3. UNPROFOR and Operation Provide Promise, the Balkans: A Case Study of the Medical Mission
IntroductionCoalition operations pose a unique set of challenges in providing the medical support for a mission in which troops are drawn from a variety of nations to create a multinational force. In these operations, coalition partners may bring in varying levels of quality of medical assets, as well as a wide range of diseases. Differences in standards of care, definitions of echelons of care, and in the level and quality of health care within a coalition soldier's own country may also influence patient care and evacuation decisions in a theater of operations.
Such was certainly the case for the United Nations Protection Force (UNPROFOR) in the Balkans, which was a coalition of UN and NATO forces for a peacekeeping mission initially established on 21 February 1992. In November 1992, UNPROFOR initially comprised units from 31 countries organized into 15 active battalions, with forces consisting of 23,000 UNPROFOR troops in the region, including the civilian employees and contract personnel associated with UNPROFOR and NATO employees and officers; by March 1994, those forces had grown to more than 40,000. This force was to be an interim arrangement to create the conditions of peace and security required for negotiating a settlement of the Yugoslav crisis.
Operation Provide Promise (OPP) stood up 1 February 1993, with Joint Task Force Provide Promise (JTF-PP) established to consolidate the oversight of a variety of U.S. missions in the former Yugoslavia, including: (a) command of all U.S. forces operating in support of UN operations in the Balkans; (b) air-land transportation and airdrops of humanitarian relief supplies into Bosnia-Herzegovina; (c) provision of medical support to UNPROFOR troops; (d) detecting, monitoring, and reporting activities along the border of Serbia and the former Yugoslav Republic of Macedonia (FYROM); and (e) conducting reconnaissance using unmanned aerial vehicles (UAVs) in support of UN, NATO, and U.S. operations.
The U.S. medical mission during UNPROFOR and Operation Provide Promise was to provide Echelon III support to UN peacekeeping forces. This mission was jointly shared by all three services, with each undertaking one or more rotations of the U.S. military hospital in Zagreb, Croatia. During the time period covered by this case study, the Army undertook the first two rotations, followed by the Air Force and then the Navy, which undertook the fourth rotation. See Table 3.1 for a list of the service rotations.
U.S. Hospitals and Rotations for UNPROFOR
|U.S. Hospitals||Rotation Dates|
|212th MASH (Army)||15 November 1992-27 April 1993|
|502nd MASH (Army)||28 April 1993-08 October 1993|
|48th ATH (Air Force)||09 October 1993-16 March 1994|
|Fleet Hospital 6 (Navy)||17 March 1994-29 August 1994|
|SOURCE: Data from briefing, "Operation Provide Promise, a Nursing Perspective," CAPT Nancy Owen, Director of Nursing Services, Fleet Hospital 6.|
In addition, the U.S. hospital in Zagreb, Croatia augmented the medical support of U.S. forces participating in the ongoing UN peacekeeping operation Able Sentry in Macedonia.
This chapter provides a case study of the U.S. role in providing the medical support mission for coalition forces participating in UNPROFOR and OPP, with a specific focus on the Army's medical role.
We start by examining the medical mission statement and the nature of the medical structure. We next turn to the demand for medical services during the operation, looking specifically at what services were demanded and at the nature of the patient population to be served. Finally, we examine how well the requirements met this demand.
In all cases, the intent here is to describe first what was expected or assumed in each of these areas. Then we examine what actually happened in each of these areas, showing how it varied from conditions at the outset.
Medical Mission Statement and Medical StructureThe medical mission statement and the medical structure for UNPROFOR and OPP are intertwined. The mission statement is what medical support U.S. forces are tasked to perform within the coalition, while the medical structure is how the coalition sets up assets and policies to execute that mission. Medical structure issues center around how the echelons of care are set up in-theater and what the evacuation and repatriation policies are. These assets and policies are driven by the differing medical assets and policies of the coalition partners, as well as by the UN's policy for medical logistics and the state of the local medical infrastructure.
Medical Mission Statement at the OutsetInitially, the medical mission during UNPROFOR was limited to providing support to truck convoys delivering humanitarian relief supplies to Bosnia-Herzegovina. During this initial phase, UNPROFOR units provided their own Echelons I and II care, with the UN purchasing Echelon III care from civilian contractors for these units. However, by July 1992 the situation in Bosnia-Herzegovina had begun to heat up, and in October 1992, European Command (EUCOM) received the order for the U.S. military to undertake the medical mission of providing Echelon III care to UNPROFOR troops. By November 1992, the U.S. Army had established a Mobile Army Surgical Hospital (MASH) at Camp Pleso on the outskirts of Zagreb, Croatia, as part of UNPROFOR.
In providing Echelon III care, the initial medical mission statement called for providing hospitalization and comprehensive care to all UN forces for up to 30 days (i.e., an evacuation policy of 30 days), including the treatment of UN civilian employees and contract personnel associated with UNPROFOR.
Medical Structure at the OutsetEchelons of care, evacuation and repatriation policies, and the contributions of coalition partners' assets. As mentioned above, the United States had responsibility for Echelon III care during the operation. The rest of the system was set up as follows. Echelon I care--defined by U.S. standards to include battalion aid station, combat medic, combat lifesaver, combat stress support, and buddy aid--was to be the responsibility of each contingent; this included treatment and evacuation capabilities from the point of injury or illness to the unit's aid station and the evacuation of patients from the field to Echelon II.
At the outset of the operation, Echelon I care ranged widely among the various contingents--all the way from a medic with a first aid kit to the U.S. Army's definition. In addition, some troops lacked key assets considered integral to the overall mission, such as preventive medicine support and combat stress capabilities. In UNPROFOR, many developing countries in particular lacked preventive medicine assets. In addition, their predeployment screening and preparations tended to be inadequate or nonexistent (e.g., no immunizations, no chemoprophylaxis or medications to protect their troops against infectious diseases, no health screening of troops prior to deployment). Most contingents also lacked combat stress support and were thus unable to identify or treat mental health problems in the field.
The British were initially tasked for Echelon II care. Their responsibilities were to include intratheater evacuation (ambulance and some air assets), the liaison function connecting Echelons I and III care, and the provision of a significant preventive medicine activity. The British also initially had overall command and control of the medical support for UNPROFOR. In addition, the French were to provide air evacuation for Bosnia; in Croatia, UN contractors were used to provide this support.
Echelon II care also included the forward surgical teams (FSTs) provided by the various contingents, with most battalions having an FST attached. The FSTs varied in size, composition, and quality of medical care provided (like the Echelon I medical assets of the various contingents). In addition, the FSTs were not evenly distributed across the various sectors.
Echelons IV and V care involved continued health care outside the theater and was intended to be a national responsibility, as was the repatriation of troops (i.e., each country was to be responsible for the transport of its own soldiers out of the theater).
What Happened to the Medical Mission During the OperationAs we look across the various rotations during the operation, we see how the medical mission began to evolve over time; this evolution was driven by directions from above, as well as by changes in the provision of the echelons of care and by evacuation and repatriation problems.
During the initial rotation, the Army's 212th MASH unit followed closely the written mission guidance of providing Echelon III care to UNPROFOR forces and to UN and NATO personnel. Early command pressure was for the task force to stay within the mission parameters. Task Force (TF) 212, the initial American medical component of this operation, thus did not get into providing refugee care, with the only civilians treated being either UN employees, NATO employees or officers, or contract personnel. Neither did TF 212 send medical personnel out into the various sectors. In addition, initially the 212th MASH was the only Echelon III hospital in the theater.
Further, the task force had established a liaison with the local community hospitals, contracting for use of certain medical equipment (e.g., CAT scanner), as well as setting up a contingency plan whereby local hospitals had agreed to take on patients from the 212th MASH in a mass-casualty situation in order to free up beds and Army medical personnel.
The Army's 502nd MASH unit, which took over the medical mission in April 1993, continued a range of activities and policies similar to those established by TF 212.
When the Air Force's 48th Air Transportable Hospital (ATH) took over in October 1994, two events occurred that led to a significant change and expansion of the medical mission.
First, the British medical battalion--responsible for Echelon II capabilities--pulled out. The British departure meant the loss of much of UNPROFOR's assets for intratheater ground transportation of patients, the loss of the liaison function connecting Echelons I and III care, and the loss of the significant preventive medicine activity the British had performed. With the departure of the British medical battalion, there were no longer dedicated helicopters or vehicles for MEDEVAC or ground transportation of patients. Although the Norwegians would subsequently be tasked to assume Echelon II activities, they did not come on-line until much later, during the fourth rotation when the Navy's Fleet Hospital 6 had already replaced the Air Force's 48th ATH in Zagreb. In addition, the Norwegians were located in Tuzla, which meant that their Echelon II capability was located far from where most of the casualties were occurring.
As a result, the Air Force (and later the Navy) undertook the job of filling in the void in Echelon II assets and assuming the liaison function for Echelon II. The Air Force did so by providing a transport team to assist in the aeromedical evacuation of UNPROFOR personnel and by establishing a sector liaison program in which medical teams were to be sent out to the various sectors. Sector activities included assessing the medical assets of other contingency forces and the quality of those assets, observing first-hand the various sectors' medical problems and hygiene and environmental conditions, and educating the various coalition forces on the type of medical support available to them from the 48th ATH.
The second factor that changed the medical mission was growing interest by the UN, the U.S. State Department, and the JTF Command for the Air Force to begin treating refugee children and adults at the ATH. A memo from the Chief of Staff dated 5 January 1994 instructed the AF 48th ATH to set aside five acute-care beds for the treatment of both refugee children and adults. The UN further sought assistance from the Air Force in providing medical help to UN personnel and their children, especially for UN personnel working in the more dangerous regions of the Balkans. In particular, there was a demand for psychiatric services and combat stress support.
As a result, the Air Force established liaisons with refugee camps (e.g., Varazdin) and began taking children for elective surgery and dental care, as well as adults for medical/surgical evaluation. The Air Force also extended hospital visits and established a medical liaison with the refugee camp at Cakovec. The 48th ATH further began coordinating with the UNHCR, WHO, UNPROFOR, and various relief agencies in treating and evacuating refugee casualties.
The operation parameters for the 48th ATH entailed being able to: (1) provide up to 40 surgical operations within a 72-hour window before requiring augmentation; (2) provide liaison and coordination with nongovernmental organizations (NGOs) in the use of the MASH for treating and evacuating refugee casualties; and (3) insofar as the primary mission allowed and in coordination with the UN Force Chief Medical Officer and Joint Task Force Provide Promise (forward) Commander (JTFPP(FWD)-CO), (a) assist with the medical evacuation of UNPROFOR personnel, (b) provide on-site medical and technical assistance to UNPROFOR medical officers and units and educational assistance in the management of cardiac and traumatic emergencies, and (c) provide planning, technical, and physical assistance to the UN Force Chief Medical Officer.
Importantly, the Air Force assumed responsibility for both filling in Echelon II and providing refugee care during the third rotation without written mission guidance and with only verbal approval from higher authority to extend the scope of the medical mission. Although the Air Force commander continually sought written guidance, this was not obtained during the six-month rotation.
When the Navy Fleet Hospital 6 took over the medical mission on 17 March 1994, it took over the Echelon II activities begun by the Air Force and extended them. This included creating seven MEDEVAC teams to be on 24-hour call who were also trained to convert helicopters to litter-bearing aircraft. The Navy continued the sector liaison program established by the Air Force but broadened it, increasing the number of sector visits. Such sector visits were conducted for a variety of reasons. For example, doctors visited each of the sectors as part of the Echelon II mission, corpsmen were sent to Tuzla to train on the Norwegians' armored ambulance evacuation capability, the hospital commander visited Tuzla to coordinate with the Norwegians on addressing the hole in Echelon II capabilities, a surgeon was sent to backfill the Norwegian hospital while their medical personnel rotated in, independent duty corpsmen were lent several times to the Canadians to fill in gaps in their medical assets, the commander sent a Navy Seabee Detachment to Split and Sarajevo to fix equipment, etc., a Navy psychiatrist was sent to Sarajevo to set up a program for individuals continually under fire and to provide group therapy for UN peacekeepers who had been held hostage by the Serbs, and a preventive medicine officer was sent to Sarajevo to assess public health conditions. (This officer was able to identify a major problem in the city's water purification system.) Navy physicians were also each assigned to a sector and were to be responsible for entry-level evacuations and for the coordination of care within it.
Another important change in the medical mission occurred early in this rotation: There was a significant increase in the number of trauma and trauma-related patients as a result of land mine injuries, which led to a change in the medical support requirements as well as to Fleet Hospital 6 taking on Echelon IV care as well.
Echelon IV care comprised the following. The Fleet Hospital 6 had established a close working relationship with the local hospitals, appointing an officer to serve as liaison. Because Zagreb's hospitals were quite capable by Western standards and had available sophisticated medical equipment (e.g., CAT scan) and expertise (e.g., neurosurgical consults and an operating capability), the Navy was able to arrange access to these capabilities and so provide Echelon IV care to coalition patients. As it turned out, some of the world's experts in the treatment of complex mine injuries were located at the University of Zagreb. The Fleet Hospital 6 staff and the university medical staff at one point held a combined symposium on complex mine injuries.
In addition to assuming Echelon IV care and filling the void in Echelon II assets, the Navy continued to serve as the primary interface with UNPROFOR, UNHCR, the U.S. embassies, and the relief agencies. Like the Army, however, the Navy provided very little refugee care; any treatment of civilians was for those who were associated with either the UN or NATO.
Finally, the Navy was able to augment the assets of U.S. forces participating in Able Sentry, the ongoing peacekeeping mission in Macedonia. For example, the Fleet Hospital 6 sent orthopedic teams monthly to assist the local physicians and implemented an aggressive physical therapy and education program for these forces. In addition, it sent a Catholic chaplain to Macedonia and made several visits to screen and put on classes on preventive treatment for U.S. forces.
In summary, the medical mission throughout UNPROFOR kept expanding in response to changing support requirements. Initially, the Army remained fairly restrictive in its activities, closely following written mission guidance. But by the third rotation, increased pressure to take on refugee care and the hole in Echelon II assets forced the Air Force to expand its activities beyond the scope of the original medical mission. The Navy similarly continued the activities the Air Force had begun to keep the in-theater medical system intact. In addition, melting snows coupled with a cease-fire led to more land mine injuries and thus an increase in the number of trauma patients seen by the Navy's fleet hospital and to the assumption of Echelon IV care during the fourth rotation.
What Happened to Echelons of Care During the OperationAs mentioned earlier, there was a wide variety in the quality of assets and medical care within the various echelons of care at the outset. During the operation, poor quality of care and inappropriate care at Echelons I and II meant that the United States, in some instances, ended up treating coalition patients with unnecessary complications. Further, delays in transporting patients to the U.S. hospital resulted in some cases in a worsening of the patient's medical condition. Thus, U.S. medical personnel sometimes found themselves having to undo what the Echelon I assets or the FSTs had done out in the field. For example, the 212th MASH had a 21-year-old Eastern European soldier who arrived at the hospital with a badly swollen face and a life-threatening gum infection. The Army's maxillofacial surgeon ended up having to pull a number of the soldier's teeth and treat him with massive doses of antibiotics to save his life. In another case, an Eastern European soldier with a chest wound had had a chest tube inserted by one of the FSTs, but he was not transported to the 212th MASH until two days later. Upon arrival, his chest tube had become clogged and infected. It took an Army surgeon four days of constant vigil to get the soldier cleaned out and stabilized.
Also as mentioned earlier, many countries did not have combat stress support assets. Consequently, during UNPROFOR, coalition troops would often seek out combat stress support from the U.S. hospital, which provided it although such support was not within the scope of the original medical mission. In general, although Army, Air Force, and Navy combat stress personnel did what they could to fill in this void, they also faced some difficult challenges, including linguistic and cultural barriers.
Inadequate health screening and predeployment preparations among some of the contingents meant that some soldiers were in relatively poor health status when they arrived in the theater, with some troops bringing in serious infectious diseases such as malaria and tuberculosis, as well as diseases not endemic to the region. Of the infectious diseases, tuberculosis was particularly problematic, with an estimated 40 percent prevalence among soldiers from the former Soviet republics.
Overall, there was wide variability in the medical and dental readiness of UNPROFOR forces. Troops from West European countries, Canada, and Australia were comparable to the United States in their level of medical readiness, although the dental readiness of some was not up to U.S. standards. Troops from some developing countries (e.g., former Soviet Republics, Poland) showed more variability in their level of medical readiness and almost no dental readiness. Troops from other developing countries (e.g., those from African countries, the Pakistanis, the Nepalese) showed the most variability in their level of medical readiness, with dental readiness being virtually nil.
Evacuation and repatriation problems during the operation. The departure of the British medical battalion left a hole in Echelon II assets. This meant that the intratheater evacuation of patients became difficult and circuitous. Specifically, there were no longer dedicated helicopters or vehicles for MEDEVAC or ground transportation of patients between Echelons I and III. Although the UN contracted out for local ground transportation and for air evacuation, using borrowed vehicles and ambulances, some of these vehicles were not specifically designed for patient transport.
In addition, the UN had contracted out MEDEVAC services with a KLM subsidiary helicopter company (IRA). Some of these helicopters, however, were not specifically set up for MEDEVAC, did not have flight crews trained in the aeroevacuation of patients, and lacked medical personnel who could provide the hospital staff on the ground with the type of information needed to arrange the transport of a patient.
Further, an evacuation request from the FSTs had to be transmitted by nonmedical personnel through several layers of UN bureaucracy, further complicating the evacuation process. For example, the FSTs would send a request for patient transport to the UN, which would then notify the U.S. hospital via the JTF air liaison officer. The hospital staff, in turn, would have to go through the JTF air liaison officer (nonmedical officer) to make arrangements to transport the patient. The fact that intratheater evacuation was being handled by civilians and nonmedical personnel meant that the U.S. hospital at times would receive calls to send a medical team to evacuate a patient but would not receive adequate information on the patient's condition, the number of patients to be transported, or the type of medical personnel and resources needed. The Fleet Hospital 6 staff tried to get around this by talking directly to the FST physicians in the field. This was not always possible, however, since the Serbs were continually interrupting the communication lines. The Serbs also controlled the air space, limiting the periods during which a MEDEVAC mission could be flown.
Repatriation, or intertheater evacuation of patients, was to be a national responsibility. In general, the Canadians, Australians, and the West European countries were able to pick up their injured soldiers and transport them home. However, the repatriation of soldiers from the developing countries (e.g., the former Soviet Republics, African nations, and Middle Eastern and Far Eastern countries) was more of a problem. Many of these countries lacked an air evacuation capability. Instead, special arrangements had to be made to retrieve an injured soldier, which often meant a significant delay in patient pick-up from the Echelon III hospital.
As a result, each of the U.S. military hospitals ended up holding on to some coalition patients far longer than they would normally expect to or than was medically necessary. During the fourth rotation, the repatriation of coalition soldiers from developing countries averaged around 2-4 weeks, whereas evacuation out of the theater of soldiers from the more developed countries averaged one week. Although the UN had published an evacuation policy, it became situational, depending on the ability or willingness of different contingency forces to repatriate their own soldiers. During UNPROFOR, the U.S. Army patient administration officers quickly learned to start the paperwork to have a coalition patient evacuated out of the theater as soon as he entered the hospital. Such difficulties in repatriating soldiers from developing countries created problems for the United States in terms of patient tracking and for the medical staff in terms of ethical and treatment dilemmas, since for some patients there was no one to transfer their care to.
The first rotation supplies another example of how concerns about the availability and quality of health care within a soldier's own country led the United States to hold onto certain patients longer than it would normally expect to in order to ensure that the soldier received appropriate care. The Army's 212th MASH took on the care of four Russian soldiers who were amputees and had been languishing in a community hospital in Zagreb. These soldiers had received inadequate nursing care, and as a result their muscles had begun to atrophy. The Russian ambassador knew that if these soldiers were returned home they would probably be unable to obtain prostheses and also that there was a good prosthetics manufacturer in Zagreb. The ambassador intervened on their behalf, requesting that the 212th MASH get them back into good medical condition and house them until they could be fitted with prostheses. However, fitting these soldiers with prostheses and getting them through the initial stages of rehabilitation took time. The 212th MASH ended up keeping these soldiers a maximum of 89 days, a stay almost three times longer than the mission's 30-day evacuation policy. The Air Force and Navy had similar cases during their rotations. As this example illustrates, the level of development of a country's health care system was a contributing factor in the United States assuming Echelon IV care for some patients.
Medical Logistics at the OutsetGoing into the operation, DoD planners assumed the U.S. task force could rely on the UN logistical supply system. Maintaining the blood supply was another critical medical logistics issue for UNPROFOR, with the various contingents intended to be responsible for their own blood supply.
What Happened to Medical Logistics During the Operation
The assumption that the United States could rely on the UN logistical supply system turned out to be unrealistic during the operation. When UNPROFOR started, the UN supply system for this operation was nonexistent. After it was set up, it was slow, taking anywhere from 4 to 6 weeks to fill requests. All the U.S. hospitals instead established a petty cash fund from which they could purchase supplies locally rather than go through the UN supply system. In general, the U.S. hospitals ended up going through U.S. channels to obtain most of their supplies and other support requirements.
Maintaining the blood supply was a critical issue throughout UNPROFOR. Although each contingent was supposed to provide its own, in reality only the United States and West European countries had the capability to do this. In addition, U.S. medical personnel's ability to tap into the civilian blood supply was limited and dependent on whether the local populace itself was dealing with a combat casualty situation. If so, then civilian casualties might mean a high demand for blood. In such instances, one would have to be able to bring in outside sources of blood. EUCOM implemented the first frozen blood supply program in a field environment during the fourth rotation. In addition to cultural sensitivities about who would receive whose blood, there were concerns about procedures for screening the blood supply for HIV-related viruses. For example, some European countries have a lower HIV rate than the United States, and for this reason alone some forces were wary of receiving U.S. blood. On the other hand, the United States had similar concerns of its own. During this operation, the U.S. policy was to use only U.S. blood to treat both U.S. personnel and coalition soldiers, since some countries do not routinely screen for certain HIV-related viruses.
Demand for ServicesIn looking at the demand for services during the operation, we examine the combination of two factors: (1) the population to be served, which centers around the mix between U.S. and other forces and between military and civilian personnel, as well as age and gender differences and the level of medical and dental readiness of the troops; and (2) patient demand, which centers around differences in demand for trauma versus primary care, the amount of disease and the type of medical conditions and injuries requiring treatment, and changes in the level of demand over the course of this deployment. Again, we first examine the expectations at the outset and then what actually occurred during the operation.
Expectations of Populations Served at the OutsetIn terms of populations to be served, the expectation going in as established by the medical mission statement, was that the U.S. hospital would primarily be treating coalition forces from other countries, including some UN civilian employees and contract personnel associated with UNPROFOR. The mission statement excluded foreign civilians and refugees from the population to be served. There was also an implicit assumption that the hospital would be primarily dealing with troops with a high level of medical and dental readiness.
Populations Served During the OperationTable 3.2 shows the number of admissions and outpatient visits by patient category for the two Army hospitals. On the inpatient side, the Army primarily took care of foreign military personnel (UNPROFOR forces) and NATO personnel. For the 212th MASH, 78 percent of its admissions were in these two patient categories, whereas only 14 percent of admissions were U.S. personnel. Foreign civilians comprised the remaining 8 percent of admissions. These proportions stayed roughly the same for the 502nd MASH.
In terms of outpatient visits, approximately 38 percent of the 212th MASH's outpatient visits were by U.S. personnel and 28 percent by foreign military personnel. NATO employees and military personnel were continually coming and going in the theater to evaluate NATO's requirements and to set up the no-fly zone. NATO personnel and UN employees accounted for a quarter of the outpatient visits and foreign civilians for 10 percent of the visits.
During the Army's second rotation, the distribution of outpatient visits across the four patient categories stayed approximately the same. The only difference between the first and second rotations was a decrease in the percent of outpatient visits accounted for by foreign military personnel (from 28 to 22 percent).
Comparison of Total Number of Admissions and Outpatient Visits by Patient Category for the Army's Rotations in UNPROFOR
|212th MASH||502nd MASH|
|Admissions||Outpatient Visits||Admissions||Outpatient Visits|
|SOURCE: Data are from the Directorate of Patient Administration Systems and Biostatistics Activities (PASBA), AMEDD Center and School, Fort Sam Houston.|
Because many UN, NATO, and contract personnel were women and because some coalition forces had a large number of female soldiers, there was also a high demand for ob/gyn care in the theater. In addition, requests to assist in the evacuation and treatment of refugee children led to the need for some pediatric services.
Further, because many countries relied heavily on reservists and civilian contract personnel, these troops tended to be older, to be in poorer health status, and to have a wider range of acute and chronic medical conditions than soldiers from countries who used primarily active-duty soldiers. As a result, for example, the U.S. medical staff had to evaluate some older soldiers and civilians for such conditions as acute chest pain during UNPROFOR.
The end result of this wide mix of patient groups was that the U.S. hospitals were pushed in the direction of providing a broader range of services, since their patient population more closely resembled that of a community hospital, as opposed to what a military hospital would expect to see in a theater of operations. To illustrate how these differences in patient groups translated into the nature of the patient population seen by the U.S. hospitals, we describe the Navy's Fleet Hospital 6 inpatient experience:
- First, over half of the admissions to the Navy hospital were for trauma or trauma-related injuries, (including complex mine injuries to the extremities, multiple shrapnel wounds, head trauma, burns to the extremities, etc.). There were also orthopedic injuries, some of which were sports-related.
- Second were gastrointestinal problems (e.g., GI bleeding, peptic ulcer, gastroenteritis, appendicitis, abdominal pain), most of which are not uncommon in a young adult male population. There were also a number of stones--kidney stones, urethral stones--requiring treatment.
- Third, there were a number of dental procedures (e.g., wisdom tooth extractions, odontectomies, abscesses, etc.), which for the most part required only short hospital stays of one or two days.
- Fourth, there were chest pains of various sorts requiring inpatient evaluation (e.g., possible myocardial infarction, atypical chest pain, etc.), as well as a few other chronic medical problems including diabetes and chronic otitis media.
- Fifth, there were infectious diseases such as tuberculosis, malaria, chicken pox, hepatitis, upper respiratory tract infections, and pneumonia.
- Sixth, there were a few rare events (e.g., Hodgkin's disease, brain tumor) and several psychiatric cases including depression, suicidal ideation, psychosis, and alcohol intoxication.
Expectations of Patient Demand at the OutsetThe initial expectation in terms of patient demand at the outset was that the U.S. Echelon III hospital would primarily be treating diseases and relatively few injuries, since most of the combat casualties were expected to occur among the civilian population, not among peacekeeping forces. Recall that the initial medical mission statement called for providing hospitalization and comprehensive care for up to 30 days, which excluded the provision of long-term rehabilitative care or more definitive therapy for patients in the recuperative phase (i.e., Echelon IV care).
In contrast, the forward surgical teams (FSTs) were expected to see the majority of emergency trauma patients in the theater. However, because of the wide variability in the quality of medical assets across UNPROFOR troops, this meant for some soldiers that if they were able to make their way to the U.S. hospital and survive any delays in intratheater evacuation or substandard care that might be provided at Echelons I or II, then by the time they reached the U.S. hospital they probably would be stabilized and require more reconstructive or rehabilitative care than trauma care.
In general, soldiers from West European countries tended to remain in the care of the United States only as long as was medically necessary; in some instances they would bypass the U.S. hospital in Zagreb altogether and be flown directly out of the theater to a fixed facility in their country.
On the other hand, soldiers from developing countries would tend to remain in the care of the U.S. hospital somewhat longer. These patients were also at greatest risk of developing complications, experiencing delays in evacuation, and receiving poor quality of care in the field. Coupled with repatriation problems, these soldiers tended to be more resource intensive to treat and to be more likely to require Echelon IV care. In addition, some patients who no longer needed medical attention still had to be housed on a minimal-care ward until they could be repatriated or returned to their unit.
Below we examine how these differences translated in terms of patient demand and length of stay differences across the various troops.
Patient Demand During the OperationTable 3.3 shows the total number of admissions and outpatient visits by rotation during this operation. Not surprisingly, the demand for outpatient services increased as the size of the UN force increased from the initial 23,000 troops to more than 40,000 by the fourth rotation. In contrast, the number of admissions for the four rotations remained fairly constant throughout the deployment.
What did change on the inpatient side, however, was the proportion of admissions that were injury-related (trauma) versus disease-related. Before the fourth rotation, two-thirds of all hospital admissions were disease-related. However, during the Navy's watch, half of the fleet hospital's admissions were now trauma-related, suggesting that the fleet hospital took on more resource-intensive patients than had the previous three hospitals.
Comparison of Total Number of Admissions and Outpatient Visits by Rotation for UNPROFOR
|U.S. Hospitals||Number of Outpatient Visits||Number of Admissions||Proportion of Disease to Injuries|
|212th MASH (Army)||4,454||338||67/33|
|502nd MASH (Army)||4,715||313||63/37|
|48th ATH (Air Force)||6,610||323||64/36|
|Fleet Hospital 6 (Navy)||9,131||353||48/52|
The total outpatient visits and admissions listed for the 212th and 502nd MASH
units differ from those reported in Table 3.2. The reason for the discrepancy
is the use of two different data sources. Table 3.2 indicated an increase of
about 1,500 visits, whereas Table 3.3 shows no increase in outpatient
visits between the first and second rotations. It was necessary to use two
different data sources because only the PASBA data allowed for a breakdown of
the utilization pattern across patient categories. In addition, because the
PASBA data gave us information only on the Army's rotations, data on the third
and fourth rotations had to be obtained from briefing charts. Both sources,
however, indicate an overall trend of increasing outpatient visits over time.
Further, both sources indicate that the admission rate remained fairly constant
SOURCE: Data from briefing charts: "Operation Provide Promise, a Nursing Perspective," CAPT Nancy Owen, Fleet Hospital 6's Director of Nursing Services. The proportional distribution column refers to admissions only.
This shift in the proportion of trauma-related admissions corresponds with changes in the operation that took place at that time. As noted above, by the spring of 1994, melting snows and the cease-fire led to an increase in the number of trauma patients with complex mine injuries. There were also important length-of-stay differences across patient categories. Table 3.4 shows the average length of stay by patient category for each of the Army hospitals.
Comparing length of stay for different patient groups, we see that the pattern differs for the two Army hospitals. Overall, average length of stay was twice as long during the first rotation (212th MASH) than during the second rotation (i.e., 7.2 days versus 3.7 days). Within the different patient categories, foreign military personnel had the longest average length of stay (10.3 days) and U.S. personnel the shortest (3.2 days) during the first rotation. The relative rank ordering of the four patient groups in terms of length of stay remained the same during the second rotation, although length of stay dropped from 1 to 5 days on average within each category. The shorter stays of U.S. personnel may be largely attributable to the fact that these personnel were primarily support personnel and were not near any of the heavy fighting.
Average Length of Stay by Patient Category for the Army's Rotations in UNPROFOR
|212th MASH||502nd MASH|
|Admissions||Average Length of Stay||Admissions||Average Length of Stay|
|SOURCE: Data are from the Directorate of Patient Administration Systems and Biostatistics Activities (PASBA), AMEDD Center and School, Fort Sam Houston.|
Previously, we noted the wide variability among coalition forces in their medical and dental readiness. Given this variability, the average length of stay of foreign military personnel shown in Table 3.4 is somewhat misleading, since this category combines forces with different lengths of stay. To examine these differences, we used inpatient data from the fourth rotation to compare length of stay across the various contingents. In Table 3.5, troops are grouped by country of origin.
Comparison of Average Length of Stay of UNPROFOR Troops by Country for the Fourth Rotation
|Contingency Force||Number of Outpatient Visits||Number of Admissions||Average LOS (days)|
Data from CAPT Carlisle, Navy Fleet Hospital 6.
NOTE: A few contingents were missing length of stay data and so are not shown. Also, throughout this operation, the composition of the force changed. Therefore, the countries shown here represent only a partial list of the nations who contributed forces during the entire deployment.
Although there is a "small-numbers" problem for some forces, in general we see that the United States and the West European countries tended to have the shortest average lengths of stay. Argentina and Egypt fell into the middle range. Beginning with Jordan, we start to see longer average LOS across the remaining contingency forces, ranging from 6.1 to 18.7 days. The coalition forces with the highest average LOS also tended to have more outlier cases. The former Soviet republics had some of the longest-staying patients. For example, a Russian soldier with an admitting diagnosis of tuberculosis had a LOS of 41 days; two Russian soldiers with mine injuries had stays of 100 and 134 days respectively; and a Ukrainian soldier with Hodgkin's disease had a LOS of 48 days.
Although variation in length of stay across UNPROFOR troops likely reflects differences in physical readiness, in quality of their medical assets, as well as in medical need, some of the longer-staying patients were not necessarily more resource-intensive to treat. For example, the Russian soldiers who were amputees did require rehabilitative care, but they also required that the MASH unit house them until they could be fitted with prostheses. In other cases, delays in repatriation accounted for some of the additional days.
Were U.S. hospitals kept busy during UNPROFOR? During the initial rotation, patient demand was lower than had been anticipated. The reasons for this were severalfold. As mentioned above, the Army closely followed written mission guidance and was more restrictive in the scope of its activities (e.g., it did not undertake refugee care). In addition, during the Army's two rotations, Echelon II was working reasonably well. Further, the U.S. hospital was never located near the mainstream of the casualty movement although the potential was there with the hospital's location at Pleso airfield.
The Air Force added on Echelon II care, sector visits, and refugee care to the primary mission of providing hospital care to UNPROFOR forces. The Navy extended the Air Force's activities and, as discussed above, saw a greater proportion of trauma patients. In addition, over time there was an increase in the total number of UNPROFOR troops requiring medical support. Nonetheless, at no point were any of the hospitals overwhelmed by patient demand in the theater or by combat casualties.
Requirements to Meet Demand for ServicesGiven the differences in types of patients deployed to the theater and the types of services they required, we next examine how well the requirements sent to the theater met these demands.
Medical Requirements at the OutsetDuring the initial rotation by the Army, the decision was made to send a MASH unit, which could more readily be broken down into its component parts, rather than to deploy a combat support hospital. The 212th MASH out of Wiesbaden, Germany initially was configured to have twelve ICU beds, two 20-bed intermediate-care units, and eight minimal-care beds (holding units). The MASH unit, normally designed to provide emergency care only, was tailored to include a wide range of services (e.g., physical therapy, surgery, internal medicine, dentistry, emergency, etc.). Again, as mentioned above, the operation parameters called for the 212th MASH to be able to provide comprehensive care and hospitalization to all UN forces for up to 30 days.
Medical Requirements During the Operation
Although advance assessment had paid off in terms of the hospital's configuration and the range of services required, the sizing was off. As mentioned earlier, the demand for services was relatively low during the initial phases of UNPROFOR. Thus, as the first rotation progressed, one of the intermediate-care units was eventually stepped down to a minimal-care unit. Low patient demand also led the TF 212 to send 43 of the 397 originally deployed personnel (257 were directly affiliated with the Army's MASH unit) back to their parent units, with the option of recalling them to the theater later on, if necessary.
All subsequent rotations fell in on the 212th MASH's hospital and equipment. In late April 1993, the Army's 502nd MASH unit replaced the 212th in the theater. Although the 502nd MASH made some minor modifications to the hospital and adjustments to the mix of personnel brought into the theater, basically the setup was quite similar during the two Army rotations.
In October 1993, the Air Force's 48th Medical Group assumed the medical mission. It comprised 142 AF medical personnel, of whom 99 were from the Royal Air Force Base (RAF) Lakeheath, Suffolk, England, and 40 were from other U.S. military hospitals and clinics within Europe. Similar to the two Army hospitals, the 48th ATH was tasked to provide a 60-bed surgical hospital with 30 beds for minimal-care patients.
The 48th ATH similarly was set up to provide a full range of services, including (a) an eight-bed intensive care unit; (b) two isolation tents; (c) two medical/surgical wards (one of which was later utilized as a classroom and to house adults accompanying refugee children); (d) 24-hour emergency services capability; (e) a pharmacy; (f) extensive postinjury physiotherapy and follow-up orthopedic care; (g) radiology capability; (h) one two-tent section (four bunks) for psychiatric treatment; (i) dental services; and (j) a variety of other services (e.g., environmental health, medical logistics, patient administration, medical food service, and communications).
The Air Force was tasked to develop a plan to establish a pediatric ward for refugee children and ultimately set aside five acute-care beds for the treatment of refugee adults and children. As noted earlier, the other significant requirement during the third rotation was for the Air Force to train its medical personnel to conduct MEDEVAC missions and to take on the sector liaison function.
The Navy assumed the medical mission in March 1994. The Fleet Hospital 6 also was tasked to provide Echelon III care for all UNPROFOR personnel. Its capabilities included 24-hour emergent and nonemergent care, a 60-bed hospital (24 acute-care beds, 6 isolation beds, and 30 minimal-care beds), physical therapy, and respiratory therapy service. Fleet Hospital 6's medical staff included 171 personnel, with a total of 313 personnel comprising JTF (FWD) Provide Promise.
The Fleet Hospital 6 initially had tailored what it brought into the theater and its mix of providers based on the previous three rotations' patient demand and support requirements. However, with the change in patient mix and the requirement for Echelon IV care, the Fleet Hospital 6 ended up making the following adjustments:
- Due to the increase in trauma patients, the number of orthopedic surgeons was increased to two and the number of general surgeons was reduced by one.
- The Fleet Hospital 6 greatly expanded its physical therapy department. The Navy also implemented an aggressive physical therapy and preventive treatment program. Accordingly, two-thirds of the physical therapy cases were referred by primary care physicians (or via the ER) rather than by an orthopedic surgeon. The Navy did so in an attempt to cut down on the number of serious orthopedic injuries. This meant bringing in a physical therapist and two PT technicians.
- About half of the Navy's patients were females, so a general practitioner with training in ob/gyn care was brought in and a cubicle set aside specifically for this purpose.
- Due to the high demand for emergency dental care, two general dentists and one oral surgeon were deployed.
In addition, all four hospitals had to contend with the following support requirements. First, the above-discussed problems in repatriating soldiers and returning them to their unit required a minimal holding unit capability. In addition, beds were needed for buddies of injured soldiers who came to the U.S. hospital to serve as the patient's translator. Further, soldiers who required such services as emergency dental care but did not need to be hospitalized still had to be housed. Adults who accompanied refugee children also required housing. The U.S. hospital at one point housed for an extended period several orphaned children.
Second, there was a need for an isolation capability in-theater. Achieving an isolation capability in a tent environment, however, is difficult to do. At times there were patients with a variety of different contagious diseases all housed on the same ward.
Third, the large number of female patients meant a requirement for an ob/gyn setup (e.g., a cubicle) to do gynecological exams, gynecological medical supplies and equipment, and a physician trained in ob/gyn care. Each hospital had to improvise to accommodate this type of patient demand. For example, the Navy brought over a general practitioner who had received extra training in this area and could bring his own instruments.
Finally, the need for translators and linguistic support was high throughout this operation. For example, initially over 31 countries were participating in UNPROFOR. Although the U.S. hospital was located near UNPROFOR headquarters in Zagreb, the UN was not always able to assist with translation. Some nationalities, such as the French and Jordanians, might send another soldier to accompany a patient and serve as his translator. Other troops such as the Russians would drop a patient off and then depart. Not only did this cause problems in communicating with the patient about his treatment, it also caused trouble tracking down his unit when the patient was to be discharged or critical treatment decisions needed to be made. Each of the hospitals had a different method for meeting their linguistic requirements. The 212th MASH, for example, had several Army personnel fluent in a number of Balkan languages whom it relied upon for translation. The Air Force hired a Croatian physician for its outpatient clinic who served as the interface between the 48th ATH and the local community hospitals. The U.S. Navy field tested a mechanical translation device during this operation.
In summary, throughout the course of UNPROFOR, sizing of the medical support was never much of a problem. In fact, as shown earlier, the number of patients admitted to each hospital remained fairly constant throughout this operation. Although the number of outpatient visits steadily increased over time, this alone was not as significant a determining factor of the medical support requirements as were other variables.
The real problem was that the mission itself was quite fluid in terms of the types of patients the hospital would end up treating and the range of activities U.S. medical personnel would be required to take on to keep the in-theater medical system going. In addition, throughout this operation there were security concerns for U.S. personnel.
Further, the medical issues that arose during UNPROFOR became more and more complex over time, including refugee care, coordination of refugee patients' evacuation and treatment with the UN, UNHCR, and various other relief agencies, assumption of Echelon IV care, problems in the repatriation of soldiers, gaps in Echelon II, and treatment of complex mine injuries. In addition, there were the above-discussed differences in medical readiness among the UNPROFOR troops and in the quality of medical assets in-theater. Combined, these factors meant that it was difficult to predict at any one time what mix of personnel, units, supplies, and equipment was needed in the theater.
Overall Case-Specific ObservationsWhen we look across the experience of the medical mission in the Balkans, a number of observations emerge. On the whole, these center around the unique problems associated with working with the UN and with coalition forces.
Problems Working with the UNA number of the problems that occurred during UNPROFOR were the result of multiple layers of command and control. During UNPROFOR, for example, there were Joint Staff orders, UN orders, EUCOM orders, and requests being made by the State Department. In the case of refugee care, at times there were conflicting requests. For example, the Air Force's 48th ATH technically belonged to the UN, which requested that this hospital provide treatment to refugee adults. At the same time, the U.S. State Department had requested that the 48th ATH take on the care of refugee children, although technically the State Department had no real authority over the hospital.
UNPROFOR headquarters was not always in agreement with the concerns of the U.S. task force. For example, the UN commander and staff did not respond to requests by the U.S. Army about hospital security at Camp Pleso. Underlying this were differences in perceptions of the level of threat and degree of emphasis on force protection.
The UN Force Chief Medical Officer is the senior medical officer in the theater with oversight over all the other force medical officers. This relationship is more than a technical one in that the UN Force Chief Medical Officer also controls the funds and can put "fences" around how the other medical officers go about their mission. For example, the UN Force Chief Medical Officer approves supplies, sets forth the medical ROEs, and enforces compliance with them. The problem, however, is that in UN operations the political realities are such that individual decisions made by coalition partners may affect the functioning of the theater medical system and at times affect the decisions made by the UN Force Chief Medical Officer. For example, during UNPROFOR the U.S. chain of command repeatedly vetoed requests by the UN Force Chief Medical Officer. In other instances, the United States was not allowed to fly into high-risk areas for MEDEVAC missions. As seen also during UNPROFOR, the decision of the British to withdraw their medical battalion impacted Echelon II. Thus, in UN operations it is political realities in terms of what each country can and cannot do that determine significantly how well the theater medical system itself functions.
The various layers of bureaucracy and unclear chain of command also made it difficult to accomplish certain tasks during UNPROFOR, such as purchasing supplies. The UN also had cumbersome reporting requirements. For UNPROFOR, it had set up a complex system to distribute funds. TF 212 had to assign extra personnel just to monitor UN funds and comply with UN reporting requirements.
In terms of logistics, planners were unrealistic in assuming that the U.S. hospital could rely on the UN medical logistics system. The UN system is highly constrained by funding. Further, that system is slow, taking anywhere from 4 to 6 weeks to fill requests. Part of the problem during UNPROFOR was that the U.S. force needed to get used to working within the UN bureaucracy and the process by which requests were approved and processed. Another aspect of the problem was the fact that U.S. medical units are required to comply with FDA standards, and so were unable to utilize some UN medical supplies.
Other problems arose because of mismatched tour lengths. UN tours are normally one year, whereas U.S. tours are typically 179 days. It takes some time to figure out how the UN system is supposed to work and then to work the system. This meant that the various U.S. task forces would just get established, work out the problems in the system, and start to run smoothly for a relatively short period before the new rotation came in.
Problems Working with Other Coalition PartnersThroughout the case study, we see numerous examples of problems arising out of differences between the United States and its coalition partners. These problems centered around differing medical policies, differing levels of assets, differing standards of care, and differing levels of physical readiness.
Differing medical policies. In terms of medical policies, countries in UNPROFOR had different views of how broad the medical mission should be. Countries with a long history of undertaking peacekeeping and humanitarian relief missions--such as Norway, Canada, the Netherlands, and Sweden--tend to define their medical mission more broadly. For example, the Norwegians normally expect to get involved with the host country and local community in providing medical care and public health services and in rebuilding the medical infrastructure. The Norwegian hospital in Tuzla, for example, not only provided care to UNPROFOR troops, but also worked with the local hospitals.
By contrast, the U.S. policy was to provide medical support to the U.S. troops and other coalition forces involved in the given relief effort and not get involved in providing refugee care or in rebuilding of the medical infrastructure, except on a very limited basis. During UNPROFOR, the U.S. medical units adhered for the most part to this primary mission.
Differences in coalition partners' medical policies can set up unrealistic expectations as to the U.S. medical mission and complicated the interactions of the U.S. military and other countries' medical teams (as well as civilian health care providers, government officials, and NGOs). For example, during UNPROFOR, the press played up the fact that the U.S. hospital did not provide refugee care.
Other coalition partners' medical policies also had the potential to affect the morale of U.S. medical personnel. During UNPROFOR, the Norwegians were kept busy treating civilians and working in the refugee camps and with the local hospitals around Tuzla. In contrast, because patient demand during UNPROFOR was relatively low and U.S. medical personnel were restricted in their activities (e.g., not allowed to volunteer while off duty to work in refugee camps or to assist relief agencies), U.S. medical personnel were at various times underutilized.
There were also varying levels of professionalism and commitment to the medical mission across the various contingents during UNPROFOR. Some contingents' contract personnel or reserve volunteers stayed for the entire rotation, while others left before their tour of duty was completed. U.S. military medical personnel were there for the long haul, tended to be held to more rigid professional standards, and often worked and lived under more restrictive conditions (e.g., 12-hour shifts).
In addition, some countries had no prohibitions on the use of alcohol by their troops, and others had less stringent policies than those of the United States. Consequently, some forces had a high rate of alcohol use in the theater.
Differing levels of assets. Beyond problems caused by differing medical policies, there were also problems due to the fact that coalition partners brought varying levels of quality and types of medical assets to the table.
Medical assets in-theater were often highly variable in type and quality as a result of being drawn from a number of different nations, each with varying levels of development of their national health care systems. Some medical units came into the theater inadequately equipped, supplied, and trained. Some troops lacked key assets considered integral to the mission (e.g., preventive medicine support). Wide variability in medical assets across contingents, however, could not always be attributed just to differences among nations in the level of development of their country's health care systems. Even among the more developed countries, there were important differences in definitions of echelons of care. For example, the Norwegian hospital in Tuzla was termed an Echelon III facility, but by U.S. standards the hospital lacked key capabilities and so was considered more of an "Echelon II.5" facility. There were also important discrepancies in terms of what various coalition partners agreed to provide versus what they ultimately delivered.
Some contingents also had difficulty keeping their medical activity going during UNPROFOR. For OOTW missions, a number of countries rely on civilians, reservists, and/or volunteers. The Norwegian hospital, for example, was staffed by contract physicians. However, more and more countries have been experiencing recruitment and retention problems because of the increased frequency of OOTW deployments. As a result, during UNPROFOR the Navy ended up loaning medical personnel several times to other forces because of their difficulties in recruiting medical personnel for this particular mission.
Variability in the quality and type of medical assets across UNPROFOR forces meant that the United States ended up plugging in the holes in the medical assets of the other coalition partners. As one JTF commander noted, the U.S. hospital saw part of its job to be to identify and fill in those gaps.
Differing standards of care. Differences in standards of care among countries both at home and in the theater also influenced patient care and evacuation decisions in UNPROFOR. Quality of care among the various troops' medical teams varied widely, with those from developing countries tending to have lower standards of care than the United States.
In addition, extreme differences in quality of medical care among some coalition countries were often an incentive for a soldier to be left by his countrymen in the care of the U.S. military hospital. Caring for some coalition soldiers had the potential to lead to resourcing problems if they drew heavily on critical supplies or required prolonged and intensive nursing and physician care.
On the other hand, some coalition forces from Western Europe or the other highly developed countries participating in UNPROFOR (e.g., the French and Canadians) did not always want the United States to treat their soldiers. Instead, some preferred that the U.S. hospital only house their soldiers until arrangements could be made to evacuate them out of the theater. The reasons for this were twofold: (1) like the United States, some countries have a policy of "taking care of their own"; (2) in addition, some contingents were wary of receiving U.S. blood out of fear of contamination with the HIV virus. Thus, in some instances, a soldier who was transported to the U.S. hospital was simply held at his country's request until he could be picked up. This proved to be frustrating to U.S. military physicians, since at times they would have patients in their care they knew they could help but were instructed not to.
 At its peak, the U.S. hospital served a UN military population of more than 47,300.
 This report covers the experience of only the first four rotations of U.S. hospitals during UNPROFOR. In August 1994, Fleet Hospital 5 assumed the medical mission. In March 1995, the Air Force assumed the mission from the Navy and has had it continuously until early 1996, when the U.S. medical mission for UNPROFOR and Provide Promise officially ended.
 The focus in this report is on the Army's medical experience during UNPROFOR and OPP. But because this was a joint mission, we also discuss in some detail the experiences of the Air Force's and Navy's hospitals to fully understand how the medical mission evolved during this coalition operation.
 These differences were related in part to the level of development of a country's health care system, cultural differences, differences in the amount of value placed on the armed forces, and for some of the poorer nations, an inability to afford these types of assets.
 The U.S. military was not authorized to care per se for contract personnel, even though they were treated during this operation. The TF enforced the policy of not treating refugees for several reasons: (a) UNPROFOR forces were to remain neutral; (b) the situation was one of multiple adversaries (i.e., Croats, Bosnians, and Serbs) and constantly shifting ethnic alliances; (c) the fact that TF 212 was surrounded by a large refugee population, the needs of which a 60-bed hospital could not begin to meet. In addition, the medical staff were kept from volunteering during their off-duty time. Interview with COL Gregg Stevens, Commander, TF 212.
 TF 212 was the initial American medical component of UNPROFOR and OPP. On 1 February 1993, Joint Task Force Provide Promise (Forward) stood up, taking on oversight of all U.S. missions in the former Yugoslavia.
 The ATH can provide Echelons II-III care. The ATH is configured in increments of 14, 25, 50, and 90 beds. The 50-bed and over ATHs are capable of providing a full range of medical services, including an operating room, and may be augmented by a Hospital Surgical Expansion Package (HSEP).
 The departure of the British medical battalion was a political decision. Initially, Britain had agreed to provide Echelon II assets for the first rotation. But as the second rotation drew near, the UN still had not moved toward replacing the British medical battalion with other patient transportation assets. The British reluctantly agreed to provide Echelon II for the second rotation to give the UN time to find a replacement. By the third rotation the UN still had not come through as promised, and so the British Echelon II assets were pulled out, although the battalion and medics themselves wanted to stay on and continue their mission. Interview with COL Robert Leitch, British medical liaison officer, OTSG.
 In addition, the Pakistanis had been tasked by the UN to take on the Echelon II function, but these troops arrived in-theater untrained and unequipped to do so. Even though the troops received extensive training and equipping, by the end of the fourth rotation they were still not ready to take over this function.
 Calls for doing so came from a number of different quarters, including U.S. Ambassador to the UN Madeleine Albright and Secretary of State Warren Christopher. In response to such requests for refugee care, the Joint Staff asked JTF-PP(F) to do a study on requirements for establishing a pediatric trauma ward in November 1993.
 For example, during the operation, five UN peacekeepers who were held hostage by the Serbs were continuously threatened with death throughout their ordeal. A Navy psychiatrist was sent to Sarajevo to set up group therapy for these hostages as well as a program for civilians living under constant attack.
 Other examples: the Navy fleet hospital treated some advanced cases of tuberculosis (e.g., patients with lung abscesses). Hepatitis B and C were also of great concern. Other infectious diseases included HIV, chicken pox, mumps, typhoid, and measles. In addition, U.S. hospitals saw individuals with diabetes as well as chronic heart conditions. The U.S. hospital also treated some patients with diseases one would not normally expect to have to treat in the theater, such as Hodgkin's disease.
 The way intratheater evacuation is supposed to work under U.S. standards is that the higher level picks up from the lower level of care. For example, an Echelon III hospital would typically have an ambulance company attached to it and would be responsible for picking up patients from the FSTs or from a medical company (Echelon II).
 The way repatriation was supposed to work was that the U.S. hospital would submit a request to the Force Surgeon, who submitted a request to the UN commander, who then turned to the individual contingency's battalion commander to request arrangements be made to send a soldier back home.
 For the most part, the medical personnel we interviewed did not feel that there was a lot of unnecessary care-seeking behavior among the coalition forces. Any anger that the medical staff did express was related more to the fact that because some soldiers were from countries with poor health care systems that could not adequately meet their needs, the United States ended up bearing responsibility for these soldiers in filling in what was missing in their own country.
 Another reason why U.S. medical units could not utilize the UN medical logistics system was FDA requirements. Because the UN accepts donated items, there was no quality control over those items; in addition, no single set of standards was adhered to. Recall that one of the assumptions in the AMEDD's wartime structure was that medical supplies would meet FDA requirements.
 From the beginning of this operation, the policy was to use U.S. blood first from Landstuhl, then take blood from U.S. soldiers, then others, and as a last resort use the local blood supply only if the need was critical. Interview with COL Stevens, CDR, TF 212.
 Outpatient visits and admissions by U.S. personnel were primarily by U.S. military personnel. A small number of U.S. civilians were also in-theater and so are included in this category (e.g., visiting dignitaries, embassy personnel, intelligence personnel).
 Throughout, the proportion of admissions that were U.S. personnel remained relatively low: 14 percent (45/333) of admissions for the 212th MASH, 12 percent (34/288) of admissions for the 502nd MASH, 18 percent (58/323) of admissions for the 48th ATH, and 9 percent (33/353) of admissions for the Fleet Hospital 6.
 Foreign civilian personnel in UNPROFOR were primarily UN contract personnel, generally Croats, who provided various services such as food, laundry, waste disposal, etc. to the JTF and the UNPROFOR headquarters in Zagreb.
 Very little of the demand for dental services during UNPROFOR was for nonemergent problems. In fact, some soldiers had so many dental problems that the U.S. military dentist would treat the most critical problem and within a month or so the soldier would be in for the others.
 The drop in average length of stay for the foreign military category during the second rotation may reflect a learning curve in that the 502nd MASH had the benefit of the 212th MASH's experience in terms of dealing with the repatriation process.
 For example, a Jordanian soldier with land mine injuries and multiple shrapnel wounds had a LOS of 56 days; a Kenyan soldier with mass in the right upper quadrant had a LOS of 26 days; and a Pakistani soldier with an admitting diagnosis of fever of unknown origin had a LOS of 28 days, to name a few.
 The mix of medical personnel included three general surgeons, one orthopedic surgeon, one anesthesiologist and four nurse anesthetists, one psychiatrist and one mental health technician, two family practitioners, two internists, two physician assistants, twenty staff nurses and the chief nurse, one physical therapist and one PT technician, one general dentist, one oral surgeon and six dental technicians, one pharmacist and three pharmacy technicians, one environmental health officer, one laboratory officer, four MSC officers, and miscellaneous other enlisted personnel including laboratory, x-ray, cardiopulmonary, etc. technicians. The commander was also a surgeon.
 The preventive physical therapy program enabled the hospital to rehabilitate soldiers quickly (e.g., within a week) and return them to their units rather than evacuating them out of the theater for treatment.
 In addition, U.S. medical personnel were exposed to a variety of serious infectious diseases. Three Navy medical personnel, for example, showed positive skin tests for exposure to tuberculosis upon their return from UNPROFOR.
 Consumption of alcohol also has the potential to create internal security problems for a task force. For example, during the initial rotation of the hospital, Camp Pleso had present troops from seven different countries, all of whom had to share the same enclosed compound, even though historically some had been enemies. Consumption of alcohol, therefore, had the potential to lead to volatile situations. Mitigating such problems was one of the concerns senior officers faced.
 A good illustration of this comes from the U.S. experience during Operation Provide Comfort in northern Iraq. For this humanitarian relief effort, a number of countries had signed on to provide medical assets. Some countries, though, did not deliver in the final analysis, and others delivered less than what had been originally promised. For example, of the 9-10 countries involved in this humanitarian relief effort, one West European country sent a field hospital but no medical personnel to staff it, another sent a medical team but no equipment or supplies, and a third sent a battalion aid station instead of a promised field hospital.
 Some West European countries have a much lower HIV rate than that of the U.S. population. The Croats in particular had a very low infection rate in their population and were especially fearful of receiving contaminated blood. Interview with CAPT Johnson, Commander, Fleet Hospital 6, 22 February 1995.