 Good afternoon. Is that better? Can people hear me in the back? Yes, we got the thumbs up. All right. I'm Gene Bonventry on behalf of the Center for Strategic and International Studies Welcome To this late afternoon event looks like a pretty good turnout a lot of familiar faces in the in the crowd Before I introduce our two guest speakers today. I want to tell you a little bit about About CSIS Hopefully, that's the only acronym that I'll use today But we'll see for sure stop us if we use too many too many acronyms Center for Strategic and International Studies got interested in health issues a couple of years ago Last year stood up a global health policy Center run by Steve Morrison with funding from the Gates Foundation Steve Did several things to look at health one of which was to form a commission? on global health policy to put some recommendations together for the Obama administration on What the US government should do regarding global health? That Commission's co-chaired by retired Admiral Bill Fallon and Helene Gale who was the CEO of care They've had well, they're about to have another meeting this week. I believe they've had two so far One of the papers that they presented was measuring the impact of of global health Engagement says the US government decides what's important in health and what's not in addition to the Commission, but separate from the Commission Steve has also asked myself and Jim Peek is a retired Army Surgeon General and former Secretary of Veterans and Veterans Affairs To put together a working group to look at the intersection of global health and national security So I think today's discussion really will feed into both groups and I see many members of the Working group here today. Thank you for coming gentlemen. I hope this contributes to our work, what we'll do is I'll introduce both of our speakers captain Turbush will go first Both presentations are are short enough to be stimulating and should provoke some questions And some discussion and we'll have plenty of time available afterwards for discussion So on my far right is captain Jim Turbush in his Navy winter uniform Oh, you're gonna, ah, okay Well, that's right. I'll continue to introduce captain Turbush Okay, we'll introduce you captain Turbush is the command surgeon for us naval forces southern command So we most of you know south com southern command. He's the command surgeon for the naval component of that He's also the command surgeon for the fourth fleet And both these gentlemen will tell us a little a little bit more about the about the fourth fleet You have captain Turbush and commander Hartgurings bio, so I'm not gonna go into detail other than to point out that Captain Turbush has done private practice He's worked for the Foreign Service has a master's degree in public health And has done a residency in preventive medicine and aerospace medicine so I can't think of a more varied experience for someone to fill his position and Then on my right commander Brad Hartgurink is a special assistant for humanitarian assistance and disaster response in the Navy Bureau of Medicine and surgery And his background is in is in nursing. He's been a nurse anesthetist since 1996 He served aboard the Comfort hospital ship in 2007 when it deployed to Central and South America and right now he's chair of the Navy medicines humanitarian assistance and disaster response working group So I'll ask him to start off with his presentation Navy Bureau of Medicine and Surgery is so View med is the central administrative headquarters for the Navy Medical Department and We're primarily responsible for for writing policy That supports the Navy medicine enterprise and also provides guidance to the fleet view med also we also are heavily engaged especially now with everything going on in Afghanistan and in sourcing our personnel to all types of missions whether it's humanitarian or or Combat roles so Again a very busy shop at at view med One thing that view med does not do and that is planning Humanitarian missions. I can't tell you how many people over the years have have said, you know when they find out what I do They'll say well Are you involved in all the planning of the missions or are you just be med plan the missions? And we don't do that and as many folks here in the audience know that that the planning happens at the geographic combatant command by the geographic combatant commanders like sent com and south com or southern command and and And southern command And also the component commands like fourth fleet where captain Turbush is and and medical Department officers only make up a small piece of the overall planning of those missions, so You know again, I just want if you take nothing else out of my lecture. It's that you know that the most all the planning occurs at the at the combatant commander level And then I just wanted to quickly define the medical stability operations And that's military and civilian activities conducted across the spectrum from peace to conflict to establish or maintain Order in states and regions Just a little bit of background so so when we get to what we're doing in our working group you understand why and The first one is sSTRO and it stands for stability security transition reconstruction operations and And again, I don't want to get caught up in the numbers or anything But there in 2005 there was an instruction the doD 3,000 point zero five and and this was really transformative In that it gave it states that the core mission. We will be prepared to conduct and support so so And it also be given priority comparable to combat operations And addressed and integrated across all activities, so they're looking at Throughout the military organization addressing doctrine organization training education exercises material leadership personnel facilities and planning and Within these sSTRO operations medical is only a small piece. They may be addressing Agricultural concerns they may be addressing The legal system within a particular country or training police to keep security So again medical is only a small piece of of the sSTRO operations Now this instruction also states that there will be integrated civilian and military efforts And they're in that that is key to successful stability And the important part which I think really gets to You know all the folks in the audience today is that doD shall be prepared to work with all relevant U.S. Departments and agencies and then foreign governments and security forces international organizations u.s. And foreign NGOs and also the private sector so just recently the assistant secretary defense for health affairs came out with a DoD D the six thousand point little a little a and and again this is to address the military health support for for the sSTRO And specifically they're asking us to organize and equip and train medical personnel to effectively execute these military Stability operations it also ensures that we that R&D programs will address MSO capabilities and will also develop measures of effectiveness to develop progress so this sort of leads us to what we're doing it at BUMED and In April of this year the deputy surgeon general Admiral Cullison Chartered this this Navy medicine humanitarian assistance and disaster response working group and With this working group we have four subcommittees. The first is medical logistics subcommittee and what we're really looking at here is is Updating the supply list for the hospital ships what we have found is You know these ships have been deployed for combat operations in the past and and so a lot of the supplies and equipment on On the on board these ships is specifically for that purpose so by What we need to do after going after being on several these missions We've we've definitely discovered that there are a lot of supplies that need to be added to the To the supply list that In inventory that will be there throughout the future missions The next subcommittee is the general principles of care and Believe I saw a dr. Bob Morrow. He's here today and he is instrumental in getting this subcommittee off the ground and And What we're looking at accomplishing with this particular subcommittee is Is producing an overarching policy On principles of care particularly an austere environment for humanitarian assistance that deals with ethical care So that could be You know many of the problems that we've seen in the past would be prescribing anti-hypertensives to to patients in a lot of these countries that have no means for follow-up or to get You know prescriptions later on so that that's a real problem and and I know Dr. Morrow has reached out to dr. Gabriel to assist with this so That's one of the main things we want to address Obviously patient follow-up Whether it's you know some of these Some of these surgeries that take place on board these hospital shifts, you know, you never really know There's no guarantees that everything is going to turn out perfect every time so when you do get to a case that There needs to be followed. We really have to make sure those pieces are in place So that's another thing we want to address in the instruction and You know credentialing we on board the comfort this past time They had a The Dutch had a surgical team and and so we have to you know, if we're gonna Do these missions with other countries? We have to make sure That that we thought out all the credentialing concerns and addressed all the potential problems with that Patient privacy, you know, again, we're seeing thousands and thousands of patients a day and And we just need to make sure that that we're doing things the right way patient selection criteria and Also working with non-us providers and there's many more but that sort of hits the major ones that we want to address in this particular subcommittee and then the third committee is education and training and And I think in general we just need to really refine How we how we train folks for our missions and and we really need to do a better job at mission specific training whether it's on board the comfort or large deck amphib or Whether it's one of those medical embedded training teams in Afghanistan We really have to train people to do these missions, right and and we've recently received some guidance from the Assistant Secretary of Defense for health affairs there's four levels of training and so we are now in the midst of Developing their requirements for each one of those levels and then the idea is to give it to the services So they can develop their own Courses from the requirements that we've already developed and that's this is all inter-service and also we have Folks from NGOs participating in addition to other Government agencies, so you know again we're We're really trying to make sure that we address everybody's concerns And then lastly we have the evaluations committee, and we're looking at measures of effectiveness and and outcome measures and this is a real hot topic right now and We're gonna have to see where this where this goes Still early on in the process, so I can't really talk too much about The direction we're heading, but I know at this point everything's on the table But we definitely have to do a much better job of being able to measure the impact that we're making in these countries Thank you very much All right, thank you Always makes me a little nervous when the senior person follows the junior person Well, there was there was meant to do my madness here. Maybe if I get a little IT help Brad started with a disclaimer, so I guess I will too if I don't fall off the stage Is that We we do in fact execute missions, and we do planning What we don't do is policy, but are happy to be guided by those who do and that's one of the functions of of course of you med and Assistant secretary depends health affairs. I wanted to say hello to dr. Kassel's and and we'll call us into here and other Distinguished guests. It's a real honor for me to be here at CSIS. I did a little research before Coming here today to find out a little bit more about you and a very broad spectrum of people involved in in policy health decisions and Security with of course this international focus, so it's a great pleasure for me to be here You might be asking yourself well, what is what is fourth fleet? We are a new command a relatively new command. We've just been around for a little over a year fourth fleet was one of the many naval commands that existed while it was actually Disestablished at the end of World War two and the the region that fourth fleet covered is Still basically the same region that it does today, which is Central America the Caribbean and South America So we are the maritime read Navy component to United States Southern command For many of you. This is old hat for some of you. It might be might be new Our our commander our former commander Admiral Joe Kernan address this group last February our new commander Admiral Vic Guillory is there Now and we are fully engaged with a number of missions in the South Com area focus And I'm going to address just one unless you ask me questions about the others and that is continuing promise 10 the one that we're planning for currently Just an overview of the continuing promise missions these are I get that right HCA missions humanitarian civil assistance missions using either the hospital ship And on this coast it's the the comfort so the large white 60-foot high Red Cross stensibly thousand bed floating hospital which has Performed quite well over the preceding years and alternating every other year with an amphibious carrier This is a this is a gray hull. It's a warship. And so it's about 800 feet long tremendous capabilities Which I'll talk about more later But in fact, I hope to make the case that in some ways and for certain parts of the mission the amphibious Carrier is even a better platform For performing some of these humanitarian missions now you see under the under the purpose there Continuing promise nine for instance accomplished over a hundred thousand patient visits and over 1500 surgeries So no points off for comfort very distinguished record and these go back now a number of years It's alternating between the hospital ship and the amphib But the purpose of the continuing promise mission as you can see right up there is to train Okay. Now. It's not necessarily to train surgeons to be better surgeons It's to train in case we the United States military are called on short notice to respond to a disaster That's one of the main Missions for our own purposes is that so that we get better at humanitarian assistance and disaster response Obviously lots of other spin-off Positive spin-offs from that, but fundamentally we're learning how to respond better To a disaster and while we're doing that while we're getting better at what we do We provide humanitarian assistance to host nation and then you can see since a strong message To to Latin America support commitment and compassion And I'm going to try and make this talk as acronym free as possible But you can already see a couple of them up there. This is commander US Navy South. That's us. That's fourth fleet And so this is how we do it and we coordinate the deployment of US Navy in this case amphibious ships to Conduct sieve mill ops that reinforce the south com message and the message is partnership for the Americas So that's the that's the first bullet that you would take away the second one you can see there highlight the word security and From from your own efforts here on on global health security Security and health in many cases are synonymous as health improved security improves and then Third bullet down Sme exchange subject matter experts and this I think is a particularly valuable to a tool that we can that we can exploit More and more and these are often mill to mill exchanges peer-to-peer Interfaces that's the level at which they're conducted where we have things to share the host nation has things to share and as a result We learned some tricks of the trade, but also it builds the host nation Capability we were just in Trinidad for instance and had an opportunity to work with some of their military leaders on Disaster response and they are thinking about what they would do from Trinidad perhaps help some of their less fortunate neighbors who who suffered a catastrophe and then finally TSC is a theater security cooperation plan and these are south com priorities and as you can see part of the Effort is also Also to help build partnerships with countries that we the United States government think might be at risk In-state it's always good to know where you're headed security stability and cooperative partnerships anti-us influence and activity are reduced and Finally as I mentioned we will get better and become more accomplished at disaster relief missions And I might add that as we do D become more effective and efficient and better trained to respond to Disasters overseas. Oh by the way, we might be better trained and more efficient to respond to disasters in the homeland so there's some real synergies there and Hope to capitalize on that So here's the money slide if you will This is a scheme of maneuver now. There are some changes already in the mix and Some of the locations might very well might very well change so don't take this to the bank but the idea being that Eight countries over four months approximately 11 days in each in each country The first one that you see there is Mexico that is still a little iffy at this point And it's being worked out between the mill group the use US embassy and in the Mexican government moving around we get to Guatemala Nicaragua Panama Colombia Haiti And then Guiana and Suriname Which I believe will be a new one and then back home in November so for four months Quite a few days of steaming and a significant opportunity to impact health in the region and the continuing part of continuing promise is that we go back and For those of you with a public health background by the way, I am a I am a late-comer to To public health after a career doing a number of other things I had a chance to go back and get my MPH at at UCLA and there's nothing wrong with UCLA But got a chance to to learn About the importance of public health and I would have to say at this point in our in our planning and in some of our themes Achievable or I should say enduring public health outcomes is also a Major theme so we get to go back those are the record of the places. We've visited over the last several years and then the locations for CP 10 Those of you in the military would be disappointed if I didn't show one of these slides. This is the the Infamous wiring diagram you can see a lot of dotted line relationships in this But I will I will tell you that the relationships not on here are those with our Particularly the interagency partners and in the NGO community at North come We had a saying that it wasn't C2 command and control, but it was a different kind of a C3 Which was a cooperate to collaborate communicate and there's a lot of that going on So I would say that particularly with regards to these continuing promise missions. There's a lot of the coordinate collaborate communicate going on and in fact Myself In team members here. We're in Washington, DC that week this week to do that very thing meeting with State Department USAID interaction whom you know a number of our other partners In order to talk about continuing promise and work together Where we get there is not important but the bottom line I think is which is that these are extremely cost-effective missions the the WASP mission actually is a little bit less than the than the hospital ship, but nevertheless both the hospital ship and the the amphib I would say are extremely cost-effective for the health impact and the Strategic communication message that is that is achieved and speaking of strategic communications. Here's the south come plan and a lot of these are going to sound very very familiar but History not withstanding well, I guess in terms of in terms of history very much that we do share common interests throughout Latin America and that as this group knows quite well security is a necessary condition for prosperity and lasting democratic institutions Regional challenges require cooperative solutions, and I would say the most recent recent h1n1 outbreak emphasizes that we were in the Caribbean on two occasions in the last year talking about how Important it is that we look at this from a regional perspective and that south come is committed to to lasting partnerships Some of the ways that we build those partnerships Interagency integration, and again, that's what we're doing This week and then next week. We'll have our initial planning conference where we've invited a number of NGOs to Jacksonville, Florida where we're based and they will participate in the IPC the initial planning conference And if they've it's about a year out and full participation in all of the the various meetings are Offered and also partner-nation integration and so in that regard Again a small team of us. I will be going downrange in the month of December to visit all eight of those countries and Work first of all with the mill group US Embassy country team We'll get out to some of the sites that we hope to visit and then also work with locally based NGOs and Hope to meet with the the ministers of health in each of those as well. So that's sort of advanced planning On the ground. We'll be working out exactly how the mission will be accomplished And we're going to be asking some questions along the way to and and some of those questions include such things as what are the host nation health priorities What are the US Embassy and USAID priorities? And how can we promote those enduring health outcomes what we talked about the enduring public health outcomes of? The Focus For many of the new activities will still be accomplishing the the surgical procedures the vaccination the The dental procedures and so on all those will be ongoing But there is likely to be a new emphasis also on on training and teaching and some of the assure activities that That can go along with building host nation capabilities so There was an Einstein said not all that you can measure matters and not everything that that matters can be measured in this case, it's important that we that we measure and We're pretty good at measuring performance Workload we're pretty good at being able to count the number of procedures that we that we've been doing But there's more to it than that and I'm not so sure that we've been good at being able to Establish have we had any enduring health impact and let me just kind of put it from the perspective of USAID who has who has been in these countries for years and years and have ongoing programs and have established partnerships and Their good work has has continued obviously and we come in and for a period of maybe 11 to 12 days have a have a big impact both medically and for the local population and Media-wise and so on and then we leave and we go to the next country and in USAID for instances Is still there working with the host nation and so on what we need to do and this is this is something that's been talked about a Lot is a firm handshake on the front end with you USAID priorities and activities our Mission is in keeping with what they do and then a solid turnover as we go so that we have Again some longer term impact and we contribute to the to the greater good Impacts on attitudes. This is something that has been has been measured in the past the Center for Naval Analysis does polling After the continuing promise mission and and have come up with very they were very favorable results And in fact one case CNA made the link that as a result of the continuing promise 09 mission that actually Crime decreased in one of the one of the areas that Was visited and impacts on behavior again those of you from a public health background know that changing health behaviors is extremely difficult And but hopefully we can measure some of that as well. So how do we do it? Here's our tool the USS Wasp had a chance to see her come in to port there in Mayport The other day 800 feet long 100 feet wide big flat deck to hold helicopters and a huge well deck that can be used to Load humanitarian supplies and also for landing craft and this is really what in many ways distinguishes the hospital ship from The amphibious is that the capability to to project to shore Logistics become much easier with the helicopters and with the landing craft We can operate in a different sort of manner. It's easier to get in close This makes a big visual impact Whereas the hospital ship might stand off a little ways and not be as obvious to the local population the the Wasp can get in closer and The CNA study indicated that to have will have humanitarian assistance coming out of a warship Was surprising to local populations and and in fact even had a had a greater greater impact here's a picture of her and You can see that the capability there the CH-46 is perhaps a Not the helicopter that we'll use will be using larger cargo carrying helicopters the CH-53 and Again a lot a lot of capacity to be able to To project a shore Let me back up one slide You see there room for 1800 Marines. Well, we're not going to be carrying Marines, but instead that frees up a lot of Bunk space if you will for NGO partners public health service Others doctors nurses other health specialists and engineers So this would be more the type of crew that we would be taking with us and not just the uniform personnel deployment objectives You see these again These are south com driven, but they're all things that should be or I'm sure are of interest to this Organization ensure the forward defense of the United States encourage regional partnerships and stability and security and these are some of the Some of the methods that we use to to get there. I would say that overall the wasp as a platform Has some some pretty Most NGOs would would give anything to have the ability to for logistic security and And communications that a Navy warship like this brings to the fight. So it's a it's a great platform And these are some of the themes again Just to put a slightly different theme on it as we're Coming here to meet with people this week some of the themes or methods that we've put together this week again Are to work closely with locally based NGOs Again the use of CP 10 principally or or in addition To its other missions as a training platform train the trainers build host nation capability to discover and enhance host nation health priorities and again to get the Ministry of Health USA ID country team and others to Hear about the mission and that we can coordinate and collaborate with it. I would like to stop at that point and let's go ahead and Open up for questions Rather than dig deeper into what the what the wasp brings to this mission. So Gene over to you Thank You Captain Cherbush There are a couple of microphones around that Not Daniel, but a couple of microphones folks in the back have As you ask a question, I'd ask you to state your name and what organization you you work for and the floor is open Is this working? Okay I always jump in first, you know, I take advantage of that hesitancy to Everybody else is gonna say well, what's going on here? Let me introduce myself. I'm Dr. Larry Casaza. I have my own NGO after years and years of working with World Vision and Another career was lieutenant commander with Namroo to in Taiwan and helped to Design the detachment which is now Namroo to in Jakarta so it's it's exciting to be here and To get reconnected with what US government and military are doing about these issues I live in in East Africa and I'm just waiting the day that you're going to start moving around Mombasa in some of these other places that need this kind of Intervention that could be so powerful in terms of counteracting what can happen and get off the ground causing great problems with insurgencies, etc. And At the same time listening to this I'm concerned that there's a good balance between top down and bottom up involvement and You've got some NGOs there, but you've got the governments and you've got USA ID, which is often not the best place to go for an understanding of what's happening at the community level and my Take is also that I like what you're doing with monitoring and evaluation Because there's another axiom besides Einstein and that is you get what you measure And if you're not asking the right questions You're not going to get the input into what you're going to need to understand about the outputs And why or why not they didn't work? So thank you so much. I'm I'm delighted to be here and to hear what's going on and To offer my services. I'm also Hopkins School of Public Health faculty that Is is another amazing resource together with NGOs for Getting the strategies right. Thank you so much Well, sir, thank you for your comments. I didn't catch the name of your NGO that might be of interest Okay Yes, very good, sir. Well, thank you and and again. Thanks for those comments Just very briefly measures of effectiveness. We were just over at the skyline buildings at the Assistant Secretary Defense Health Affairs International Health Division where this group is helping us we have some I guess Strategic measures that we're looking at and in the Center for Naval Analysis helps us with that On a very fundamental Level we can count the things that we do, but it's those intermediate level measures that We're we're getting some help from The International Health Division there and and others I should say also that during the pre-deployment site survey that we're We're going around to those eight countries. You're absolutely right. It's important to have the baseline data Otherwise you get what you measure you're right So so getting the getting some baseline data to begin with in order to know what to measure and go from there So thank you Dr. Casellis superb superb presentation, I just want I hope people in the audience are aware that you were Advancing this cause before all the brass embraced it and I certainly remember those days And I think it's wonderful that Admiral Cullison is here. He's he's heard you give this talk before I think it's obviously a sign of the big Navy support and certainly the Surgeon General to be here so Just a quick question for you. I wasn't sure I Got called out by a page, but Are you taking full advantage of the telemedicine capabilities in your planning so that we can Get the reach-back consultation firstly secondly Get our Shore-based students and doctors excited about the trip seeing it you know on the video and thirdly, of course The communication to the world so they see it so it doesn't get too filtered by some of the local Governments, this has been a problem with you know our some of our other missions comfort and mercy and Maya gas and previous wasp It's having really taken full advantage of some of the Navy's own telemedicine capabilities Yes, sir. Thank you, and I feel like I just I understand up when I when I address your question I know I know of your long-standing interest in it and the answer is yes Just this morning. We were at interaction and talking with a group who Planned to use a another it tool for tracking patient encounters, and it's really very forward-leaning Stuff there are a number of acronyms associated with it, but in the past a lot of missions have used a Pin-in-paper or various other forms to to keep track. It's collated But there are some new technologies that we think could either be incorporated into a handheld and We know that there needs to be a deliverable back to the host nation Some not just collated data, but individual data necessary for follow-up I would speak directly to telemedicine two things one We were just at south com the south com surgeon held a conference where all of the components came together and Ron poor paddage from from Tattrick was there. He was the Co-lead for that and each of the components brought a Request if you will for a project a telemedicine project that we hope that Tattrick could support ours Ours is a it's called face. It's one that has to do with the telemedicine to help facial Cosmetic repairs of children and so on. So there's a lot of emphasis on that I'm not sure we address exactly all of the things that you were concerned about with the comfort where for instance Video teleconferencing and some of the other things. I think we still have challenges in that in that area, sir But we're definitely working on it. Thank you Just to add The surgery department on board comfort used it this last mission I do know that I was talking to the department Department head on of surgery and he was telling me that they had a lot of great experiences with the telemedicine Yes, good afternoon lieutenant commander Andy Baldwin. I was provider on continuing promise 2009 and just a couple comments With the NGO Navy interaction I work at Bumet in a capacity as an advocate for Navy medicine I don't do a lot with recruiting. It's invaluable the On the ground in the field experience that these civilians get to see and what they take back and can share with others So easy to that the more that we can do the better. We had Roughly 50 pre-med and pre dental students out there and I I think I could say confidently But we're gonna get 10 of them coming into the Navy as Navy docks and Navy dentists. So That's one comment as far as the wasp and its ability to project forward That's huge and we had so many issues with the comfort and getting a shore and having doc Or having to drop anchor way offshore. So and then about the numbers we had we'd have comments every night You know how many it's not all about the numbers. It's not all about the numbers as You smile and that's true. I know back here in DC We really need to have empirical data that we can really measure the impact we had but as providers and surgeons and dentists and optometrists we all really We couldn't wait for the end of country brief when we could see the the heart touching Stories of lives that we were able to impact. That's really the true Impact of what we were able to have in country and so good balance As the gentleman said, you know effectively measuring that impact We could dole out as much medication as we wanted to but I thought that the health education What we left these people with from a health prevention standpoint was Was the most effective so? Sir I appreciate your comments and go get them Thank you, I believe the cabin Jim where they had a particularly nice turn of phrase and that he mentioned that every person that the Mercy touched was a truth point of one and Another way to measure that so those those stories that you mentioned those heartfelt stories are still obviously a very important part of What we do? Thank you Yes in the middle I'm dr. Bob Morrow. I'm a currently contractor working with the town in support of maybe medicine I'm a preventive medicine officer, and I feel like jumping for joy. This is such a great day. I Was wondering how you sir feel about now that we're engaged in military stability in military and medical stability Operations as a national strategy, and there are other nations which are engaged and similar you mentioned the Dutch We have our French colleagues here. There are other NGOs There's like I grew up on the ship hope so I'm 50 years associated with project hope And I know that there are many civilian Maritime medical missions as well. How do you see your role as now developing with an ongoing military mission? interaction Interacting with strengthening leveraging and working with those other assets for our national security needs Okay, well, yes, sir And in fact you don't want to talk about future operations, but one of the one of the partner nations that we will be Working with not one of the ones that will actually touch this time, but would like to consider Sending a another platform of ship alongside and then another nation that we have Talked to would also like to send shipwriters with us to go visit some of these places and also under the under the Idea of disaster building disaster response capability, so these mill mill Exchanges with with partner nations now we distinguish partner nations those that go with us from host nation that we're visiting but partner nation Capacity and capability building are an important partner in our in line exactly in line was with south com priorities and things Bill Lierley homeland security department But formally USAID for 14 years DOD for 28 anyway Jim you you mentioned a robust developing a robust Measures of effectiveness. You also met mentioned Center for Naval Analysis One of the real challenges we've had in the past in humanitarian assistance operations and even development In austere environments is the whole issue of operations research and being able to work in a platform where you can actually Learn from what you do and apply it For future operations seems to me you have an opportunity a target of opportunity here You said you're going to be working on new technologies from the IT perspective New procedures etc. Etc. Is there an opportunity to really because you're already going to be collecting robust MOE's to to be able to apply that not just to the actual operation, but but to actually conduct operations research to see What are some promising practices that perhaps you're running into and that you have a platform where electricity works? Running water and not often a lot of NGOs have that Robust capability for actually doing research operations and practical research Funny you should ask we just left a meeting there over at skyline where as almost an afterthought One of the staff members there Lynn Lowry whom some of you probably know offered that there were two graduate students at the Uniform Services University Who were looking at that very thing which is measures of effectiveness? So the the off-the-cuff answer would be that that type of research as I mentioned We've got a lot of birthing space and so other things not withstanding I guess my requirement back to her was that it needed to be self-funded and they were going to be aboard a long time So it was something that at least is in the very Preliminary stages Of talking about that but yeah some research on board the ship while she's underway Particularly on those measures of effectiveness that the thing is we need to do a lot of that work actually before What the research may be useful for is the next CP mission in terms of gathering a baseline Determining what the metrics are going to be and then how we go about collecting it So their research may not directly impact this mission, but it might very well for future Sir Brutum Courtney Scott office health affairs Department of Homeland Security I've had a privilege to work with a working group here and one of the questions that we've been wrestling with is When you do these humanitarian assistance missions, sometimes you do it from a motivation of it's just the Fundamentally intrinsic right thing to do and sometimes you do it because you're leveraging your ability put to To deliver this healthcare as an instrument For other purposes And my question to you is if you do that if it's the latter or if it's perceived to be the latter We're advertised by your adversaries to be the latter. How do you how do you overcome that? How do you turn that into a positive message and And communicate that in a way so that you don't look like the ugly American when it's over said about Good question Messaging is terribly important and this is such a good news story It would be terrible if there was anything that would Detract but detractors there are I would say that from a personal example when I went back to meet my new boss at the time I was Lined up to take this job and this was Admiral Joe Kernan now vice-admiral Joe Kernan who is a Navy SEAL and I went in with my head full of a lot of these ideas that you're talking about which is that we do it Further US interests and we do it as a strategic communication message and we're improving security and stability and all those things are true Those are all good reasons and we're improving our own ability to respond to Disasters but I'll go ahead and quote him and I hope he doesn't mind But he did kind of the one-finger CPR and he said Jim sometimes we do good things because they're good things And I remember that and so I think there's really a case for compassion here. I think we can do it all I think we can do both the the training objective and the strategic communication and I think that we can Do a lot of those things that are in the interests of our ourselves And our partners But I think we can also do good things because we're a nation of good people and we have big hearts And we do outreach sometimes just because it's a good thing. I don't I don't see those as incompatible at all Just a dovetail off that you know for somebody I was on the 2007 mission and I think when you're a provider or you know, you're a corpsman or Nurse whatever whatever you are When you're when you're on the ground and you're providing the care It's it's sort of a natural extension of what you know We what you do when you're back in the States when you're when you're working in your hospital or whatever You don't think when you're when you're talking to somebody you're trying to do the right thing You're not saying well, you know, we're trying to you know use this as a You know for some of their political gains, so I you know I think you can do both at the same time It's sort of my sense of the two Good afternoon. My name is John Andrews. I'm a newly appointed deputy director at the Pan American health organization I'm like to commend you for your efforts and I'm on a learning curve So it's exciting to be here and hear about what you're trying to do in a former life I work for the Centers for Disease Control as a vaccinologist epidemiologist and I see those Examples of successes doing exactly what you're trying to do maintain security in the region polio Ratication measles elimination Bella elimination where it has that win-win of US support to supporting a an activity that's a priority, but also Bridges from humanitarian Impact to this the security you're mentioning I was pleased to hear about your training because you've framed the issue quite well and Chant the challenge when you're only there for 11 days, and how do you measure your impact? Prior to six days ago. I was at the George Washington University where I taught a course and I think it's important to recognize I think someone mentioned it Recognizing the difference between process indicators output indicators and then outcome Impact rather impact and and and being realistic about what you can measure So that was one thought the other thought was in regards to training what I see in the field Particularly with immunization services where you think over the years quality of care would be top-notch where we see pockets of Services where safe injection practices for example are quite poor And it just it's a continue Day-to-day battle to maintain Quality of service and that that's an example that I refer to you But as you teach these young Dedicated professionals that the quality of care is very very important just search So I'll stop there, but thanks again, and I appreciate this briefing. Thank you Hello, I'm commander Bruno Himmler public health service officer currently detailed to the Army War College and fellow CPO 9 alum Couple of things that we brought out of the from the lessons learned from CPO 9 One was the issue about a lot of the training we trained on equipment and things like that that the host nation Did not have or they'll be the support and so on the thought was to say you know in 2010 and beyond would we be able to get Donated equipment from hospitals and other things that would be used to train But then be able to leave it behind with the host nation so they have the equipment That they are being trained on how to use like for acls defibrillators was the prime example the other key fought to Get my notes was the public health and preventive medicine they've been doing a lot of assessments in many of these communities and Seeing that there's issues with drinking water collection and Setting up sand filtration systems and holding takes and things like that But they've not been equipped with the materials that would be necessary to implement many of their recommendations with the host nations Is there a thought in 2010 to spend less money on Motrin and those types of medicines and be able to allocate the funding for the engineering project That they would need supplies so they can bring them on board and implement some of the recommendations in 2010 And then my final question is what is good enough? And I think that's one of the key questions that we look at is we bring in you know doctors nurses dentists everybody with US standard of health care to these communities and we're trying to You know impose on them, you know our standards at times But you know can we Decrease the level of expectations that would then allow greater participation Of the host nation and partner nations in these activities, you know specifically dealing with Credentially and privileging in some of these medical legal issues Three three questions while trying to do justice to three answers the first one you mentioned had to do with donated medical equipment and Yes, in fact, we had an NGO approach us project cure that collects and distributes Donated medical equipment to a variety of countries they actually had a Need to get things into Haiti and it just so happens we're going to Haiti So they sought us out and with that big well deck as you might imagine We can hold a lot of donated medical goods so this in in this case It turns out we were a Convance of convenience, but it turns out I think also there'll be other donated medical equipment going to each of the other Countries that would be the plan so they they they certainly got invited to the IPC Your second question though I think speaks to the heart of it and a little bit of a little bit of a difficulty is that We in DOD are restricted from reaching out to the NGO community and saying specifically You do water really well. We would like for you to come with us or you do A maternal child health really really well, there's a there's a legal impediment in there And I'm not a lawyer so I'm not going to speak to it But we find out that if there is a brokering organization such as USAID for instance or maybe interaction or maybe Some other organization that can help us to reach out to the NGO community of which there's just this universe of opportunities of NGOs that specialize in this or that and those skill sets then could be brought on board and so that's the bit of a conundrum that we're in right now is Finding out what's out there? And what skill sets they can bring and how can we incorporate them and stay within our our legal boundaries? So that's something we're working on right now and then the third question you ask I think there's no excuse for for poor quality and I think dr. Paul farmer Had a an expression for that. He said you know the poor always get blank No, we need to we need to do the right thing. We need to do it in a quality manner It's first first world health care all the way. There's no no lesser standard Then I know so that would that would be my reply on that So I understand you're concerned to in 2007 pharmacy Was the largest they had the largest budget so out of everything that we did Whether it was surgery or medicine or whatever pharmacy had we spent more money on pharmacy than any other Service so You know, I think we do have to sort of figure out You know, what do we want to use pharmacy for you know? What you know and then kind of give some guidelines because it can get very expensive in a hurry and You only you know you only get so much I mean, I don't remember exactly the numbers that you put up on the screen, but it was Somewhere between 20 and 30 million dollars for a comfort mission And out of that, you know, I think it's like probably two or three million for patient care You know so You know That all has to be figured out as well But the the pharmacy question was definite is definitely, you know, a lot of times you're giving out vitamins You're just giving out stuff to anybody at least in 2007. Maybe things got a little better in 2009, but we you know, it's one of the areas that we're looking at too One of the points that was made with regards formula areas to find out for sure what the host nation has and what their Formula areas and then try and correspond with that particularly for follow-up care that We're not initiating medical care. They can't be sustained Front had a question here up front first and then on the side Thank you very much for your presentation. My name is Ahmed Meir I used to be handling science and health policy of the State Department But retired since then clearly you're doing a job that is much bigger Then your team can probably cover Which are the other countries that I have similar efforts and is there some effort to further Encourage countries that have the resources You know like both the NATO and in Asia and so on To develop such efforts and work together Yes, sir, and in the first week in November, we'll be going down to Brazil for Navy to Navy talks and Brazil of course is a very capable partner nation and I think them As as an example as an example might be able to participate More in future missions P Chen I'm the physician. I'm also committing general for 807 medical command, which is a theater medical command for south come my question is Yeah, a lot of people going to sell I've been doing this for two years now A lot of people going to South Central America and do a good thing NGO, you know army Navy Everybody, but it's no synchronized Strategy everybody going there everybody doing good thing, but I don't see any impact I think the key is how we going to as you just said difficult to Deal with the NGO telling what to do, but at least within a DOD I think the merit and Continue promising should be synchronized at a higher level and that's number one number two respond to this gentleman's question about a different level of service a different level of health care system I think the key is I find out is I visit all the seven priority countries and I find out a question is in the past We just send a merit medical team going there because what we think they need I think the key is we have to ask them. What is your strategic? Strategic priority. I went to a trend of that. They tell me the number one priority or in that country It's not really coming to treat a diabetes hypertension. It's cataract surgery They have a 7,000 cataract surgery backlog and don't have a 23 of the mottages and they really They're forever. We send a merit team to there for like 20 days you can only do maximum 220-250 surgery and just continue grow so now we in the do a concept plan see if we can do something to help the Government to train to teach local to fish putting this way have a sustained the effect and I also tried to working with their defense force starting with the basic life compact saver and gradually progress it to the EMT level that's slowly gradually up So I think the key is go we got to ask what the local government Their priority and which are to match. We're doing good things, but I think I just Needed to be simple not to stop Yes, sir very good comments, and I appreciate those and in fact it may seem That there is You know a lack of strategy. We always are told that we need more as you mentioned For eye surgeries, but also more women's health issues and Dentists, so we're also told that veterinarians are ever popular So so we need to bring more veterinarians Those are all things that come as you mentioned from the from the ground up one of the things We hope to do is to help to determine To a greater extent what the host nation health priorities are and that's part of that that visit But I will speak to the strategy piece a little a little bit and there is a strategy and it's a there's a national level strategy And then as that comes down the the food chain it gets to the geographic combatant commander and they developed that TSC this theater security cooperation plan and those are the objectives. Those are the the themes That in this case Southcom puts forward a Specific command has a you know another similar Set of the set of themes and then from those we derive Missions and then we go out and accomplish those objectives. So that that is kind of the way that strategy flows into Eventually to to what we do at fourth fleet But I would highlight these are some of the other things that are out there And there's a whole panoply of different activities that are going on in the Southcom region It's not just continuing promise and so the army and the and the air force have a big plug med readies As you mentioned do accomplish a lot the primary purpose of med readies though is actually training for DoD personnel So that that is the that is the driver on that along the way We also do some some good, but your points are well taken and host nation health priorities are exceedingly important Thank you very much. My name is Joshua Marques from Booz Allen Hamilton I wanted to ask you a question about your training Emphasis and that is that it's very clear what tremendous impact you can have at phase 0 But what insights have these experiences given you for how you would apply medical spill at stabilization operations? For the full spectrum of conflict So looking into the future are any of the skills that you're training your forces and these missions applicable to Semi or non permissive environments not entirely. I mean, you know Admittedly, you know, the training piece is something that we really need to get a better handle on and So I don't think the way the way we're training for these missions now does Address the concerns you're talking about But I think I think in a couple years when these requirements are Identified and we've started the tree. We've actually started the training programs. I think we can You know, we can really help with that I know the USA ID puts on a great course the joint humanitarian operations course You know, we continue to train our folks and send them to that there's dimmer tie defense medical readiness training Institute along with our US government government partners like USA ID in particular. I know I saw John there a couple of weeks ago There's a medical stability operations course that's being developed that that will help with that somewhat not as much as the joint humanitarian operations course, but and then there's Out in pay-com Center of excellence that also has some some courses now. I've heard they want to get out of the education role but But as as is right now, there's a chart course and some other courses that can also help it You know, I think we're getting better. You know, we're still pretty new at this the military so But over the course of time and as people take more and more these courses, I think you know We'll definitely increase our capability Let me make a comment about that because you're right for specifically a non permissive environment combat arms Maybe these missions are not exactly the very best for teaching and training our health care providers to operate in that arena, although they're not bad But I would say that there is a an environment for which they are particularly suited and The office at North com that I had the opportunity to to work with Did a what's called a CBA capabilities based analysis of those skills those You know man training equip skills the capabilities needed to do overseas humanitarian assistance and Excuse me overseas disaster response and domestic disaster response and they found with very very few Acceptances that the skill set the capabilities the equipment the training needed for those two missions were almost an exact overlap So I guess I would make the point that as we get better on these missions learning how to do Disaster response overseas those same skill sets that same training Tactics techniques and procedures if you will can be used in the homeland. So there's a big payoff there There may indeed be some synergies Cost-wise and mission-wise. So I think there is overlap. It may not be combat arms It may be a non It may not be that kind of environment for but for domestic disaster response. I think there's a lot of Hillary critchley working for dr. Cassell's I have a bit of a background in public global health So two of the things that have kind of been pounded into me are firstly Sustainability so I have two questions about that firstly. Is it Deep are there any risks to this program or does it seem like it's going to be continually appropriated funded? No problem into the future. You can plan indefinitely secondly when you when you Go when you plan the route. Is it something that countries can count on happening every? Every year every five years every ten years is it a campaign? Do you revisit the same countries or do you try to kind of spread it around and is that linked with our kind of state department? global diplomacy goals, and then the second thing that is generally pounded into public health people is And as has been addressed It's responding to the needs of the host country. So The my background is malaria and waterborne disease So do you just kind of serve on a on the kind of first come first serve basis? Or is there a prioritization of patients according to you know, what is of most risk to that country's population? Well, you know, I expected some hard questions from this group and it had to come from a fellow public health or so The sustainability question is one that has been asked before and in fact It's it's even sometimes been asked a little harsher than you which is there are some of these activities inherently destabilizing if we go in to a country and provide first world medical care does it cause the Host nation population to think ill of their own government or does it somehow interfere with the the local medical Establishment and put them out of business those are things that we hope to address during these pre-deployment site surveys and Again the train the trainer approach with an increased emphasis on training to help Build host nation capability. I think then that would be a sustainable health outcome. Those would be things that could be measured Over a longer period of time now your second question had to do about the route and do we go back? Yes, continuing promise. That's part of what we do now. It's not the same eight countries every time But over time we tend to go back and visit we don't always visit the same site and those countries and those sites are Picked up kind of to a certain extent by design a certain extent. Maybe There might be a little ad hocary in there But it comes up with a mix between Southcom priorities and host nation priorities and most importantly also country team priorities So that you know, there are a number of people that get to vote in this the country's Chosen themselves that is something that has been laid out and that's been a subject of considerable discussion at Southcom But good points all The final thing I think you mentioned where the host nation health priorities and again That's one of the themes that we hope to really push this time when we go around to the eight countries and find out from the Ministry of Health What are there? What are their priorities and how can we work that into the mix? So? Thank you for that question. I think another thing that we have to get better as working with the local NGOs in a particular Country so and I think that's through USA ID and I think as we get better with working with USA ID In in these you know, the country teams will get better at working with local NGOs and and Taking on the projects that they feel are the most important for that country and trying to piggyback on those as much as we can and in sort of Go after this with a whole government approach And I think there was a question there about State Department's foreign policy goals to say how do you house that relationship? We at fourth fleet now have a poll at a political at a shea and she and I are Talking now almost on it on a daily basis this Thursday. We're actually going to get to go over to the State Department We have a separate meeting with USA ID, but then to meet with the representatives the State Department representatives from the various countries and Certainly, I know that there is Collaboration coordination Ongoing but for me this is a little bit of a new territory and that's one of the things that we're addressing this week So I will be smarter at the end of the week Chris Stacker office of the director of national intelligence What you guys do does an incredible amount of good One question. I have is you you mentioned that you were one of the impacts You were trying to measure was the public perception public perception of the US public perception of the US military Do you do your? Polling or whatever in time series so that we have an idea of what the half-life is of the impact Center of naval analysis has been our primary polling Arm and they have gone back into a limited number of countries already that were visited by Continuing promise o9 and I think you're exactly right. I think that Opinion change over time Was one of the big lessons that we got out of the tsunami wasn't it which is that initial results were quite favorable but then over time the Opinion sort of swung back in the other direction and that's driven by a lot of different things that are out of our control to include Each five and one which was one of the considerations there So I would like to see the opportunity to go back to these countries and do assessments after we have come in with the hospital ship or With the with the amphibious ship I think that would be very valuable and again repeated visits into the locations to see how things over China Change over time and see if there is enduring Benefit from these missions. I think we can see it in the short term. I'd have difficulty proving that over the long term Last question Thank you. Hi, I'm James tail. I'm dr. Chief of staff and I was with him in the Pentagon to and a public affairs capacity I'm gonna channel a little bit here because it's I know this is something he's talked about before But are you guys doing any mill-to-mill? training when you go to these countries and if so, what's the extent I know Dr. Sells talks a lot about How the military in some of these developing countries is often the most stable institution in the most ubiquitous institution in these areas So having a well-trained Military medical facilities with the military is very useful Well, actually we have some pretty unique capabilities here in the Courtney Scott is here former director of the dimmer tie and the defense medical readiness training Institute and The courses that of course come out of a dimmer tie are are fantastic the opportunity to do Mill mill subject matter expert exchange Is is something that we look forward to I did mention the business with the Trinidadians for whom we hope to do that on the short term I know that the Comfort mission did a fair amount of that as well. I think mill to mill subject matter expert exchange and Training of that sort would would be very valuable and I would I would say those probably are enduring Changes that we could you know, it's interesting is that as you interact at a certain level Those health leaders in the host nation often become their Surgeon general or or a minister of health at some later stage So these relationships which are built early on by these continuing promise missions may very well Bloom at a later date and in ways that are that are unexpected In addition to that in Thailand There's Cobra Gold and and there's often a med cap associated with that. So so there are There are some mill to mill Missions elsewhere in the globe Larry you had a follow-up question Yes, thank you it's a part of what I Expounded on that I didn't hear an answer and that is where is Africa going to factor in here And I know you're out there chasing pirates, you know off the coast of Somalia Be so good to have the the ship pull into Durban or Mombasa and Perhaps change the tone of what's going on. There's some Center for disaster humanitarian assistance medicine out of part of which is like part of USIS uniform services University of the Health Science They're doing a lot with setting up contingency missions throughout Africa For the you know, in this case, there's a spread of H1N1. So there is some of that going on I don't know a whole lot about Africa partner Partnership station there's I don't have a lot of visibility on that but there there's some going there. There's it's getting bigger There is a there's a was a West Africa training As an invited guest maybe Colonel Skyler Geller who's the African surgeon could come and speak to this group He'd probably like to come here for a visit But he would he'd be able to speak to all of the similar efforts that are going on in Africa partnership station was based on large part in the success of mercy and comfort and also Studied tsunami relief. So I'd say that at least in the Gulf of Guinea There's an extensive effort to try to bring some of these benefits to at least that slice of the continent and whether it can be expanded You know on the Horn or other areas. I think it's a great question If not, I hope you'll join me in thanking our two presenters Captain James