Humanitarian Assistance Missions Research Articles

Experiences of Deployed Physicians in Support of Operation Allies Refuge/Operation Allies Welcome: Lessons to Inform Improvements in Training.

Stability operations, including humanitarian assistance and disaster relief missions, are key functions of U.S. Military medicine and the Military Medical Humanitarian Assistance Course (MMHAC) is a 2-day course widely used to prepare military medical personnel for such missions. It focuses on caring for those most vulnerable in the wake of disasters, particularly children. The large-scale humanitarian deployment of military medical providers in support of Operation Allies Welcome/Operation Allies Refuge (OAW/OAR) presents an opportunity to evaluate the preparedness of these providers to care for the needs of the Afghan travelers, so we explored the experiences of military medical providers deployed in support of OAW/OAR to inform improvements in the MMHAC. We conducted a qualitative study of military medical providers who were deployed in support of OAW/OAR using a series of three virtual focus groups. Focus group questions were structured around the main topics covered in the MMHAC (patient care, ethical considerations, logistical concerns, and preventive and public health) and explicitly asked about adaptive leadership challenges faced and strategies used to overcome them. We analyzed transcripts using inductive thematic analysis within a constructivist paradigm, with adaptive leadership as a sensitizing concept. The study was approved by the Institutional Review Board of Uniformed Services University. We constructed 4 themes from participant responses, each addressing challenges that medical providers faced during their mission: (1) Medical providers navigated tension between medical and public health priorities and military mission priorities; (2) Chronic and complex care needs posed unique challenges for medical personnel; (3) Challenges in patient care were compounded by logistical and system-based barriers; and (4) Cultural barriers led to ethical dilemmas that physicians felt inadequately prepared to handle, most notably with respect to gender-related concerns. Within each theme, participants described which aspects of MMHAC training were most helpful and which areas were inadequate. Physicians found the OAR/OAW mission meaningful but also identified challenges related to medical care provision, public health, logistics, and ethical dilemmas that hindered their ability to carry out their medical mission. Lessons learned from OAW/OAR highlight several areas in which the MMHAC training could be augmented and improved to further mitigate these challenges.

Humanitarian Assistance Lessons Learned From Providing Acute Medical Care for Afghan Nationals on a U.S. Military Base.

Operation Allies Welcome provided a unique opportunity for military medical personnel to engage in humanitarian assistance operations on military bases in the USA. With thousands of Afghan nationals evacuated from Kabul in August 2021 to various military installations across the USA, the Military Health System was tasked with health screening, emergency care, and disease prevention and surveillance in resource-limited settings. Marine Corps Base Quantico served as a "safe haven" site from August to December 2021, providing refuge to nearly 5000 travelers awaiting resettlement. During this time, active duty medical personnel provided 10,122 primary and acute patient encounters to patients aged < 1 to 90 years. Pediatrics represented 44% of the total encounters and children aged less than 5 years represented nearly 62% of the pediatric visits. In caring for this population, the authors were able to learn important lessons about humanitarian assistance capabilities, the difficulties of establishing acute care centers in a resource-limited environment, and the importance of cultural competency. Recommendations include staffing with medical providers that can see a large volume of pediatric, obstetrics, and urgent care visits, with less emphasis on trauma and surgical capabilities, which are the more traditional focus of military medicine. To this end, the authors advocate for the creation of specific humanitarian assistance supply blocks that would focus more on urgent and primary care treatments as well as an ample supply of pediatric, neonatal, and prenatal medicines. Further, early engagement with telecommunications companies when practicing in a remote location can be crucial to mission success. Finally, the medical care team should maintain continued mindfulness of the cultural norms of the population to which aid is given, particularly the gender norms and expectations of Afghan nationals. The authors hope that these lessons can prove informative and may provide increased readiness for future humanitarian assistance missions.

Climate Change: An Opportunity for INDOPACOM

US Indo-Pacific Command should actively plan for operations to respond to and combat climate change because it will grow US influence in the region and provide a compelling alternative to China’s influence. Combating climate change supports the primary objective of countering China, operationalizes climate change response for US commanders, and offers a less threatening means to develop partnerships. Through qualitative analysis of threats to US security, current policy analysis, and select case studies of humanitarian assistance and disaster-relief missions to operationalize climate change as a US military mission, this article will assist US military and policy practitioners in planning for climate change in Southeast Asia and future exercises in the region.

A Decade of Surgery Aboard the U.S. Naval Ship COMFORT (T-AH 20).

The U.S. Naval Ship COMFORT has performed six humanitarian assistance and disaster relief mission since 2007. This paper describes the surgical volume per surgical specialty for five missions spanning 19 countries. Raw surgical case logs were analyzed for total case volume, total operating days, unanticipated return to operating room, and percentage of pediatric cases (<18 years old) for each country visited. Total surgical volume for the five missions was 5,142. The countries most frequently visited were Columbia and Haiti with seven and five visits, respectively. General surgery, ophthalmology, and plastic surgery have had consistent volume over time. Orthopedic surgery volume has steadily decreased with the exception of the 2018 mission. As volume in military treatment facilities declines, alternative sources of surgical volume for military surgeons are being examined. This paper highlights the historical volume which can inform future personnel planning requirements of U.S. Naval Ship COMFORT missions. With the exception of orthopedic surgery, surgical volume has remained consistent over the last decade. For future best practice, historical case data should be used to determine staffing needs on hospital ships and case logs and operating procedures and follow-up protocols should be standardized.

Portable Ultrasonography Onboard Deployment in the PLA(N) Peace Ark Hospital Ship in Mission Harmony 2018.

From June 28 to November 22, 2018, the Chinese People's Liberation Army Navy - PLA(N) - Peace Ark hospital ship had conducted Mission Harmony 2018, providing humanitarian medical assistance and carrying out international cooperation, in 4 Pacific island countries and 6 Central and South American countries. Compared with its application only in onshore outreach medical teams in the previous Mission Harmony, portable ultrasonography was used both onboard and onshore in Mission Harmony 2018. The purpose of this study was to assess the performance of onboard portable ultrasonography in PLA(N) Peace Ark hospital ship during Mission Harmony-2018, share our onboard working experience, and provide a reference for humanitarian assistance missions in the future. A retrospective review was performed on a cohort of patients checked by onboard portable ultrasonography. Patients' gender, age, the distribution of examined organs, and multiple applications of the portable ultrasonography were analyzed. Some limitations of portable ultrasonography on the mission and possible improvements in the future were also discussed. A total of 5277 cases (mean age: 43.74 years; range: 2 months-105 years) of ultrasound examinations were performed during the mission; among them, 3126 (59.2%) cases were performed by portable ultrasonography, including 3024 onboard cases and 102 onshore cases. The portable ultrasonography had been applied in many scenarios, for example, onboard emergency triage process, onboard bedside medical support, and onshore outreach medical service, which had become one of the indispensable auxiliary examination methods for its compatibility, portability, and flexibility. The onboard deployment of portable ultrasonography played a versatile and irreplaceable role in the humanitarian medical assistance and medical cooperation carried out by the PLA(N) Peace Ark hospital ship, and will contribute to such kind of missions in the future.

Utility of Point of Care Ultrasound in Humanitarian Assistance Missions.

Point of care ultrasound (POCUS) is increasingly used in primary care in the USA and has been shown to provide significant benefit to care in deployed military settings and during disaster relief efforts. It is less studied as a tool during humanitarian assistance missions. We sought to determine the utility of POCUS in a humanitarian assistance setting during the February 2019 joint U.S.-Brazilian hospital assistance mission aboard the Hospitalar Assistance Ship Carlos Chagas along the Madeira River in the Brazilian Amazon. Point of care ultrasound was offered as a diagnostic modality to primary care physicians during the course of a month-long mission. A handheld IVIZ ultrasound machine was loaned for use during this mission by Sonosite. A P21v phased array (5-1 MHz) or an L38v linear (10-5 MHz) transducer was used for scanning. Requests for POCUS examinations, their findings, and changes in patient management were recorded. Point of care ultrasound examinations were requested and performed in 24 of 814 (3%) outpatient primary care visits. Ten of these studies (42% of POCUS examinations, 1.2% of all patient visits) directed patient management decisions, in each case preventing unnecessary referral. In this austere setting, POCUS proved to be an inexpensive, effective tool at preventing unnecessary referrals. Future medical humanitarian assistance missions may likewise find POCUS to be a primary care force-multiplier.

Remote, informal, and ephemeral communities for testing technologies

Nowadays our world is more connected than ever, and as a consequence, truly isolated places on planet Earth are very rare. This is perhaps because humankind has always travelled beyond frontiers to explore faraway places, and also because technology enables the application of science and skills, and the extraction or collection of resources from new regions.Some technologies can change the current view and future expectations of our societies, and the way that people interact within their immediate environment. Remote communities offer the opportunity to research the next step in the evolution of technologies. Through the study of narratives, this paper investigates the remote, informal, and ephemeral communities of practices (RIE-CoP) that undertake the brief use of some technologies. The use of additive manufacturing technologies for improvised repairs, rapid tooling, the study of potential efficiency energetic measures, and previous tests in the Spanish Antarctic Base provide short-term benefits such as reducing emissions and logistics costs, and making life more sustainable on the frozen continent. Furthermore, these technology tests offer action-based research about the management and future of RIE-CoP under extreme conditions across four Antarctic missions (from December 2015 to March 2019). The experiences provide narrative foresight for the future RIE-CoP, and the results are valuable in sectors such as military and humanitarian assistance, construction, and space missions.

Developing the Prototype Embedded Health Engagement Team.

Small, well prepared, culturally competent, and embedded health engagement teams (EHET) tailored to work within a partner health system, rather than outside of it, will achieve greater mutual benefit, desired military objectives, and better health outcomes for the United States Department of Defence and its partners. EHETs have significant advantages over traditional methods of choice for health security cooperation and humanitarian assistance missions. These advantages include enhanced capability and capacity building, greater trust through intentional cultural expertise, a ready platform for enduring relationships, enhanced host nation legitimacy, and flexibility to target specific issues with greater fidelity. We must first define a prototype EHET, compare the concept against prior units that have executed health engagement, and test it prospectively in employment. The U.S. military and the civilian business world each have extensive experience in employing small teams that the health community can emulate. The ideal EHET should have the following nine characteristics: 12 people or fewer, skillsets for the tasks, global health knowledge, be multidisciplinary, a balance of experience, local language capability, geopolitical and cultural competence, targeted preparation for specific security and health objectives, and joint representation. This paper will explore these components of the prototype EHET as it will be tested in our research project.

Rationale for Military Involvement in Humanitarian Assistance and Disaster Relief.

Good relations and trust are the foundation of soft power diplomacy and are essential for the accomplishment of domestic interventions and any bilateral or multilateral endeavor. Military use for assistance and relief is not a novel concept, but it has increased since the early 1990s with many governments choosing to provide greater numbers of forces and assets to assist domestically and internationally. The increase is due to the growing lack of capacity in global humanitarian networks and increasingly inadequate resources available to undertake United Nations humanitarian assistance and disaster relief (HADR) missions. In response, the military has been more proactive in pursuing the improvement of military-to-military and military-to-civilian integration. This trend reflects a move towards more advanced and comprehensive approaches to security cooperation and requires increased support from the civilian humanitarian sector to help meet the needs of the most vulnerable. Military assistance is progressing beyond traditional methods to place a higher value on issues relating to civil cooperation, restoring public health infrastructure, protection, and human rights, all of which are ensuring a permanent diplomatic role for this soft power approach.

Military Telehealth: A Model For Delivering Expertise To The Point Of Need In Austere And Operational Environments.

Austere clinical environments are those in which limited resources hamper the achievement of optimal patient outcomes. Operational environments are those in which caregivers and resources are at risk for harm. Military and civilian caregivers experience these environments in the context of war, natural disasters, humanitarian assistance missions, and mass casualty events. The military has a particular interest in enhancing local caregiver capabilities within austere and operational environments to improve casualty outcomes when evacuation is delayed or impossible, reduce the cost and the risk of unnecessary evacuations, enhance the medical response during aid missions, and increase combat effectiveness by keeping service members in the fight as long as possible. This article describes military telehealth as it relates to care in austere and operational environments, and it suggests implications for policy, particularly with respect to the current emphasis on telehealth solutions that might not be feasible in those settings.

Observations of Pediatric Disease Prevalence from Pacific Partnership 2015.

Pacific Partnership is an ongoing yearly humanitarian assistance mission to Pacific Rim countries. Although many case reports and surgical successes have been documented, few data have been published specifically about the primary care mission. This article analyzes outpatient pediatric data collected during Pacific Partnership 2015. Eleven different providers documented care delivered to children from birth through age 18 yr, inclusive. Personally de-identified data were entered into spreadsheets, sorted according to country visited, and analyzed with IBM SPSS software looking for disease frequency. One thousand eighty-seven pediatric patients were seen across Fiji, Papua New Guinea (PNG), and the Philippines (PI). Asthma was the first, second, and third most prevalent diagnosis in PNG, Fiji, and PI, with a relative proportion of the total patients seen at 5.4%, 7.2%, and 5%, respectively. In PI, 123 cases of upper respiratory infection were seen, more than four times the next most common diagnosis of normal exam. Thirty-six patients with scabies were seen in Fiji (number 1), with abdominal pain at number 3 (26 cases, 6.5%). Surprisingly, helminths were rarely seen, comprising the sixteenth and fourteenth most common diagnoses in Fiji and PI and only two cases in PNG. Future Pacific Partnership missions can plan medication stock, personnel assignment, equipment needs, and educational literature based on these data.

Medical resource preparation and allocation for humanitarian assistance based on module organization

This research aims to associate the allocation of medical resources with the function of the modular organization and the possible needs for humanitarian assistance missions. The overseas humanitarian medical assistance mission, which was sent after a disaster on the hospital ship Peace Ark, part of China's People's Liberation Army (PLA) Navy, was considered as study model. The cases used for clustering and matching sample formation were randomly selected from the existing information related to Peace Ark's mission. Categories of the reusable resources clustered by this research met the requirement of the actual consumption almost completely (more than 95%) and the categories of non-reusable resources met the requirement by more than 80%. In the mission's original resource preparing plan, more than 30% of the non-reusable resource categories remained unused during the mission. In the original resource preparing plan, some key non-reusable resources inventories were completely exhausted at the end of the mission, while 5% to 30% of non-reusable resources remained in the resource allocation plan generated by this research at the end of the mission. The medical resource allocation plan generated here can enhance the supporting level for the humanitarian assistance mission. This research could lay the foundation for an assistant decision-making system for humanitarian assistance mission.

Humanitarian Assistance and Disaster Relief mission by a tripartite medical team led by the Singapore Armed Forces after the 2015 Nepal earthquake

This study aimed to report the injury or disease patterns, challenges, key observations, and recommendations by the Singapore Armed Forces (SAF) team that embarked on an Humanitarian Assistance and Disaster Relief (HADR) mission in the aftermath of the April 2015 Nepal earthquake. The SAF medical team that provided HADR assistance to Nepal consisted of personnel from the SAF, Singapore¢s Ministry of Health and the Royal Brunei Armed Forces. Upon arrival in Kathmandu, Nepal, the SAF medical team was assigned to the Gokarna district by the local health authorities. In addition to providing primary healthcare, the medical facility was equipped to perform resuscitation and minor procedures. We also assembled mobile medical teams (MMTs) that travelled to various remote areas of the country to deliver medical aid. A total of 3,014 patients were managed by the SAF medical team. Of these patients, 1,286 (42.7%) were men. 574 (19.0%) patients sustained earthquake-related injuries or illnesses, while 2,440 (81.0%) sustained non-earthquake-related injuries or illnesses. The team treated a total of 447 (77.9%) adults and 127 (22.1%) paediatric patients with earthquake-related injuries or illnesses. A significant number of patients developed exacerbations of underlying medical conditions. 2,161 (71.7%) patients were treated in our main facility in Gokarna, while 853 patients (28.3%) were treated by our MMTs. The ability to transport healthcare personnel and essential medical equipment within a short time allowed the SAF medical team to provide crucial medical care in the aftermath of the 2015 Nepal earthquake.

Incidence and risk factors for disease and non-battle injury aboard the hospital ship USNS COMFORT during a Humanitarian Assistance and Disaster Response Mission, Continuing Promise 2011.

BackgroundDisease and non-battle injury (DNBI) are a leading cause of morbidity in deployments and can compromise operational mission performance. No study to date has examined DNBI incidence and impact aboard humanitarian aid/disaster response (HADR) mission ships.MethodsFrom April to September 2011, US military and civilian personnel participated in Continuing Promise 2011, a HADR training mission aboard USNS COMFORT (T-AH 20). Health surveillance was conducted for the purpose of assessing DNBI trends and improving force health protection during the deployment through passive surveillance, collection of DNBI data among those seeking care at the ship’s clinic, and actively through use of an anonymous weekly, self-report questionnaire. Categorical and total DNBI incidence rates were calculated per 100 person-weeks and incidence rate ratios (IRR) were calculated utilizing a negative binomial model to assess potential risk factors.ResultsThe leading syndrome-specific cause of weekly visits to the ship’s clinic was gastrointestinal (GI) followed by dermatologic and respiratory conditions (2.22, 1.97, and 1.46 cases per 100 person-weeks, respectively). The top three categorical DNBI were similarly represented by the questionnaire, with respiratory conditions having the highest reported rate followed by dermatologic and GI (11.79, 8.71, and 7.38 cases per 100 person-weeks, respectively). GI had the highest morbidity measures accounting for 61.9 % of lost work days and 27.3 % of reported moderate/severe impact to mission performance. Several factors were also associated with increased DNBI rates including personnel ages 26–36 (IRR = 1.23), officers (IRR = 1.23), days-off-ship (IRR = 1.09), and affiliation with nursing services (IRR = 1.48), naval mobile construction battalion (IRR = 3.17), and security (IRR = 1.71).ConclusionsDNBI can significantly impact mission performance on HADR missions, and establishing baseline rates and identifying risk factors can help improve force health protection in future HADR missions.

Military Foreign Humanitarian Assistance and Disaster Relief (FHA/FDR) Evolution: Lessons Learned for Civilian Emergency Management Response and Recovery Operations

The military and civilian models for emergency management differ significantly in both structure and execution. In order to appreciate the differences, similarities, and potential value of each approach, it is important to first frame these systems through a common lens of the emergency management cycle, mission areas, and system, as practiced in the United States. This analysis deliberately does not focus on the use of military in support of domestic emergency management operations within the United States. Instead, case studies were carefully chosen to highlight the military contribution to international disaster response through foreign humanitarian assistance (FHA) and foreign disaster relief (FDR) military mission. Ultimately the strengths and weaknesses of these military emergency support operations were assessed and lessons learned extracted. These lessons learned were then aligned with the civilian model and recommendations made suggesting the adoption of military techniques to civilian emergency management actions in response to catastrophic disasters.

China's Engagement with Regional Security Multilateralism: The Case of the Shangri-La Dialogue

Making sense of the implications of China's rise has become something of a scholarly industry. Given its scale, civilizational legacy and its place at the heart of the global economy, this is entirely appropriate. In International Relations (IR) debate the main focus is on whether China's economic growth is likely to lead to conflict with the United States and its allies. Some commentators argue that war between a dominant and rising power is almost inevitable, (1) while others contend that it can be avoided. (2) More liberally minded scholars make the case that China's interests are not well served by contesting power with the world's largest military, which also happens to be its biggest customer. (3) At the heart of this particular debate about the implications of China's rise is the extent to which a more prosperous and powerful China is likely to be a status quo or revisionist state. (4) Will a richer and more confident China accept existing arrangements or will it seek to rewrite the rules of the game? This question is of interest in many spheres, from trade policy to monetary arrangements, international institutions to development programmes; whether China supports or changes the established order has implications across almost every imaginable international policy field. One of the most important developments in international security policy in the post-war period has been the emergence of multilateral security cooperation as a core part of almost every state's security arrangements. Prior to 1945, apart from some ill-fated experiments at the League of Nations, multilateral security cooperation barely existed. Groups might form strategic alliances--as they did so disastrously prior to the First World War--but there was nothing resembling the scale, volume or frequency of the gatherings that now so routinely occur. States today regularly gather in multilateral groupings to collaborate on a vast array of security matters. This includes everything from cooperation to combat non-traditional security concerns such as infectious diseases and organized crime to multinational humanitarian assistance and disaster relief (HA/ DR) training missions, from institutionalized summitry to gatherings of defence college heads. Prompted by the expansion of security challenges caused by globalization, changes in the understanding of what constitutes a security threat and broader normative shifts in world politics--perhaps the most important being the strong norm curtailing the use of force--multilateralism in security policy has become core business for all states. In Europe the embrace of multilateral approaches to security began shortly after the end of the Second World War. In the nascent structures of what became the European Union (EU), such as the Council of Europe, the European Atomic Energy Community (EURATOM) and the European Coal and Steel Community (ECSC), states began to work collectively to advance commonly held security aims. In East Asia, the turn to multilateralism was rather more circumspect. During the Cold War, security arrangements were almost entirely in the hands of states themselves or organized through traditional bilateral alliances. Efforts such as the Southeast Asian Treaty Organization (SEATO) and the Five Power Defence Arrangements (FPDA) were very much the exception and at the margins of strategic influence. Beyond these, perhaps the only example of an institution associated with security multilateralism was the Association of Southeast Asian Nations (ASEAN) that was founded in 1967. Intended to provide an international framework to produce more harmonious regional relations, and as a bulwark against communist insurgency, this new body had some security dimensions. (5) Yet it was still principally a means to support the broader state and nation-building projects of societies newly liberated from European and Japanese imperialism. Since the mid-1990s, however, East Asian states have made up for lost time and have created a wide range of multilateral processes and institutions with security as a key part of their purpose and rationale. …

Professionalization of anesthesiologists and critical care specialists in humanitarian action: a nationwide poll among italian residents.

Over the last decades, humanitarian crises have seen a sharp upward trend. Regrettably, physicians involved in humanitarian action have often demonstrated incomplete preparation for these compelling events which have proved to be quite different from their daily work. Responders to these crises have included an unpredictable mix of beginner-level, mid-level, and expert-level providers. The quality of care has varied considerably. The international humanitarian community, in responding to international calls for improved accountability, transparency, coordination, and a registry of professionalized international responders, has recently launched a call for further professionalization within the humanitarian assistance sector, especially among academic-affiliated education and training programs. As anesthetists have been involved traditionally in medical relief operations, and recent disasters have seen a massive engagement of young physicians, the authors conducted, as a first step, a poll among residents in Anesthesia and Critical Care Medicine in Italy to evaluate their interest in participating in competency-based humanitarian assistance education and in training incorporated early in residencies. The Directors of all the 39 accredited anesthesia/critical care training programs in Italy were contacted and asked to submit a questionnaire to their residents regarding the objectives of the poll study. After acceptance to participate, residents were enrolled and asked to complete a web-based poll. A total of 29 (74%) of the initial training programs participated in the poll. Out of the 1,362 questionnaires mailed to residents, 924 (68%) were fully completed and returned. Only 63(6.8%) of the respondents voiced prior participation in humanitarian missions, but up to 690 (74.7%) stated they were interested in participating in future humanitarian deployments during their residency that carried over into their professional careers. Countrywide, 896 (97%) favored prior preparation for residents before participating in humanitarian missions, while the need for a specific, formal, professionalization process of the entire humanitarian aid sector was supported by 889 (96.2%). In Italy, the majority of anesthesia/critical care residents, through a formal poll study, affirmed interest in participating in humanitarian assistance missions and believe that further professionalization within the humanitarian aid sector is required. These results have implications for residency training programs worldwide.

HAMPP: A Handheld Assistant for Military and Police Patrols for HA/DR Missions

Military and police patrols are an important component of Humanitarian Assistance and Disaster Relief missions. These patrols need to access timely, relevant information about events and conditions along their patrol route, both historical, and ongoing. In the current practice, this information is gathered manually prior to the commencement of the patrol through the use of historical databases, current event repositories, and by conducting a review of records that may be relevant to the area to be patrolled. Being manual, this process is fraught with several problems including high-cost, slow-speed and low-reliability.We are developing HAMPP (Handheld Assistant for Military and Police Patrols) to enhance the effectiveness and security of the patrol units and reduce the cost and time required for patrol planning. HAMPP is designed to assist with gathering detailed information about relevant events along the patrol route and alert the patrol unit when they are in the vicinity of these areas during the patrol. In addition, it performs several other activities which relate to the security of the patrol unit. The goal of this paper is to present our system architecture for a device-independent mobile software system that enables planning of the patrol route and linking of related information to that route, and as the patrol starts, tracking the unit's current location and providing real-time information and alerts about areas of interest along the route of a patrol. Any deviations from the planned route are flagged and alerts sent to the command post.

Reshaping US Navy Pacific Response in Mitigating Disaster Risk in South Pacific Island Nations: Adopting Community-Based Disaster Cycle Management

The US Department of Defense continues to deploy military assets for disaster relief and humanitarian actions around the world. These missions, carried out through geographically located Combatant Commands, represent an evolving role the US military is taking in health diplomacy, designed to enhance disaster preparedness and response capability. Oceania is a unique case, with most island nations experiencing "acute-on-chronic" environmental stresses defined by acute disaster events on top of the consequences of climate change. In all Pacific Island nation-states and territories, the symptoms of this process are seen in both short- and long-term health concerns and a deteriorating public health infrastructure. These factors tend to build on each other. To date, the US military's response to Oceania primarily has been to provide short-term humanitarian projects as part of Pacific Command humanitarian civic assistance missions, such as the annual Pacific Partnership, without necessarily improving local capacity or leaving behind relevant risk-reduction strategies. This report describes the assessment and implications on public health of large-scale humanitarian missions conducted by the US Navy in Oceania. Future opportunities will require the Department of Defense and its Combatant Commands to show meaningful strategies to implement ongoing, long-term, humanitarian activities that will build sustainable, host nation health system capacity and partnerships. This report recommends a community-centric approach that would better assist island nations in reducing disaster risk throughout the traditional disaster management cycle and defines a potential and crucial role of Department of Defense's assets and resources to be a more meaningful partner in disaster risk reduction and community capacity building.

Hospital Ships Adrift? Part 2: The Role of US Navy Hospital Ship Humanitarian Assistance Missions in Building Partnerships

US Navy hospital ships are used as a foreign policy instrument to achieve various objectives that include building partnerships. Despite substantial resource investment by the Department of Defense (DoD) in these missions, their impact is unclear. The purpose of this study was to understand how and why hospital ship missions influence partnerships among the different participants. An embedded case study was used and included the hospital ship Mercy's mission to Timor-Leste in 2008 and 2010 with four units of analysis: the US government, partner nation, host nation, and nongovernmental organizations. Key stakeholders representing each unit were interviewed using open-ended questions that explored the experiences of each participant and their organization. Findings were analyzed using a priori domains from a proposed partnership theoretical framework. A documentary review of key policy, guidance, and planning documents was also conducted. Fifteen themes related to how and why hospital ship missions influence partnerships emerged from the 37 interviews and documentary review. The five most prominent included: developing relationships, developing new perspectives, sharing resources, understanding partner constraints, and developing credibility. Facilitators to joining the mission included partner nations seeking a regional presence and senior executive relationships. Enablers included historical relationships and host nation receptivity. The primary barrier to joining was the military leading the mission. Internal constraints included the short mission duration, participant resentment, and lack of personnel continuity. External constraints included low host nation and United States Agency for International Development (USAID) capacity. The research finds the idea of building partnerships exists among most units of analysis. However, the results show a delay in downstream effects of generating action and impact among the participants. Without a common partnership definition and policy, guidance, and planning documents reinforcing these constructs, achieving the partnership goal will remain challenging. Efforts should be made to magnify the facilitators and enablers while developing mitigation strategies for the barriers and constraints. This is the first study to scientifically assess the partnership impact of hospital ship missions and could support the DoD's effort to establish, enable, and sustain meaningful partnerships. Application of the findings to improve partnerships in contexts beyond hospital ship missions may be warranted and require further analysis. This unique opportunity could bridge the rift with humanitarian actors and establish, enable, and sustain meaningful partnerships with the DoD.