Report: Colonel Bruno Most
Service as J Med Plans Officer at HQ ISAF
From November 2008 to February 2009, the author served at HQ ISAF in Kabul as Deputy Medical Director ISAF and J Med Plans Officer. In this article, the author outlines his own personal experiences of this period and concentrates predominantly on aspects of the staff work and the medical planning strategies of the J Med Branch.
Since the return of the author, HQ ISAF has been reorganised.
J Med at HQ ISAF
During my tour of duty, the department had 11 officers and non-commissioned officers and was under the command of a colonel who had also been appointed Medical Director ISAF. There were two departments within the branch, J Med Plans and J Med Ops. The core tasks of J Med Plans were planning of the medical support of ISAF over the mid- and long-term, Reconstruction and Development (R&D), collaboration in the medical sector with the Afghan security forces, preventive medicine and the supervision of the military medical infrastructure. J Med Ops, on the other hand, was responsible for short-term planning of military medical operations and administration through the provision of military medical personnel working on a shift basis at the ISAF operational HQ.
The branch’s personnel in winter 2008/2009 were drawn from seven different nations (UK, USA, the Netherlands, Greece, Croatia, Turkey and Germany). This meant that they needed to be both familiar with standard NATO staff operational procedures and have a good command of English. This was all the more important as many of the personnel of the branch also had to liaise with the various JOPGs (Joint Operation Planning Groups) at HQ. An awareness of the fundaments of staff work and a certain level of linguistic abilities were thus essential to ensure that medical military requirements were appropriately provided for.
Military medical personnel working at multinational headquarters of this size need to be possessed of considerable determination as many staff officers of other command sectors tend to bring with them from their homeland a rather negative view of the administrative abilities of medical officers in general. It is necessary to actively demonstrate that one is capable of drafting orders, preparing and presenting briefings and is fully as competent as the general staff officers of other departments. The countries supplying personnel for these posts thus need to ensure that they select individuals with the required abilities and provide these with adequate preparatory training.
I am today able to express my gratitude to Cdr Ian Dell of the Joint Warfare Centre in Stavanger, who collaborated with us at J Med Branch for several weeks in the preparation of formats outlining the job descriptions and qualifications required for the various posts at the J Med Branch. These will provide the contributing nations with exactly the sort of information they need to select and train their personnel.
Reconstruction and Development (R&D)
I discovered that it was R&D that was the focus of the activities of the J Med Plans Branch. This involved not only documentation of the activities of the Regional Commands (RCs) and Provincial Reconstruction Teams (PRTs), but also liaison with government bodies and international aid organisations for the purposes of planning the establishment of a functional medical care system within Afghanistan. The information obtained was fed into the planning activities at HQ to ensure that medical reconstruction became a primary benchmark and crucial aspect of ISAF operational planning. Here it was also important to make sure that medical military R&D represented a factor within overall medical situation review and planning and did not merely remain a concern of department J 9. Close collaboration between the two departments was also indispensable to coordinate civilian reconstruction efforts. Medical R&D should remain the concern of J Med as this allows all the expertise available at the branch to be deployed. What proved to be a problem was the fact that only one of the five RCs had its own specialised R&D Medical Staff Officer. At the other RCs, the relevant tasks were undertaken by other officers, meaning that this issue was not always accorded the importance it deserved. On the other hand, there were also successes in the area of R&D that were achieved in particular through the use of military medical officers as trainers and administrators in civilian hospitals. Similarly successful was the strategy of training Afghan physicians and nursing personnel in ISAF hospitals. But the assumption by ISAF medical services of full responsibility for the provision of basic medical care to larger sections of the civilian population must be seen in more critical terms. Although this kind of activity undoubtedly caused many Afghans to see the ISAF in a more positive light, it also tended to hinder the growth of Afghanistan’s own health care structures and delay recognition of the fact that it is the Afghan government that will eventually be the body responsible for health care.
Preventive medicine is essentially a national concern within the ISAF. This approach is rational as this means that each of the contributing nations is free to implement standards of preventive medicine that are better than the NATO standards within its own force. At the same time, the activities relating to the gathering of preventive medical data and the coordination of national activities need to be assigned to HQ ISAF. I would like to cite one example to illustrate this. In the middle of my tour of duty, evidence suddenly came to light that certain batches of the drinking water supplied in bottles could be contaminated with E. coli bacteria. Clearly, we had to follow up this information as quickly as possible, and determine whether this was a regional or ISAF-wide problem. It was necessary to disseminate appropriate information throughout the ISAF as a whole to the effect there was no extensive risk to health, but at the same time make possible a rapid decision at HQ as to the further procedures required. As the results of tests performed by the German laboratory in Mazar-el-Sharif showed that other batches could well be affected, the water in question was placed under quarantine and water was obtained on short notice from an alternative supplier. Fortunately, there were no documented cases of infection caused by the contaminated water. This example demonstrates that decisive and rapid information and coordination activities are required in such situations, not only to protect the health of the troops on the ground, but also to prevent confusion and misunderstandings arising.
Planning of military medical strategy
The various national sections of the ISAF are primarily provided with medical care through their own military medical organisations. This is a fundamental concept that should not be called into question, as this motivates the creation, maintenance and provision of medical services and resources by the individual contributing nations. On the other hand, more than 40 different countries contribute to the ISAF, and some of these are represented by tiny contingents of troops who are distributed throughout Afghanistan. As a result, it is essential that shared level II and III military field hospitals and air medevac services are available. While I was there, construction of the Common Funding Project role 3 Hospital at Kabul International Airport (KAIA) was nearing completion. It makes good sense to have a multinationally financed and administered role 3 hospital in an area in which a large number of different nations are dependent on communal health care facilities. The multinational input means that it is possible to provide medical care to a high standard, circumventing any potential problems associated with national shortages of resources. However, it is questionable whether this form of multinationalisation should also be extended to level I military medical care. Provision of health care by the individual nations should continue to be given precedence at this level, as this is the only way to ensure that there is appropriate allowance for differences in national practices and that service personnel can feel that the medical care they are receiving is not so dissimilar from what they could expect at home. I have personal knowledge of several cases in which service personnel preferred to travel larger distances and were willing to accept additional risks in order to be attended by a medical officer of their own nationality. It is often essential to employ a lead nation principle at headquarters that have a multinational staff for the purposes of the provision of medical services to military units, but multinationalisation at level I should not be extended to all operational areas.
At the core of ISAF operational military medical planning was the management of tactical forward air medevac. COMISAF had stipulated that the time for transport between the site at which the patient was wounded and a level II/III treatment facility was to be minimised. Transport times were documented, the procedures analysed, and the lessons learned were taken into account in planning. It became apparent that, because of the wide-ranging territory over which the ISAF was deployed, an extensive network of medevac helicopters was required if severely wounded personnel were to be provided with adequate treatment without unacceptable delay. In spring 2009, considerable effort was extended on the establishment of such a network in RCs South and East, but the contributing nations in RCs West and North were unable to find air rescue machines in sufficient numbers, and were confronted with large gaps in their medevac coverage. This not only has a consequence as far as timelines of treatment are concerned, but also places restrictions on the freedom to act of the commanders on the ground. An inadequate network of medevac helicopters also means that more medical personnel must be assigned to ground-based wounded transport vehicles, creating a shortage in the availability of this medical resource.
Another important aspect of military medical strategy planning that also required coordination of the various contributing nations was the treatment of civilians who had been wounded during NATO operations or as a result of the activities of insurgents. It was necessary to make it evident to the contributing nations of the ISAF that the treatment of civilian casualties was an approach through which the hearts and minds of the Afghan population could be won over and that the burden should be equally shouldered by all the nations. The main problem was to achieve some sort of balance between the regions with a high frequency of assaults, such as the area around Kandahar, and those less affected – such as RC North - by means of the provision of relief transport. It was also crucial to persuade those involved that medical and surgical resources that were not currently being used should not be extensively hoarded as reserves, but should be made available as potential support for regions that were under increased pressure.
Security situation and circumstances in Kabul
The situation 12 months ago was characterised by several major suicide attacks and concentrated assaults by the Taliban on some of the government ministries in Kabul. Whenever we drove through Kabul, there was always the thought at the back of our minds that one of the vehicles close to us on the busy roads could well be bearing a deadly load of explosives that might be triggered at any time. Although this meant that our vigilance was increased, we were determined not to let this impair our capacity to complete our assignments or limit our efficiency.
Our work was considerably facilitated by the fact that the department was provided with its own vehicle. We were thus able to arrange appointments and meetings with our Afghan counterparts without worrying about whether HQ would be able to arrange transport for us. No driver had been assigned to our department, so that all department personnel – from sergeant to colonel – had to have appropriate driver qualifications. It was a great advantage to have completed a field driving course at home, but HQ was also able to provide the necessary training.
It is essential, in order to negotiate the chaotic traffic on the streets of Kabul successfully, to exhibit aggression and consideration in the correct proportions – one needs to be aggressive to progress and not become a potential sitting target while consideration for other road users is vital to make sure that one does not attract attention as a member of the “occupying forces”.
Another of the aspects associated with working in Kabul is the high level of air pollution. A pall of smog envelops the city on a daily basis. Leave the city for a point on the high ground surrounding it, and it is possible to look down on this layer of haze and speculate about just what the millions of inhabitants are pumping out into the atmosphere every day. In view of the fact that their daily survival is currently of greater concern to them, the population has yet to come to grips with concepts such as environmental protection (figure). Many of the personnel at HQ complained of persistent coughs and I myself was plagued by this problem over my whole tour of duty.
All personnel deployed to the multinational melting pot that is a HQ of this magnitude need to be confident in the use of English, as this is the working language, and be familiar with the standard procedures of NATO staff operations. The contributing nations must thus ensure that they appropriately select and train the personnel they are assigning to these posts. The military medical services of the ISAF play an essential role in R&D. This means that suitable personnel are also needed in the J Med departments of RCs to support this process. Multinationalisation and common funding are important strategies that ensure that there is no unnecessary duplication of valuable resources, but these should only be employed for certain high level projects; level I medical care needs to remain in the hands of the various nations. The adequate provision of medevac helicopters to all Regional Commands is the method of choice if casualties are to receive timely treatment and the whole area over which the ISAF is deployed is to be covered – this will also mean that fewer physicians will need to be assigned to ground-based casualty transport units. The treatment of civilians wounded in conflict situations in ISAF military hospitals is an essential aspect of support of ISAF operations – burden sharing and the provision of relief transport by RCs in which there is a lower level of conflict is required to counter the effects in RCs in which there is a higher frequency of assaults.
Source: Medical Corps International Forum (1/10)