In 1989, Serbian forces dissolved the government of the local Kosovars and absorbed the Kosovar health system into the Serbian administration. This move dramatically limited access to healthcare for the people of Kosovo. Three years later, the Kosovo Liberation Army’s (KLA) increasingly violent clashes with Serbian forces highlighted the need for a Kosovar field health system, serving both combatants and civilians.
The article “Field-Improvised War Surgery in Kosovo: Use of Kitchen Utensils as Surgical Instruments” [gated] in the journal Military Medicine tells the compelling story of a Kosovar field hospital hidden in the Molopolce mountain region:
The conflict in Kosovo left surgeons and medical personnel with limited supplies during a time of war. The field hospital, located in a three-story building in the Molopolce mountain range, consisted of one operating theater, one recovery room, one examination room, and a room where minor surgical procedures could be performed (Fig. 1). At the Nerodime field hospital, skilled surgeons had to resort to the use of simple kitchen utensils as tools in the operating theater. Utensils with handles of plastic were transformed into retractors and used during major abdominal operations (Fig. 2, 3). The concavity of tablespoons was taken advantage of, allowing these utensils to be employed as retractors during appendectomy procedures. A light used for theatrical stage shows was improvised and used to illuminate the surgical field during procedures at the field hospital.
In addition to the main field hospital, the Kosovars established several second-line clinics consisting of one physician and three nurses working out of a private home. These clinics treated postoperative and minor wounded patients, thus increasing bed avalilablity in the main field hospital.
The incredible story of this make-shift health system in the Molopolce includes an equally dramatic ending.
After a NATO air strike on Yugoslavia in March 1999, the Serbian campaign more aggressively bombarded the Molopolce mountain region. A Serbian operation was launched in the eastern and southern areas and advanced in the direction of the KLA-controlled area. Eventually, an emergency midnight evacuation of all medical staff, patients, and remaining medical equipment was necessary. This evacuation was accomplished on a footpath through the hills with doctors and other medical personnel carrying patients on hand stretchers to a previously established rendezvous point located in a cave.
I have been holding back mentioning anything until the details were finalized. However, as of this morning everything is set and confirmed. Therefore, I am pleased to announce I will be accompanying the USS Kearsarge (LHD-3) for the first two weeks of her deployment as part of Operation Continuing Promise, and (most importantly) taking War & Health’s readers along for the ride!
In early August, I will be blogging onboard the Wasp-class amphibious assault ship as it deploys to South America to provide humanitarian and medical assistance. Readers of War & Health will get to see a US Navy humanitarian assistance mission from the inside. Is the USS Kearsarge equipped to be a floating hospital? How well does the US Navy interact with humanitarian NGOs? Does providing health care really win minds and wills? Is the US Navy an appropriate tool for delivering long term medical care? Are humanitarian deployments the white fleets of the 21st century? Does Chris get sea-sick? All these questions and more will be tackled through daily (hopefully more) articles on War & Health.
So, stay tuned to War & Health, it is going to be one heck of a journey!
And, if you haven’t subscribed to War & Health already, now is your chance to get regular updates sent straight to your feedreader.
Bill Murray from The Long War Journal has a good article about a new water distribution site in Baghdad. The $400,000 water facility will provide free water to 3,000 families and cover 60% of the need in the area. Two additional sites under construction will provide the remaining 40%. However, the most interesting fact about the facility is its location:
Water from the site, located within the walls of a US-operated Forward Operating Base, is then piped underneath the 15-foot-high reinforced concrete barriers surrounding the base to taps at a drive-through location.
In that community, Iraqis receive their water directly from a US FOB, a fact that speaks volumes about the securitization of services. Specifically, this is notable for two reasons. First, the placement of the water facility inside the FOB might very well discourage attacks, since an attack on the FOB is also, literally an attack on the community’s access to water. Second, the location gives US and Iraqi security forces full credit for providing the service. That is, the population physically visits the FOB to collect their water and knows clearly who provided it, winning hearts and minds. This point was apparently not lost on the Iraqi security forces:
As services return to the area after many years of sanctions, neglect and civil unrest, police expect increased access to information about the Shia insurgency, because the area has been a haven for arms caches and terrorist cells associated with Muqtada al Sadr’s Madhi Army and Iranian trained “Special Groups.”
Winning hearts and minds, gaining useful intelligence, and providing free, clean water to a poor community. That is a trio anyone can appreciate.
I am a first generation American from Zimbabwean parents, and so the recent events in Zimbabwe have had a particular personal significance. On April 29th, the Times Online reported on the growing evidence Zimbabwean government officials, including the Minister of Health, are using the nation’s health system to facilitate violence against opposition supporters. Accusations include using hospital grounds for political rallies, threatening physicians treating opposition victims of violence, raiding medical wards, and seizing patient lists. Opposition members have reportedly resorted to seeking treatment at sympathetic private clinics.
As evidence of increasing government-sponsored violence against the Zimbabwean opposition mounts a pattern is emerging of deliberate attempts to obstruct medical treatment for its victims and to cover up the violence. The Zimbabwean Minister of Health and other doctors who are linked to the ruling party have been implicated in orchestrating the violence and using government medical facilities for their activities.
The US Ambassador to Zimbabwe James McGee (my new hero) experienced this first hand in May when himself and other diplomats were detained for 45 minutes after visiting hospitals outside the capital to document violence against opposition supporters.
The diplomats involved in the incident at a roadblock on the edge of the capital, Harare, had just completed a tour of hospitals and an alleged torture camp when police demanded they prove they had official permission to visit the sites.
At one point, a police officer threatened to beat one of Mr. McGee’s senior aides. The officer got into his car and lurched toward Mr. McGee after he had demanded the officer’s name. The car made contact with Mr. McGee’s shins, but he was not injured.
Mr. McGee climbed onto the hood of the car while his aide snatched the keys from the ignition, then the diplomats used their mobile phone cameras to take photographs of the officer.
Zimbabwe’s healthcare system is already in deep trouble and these reports do not make me hopeful for the country’s health prospects in the future.
Today, the Combined Arms Center’s Inter Agency Symposium is taking place. The purpose of the gathering is admirable and ambitious:
It has become apparent that success in Twenty-first Century Warfare requires a “whole of government” or unified approach. The nation must utilize all elements of National Power to ensure victory in this era of persistent conflict. Over the next two days, members from across our government will meet to discuss these issues. It promises to be an insightful and spirited debate which will create a clearer picture for the way ahead as we conduct complex stability and support operations.
The symposium is being liveblogged and yesterday they solicited questions through the internet for the panel to answer. Able to see an opportunity when presented to me on a silver platter, I submitted the following question:
Following the notion of a “whole of government” approach, what role does the provision of health services play in ensuring victory in future conflicts?
Very kindly, panelist Dr. Stephen Redd, Naval Officer and Director of Pandemic Influenza Surveillance Unit, responded:
Providing healthcare is very important in all operations including stability operations. By caring for the health of the populance, a government shows it is responsive to the basic needs of its people. In addition, the provision of healthcare gives people confidence in their government. Most stability operations take place in states that are weak or failing. One definition of a failing state is its inability to provide for the needs of its people. Hence, by providing healthcare, a state begins to strengthen and demonstrate its ability to reverse some of the trends that led it to become a weak or failed state in the first place.
Dr. Redd’s response is excellent and demonstrates a firm understanding of the dynamics between health services and political stability. I agree whole heartedly. To win hearts and minds, governments must prove themselves as legitimate institutions. The provision of health services is a key opportunity to gain that legitimacy in a value-added, cost-effective manner. Hopefully, through more discussions like the CAC’s IA symposium, health services will take a more prominent role in future stability operations.
Last friday at 9:30pm local time, a Taliban suicide bomber detonated his vehicle at the gate of Kandahar city’s Sarposa prison. Following the blast, witnesses report 30 motorcycles entered the breach and blew a second hole in the rear wall of the prison. During the following firefight nine hundred prisoners escaped.
Colonel Thomas J. McGrath of the Afghanistan Regional Security Integration Command - South (ARSIC-South), attended a Department of Defense Blogger’s Roundtable this morning to discuss the aftermath of last week’s prison break in Kandahar. You can listen to the entire conference call here. Significant to this blog, according to Col. McGrath the prison break has had no immediate effect on humanitarian, MEDCAP, or PRT programs. That is good news, however I worry the increased Taliban presence in the region might disrupt the programs in the future. Nevertheless, Col. McGrath was confident in the ability of Afghan and Coalition forces not to be derailed by the prison break, “We are making a lot of progress here.”
We wish him luck.
The 20/20 Health Systems Project just launched with a new web-accessible database of health systems statistics:
The Health Systems Database draws data from publicly available and internationally comparable databases. Sources are publications from the World Health Organization (WHO), the World Bank, and the United Nations Children’s Fund (UNICEF). More recent data may be available from other sources including in-country sources. The user contribution section of this tool is designed to capture and share such information.
Hat tip to the Global Health Policy blog.
Full list of variables in the datasets after the break.
At approximately 10:00am on May 3rd, the United States fired three precision-guided weapons at a small building next to Sadr General Hospital in the Sadr City slum of Baghdad. The building is alleged by coalition forces to be a “criminal element command and control center“. The first munition struck the small building, the second struck the hospital’s ambulance parking lot and broke the hospital’s water line, and the third hit a generator used by the neighborhood but not the hospital.
McClatchy’s Leila Fadel and Shashank Bengali described the damage:
Sadr Hospital, one of two main hospitals serving the massive Shiite Muslim slum, is operating on a backup water supply that wasn’t expected to last longer than 48 hours. On Sunday afternoon, a main street outside the hospital was flooded as workmen tried to repair a series of underground pipes that ruptured when the missiles targeted what U.S. military officials described as a militia outpost a few yards from the hospital.
“If there are no more attacks, we might be able to fix it. We don’t know,” said a hospital security official who gave his name as Abu Sajjad. “Otherwise, in two days we will run out of water and the hospital can’t go on.”
The official said that the U.S. strike also damaged 15 ambulances and forced many hospital staff to flee. Not everyone returned to work Sunday, leaving a Spartan emergency ward nearly empty of doctors.
The airstrike betrays an understandable ignorance in coalition forces towards the nature of health care delivery. While coalition forces avoid targeting hospitals directly, this does not protect the ability of the hospital to function. The rational for not striking hospitals is to keep them operating and providing health to the local population. However, any hospital’s functions are reliant on a large network of facilities and services. This network includes ambulance facilities and water lines. Most of these network nodes exist outside the hospital’s physical perimeter and whose presence is not calculated into airstrike planning. If policy makers truly want to maintain access to healthcare during armed conflict they must consider not only the hospital’s physical facilities but also key nodes in the area’s health care network, regardless of whether or not they fly the red cross.
Oops! Looks like some intern forgot to renew the domain name and now the Iraqi Ministry of Health website is owned by a domain squatter. H3r8?/\L V1AG4A ne1?
Sigh.
Hat Tip: FP Passport
The Long War Journal has a gallery of photos from the Sayafiyah Combined Medical Engagement (CME) clinic.
The CME was set up as an outreach program to provide needed medical care and help establish Coalition forces as an agent of goodwill amongst the people in Sayafiyah and Al Sur. The 5/7 Cav has conducted numerous CMEs during its time in Iraq, which helped the CME in Sayafiyah to come together smoothly.
The key to hearts and minds is jobs and health care. If the US is serious about rebuilding its image in the world, these medical operations must be more than token photo-ops and be placed at the core of US global strategy.