of these selfsupporting actions and the reasons behind them. The team worked within the resource constraints imposed by locally available equipment and the limitations of the team’s onboard supplies. Cambodian surgeons were sometimes obligated to purchase non-standard materials and tools from local merchants to make their own surgical screws or external fixation devices. We determined that future missions should not rely on local medical supplies and must bring sufficient pins, hardware and related supplies to meet anticipated needs.
Understand the ‘silent economics’ of equipment repair Many NGO and Government hospitals in Cambodia receive equipment and supplies from a range of donors including Foreign Governments, United Nations’ agencies, private volunteer organizations (PVOs) and NGOs from Asia, Europe and US. Local care facilities are accustomed to frequent visits from donor agency surgeons and other clinical providers, but trained equipment repair technicians are in much shorter supply. As a result, much of the donated equipment becomes rapidly unserviceable due to improper installation, operation and/or maintenance. A less frequently observed but interesting aspect of donated equipment was the value placed on broken equipment and the lack of incentive to provide routine maintenance. We learned of a local hospital administrator who discovered that wellmaintained equipment hindered the donation of newer, more sophisticated technology, while equipment rendered unserviceable through deferred maintenance would be replaced with new. This ‘let it break, they will bring more’ lesson does not reflect a universal value among Cambodian providers, but it was clearly a well-learned strategy among some organizations. Future teams should consider both direct and indirect impacts of the services of biomedical equipment repair personnel.
425
Provide the military team with predeployment training on the types of NGOS and their methods of operation The term ‘NGO’ describes a very broad range of organizations; their respective sponsors, financial resources, mission parameters and levels of training vary dramatically. Training should include general principles for the development of civil – military relationships and problem solving within that context. Teams may find it useful to develop ‘go, no-go’ guidance for determining minimum standards or operating principles for the establishment of collaborative relationships with non-military assets in the field. Cambodia is at a stage of development where outside medical assistance is of great benefit to a vastly underserved population. Well-executed civil – military collaboration provides a potentially synergistic platform to enhance medical aspects of public health capacity. Such assistance must be focused on support and development of the existing medical infrastructure. Future missions should consider bringing a variety of teaching presentations on anatomy, physiology, surgical procedures and treatment options. Presentations should be prepared with the understanding that teaching and treatment resources are limited. Teaching aids should be well planned and include many pictures. Reliance on technologically mediated teaching resources is contra-indicated.
References 1. UNAIDS, Cambodia, 2002: Asia and the Pacific. UNAIDS; 2002. http://www.unaids.org/EN/Geographical þ Area/by þ country/cambodia.asp 2. Clarke T. Personal communication. 3. Cambodian demographic and health survey. Phnom Penh: National Institute of Statistics, Ministry of Health and Ministry of Planning; 2000. 4. The state of world population. United Nations Population Fund, UNFPAUN Population Fund; 2000. http://www.unfpa. org/swp/swpmain.htm 5. Landmines in Cambodia; 2002. [http://www.mekong.net/ cambodia/mines.htm] 6. NGO Forum on Cambodia. NGO Statement. Consultative Group Meeting on Cambodia; 2000. http://www.camnet. com.kh/ngoforum
Humanitarian military medical mission in a postconflict environment: lessons from Cambodia M.E. Hubnera, Thomas F. Ditzlerb,* a
USAF Medical Corps, International Health Specialist, Medical Public Health Unit, Center of Excellence in Disaster Management and Humanitarian Assistance, Postconflict Tripler AMC, Honolulu HI 96859-5000, USA b Director of Research, Department of Psychiatry, Tripler Army Medical Center Adjunct Faculty, Center of Excellence in Disaster Management and Humanitarain Assistance Honolulu HI 96859-5000, USA Received 1 May 2003; accepted 4 December 2003 Available online 28 March 2004
KEYWORDS Civil–military collaboration; Nongovernment organization
Summary In the aftermath of a genocidal civil war, the Government of Cambodia is left with major deficiencies in its healthcare system. This article recounts a military medical mission to Cambodia; the authors describe the objectives of the mission and provide a summary of the lessons learned. Specific areas of concern include healthcare infrastructure, logistics, standards of care, social traditions, organizational issues and potential problems in civil –military collaboration. This report is offered as a heuristic device to illuminate some of the issues that can mediate the success of military medical missions in postconflict environments. Published by Elsevier Ltd on behalf of The Royal Institute of Public Health.
Recent history of Cambodia Cambodia is a poor but developing nation governed by a parliamentary democracy with a constitutional monarch. Much of the current poverty and deprivation in the country finds its roots in the 1975 revolution in which communist Khmer Rouge forces took over the government and pursued a policy of strict agrarian Maoism. In 1978, an invasion by Vietnamese forces drove the Khmer Rouge into the countryside and initiated another 13 years of fighting. Following national elections in July 1998, the two major political parties formed a coalition government that brought renewed political stability. *Corresponding author. Tel.: þ 1-808337035; fax: þ 18084331757. E-mail address: [email protected]
Overview of public health issues in Cambodia As Cambodia addresses the ravages of armed conflict that plagued the country for the last 25 years, the most pressing medical concerns are lack of public health infrastructure, inadequate primary care, public safety risks, communicable disease, and a fledgling medical and nursing education system. Medical facilities and primary healthcare outside the capital of Phnom Penn are very limited; some areas are virtually devoid of medical resources. Specific problems involve a range of issues related to lack of resources, endemic diseases and environmental risks. In addition, the nation also suffers from problems attendant to the nation’s recovery efforts themselves. For example, improved roads and increased traffic flow have led to an alarming increase in motor-vehicle-related
0033-3506/$ - see front matter Published by Elsevier Ltd on behalf of The Royal Institute of Public Health. doi:10.1016/j.puhe.2003.12.007
422
injuries. Increased commerce and tourism have brought much needed income, while simultaneously fostering a dramatic increase in prostitution and associated sexually transmitted infections (STIs) including HIV/AIDS.1 Another interesting and somewhat unexpected result of the protracted conflict is a high prevalence of Down’s syndrome. The war left many widows who are now approaching 40 years of age. It has become a social custom for younger men to marry these older women who then continue to have children into their 40s.2 Commonly presenting tropical diseases, as well as those traditionally associated with poverty, continue to be a problem. The infant mortality rate remains the highest in Asia due primarily to diarrhoeal, respiratory and vaccine-preventable diseases. Infant mortality rates range from a low of 58/10003 to a high of 103/1000.4 Anecdotal evidence from non-government organization (NGO) sources places the rate at 115/1000 in more remote areas. Malaria is endemic with 500 000 active cases and 5000 deaths annually, and the prevalence of active tuberculosis, currently 4.5/1000, is on the rise due to the rise in HIV. In addition, mental health issues associated with human rights abuses under the Khmer Rouge remain largely unaddressed. Many rural parts of the country lack adequate police, and some areas are subject to banditry. Although demining activities have been successful in reducing the threat of landmines and unexploded ordnance, surviving landmine victims are a disturbingly common site; over 40 000 Cambodians have suffered landmine-related amputations.5
Mission activities This mission was authorized and co-ordinated by the United States Pacific Command Surgeon’s Office, the Pacific Air Force Surgeon’s Office and the US Embassy, Phnom Penh. The team was composed of 15 personnel, representing orthopaedic and plastic surgery, primary care, preventive medicine, physiatry† and physical therapy, anaesthesiology, dentistry, operating theatre staff, and equipment repair. Manning was provided primarily by the US Air Force, with support from Tripler Army Medical Center. The focus of the mission was primarily surgical, but all services evolved in the context of a postconflict environment in which mission success was greatly influenced by a depleted host country economy, limited public health infrastructure, socio-cultural issues and civil– military relations. †
The speciality of physical medicine and rehabilitation.
M.E. Hubner, T.F. Ditzler
Team members responded to a range of pathology typically seen in US, as well as less commonly presenting problems including tuberculosis, HIV, malaria, dengue fever, meningitis, polio, typhus, fungal infections, Hansen’s disease, amebiasis, protozoal infections, skin lesions and worm infestations, as well as congenital deformity not typically seen in the primary-care setting in US.
Surgical care The team performed more than 90 surgeries and related medical services for children and adults at five hospitals in three locations. Surgical activities focused on orthopaedic and trauma care. The plastic surgeon brought additional value by virtue of the highly visible and dramatic impact of reconstruction of cleft palates, burns and similar psychosocially debilitating conditions. The team’s operating room nurses provided significant training in the fundamentals of instrument and equipment sterilization, principles of infection control, creation of a central supply system, and OR support and flow in three of the mission’s locations. The team also provided much-needed equipment service support through the work of its equipment repair technician. After action, staffing analysis determined that future missions would benefit from the addition of a general surgeon.
Rehabilitation Rehabilitation is in its infancy in Cambodia; services and resources are minimal. The team’s two rehabilitation specialists taught classes and saw patients in all locations, and were instrumental in bringing an emphasis on rehabilitation to the Cambodian healthcare facilities. The medical staffs at various hospitals were eager to learn about and incorporate rehabilitation principles into patient treatment. Staff teaching worked best with hands-on demonstration and interaction. Pictures and drawings were helpful in augmenting besides teaching. The physical therapist was of greatest service at the hospital level in teaching the local staff and direct patient care; the physiatrist focused on programme development, co-ordination and planning with the Ministry of Health.
Dental care At the suggestion of US Embassy, the team included a general dentist. The logistical requirements for dental services were minimal in relation to services provided. In general, dental services are discrete, well defined and reduce pain; recipients are
Humanitarian military medical mission in a postconflict environment: lessons from Cambodia
typically very appreciative. The dental component was highly successful clinically and had a significant effect on the goodwill impact of the mission.
Issues in clinical performance Training and professional development Our Cambodian colleagues were eager to share their expertise and participate in teaching rounds, but were constrained by resources and limited training in preclinical sciences imposed by the protracted conflict. This provided team members with a natural laboratory in which to develop more refined skills in cross-cultural aspects of care. Our team learned to be careful not to usurp the local medical hierarchy and leadership. When interacting with local physicians, our personnel learned to explore the possible reasons for strategies or techniques that appeared at odds with Western standards. Local providers were often masters of innovation and improvisation in their utilization of available resources. This provided a unique opportunity for our team members to develop highly useful practical techniques for operating in austere or depleted environments.
Anaesthesia resources Our team faced the problem of limited anaesthesia capacity, particularly in the delivery of paediatric care. Locally available anaesthesia resources were varied and inconsistent. In cases presenting unacceptable risk, we found it necessary to establish clear operational parameters. One benchmark we developed was to operate only on children weighing more than 20 kg, with exceptions made on a case-by-case basis. This is a good example of a technology-driven clinical problem typical of postconflict environments, and points to the need for military planners to develop standards of practice policies prior to deployments. Such clinical parameters provide a foundation for patient selection while allowing for appropriate adjustments in special cases.
Issues in civil – military collaboration The Cambodian Ministry of Health recognizes the pressing need for outside assistance as it develops its healthcare system, and accepts virtually all offers of aid. Since the national elections of 1998, Cambodia has benefited from a dramatic increase in the number of NGOs who provide a broad range of
423
aid. By 2000, there were over 200 international and 600 local NGOs registered with the government. Individual organizations range in size and complexity from large-scale, internationally funded NGOs focused on infrastructure development and reconstruction to small, community-based social service organizations.6 The Ministry of Health has crafted an ad-hoc style of management to accept and integrate this patchwork assistance; a strategy influenced by Cambodia’s long-standing Buddhist tradition. It was the government’s view that although the system created some short-term discontinuity, it afforded more broadbased development in the long term. Within this system, the Ministry sought to provide appropriate oversight and quality control of the activities of the various donor agencies active in the country. For people accustomed to working in highly organized environments focused on efficient and cost-effective service, this can be vexing. Our team members found it useful to view their contribution as part of the greater patchwork. Not surprisingly, patience and a sense of humour were also helpful. During the mission, the team had an opportunity to work with several NGOs. All were internationally funded health organizations that supplemented their respective teams to varying degrees with local caregivers. Our team members became acquainted with the structure, philosophy and capabilities of our NGO partners, and worked in a supporting role within the parameters of the particular NGO’s mission. Civil and military organizations have their respective cultures, missions and operational styles. Our team worked in an environment characterized by chronic material shortages, infrastructure deficiencies, inconsistent governmental oversight, and lack of medical and nursing professionals. These limitations are characteristic of many postconflict environments, and provided the team with valuable real-world experience in civil–military collaboration.
Goodwill and NGO resources Although a few of the larger NGOS are well funded, many struggle for funding and supplies. As a result, those providing direct healthcare may often operate with limited resources. Our team learned of a previous instance in which a US medical team deployed to a remote area completed many procedures and then departed, leaving the rural hospital’s supplies depleted. This inadvertently limited the hospital’s ability to deliver care over the following months while it built up its hospital stores. We determined that future missions should
424
take more than 100% of predicted needs in order to prevent depletion of the local supplies.
Language ability Our team was very fortunate to have a surgeon who was fluent in Khmer; this had a dramatic impact on mission function, relationship building and establishment of goodwill. The presence of a native speaker carried a strong behavioural message of respect for the culture, and exerted a significant impact on the team’s ability to forge important relationships.
Lessons learned Be aware of the financial and social impact of the mission on indigenous providers During the mission, our team faced several awkward situations regarding the financial impact of our services on the developing local medical service sector. In one situation, local physicians appeared reluctant to operate or round on patients in the afternoons. This was initially confusing until we learned the local system for physician compensation. The Government hospitals pay approximately 10% of the average physician’s salary; the remaining 90% is derived from fees for service consultation, typically in the afternoons. One dentist confided that while he felt our visit provided him with beneficial training, the time away from his practice cost him an entire weeks’ earnings, imposing considerable financial hardship. In a related issue, team members provided medical lectures to a group of local staff physicians. At the completion of the training, the team was informed that it was customary for the teaching party to pay the attendees a modest amount of money to compensate for wages lost while attending the lecture. Following guidance from the Embassy, the team declined to pay the student ‘retainer’ fees. Future missions should be aware of local methods for provider remuneration to include both ‘official’ and ‘unofficial’ economies.
Be prepared for body fluid exposure in the OR During the mission, one team member was cut with a bloody instrument during a surgical procedure. Since the patient had an undetermined HIV status, the team member was immediately started on antiHIV medication while the patient’s blood sample was sent for HIV testing at a reputable laboratory.
M.E. Hubner, T.F. Ditzler
After the test came back negative, the medication was stopped. The team member had appropriate follow-up upon return to the USA. This incident illuminates the risks and raises a number of thorny questions regarding surgical intervention in an austere or sub-optimal environment with a high prevalence of HIV in a largely untested patient population. It was very helpful to have up-to-date information on reputable laboratories in the area in addition to US-made antiretroviral medication. Teams must anticipate operative mishaps and have laboratory and medical assets in place to care for team members while preserving patient confidentiality and dignity.
Understand that competition for resources and patients can disrupt the civil– military collaborative process In some environments, there is competition between various organizations for both medical providers and patients. In one underserved area, several hospitals had been built by foreign NGOs motivated to demonstrate the value of their respective organizations to the community. Hospital administrators later found it necessary to provide increased financial incentives to attract and retain both patients and hospital personnel. On occasion, groups have aggressively pursued public collaboration with visiting military assets in an effort to imply ‘endorsement by association’ for their organization or services. When establishing civil– military collaboration, it is important for military personnel to understand the role of funding and visibility needs for many NGOs. Future missions should be mindful of the local social and economic issues affecting relationships among the various indigenous and external donor agencies before crafting civil–military agreements.
Understand local resource procurement and allocation The impact of the stunted economy was often reflected in the management of material donation. In some instances, facilities accepted whatever medical supplies were offered, even if not needed, in the hope that the supplies could be traded or sold at some later date. One facility asked the team’s equipment technician to repair three of its six electrocardiogram (EKG) machines, although it never used any of them. Discussions revealed that the facility was planning to trade them for equipment with other hospitals. Care providers unfamiliar with contingency or postconflict environments could view these situations in disparaging terms. In the context of
Humanitarian military medical mission in a postconflict environment: lessons from Cambodia
the existing resource limitations, however, they demonstrate a high degree of resourcefulness developed from living and working in an uncertain and depleted environment. These adaptive strategies may become barriers to maximizing mission objectives. Teams need to be aware of these selfsupporting actions and the reasons behind them. The team worked within the resource constraints imposed by locally available equipment and the limitations of the team’s onboard supplies. Cambodian surgeons were sometimes obligated to purchase non-standard materials and tools from local merchants to make their own surgical screws or external fixation devices. We determined that future missions should not rely on local medical supplies and must bring sufficient pins, hardware and related supplies to meet anticipated needs.
Understand the ‘silent economics’ of equipment repair Many NGO and Government hospitals in Cambodia receive equipment and supplies from a range of donors including Foreign Governments, United Nations’ agencies, private volunteer organizations (PVOs) and NGOs from Asia, Europe and US. Local care facilities are accustomed to frequent visits from donor agency surgeons and other clinical providers, but trained equipment repair technicians are in much shorter supply. As a result, much of the donated equipment becomes rapidly unserviceable due to improper installation, operation and/or maintenance. A less frequently observed but interesting aspect of donated equipment was the value placed on broken equipment and the lack of incentive to provide routine maintenance. We learned of a local hospital administrator who discovered that wellmaintained equipment hindered the donation of newer, more sophisticated technology, while equipment rendered unserviceable through deferred maintenance would be replaced with new. This ‘let it break, they will bring more’ lesson does not reflect a universal value among Cambodian providers, but it was clearly a well-learned strategy among some organizations. Future teams should consider both direct and indirect impacts of the services of biomedical equipment repair personnel.
425
Provide the military team with predeployment training on the types of NGOS and their methods of operation The term ‘NGO’ describes a very broad range of organizations; their respective sponsors, financial resources, mission parameters and levels of training vary dramatically. Training should include general principles for the development of civil – military relationships and problem solving within that context. Teams may find it useful to develop ‘go, no-go’ guidance for determining minimum standards or operating principles for the establishment of collaborative relationships with non-military assets in the field. Cambodia is at a stage of development where outside medical assistance is of great benefit to a vastly underserved population. Well-executed civil – military collaboration provides a potentially synergistic platform to enhance medical aspects of public health capacity. Such assistance must be focused on support and development of the existing medical infrastructure. Future missions should consider bringing a variety of teaching presentations on anatomy, physiology, surgical procedures and treatment options. Presentations should be prepared with the understanding that teaching and treatment resources are limited. Teaching aids should be well planned and include many pictures. Reliance on technologically mediated teaching resources is contra-indicated.
References 1. UNAIDS, Cambodia, 2002: Asia and the Pacific. UNAIDS; 2002. http://www.unaids.org/EN/Geographical þ Area/by þ country/cambodia.asp 2. Clarke T. Personal communication. 3. Cambodian demographic and health survey. Phnom Penh: National Institute of Statistics, Ministry of Health and Ministry of Planning; 2000. 4. The state of world population. United Nations Population Fund, UNFPAUN Population Fund; 2000. http://www.unfpa. org/swp/swpmain.htm 5. Landmines in Cambodia; 2002. [http://www.mekong.net/ cambodia/mines.htm] 6. NGO Forum on Cambodia. NGO Statement. Consultative Group Meeting on Cambodia; 2000. http://www.camnet. com.kh/ngoforum