 It's a real pleasure to be here. I'm Tom Cullis, and I'm from the Uniformed Services University of the Health Sciences in Bethesda. And during this session, we're going to explore further some issues that have been brought up earlier about, what's the military's role in all of this? And how does the United States military engage in the Asia-Pacific region specifically in the lower Mekong region? And explore some of those issues. Perhaps get a word about the US military support of the USAID Office of Foreign Disaster Assistance efforts in the Philippines that are currently going on. And to address this, it's our pleasure today to have Rev. Colin Chin, who's the US Pacific Command surgeon. Dr. Chin has worked in the Asia-Pacific area for about the past 15 years, and one guys or another. He was stationed in Okinawa as a gastroenterologist at our hospital there. He has been the Marine Forces Pacific surgeon, in which capacity he's worked with disaster response and health issues in support of the Marine Corps throughout the Pacific area, including many health engagement operations. He was the officer in charge of the US military tri-care office in the Pacific region, which looks at the military's health care delivery plan in that area, and currently is back in the Pacific at the US Pacific Command as a surgeon. So we welcome Rev. Colin Chin. Dr. Colson, thank you very much for that introduction. And Dr. Morrison, thank you very much for inviting me to be here with this August panel. I appreciate you bringing me back from Hawaii to here to the DC area, but it truly is a privilege for me to represent US Pacific Command at this very important and vital symposium. Since I have the pleasure and the honor of presenting during my presentation one hour after we all had lunch, and for those who are jet lagged, I decided to do things a little bit different. You're going to have a very short, I trust you, very short presentation of what PACOM is all about and what I and my staff do in the surgeon's office. So here is the area responsibility for US Pacific Command. It encompasses half of the Earth's surface. It encompasses a wide area, as you can see, encompassing over 50% of the world's population. Three of the largest nations in terms of population reside in our AOR. And three of the largest economies are in the Asia Pacific region. However, also seven of the poorest countries in terms of economy are in this area. So it's a very large and diverse region, and we like to say it stretches from Bollywood in India to Hollywood in Southern California. So with that, there are several threats to health in the region that we deal with, starting with natural disasters. As evidence in the Philippines last week, every year there is some form of natural disaster that will occur in the Pacific, whether it is a typhoon, an earthquake, a tsunami, or a volcano that's erupting. It occurs in the Pacific region. And if a disaster is declared by the country and the US ambassador in the region in the country also declares a disaster, USID takes the lead for the US government, and DOD is a supporting element for the US effort. So we have natural disasters, but we also have very high population densities, the emergence of mega cities, as well as a water quality in some areas that may not be the best. So you combine these factors, as well as the deforestation that you heard earlier, which then human populations going into the forest are then exposed to emerging or novel viruses and other diseases, sets up a situation in which disease transmission is very easy and creates problems for the population there. In addition, as these countries are increasing their economic abilities, their standard of living increases, and with that, the aspirations to follow Western lifestyles and Western diets. And of course with that comes what we've been experiencing here in the United States and in the Western societies, the plague of noncommunicable diseases. So the obesity epidemic that we have here in the United States, the problems with hypertension, diabetes, heart disease, and what we're seeing is these countries are now beginning to see these problems. So what do we do in US Paycom Command Surgeon's Office? These are my priorities. I think it's very important for peace and stability in the region that engagements between the Chinese and US militaries are peaceful and productive. And health is a very easy way for that type of relationship to develop and to build. And that is what we are doing today as I speak. Engagement with China is my number one priority. But closely following that, as we heard here, I thank Dr. Ort for your question about malaria elimination and what is the military role. Well, we are heavily engaged in this. And I would like to discuss that further when I talk with Dr. Cullison. So there's more to follow on that. As we saw last week, health response to disaster is a major effort at the Paycom Surgeon's Office that we participate in. Do we have a role in the Philippines right now? The fact that I am standing here before you means that, no, right now, as we get the information from USID folks on the ground, that from a health perspective, DOD is not required at this time to respond. Now, DOD is providing significant logistic support to the Republic of the Philippines. They've asked for heavy and medium lift to transport supplies, equipment, food. We are asked for search and rescue teams. We have asked to provide imaging to provide our aircraft and our altitude aircraft to survey the area of devastation to give the planners a better idea of exactly what the level of destruction is required and what planning efforts need to occur in the future. But as it stands right now, there is no requirement for DOD to provide any medical response teams. And then finally, I'll say that emerging infectious diseases is another large area of interest for us. Obviously, about five years ago, when avian flu was a very hot topic, we were very much engaged with that. Dr. Cullison was engaged in some of those efforts. And we use our military labs, AFRIMS in Thailand and the Naval Medical Research Center Asia which is now headquartered in Singapore, to work with regional labs, labs such as the Institute Pasteur in Cambodia, Institute Pasteur in Laos to work together on disease surveillance, vector control, and vaccine research. And we're also working with, again, the countries in the Mekong, as well as the entire AOR, to help them achieve the World Health Organization and now international health regulation standards. So we are, again, working very closely with those organizations to achieve those goals. So how do we do that? Well, we partner. Now, in the past, I would say that DOD has probably been criticized and probably rightfully so that we worked in a vacuum. We just sort of did what we did and didn't consult or collaborate or communicate with anyone else. Even among our four services, we were guilty of that. We would have a marine unit go to a country and do a health engagement. A month later, there would be an Air Force team that would go to the exact same location, do the exact same thing. And the question would be then asked, did we accomplish anything? The answer is no. Because the goal back then was to do some things we called med caps. You come in with a team, you bring in dentists, pull a bunch of diseased teeth, bring an optometrist, maybe provide some new glasses, deworm the kids, and then we leave. Did we build capacity for that local health system? Did we build capability for that country? By doing that, the answer is no. Because a week later, the kids are bathing or playing or drinking the polluted water. They're reinfected with their worms. By pulling all the teeth, we may have just put out out of business the local dentist and providing eyeglasses put out of business the optometrist. So we're changing our approach now as we engage with our partner nations in terms of trying to work with them to build their capacity and capability. No longer are we doing med caps and dent caps, we're doing subject matter expert exchanges, we're doing academic exchanges. Again, trying to build capability capacity. And we're also trying not to do this in a vacuum. We try to do this with our US government interagency partners, some of which I have listed there. This is not an all-encompassing slide. You don't see your logo. That doesn't mean that we don't work with you. We try to work, again, a whole of government approach. So it's not just DOD going in by themselves. We go in working, if you go to the embassy, I met with many of the ambassadors, met with many of the country teams and say, how can we work with you and your team to better coordinate DOD's effort for your effort, Mr. Ambassador, for your goals for this country? So that is our new approach. Likewise, again, we work with several NGO organizations. We work with private organizations, private universities, again, with a whole of government approach and likewise in the country, trying to use a whole of government approach as well. So I'll take malaria, for example, in many countries, and it was alluded to in the malaria panel, that the Ministry of Health may have a national program for malaria elimination. And several times, the military, that nation's military may not be invited. So what I'm trying to do is work with that military, work with the ambassador to get the Ministry of Health, the Ministry of Defense together so that we can include the military as part of a national effort. Again, for a whole of government approach, not just a whole of US government approach, but whole of government approach for our partner nation. So Pacific Partnership is a prime example of one of our many engagements that we do in the AOR. This stemmed from the 2004-2005 tsunami, as you may or may not recall, about the huge tsunami that affected a huge part of the region, Indonesia, Thailand, all the way into the, I think to the Maldives. And we responded initially with the USS Abraham Lincoln and the USNS Mercy. That opened a lot of eyes, that event, because poles were taken in Indonesia before, in which the favorable rating for the United States was 20%. After our response to the tsunami, it was over 60%. Admiral Mullen, when he was the Chief of Naval Operations, wanted to kill the hospital ship program that the Navy had. When he was Chairman of the Joint Chief of Staff, he said he's glad that he did not kill that program. So since then, we have an annual program, it's called Pacific Partnership. Every year, we either send the Mercy, or we send a large amphib to go over several months, to several of the countries in the region, and we rotate that. It's not always the same country. Working on disaster response preparedness, not just for us, but for our partner nations. I think, even though it's been a devastating event for the Philippines, from the typhoon, and again, time will tell, but I think their response has been tremendous, because I'll look back to, again, US military medical has not been asked to come. They're taking care of many of these issues on their own, so we will see. So I just wanted to tee up these topics for you to give you an idea of what we do in US pay-com, and I look forward to the discussion with Dr. Colson, as well as your questions, and I leave this last slide for my colleagues, members of the audience, who come from the warmer regions of the world. As you're shivering here, I see lots of people with heavy overcoats. Think of the picture here, hopefully that will warm your hearts. Thank you very much. Colin, thank you very much. The military has been accused of not following humanitarian principles, humanity, neutrality, impartiality. Is it reasonable to expect the US military, or any other military, to follow the same principles that NGOs might follow, or the ICRC, or other totally neutral organizations? What is the role of the US military at large, and how does health play in that role, particularly in the Pacific? So thank you for that question. Let me first respond to how does health, what is the role of health in the Pacific? And I'll get back to the President's Rebalance Initiative. I think health plays a huge role, at least in the US government's response for the rebalance, is that we play a huge role in that, because we all think about in terms of the rebalance, in terms of DOD, is shifting aircraft, shifting ships, shifting large units. And that is happening. However, as Admiral Lachler, the US Pacific commander, has mentioned several times, in public cases, mentioned to me, is that health is, in many respects, leading the rebalance efforts in US pay comm, because, and as I said before, and I alluded before, that health is considered non-controversial, health can be considered safe, in several of these countries, in which we're having emerging relationships, and health can open doors for military to military health engagements that are not open for traditional military to military engagements. So for example, Mirrenbar, that is a country that is emerging with their new democracy, but because of the history of that military, there is the human rights abuses from that military in the past, we have to be very careful in DOD in what types of engagements that we can have. There are some openings in the legal profession that are starting, and there are initial discussions about can health be the next step? And so in August of this year, we participated in a multilateral health engagement in Thailand, hosted and led by the Thais, with us invited, and Mirrenbar Medical, military medical folks were invited, to discuss tropical disease topics, as well as disaster relief. So that is an area where, again, the answer is how does health play a role in the Pacific? I think that is one very important area. And to answer your first question, we need to follow all the standard rules of conduct. We can't just go into a country and do what we want to do. We do have to follow all the standard rules. I mean, Secretary Russell was just here, he just talked about what the State Department does in terms of diplomacy is not altruistic, it's in the United States' best interest, and I think it's safe to assume that people who wear a uniform are there to represent their country, and it is about advancing that country's issues. And in that regard, we've had a lot of talk about malaria, we've had a lot of talk, sort of some allusions to the overseas labs, to Namru and the Navy Medical Research Center Asia. Explain a little bit about what the military's interest in infectious disease was initially in terms of force health protection, how that evolved into permanent overseas labs, and how that's kind of evolved into a national capability that the United States and others can use, and the host country can use. But we did something selfish, and it turned out to be something that other people are using now. Right, obviously, we will do things that obviously is good for the US military, but it does translate into good things for our host and partner nations. But going back to, let's go back to the beginning, why is the military involved in infectious diseases? It just goes back, just think of some of the, just again, let's start with malaria, Panama Canal, the efforts to build that canal multiple times in the past were thwarted by malaria, but it was a US Army physician who solved that problem, and we were able to build that canal as a nation, which obviously benefited the United States, but then benefited the world, because now we have this canal. But one of my charges as a command surgeon is the health of our active duty forces. And so we will go to areas in the world in which there are significant infectious disease threats. And so I have to read, so it's in our interest to do research in infectious disease for surveillance, vaccine research, treatment research, prophylaxis and prevention, so that we can deploy a healthy force who will not get ill while they're deployed. Historically in the wars that we have had, it's something we call non-battle diseases, meaning infectious diseases was the main reason why military members could not fight. It wasn't from wounds or injuries from battle, it was from infectious diseases. So that's really the genesis of why the U.S. military is involved in infectious disease research and then coordinates to why do we have overseas laboratories? So we have, the Army has a joint U.S. Army, Royal Thai Army, AFRIMS, Armed Forces Research, Institute of Medical Sciences. It's based in Bangkok, Thailand. They have been there for over 50 years. A joint Thai U.S. Army lab that's done tremendous work in Thailand and in terms of all sorts of infectious diseases, malaria, dengue, tuberculosis, you name it. The reason why is because that's where those infectious diseases are located. If we located that lab here in the United States in which we don't have those infections or these infectious diseases on a day-to-day basis, I think it'd be very hard to provide truly groundbreaking research. You have to go where those diseases are located and also I'll make a comment that even though our infectious disease specialists are securely trained and they have great knowledge, book knowledge of all the infectious disease out there in the Mekong, the doctors who treat these infections on a day-to-day basis have much to teach us on how to manage those diseases. So that's why we have our lab. So we have the lab in Bangkok. We also have the Navy Medical Research Center Asia which is now in Singapore. That has a history of I think 60 to 70 years and they have been through and former commanding officer Dr. Daniels standing right here right in front of me but they have been actually started in the Philippines. They went to Indonesia and now they are very briefly headquartered in Honolulu but we have reestablished them in Singapore but they also have a hub in Cambodia and also they have some people working in the Afrim's lab and there's possibilities that we may be able to expand throughout the region, other satellite laboratories and we're looking at that. We could talk about a lot of things but we have a few minutes left so let's take a few questions from the audience. We have two Navy guys here so the Air Force told me they wanted a pair of time. So Colonel Chambers. Good afternoon, Lieutenant Colonel Allen Chambers of the Air Force International Health Specialist Program. First Admiral Chen, thank you for your leadership and guidance on these important topics that affect all of us. Our organization in particular is at one challenge I'd like to ask you about. You talked briefly onto the podium in that as we've noticed working with a number of countries in a variety of continents especially hosting an educational forum for disaster preparedness where we attempt to bring representatives from both the Ministry of Defense and Ministries of Health together. Many times it becomes apparent that that's the first time those participants have sat together on the same table. So my question for you sir is how can the military and I'm speaking specifically with me and Marv at other countries in mind sir as we engage with other countries in your AOR how can we help encourage them to facilitate a dialogue, to better coordinate and prioritize initiatives between the Ministry of Defense and the Ministry of Health. Thank you. Okay, other questions in the back back there. Sorry, Adam Cameron Scott from University of Sydney. I'm actually over here doing a study on civil military cooperation in health security. So this is very fortuitous. My question really is there's a lot of debate on both sides of public health and the military about the right or the purpose of military engagement in health issues. Talking with some of the people here in DC as well as some of the locations. When I asked them what is the value that the military bring almost unanimously the first thing that comes to mind is seems to be the money and the resources. So I'm just interested in your perspective other than you've already mentioned research other than that what areas do you see as the military bringing value adding given that trust seems to be such an issue. Let's take one more. Hi, Jill Gay, What Works Association. And the military has been a leader on HIV vaccines, so especially in Asia. Could you talk about what the military is doing vis-a-vis HIV in specifically Myanmar and Laos? Thank you. So we've got, how does US military engage other countries, military to military and military to military to other parts of the country and how do we encourage discussions? What does the military bring besides money? Is that right? The question that we discussed earlier is the military tends to do episodic engagement. The development agencies tend to be there long term. The one exception to that is the overseas labs. So how does the episodic engagement facilitate or compete with the ongoing engagement? And then HIV in Myanmar and Laos. So let me, so first of all on Myanmar and HIV. Again, this is a very early relationship that, so we haven't done anything specifically with HIV. But right now we've only discussed tropical diseases and disaster relief. We have to take that a step at a time. I have to make sure that I'm not stepping ahead of US government policy in regards to engagement with Myanmar. But obviously that's a disease of interest, disease of concern. So what I think we would do, once we get to a point, we would perhaps follow the model that we have used in Vietnam. In which we have done a lot of success. And Vietnam has had tremendous success in working the AIDS and HIV issue in Vietnam. And use the PEPFAR program. So I think that would be how we would, again, given the right time, how we would engage HIV in Myanmar when the time is right. That would be the model that I think I would look at. As far as our engagements with other militaries, I mean, I may be a little bit biased here, but I think there is a lot of benefit to doing that. We don't go to a country unless they ask us to go there. I don't force a program upon a host nation military unless they ask for it. We will provide them visibility of the different types of programs that we have and we'll see what are you interested in. So for example, with China, they're having problems obviously now with non-communicable diseases. And they have come to us when I have academic exchanges to work on that problem. The other thing that we can help benefit is to provide an avenue for them to work with their counterparts in their civilian sector. Because as I mentioned earlier about the malaria issue, many of these nations, militaries, are not included in the discussion. And so I come to forums like this and hear how much of a problem it is. And as I look at the military population, I see that that is a mobile population. Just like the migrant workers, they are also very mobile. They are going to the border regions where there's drug-resistant malaria. They then go home for leave. So they go from that high endemic area back to their city, where they're from, where the village where they're from, maybe in which there is no drug-resistant malaria, but they're infected. So maybe they're bringing it. So also they, many of these militaries are using monotherapy as their program. So we're trying to open their eyes to the fact that that is probably not the best approach. And perhaps combination therapy is the way to go. And many of them are coming to the realization that they need to do that. And we're encouraging them and helping them and giving them in contact with the right people to develop a program, getting them in contact with their Ministry of Health. Make sure that they are interlinked with the national program. Another area of concern, which I think will be beneficial, is many of these countries are engaged with or want to be part of the UN Global Peacekeeping mission going to Africa. Okay, so they're at the border regions. Some of their people may be infected with drug-resistant malaria. They don't have programs right now to test their troops before they send them. We're actively engaged with them, encouraging them. You need to have a screening program and a treatment program and they were assisting them with that effort. Because I think the worst thing we could do, and I think it's great that they're engaged in the peacekeeping program, but then to send their folks over to Africa and that that is one of potential vehicles to introduce drug-resistant malaria to the African common. So those are just some examples of how we're trying, how I think it's beneficial that we are engaged, heavily engaged and actively engaged with our host nation militaries. What about the question of working with other organizations and I'd add to that, are there areas besides infectious disease, such as trauma care or some other military specific things that the military engages in? Right, so we've had, the U.S. military has had 12 years of war in the Middle East and we have learned huge lessons on management of trauma and the results of trauma. So very recently we have gotten inquiries from Singapore, actually, because they have some patients who are triple amputees, not a result of IED injuries, but they have some triple amputees and they wanted to know what is our approach to managing long-term of these patients? So we're sending a rehabilitation team from the Walter Reed National Military Medical Center in a couple weeks to Singapore to, again, as a subject matter expert exchange, to have a symposium on this and then my goal is, because Singapore has a very robust healthcare system, but we have other countries in the Mekong in which perhaps as a result of this bilateral exchange, we can then develop a multilateral exchange because I heard some questions about the mine issue in Laos and Cambodia. So I think that's something where we can help. I know these countries are, it's an issue and we would like to share our experience of knowledge from the last 10 years to these countries. I think we have time for one more round of questions if we could in the back. At first, I'd like to thank you for the slide of the warm horizon there. Secondly, let's say you get the green light to do Mill Mill Health Collaboration in Myanmar. What are your concerns or what are the sensitivities and consideration of partnering with a state that is party to ongoing conflicts? You talked about democracy and past human rights abuses, but it's a government that's only in name civilian, same actors as you know. And secondly, there are still ongoing conflicts. And secondly, we just met with the president last week who said that he's ordered his military to honor the ceasefires, but that if it's not carried out in the field, it's not necessarily because it's not the state's will. So you may be partnering with the state, but implementing in the field where local officers are not following state command. Other questions? Well, let me, so as I alluded to, this would be a very delicate relationship that we would, if we do engage more into it. An area of concentration that I probably would stick to in the beginning is drug resistant malaria. That is one of the epicenters of this problem. And I think that's the one that I think I would focus on. Fully understanding the problems with the military in Myanmar, their past history. And as I said before, I am not gonna get forward of US government's intent. And obviously we coordinate very closely with OSD policy and all sorts of these types of issues. Even before our multilateral engagement hosted by Thailand, we checked, we made sure that we got approval from OSD before we did that. So again, it's a very sensitive issue. And it's a delicate issue. We fully acknowledge that and we will take those precautions before we engage. And so that's, again, as I said, we will start with malaria. And as I said, go very slowly. I'm delighted to see so many US military folks here, including General Schoolmaker, the former Surgeon General of the Army. Thank you very much for coming. And Admiral Chin, thank you very much for your comments. We very much appreciate having you here. Thank you, thank you very much. Okay. Thank you. About the brand new... Oh, yeah, I love that. I want that.