4. Operations Restore Hope and Continue Hope, Somalia: A Case Study of the Medical Mission
"Somalia was a nation divided and torn apart by a civil war. . . . Bandits ruled the major lines of communications. . . . All supply lines were blocked by roadblocks to extort 'tolls,' and ambushes were a way of life. . . . Twenty-four hours a day [U.S.] soldiers lived with the threat of being shot at, having a hand grenade thrown at them or receiving indirect fire attacks."
IntroductionSomalia was a case of the AMEDD doing its combat mission in an operations other than war context. OOTW can range from well-defined missions with clear-cut, limited objectives to less well-defined missions with open-ended endpoints; Somalia was one of the latter.
In Somalia, the nature of the medical mission was in terms of peaks and valleys in that the demand for medical services overall was relatively low and primarily for routine care, yet this mission was punctuated with periods of combat. Planning the medical support for such operations can be a difficult challenge, as commanders need to be able to respond to the worst-case scenario and yet make the best use of their medical assets. In addition, because patient demand tends to be relatively low in these operations, the medical staff may be underutilized at times. As a result, there is a natural tendency in OOTW to want to use any excess medical capacity for purposes that may go beyond the original medical mission.
Unlike in the Balkans, where U.S. forces were part of a coalition, in Operations Restore Hope (ORH) and Continue Hope (OCH) the United States was the primary actor in the humanitarian and peace enforcement mission undertaken by the UN in Somalia. Prior to ORH and OCH (in July and August 1992), the UN had undertaken a limited peacekeeping effort in Somalia--UN Operations Somalia, UNOSOM I--with a small contingent of Pakistanis having been sent as monitors of the March 1992 cease-fire. Around the same time, the U.S. effort in Operation Provide Relief (OPR) began, involving the airlift of humanitarian relief supplies from Mombassa, Kenya, for the NGOs operating in Somalia. However, by September 1992 it was clear that conditions were rapidly deteriorating in Somalia and that security for the relief convoys had become critical and would require a larger force than had originally been anticipated.
OPR led directly into ORH, which officially started in January 1993, with planning of this operation having begun in mid-November 1992. ORH was the U.S. component of the UN's humanitarian (and peacekeeping) effort--United Task Force, UNITAF. Operating under a UN mandate, UNITAF's mission was to secure relief operations in the assigned Humanitarian Relief Sectors, with the United States responsible for four of the nine of them. The ultimate goal was to transfer all responsibilities of the mission over to UNOSOM II by May 1993. UNITAF evolved into a joint and combined task force led by the United States under UN auspices. The Commander-in-Chief, Central Command (CINC, CENTCOM) was tasked for this mission.
During UNITAF, there was also pressure from the UN for the task force to expand the original relief convoys and security mission to include disarmament and to establish a presence in the northern section of the country. The U.S.-led task force strongly resisted this expansion of the UNITAF mission but eventually did undertake some limited disarmament.
In early May 1993, UNITAF transferred responsibilities to UNOSOM II, and OCH began (the U.S. component of UNOSOM II). Starting in January 1994, the withdrawal of U.S. forces from the theater began, with a March 1994 deadline set for removing all but a small contingent from Somalia.
During the seventeen months of the Somalia deployment in ORH and OCH, the AMEDD had two major operational components: (1) medical units organic to the 10th Infantry Division (Mountain) and Task Force Kismayo; and (2) medical units included as part of the Joint Task Force Support Command-Somalia (JTFSC-S). During that time there were three rotations of medical units into the theater. Table 4.1 lists the medical units deployed to Somalia for each rotation by home base and by medical group or task force. The medical units listed are in addition to the organic medical assets belonging to the 10th Mountain Division.
As in the previous chapter, here we examine the medical support requirements for Somalia, looking first at how the medical mission evolved over the course of this deployment and at how patient demand changed over time. We then compare how well demand matched the medical support provided and the specialty mix of providers in the theater and discuss the implications for planning.
Medical Mission Statement and Medical SupportMedical Mission Statement and Medical Support at the Outset
The U.S. medical mission at the outset was to provide comprehensive care to all U.S. forces involved in the security and humanitarian mission and to provide limited support to other coalition forces in the theater (i.e., on an emergency-only basis). More specifically, the initial medical mission was twofold: (1) deploy Army medical units required to support the deploying force and then tailor back once in-theater; and (2) provide treatment of combat casualties as well as routine DNBI for Army and other U.S. forces in Somalia.
Army Medical Units Deployed to Somalia as Part of ORH and OCH
(ORH: 9 December 1992 to 1 May 1993)
|62nd Medical Group (Fort Lewis, WA)
86th Evacuation Hospital (Fort Campbell, KY)
|2nd Rotation (OCH: 1 May 1993 to 15 August 1993|
|42nd Medical Task Force
42nd Field Hospital (FH) (Ft Knox, KY)
|3rd Rotation (OCH: 15 August 1993 to 31 March 1994)|
|46th Medical Task Force
46th Combat Support Hospital (Ft Devens, MA)
Providing care to Somali nationals (refugees) or to relief workers operating within the theater was not part of this medical mission. Neither was getting involved in the actual humanitarian relief activities within the various sectors--that was to be the purview of the NGOs. In theory, all the U.S. military's medical resources were to go in support of U.S. forces during this operation.
In addition, unlike in the Balkans where there was a close working relationship with the local hospitals in Zagreb, which were quite capable by Western standards and thus able to support Echelon IV care, in Somalia the local medical infrastructure had been completely destroyed, evacuation times were longer than doctrine normally calls for, and there were long distances between the theater Echelon III hospital in Mogadishu and fixed facilities in neighboring countries.
What Happened to the Medical Mission and Medical Support During the OperationFigure 4.1 illustrates how the medical mission and medical structure evolved over the course of this operation. Shown are the total number of PROFIS medical personnel (N = 991) in-theater over the 17 months of this deployment. The x axis represents the number of months in-theater beginning with November 1992 and ending with March 1994. The y axis represents the number of PROFIS personnel in-theater at the midpoint of each month.
Figure 4.1--How the Medical Mission and Support Changed During the Operation
Health service support initially was to be the responsibility of the Commander, Joint Task Force-Somalia (CJTF-S) Surgeon's Office, backed up by the Navy and Marines (MARFOR). U.S. forces were to receive Echelons I and II care from organic medical assets, with the USS Tripoli serving as Echelon III support.
The rapid rise in Army medical personnel seen during December 1992 and January 1993 represents the transitioning into the theater of various Army medical elements in anticipation of the Army assuming theaterwide health service support. These elements included an advance assessment party, headquarters of the 62nd Medical Group, and the 86th EVAC, which arrived in-theater on 24 December 1992. Headquarters, 62nd Medical Group arrived on 29 December 1992 to initiate plans and activities to assume responsibility for theaterwide medical support. The 86th EVAC, a 104-bed hospital, took the first rotation into Somalia, arriving in-theater on 18 January 1993. With the arrival of Army corps-level assets, the Army assumed Echelon III medical care and hospitalization for U.S. troops.
Starting with the peak of 91 PROFIS personnel in January 1993, medical support in the first rotation plateaued at around 70 personnel by March 1993, which probably represented the true level of support during most of ORH. The peak in medical support corresponded to the peak in the number of U.S. troops that occurred on 16 January 1993.
First rotation: January 1993 to May 1993. During the first rotation, the overall mission was primarily a humanitarian relief effort, with the medical mission quickly evolving into one of primarily providing routine care to U.S. troops. Although U.S. troops and the 86th EVAC itself took a fair amount of sniper fire during this period, Somalia still represented a relatively benign environment with few combat casualties.
In addition, during this period the Army did take care of some civilian casualties. These patients often were brought in by enlisted troops rather than by the medical staff. However, it rapidly became clear that the NGOs were not happy with the Army providing medical care to the Somalis, fearing the loss of some of their own "business."
During the first rotation, the demand for medical services was lower than initially anticipated. The outpatient rate, for example, was roughly half that of the predicted rate, and the DNBI rate was also lower than expected. By the end of this rotation it appeared that the Army did not require nearly as many medical assets in-theater as what had initially been brought in.
Second rotation: May 1993 to August 1993. On 1 May 1993, the second rotation and the transition from ORH to OCH occurred, with the 42nd Field Hospital (FH), a 32-bed facility, taking over from the 86th EVAC. In early May, the 42nd Medical Task Force (MTF 42) assumed JTF medical responsibilities as the senior medical headquarters. As shown in Table 4.1, MTF 42 was to provide command and control, Echelon III care and hospitalization (42nd Field Hospital), medical logistics (147th Medical Logistics Battalion), outpatient services and ground evacuation (61st Area Support Medical Battalion), helicopter aeromedical evacuation (45th Medical Company--Air Ambulance), preventive medicine (105th Medical Detachment--Sanitation), veterinary support (248th Veterinary Detachment), and mental health and combat stress control (528th Combat Stress Control Detachment).
During the second rotation, we observe a tailoring back of the medical personnel such that by May 1993, the total number of PROFIS medical personnel in-theater had been greatly reduced from the high of 91 to about 45. There are a number of reasons for this, but the primary one is that medical support tracks the decline in U.S. troops to support. The number of U.S. troops in-theater peaked at 25,400 on 16 January 1993 and then steadily dropped to about 10,000 by late April 1993. After the first rotation, the number of U.S. troops in-theater averaged around 4,000 and 4,200 during the second and third rotations that took place during OCH. Further, we see a narrowing in the difference between the number of providers and nurses in-theater at this time.
When the operation shifted from ORH to OCH, the United States continued its medical mission of supporting U.S. forces involved in this humanitarian and peace enforcement effort and of providing emergency-only support to other UN forces within the theater. Although this was a humanitarian action, throughout ORH and OCH the mission was characterized by constant sniper fire, punctuated by periods of combat.
However, one event changed the overall mission and the medical support mission. On 5 June 1993, 24 Pakistani soldiers were ambushed while taking part in the UN peacekeeping operations within Somalia. While responsibility was never proven, the ambush was believed to have been directed by General Mohamed Farah Aideed, one of the dominant clan leaders in the country. Following the Pakistani ambush, tensions within the theater rapidly escalated, with the mission going from one of "guarding the beach and handing out food" (i.e., humanitarian relief) to one of being in a combat-like environment, now with a tangible threat.
Although during May the amount of sniper fire into the embassy compound where the 42nd Field Hospital was located had been steadily increasing, after the Pakistani incident U.S. troops were increasingly locked down; with the Italian, French, and Norwegian medical personnel coming under fire, concern grew for U.S. medical personnel. As a result, for security reasons, the 42nd Field Hospital's staff were closely tied to the embassy compound. The hospital began seeing an increasing number of U.S. casualties, and there was a substantial increase in the level of stress among U.S. troops. Also, following the Pakistani ambush, there was a growing resentment among the medical staff at having to treat Somali patients. As a result, the hospital commander tightened up on the treatment of civilian casualties.
Third rotation: August 1993 to March 1994. On August 15th, the third rotation began with the 46th Medical Task Force (MTF 46) assuming JTF medical responsibilities for the third and longest rotation. MTF 46 comprised 270 PROFIS personnel and was tasked to provide health services and hospitalization to the U.S. contingent and to UN forces on an emergency basis, as well as treatment to Somali nationals who were wounded as a direct result of confrontation with UN forces. In addition, the 10th Mountain Division during the third rotation had health service support to assigned division personnel. At this point, the 46th Combat Support Hospital (CSH) took over hospitalization care from the 42nd FH.
In Figure 4.1, the steep rise in PROFIS personnel during late July and the decline in September represent the transition of medical units into and out of the theater. This transitioning of the medical support took somewhat longer than the previous one. This may have been due partly to the fact that PROFIS personnel for the 46th CSH were pulled from a number of different MEDDACs and MEDCENs across CONUS and so did not arrive in-theater as a single group. Medical personnel had to wait until their replacement had been identified and then sent over before being able to rotate out of the theater. As a result of this rotation policy, divisions began to develop between the newer and older staff in the theater. For example, by the time of the third rotation, many who had been in-theater longer and had experienced the escalation of tensions felt a lot of anger with the Somalis and were reluctant to treat Somali patients--the growing resentment discussed above. The newer hospital staff, who had not yet experienced any of these incidents, did not understand the anger. There was one report that during the third rotation, the older staff considered segregating the Somali patients into a separate ward and having only the newer staff provide care to them.
During the transition between the second and third rotations, we also see for the first time an increase in the absolute numbers of nursing staff in-theater, while the total number of providers declines to its lowest point (see Figure 4.1). By the beginning of October, the number of providers and number of nursing staff in-theater were roughly equal (23 and 19, respectively), with the total number of PROFIS personnel between 55 and 60 individuals.
In addition, the medical mission during this period continued to be primarily one of providing routine care. The outpatient visit rate had remained at half its predicted rate. Further, because of increased tensions in the theater, the hospital staff were mostly confined to the embassy compound for security reasons, with little opportunity to undertake sector visits or volunteer with the HROs.
During August and September 1993, tensions in the theater continued to rise, with an increase in the number of demonstrations and displays of weaponry. The 46th CSH took more and more rounds into the embassy compound, and Somalis were attacking UN personnel, the media, and relief workers. In September, the 362nd Engineering Group was ambushed, and on 1 October 1993, a U.S. helicopter was shot down, killing three U.S. soldiers.
The Ranger firefight on 3 October 1993 marked another key change in the overall mission. During the firefight with supporters of General Aideed, 18 American Rangers were killed and 77 wounded. The firefight was a culmination of an extended manhunt by U.S. troops to capture General Aideed for his alleged role in masterminding the June 5th ambush of 24 Pakistani peacekeepers. In addition to U.S. casualties, an estimated 300 of Aideed's followers were killed and another 700 wounded in this firefight. Because of the high number of American casualties incurred in this incident, U.S. public opinion turned strongly against a continued U.S. presence in Somalia.
As noted above, by this point the number of providers in-theater was at its lowest level (Figure 4.1). As a result of the Ranger firefight, the Army again increased the number of beds and medical personnel in-theater and would sustain this level for the remainder of the operation.
After 4 October 1993, the entire theater shut down and security measures increased, including greater restrictions on the movement of AMEDD personnel within the theater. Tensions in-theater remained high throughout the remainder of the operation. Starting in January 1994, we see the reduction in medical support starting to occur as the March 1994 deadline for withdrawal approached (Figure 4.1).
When we look across the 17-month deployment, we can summarize the change in the medical mission as follows: The initial mission began as a humanitarian relief effort in a relatively combat-free zone, in which the primary medical mission was to support U.S. troops and possibly provide care as well to Somalis, coalition forces, and NGOs; it evolved to a mission of supporting U.S. forces only and UN troops on an emergency basis in an increasingly combat-like environment. Although the medical need much of the time was mostly for primary care, there was the potential, especially in the latter half of the operation, for combat casualties.
What Happened to the Medical Structure During the OperationWhen we examine the medical support during the operation--especially between the first two rotations--we see that Army had more medical assets in-theater than it needed. The fact that the medical support was at its highest level in-theater during the first rotation was partly the result of the need to support a larger number of U.S. troops at the beginning. Initially, the number of U.S. troops requiring medical support was high; it peaked at approximately 25,400 troops on 16 January 1993, and then steadily dropped to about 10,000 by late April 1993. After the initial rotation, though,the number of U.S. troops in-theater averaged between 4,000 and 4,200 during OCH (UNOSOM II).
However, there was another reason for the excess medical capacity brought in initially. Although humanitarian medical support to Somalis and to NGOs was not specified as a task in the initial medical mission statement, these objectives were taken into consideration in tailoring the medical support for this operation. More specifically, this expectation probably influenced the large number of providers sent and the mix of specialties brought in. It may also explain why there was a much greater number of providers in-theater relative to nurses during ORH: the range of specialties was increased to accommodate the expected need of these other patient populations. The large proportion of providers relative to nurses was clearly an intentional decision, since an EVAC hospital--like the deployed 86th during the first rotation--typically has a ratio of one Medical Corps officer to every three Nurse Corps officers. In addition, the large number of providers in the initial phase may have been a function of the deployment of advance assessment teams.
Although the number of beds and personnel was subsequently cut back, the structure tended to follow the key events. Following the June 1993 Pakistani ambush during the second rotation, the Army increased the number of beds and medical personnel in-theater.
The number of beds and personnel tapered off once again over time, so that by the time of the Ranger firefight in October 1993 during the third rotation, the number of providers in-theater was at one of its lowest levels. In response, the Army again increased the number of beds and medical personnel in-theater and sustained this level through the beginning of 1994.
See the "requirements" section below for a more complete discussion of the evolution of the number and mix of providers during the operation.
Demand for Services
Expectations as to Patient Demand at the OutsetIn planning the medical support for this humanitarian operation, the requirement was for a corps-level package to support a brigade to assault an airhead with an unknown level of combat. That is, although the medical planners were aware that this mission was primarily humanitarian in nature, given the lawlessness of the situation and the number of warring factions, it was difficult to assess to what degree U.S. troops might encounter armed opposition in accomplishing this mission.
Therefore, in terms of patient demand the expectation was a requirement for routine primary care but also a requirement for an unknown level of trauma care. Given that the planners did not know what level of combat might be associated with this mission and the large number of U.S. troops to support during ORH, it was difficult to estimate the demand for trauma care and surgical services during the first phase of the Somalia mission.
Patient Demand During the OperationTable 4.2 shows the total number of admissions and outpatient visits across the rotations. We grouped outpatient clinic visits and emergency room (ER) visits into a single category, since the coding of these two types of visits did not appear to be consistent across the three rotations.
Comparison of Total Number of Admissions and Outpatient Visits by Rotation for ORH and OCH
|Rotation||Number of Outpatient Visits||Number of Admissions|
|1st rotation--86th EVAC||4,914||971|
|2nd rotation--42nd FH||2,906||361|
|3rd rotation--46th CSH||4,903||568|
|NOTE: The outpatient visits category refers only to the 86th EVAC, the 42nd FH, and the 46th CSH (i.e., the data exclude sick call for the outlying field units).|
Table 4.2 indicates that the peak in admissions and outpatient visits occurred during the first rotation, between January 1993 and May 1993, when the largest number of U.S. troops were in-theater. Still, as noted earlier, the demand for medical services during this rotation was lower than initially anticipated. After the first rotation, although not shown, the patient load became fairly constant over the remainder of the deployment, with the number of admissions averaging 166 per month and the number of outpatient visits averaging 1,000 per month.
We also examined the breakdown of the admissions shown in Table 4.2 by clinical service to understand differences in the proportion of admissions across services for each of the three rotations. To do so, we grouped the inpatient admissions into four categories: internal medicine, surgery, ob/gyn, and psychiatry. Table 4.3 shows the following trends over the course of the deployment in terms of the relative distribution of admissions across clinical services: The proportion of internal medicine admissions decreased over time from a high of 62 percent in the initial months to around 40 percent by the third rotation. In contrast, the proportion of surgical admissions steadily increased over time. As a result, the relative distribution of admissions between internal medicine and surgery changed over time from 62 percent internal medicine/35 percent surgery at the beginning of the first rotation to 42 percent internal medicine/51 percent surgery by the end of the third rotation. Part of the increase in the proportion of surgical admissions may have been related to an increase in the proportion of Somali patients being treated by the AMEDD, since the physicians were selectively treating foreign nationals who required surgery. (See the next section for a discussion of populations treated.) However, the fact that tensions within the theater were increasing over time and, thus, the probability of combat casualties likely explains much of the rise over time in the proportion of surgical admissions.
Percent of Total Admissions by Clinical Service for Rotations in ORH and OCH
|NOTE: The patient data cover the period between January 1993 and January 1994 and do not include the first few months (November and December 1993) or the latter few months (February and March 1994). Also, patient data were unavailable for April 1993 and August 1993, the two months when the rotation of U.S. troops and hospital units into the theater took place.|
Some of the small proportion of ob/gyn admissions represented female soldiers who had tested positive for pregnancy. Because the antimalarial drug, mefloquine, could not be administered to these soldiers, they were admitted and put under netting to protect them until they could be rotated out of the theater.
Expectations of Populations Served at the OutsetAs mentioned earlier in the discussion of the mission statement, the U.S. military was expecting to serve primarily U.S. forces during this operation. It was also expecting to serve coalition forces on an emergency-only basis. Providing care to Somali civilians, refugees, or relief workers operating within the theater was not part of this medical mission. Neither was getting involved in the actual humanitarian relief activities within the various sectors.
Populations Served During the OperationTo examine the populations served during the operation, we broke the above admission data down further by the following categories: U.S. personnel, foreign military, and foreign civilians. As shown in Table 4.4, the peak in the total number of U.S. personnel admissions occurred in January and February 1993. The table also shows the fluctuations in the admission of U.S. personnel over time, with the jump in admissions to 166 in October 1993 corresponding to the Ranger firefight. Table 4.4 also indicates that the number of admissions of foreign personnel (military or civilians) was relatively low over the course of the Somalia deployment. The increase in the number of foreign military admissions in June 1993 corresponds to about the time of the Pakistani ambush.
Number and Percent of Total Admissions by Populations Served for Rotations in ORH and OCH
|NOTE: Patient data were not available for April and August 1993, when the rotation of the hospitals occurred.|
When we look at the proportion of total admissions that were U.S. personnel, foreign military, or foreign civilians, we see that the proportion of total admissions that were U.S. personnel started at just above 90 percent and then declined somewhat over time. Table 4.4 also indicates a seesaw nature in the admission pattern of U.S. personnel.
In comparison, the proportion of total admissions that were foreign military was about 10 percent for most of the deployment. The increase to 30 percent in June 1993 corresponds to the time of the Pakistani incident. The fall in the proportion of admissions of U.S. personnel during this same period is coincidental, being more related to the rotation of U.S. forces at this time and a decline in the absolute numbers of U.S. personnel in the theater between the first and second rotations.
The proportion of total admissions that were foreign civilians went from 8 percent initially to a high of 29 percent in December 1993. Thus, the AMEDD did treat Somali nationals throughout this deployment, with the proportion of Somali inpatients steadily increasing over time.
We also compared differences in average length of stay (LOS) between U.S. personnel, foreign military, and foreign civilians for each rotation. Figure 4.2 shows the average LOS for each rotation by hospital and by patient category. Overall, the average LOS during this deployment by patient group was 2.7 days for U.S. personnel, 3.4 days for foreign military, and 4.9 days for foreign civilians. Although the overall average LOS for each of the rotations was 3 days, when we broke out the LOS data by patient categories, we found that foreign military and foreign civilians tended to have longer lengths of stay on average than U.S. personnel for each of the three rotations.
Figure 4.2--Average Length of Stay by Rotation of Patient Populations Served
Although the numbers are small for foreign military and foreign civilians and thus any trends identified need to be interpreted with caution, the results shown in Figure 4.2 suggest that foreign military and foreign civilian patients tended to be more severely ill and more resource intensive than U.S. personnel. In the case of the Somalis, these patients tended to be more severely ill, partly because the AMEDD medical staff at times deliberately selected the sicker patients to treat. The longer LOS for foreign military personnel also reflects the fact that it was difficult for the AMEDD at times to repatriate injured coalition soldiers. As a result, the AMEDD ended up hanging onto coalition patients longer than would normally be expected.
Overall, the data suggest that although the foreign patients (military and civilians) made up a relatively low percentage of the total admissions, they used a disproportionately larger percentage of a hospital's resources. For example, many of the coalition forces in Somalia did not maintain tight controls over their food and water supplies or enforce good sanitation within their living quarters. As a result, some troops had a lot of problems with diarrhea and upper respiratory infections. In Somalia, the high malaria rate among some troops (e.g., Pakistanis) was the result of a number of factors: (1) no preventive medicine precautions were undertaken before or during the deployment by some contingents; (2) in some cases, inappropriate chemoprophylaxis was being used (i.e., outdated or less effective medications); (3) some countries were unable to afford the more expensive, modern antimalarial drugs; and (4) the United States had bought up much of the world's supply stocks of mefloquine, making it difficult for other coalition partners to obtain this drug even if they could afford it.
In the last chapter we discussed these issues at length, using patient data from UNPROFOR. In Croatia, the AMEDD's mission was to provide hospitalization care (Echelon III) to all the coalition forces, so the number of foreign military patients is larger in that operation and better illustrates the differences in resource intensity between U.S. personnel and foreign patients.
Requirements to Meet the Demand for ServicesTo understand how well the requirements matched the demand for services, we examined how the specialty mix of PROFIS personnel changed overall and then within categories. Specifically, we compared the percentage of total PROFIS personnel who were providers, nurses, or other officers. We then broke down the provider and nursing categories into their various components to look at changes in specialty mix within categories over time. Although some of the changes in specialty mix seen are likely a function of the type of hospital deployed, not all changes may be attributable to the TOE requirement alone.
How the Overall Mix Between Providers and Nursing Staff ChangedIn January 1993, at the official beginning of ORH, and throughout the first rotation, approximately 60 percent of the total PROFIS personnel in-theater during the first rotation were providers (see Figure 4.3). This proportion then leveled off at around 50 percent during the second and third rotations.
Figure 4.3--How the Proportion of Medical Personnel Changed Overall During the Operation
The increase in the proportion of nurses over time further supports the evidence shown above on patient demand that the medical support evolved into a primary care mode over time. Figure 4.3 also indicates that the proportion of administrative and other officers declined over this same period.
How the Specialty Mix of Providers Changed Over TimeFigure 4.4 shows how the mix of provider specialties changed over the course of the Somalia deployment. The most interesting story is the seesaw effect seen in the mix between primary care physicians and surgeons. At the beginning of the first rotation, primary care physicians clearly dominated the mix over surgeons, 45 percent versus 29 percent, respectively. Still, as the figure shows, this relationship was already trending in opposite directions, since in December 1992, the primary care/surgeon mix was 50 percent versus 19 percent. In fact, there was a steady increase in the proportion of providers who were surgeons during the first rotation, such that by the second rotation (months 7-9), the proportions of surgical and primary care providers were approximately equal.
Figure 4.4--How the Mix of Providers Changed During the Operation
As shown in Figure 4.4, the 61 percent in October 1993 of the deployment represents the peak for primary care; for the remainder of the rotation, the proportion of surgeons began to grow again, such that by month 16, the two categories of providers were equal.
Still, the increase in the proportion of primary care providers over time (combined with the increase in the proportion of nurses) supports our hypothesis that the medical mission had evolved into a primary care mode by the third rotation. There is also a mismatch between demand and supply here. Recall that Table 4.3 shows that the demand for surgery grew larger during the third rotation, rising to 69 percent of the admissions during October 1993, when the Ranger incident occurred. However, as Figure 4.4 shows, in October 1993 only 26 percent of the providers were surgeons. While there is a steady increase in the proportion of surgeons after October 1993, no doubt in response to the increased demand, the proportion of surgeons steadily declined from July to October 1993 (from 47 to 26 percent) as the mission evolved toward primary care, despite the earlier growing demand for surgery from July to October 1993 (from 44 to 69 percent).
Thus, we see that changes in the medical need in Somalia did not always closely match changes in the mix of providers within the theater of operation, particularly as the threat level increased.
Figure 4.4 also shows that the proportion of PROFIS personnel who were mental health providers was initially too high and then went too low. In the first rotation, the mental health providers started at approximately 18 percent of the total number of PROFIS providers in-theater in January 1993, declined to around 12 percent by April 1993, and then declined further during the second rotation (to 0 percent in June and July 1993), before rising to about 5-6 percent for most of the third rotation.
Recall that during the first rotation, the theater was still relatively benign, and tensions had not yet started to heat up. In the second rotation, the combat stress assets were subsequently tailored back. As a result, however, the mental health assets in-theater from this point onward were probably too low; after the Pakistani incident, conditions in the theater became more combat-like, and the concomitant level of stress also increased among U.S. troops and AMEDD personnel. The stress level would remain high for the duration of the deployment.
As shown in Figure 4.4, the dental assets grew from 9 percent to around 12 percent during the first rotation, dropping off to around 5-6 percent during the second rotation, and ultimately falling further to around 3 percent during the third rotation. The dentists were some of the busiest of all providers, with one individual estimating that as much as 20 percent of all outpatient visits during the first rotation were for dental care. Coalition forces in particular sought dental care from the Army.
When we consider the match between demand and requirements, was the medical support provided too much, too little, or just right for Somalia? The answer depends on one's perspective. The medical support was more than adequate for most periods when not much was happening in-theater. In the case of the mass-casualty incident (i.e., the Ranger firefight of October 1993), however, the AMEDD was stretched thin. Within the first 34 hours, the 46th CSH received 36 cases. Most of the cases seen were trauma patients (with limbs blown off, bad burns, etc.). There was a total of 110 casualties during this period, all requiring surgery. Recall, as discussed above, that this incident occurred at one of the times when the United States had the fewest number of surgeons in-theater and the fewest number of providers. At this point in the operation, the 46th CSH only had assigned two general surgeons and one orthopedic surgeon. As a result, the AMEDD ended up transferring four orthopedic cases to the Swedish hospital, which was co-located with the Army hospital in the embassy compound.
Overall Case-Specific ObservationsWhen we look across the experience of the medical mission in Somalia, a number of observations emerge. On the whole, these center around the problems of planning medical support given the variable demand, problems with treating civilian populations, and issues of training.
Planning the Medical Support for Variable DemandSomalia was an example of an OOTW characterized by low-intensity conflict but also having the potential for combat. As a result, Somalia illustrated how difficult it is to plan the medical support for an operation in which patient demand is characterized by "peaks and valleys" and how key events may often drive the medical support and planning process once in-theater. In such a situation, commanders need to be able to react to events as they unfold. At the same time, a commander must be able to make the best use of his medical assets. As shown in the case study, the medical need may not always closely match the type and amount of medical support in-theater. In these operations, then, flexibility in planning becomes key.
The initial planning process for a deployment and the decision on what mix of specialties may be required typically takes into account five key factors: (1) the nature and level of the medical threat; (2) the medical mission statement and number of troops to support; (3) the doctrinal employment of units and the organizational capability of those units; (4) what augmentation of the TOE requirement for a hospital may be required; and (5) which unit is ready to be deployed and best meets the requirements of the specific mission.
This yields a certain level of hospital with certain capabilities. If there is some excess capacity as a result of this process, then one may choose to provide some additional level of support to other coalition forces or civilians, or one may want to tailor back. For Somalia, after the first rotation, the equipment and supplies were larger in place than was needed and the mix of medical personnel was too heavy on the surgical side. The tailoring back of the support that occurred at the beginning of the second and third rotations was based on operational needs rather than on organizational structure.
During an operation, the prerogative of the theater commander is paramount. The in-theater medical commander needs to be given the flexibility to tailor or modify the medical support brought in as he sees fit to meet the needs of the day-to-day operation. However, he also needs high-level guidance to ensure that a minimum level of medical support is maintained in-theater throughout the deployment. The best way to accomplish this may be through doctrine.
Given the demand variability associated with some OOTW, the key question from a planning perspective is how to determine the right level of medical support required and the right mix of medical personnel. The lesson from Somalia for DoD and Army planners may very well be to staff for a little more than the average and then extend for the surge. In OOTW, one cannot staff for the worst-case scenario and support it. However, by staffing for a little more than the average, one is ensured of an extended capability in-theater. The idea would be to have enough medical personnel in-theater to get through the initial 24-48 hours of a mass-casualty situation. One would not want to staff just for the average, because this would take the elasticity out of the system.
It is also clear that the size of hospitals in OOTW is small, which means they may easily be overwhelmed in a mass-casualty situation. This suggests that medical evacuation becomes a top priority in these operations. The Army may want to consider having on call a backup team of medical personnel based in Italy or Germany or located on a carrier that can be flown into the theater within 24 hours to support the medical personnel already in-theater if there is a mass-casualty situation. The airplane transporting medical personnel could then be used to evacuate patients.
In addition, the Army might want to consider developing a staging team along the Air Force model, in which 15-20 medical personnel and a 25- to 30-bed tent capability are equipped and trained to take casualties and move them out. Such a team would be capable of accepting casualties for initial treatment and then evacuating them out of the theater. Once a field hospital or other type of treatment facility is overwhelmed, the overflow of patients could be picked up by the staging team, which would then arrange air transportation for them. Such a staging team, though, would need either to be co-located with the military treatment facility in the theater or be on 24-hour call for rapid deployment in the event of a mass-casualty situation. This would formalize the ability of the Army to deal with such surges and serve as a means of redistributing patients quickly and safely.
Somalia further provided us with a sense of what the low-end requirements are for these types of missions. The U.S. Army is very good at planning the medical support for combat operations; however, it does not have much experience in planning for the lower-intensity end of the spectrum. The patient-level and provider-level analyses of how well demand matched the medical support during this deployment may be useful in better understanding this relationship and in planning future operations.
Another issue associated with planning medical support given variable demand illustrated by Somalia is the need to manage the tradeoff of maintaining relatively rare (and expensive) medical specialties (e.g., neurosurgeons) in-theater versus using them in the peacetime structure. Although the medical need for much of the time was clearly for primary care, the hospital commander faced the problem of keeping his medical staff busy between incidents. This was especially true of the low-density areas of concentration (AOCs) like neurosurgery.
Finally, from a planning perspective, Somalia also illustrated well the tensions that having excess medical capacity in the theater may create in terms of the potential for mission change. In OOTW, having excess medical capacity in-theater is to a certain extent unavoidable, since demand may fluctuate widely and the missions can be highly fluid in nature. If one has excess medical capacity in-theater, demand for services is relatively low, and the medical staff is being underutilized, then there will be a natural tendency to want to use that excess capacity in ways that may go beyond the original mission. In Somalia, this meant providing some care to Somali citizens. This is a key dilemma commanders will continue to face in these operations: how to maximize the efficient use of their medical assets while avoiding taking on an additional mission.
Problems in Treating Civilian PopulationsAs the case study makes clear, providing medical support to the Somali civilians was not part of the original mission statement, although the medical planning took into account the possibility of the AMEDD being tasked to treat civilians. Still, the medical staff did end up treating Somalis over the course of this deployment (more at some times than others). Partly this was done to fill in the lulls and maintain clinical skills. But it was also because the medical staff and the enlisted personnel saw an overwhelming need in the community. Initially, the medical staff was highly motivated to participate in this humanitarian relief effort and provide care to Somali nationals.
Doing so, however, created a host of clinical and operational dilemmas for the AMEDD, with commanders worrying about the potential for mission creep. These dilemmas included:
- What level of medical care to provide Somali civilians in a situation where the host country's standards of care were either rudimentary or nonexistent;
- Whether to treat a medical condition the AMEDD staff knew was treatable by Western standards but not by that of the host country (e.g., diabetes or cancer);
- How to transfer a patient's care to community providers or to a coalition soldier's own country, and what kind of treatment to provide when one knew a patient likely would not have access to follow-up care;
- Whether to provide a level of care the host country might not be able to sustain once the Army departed.
In addition, as Somali support for the mission deteriorated and the risk of U.S. personnel being shot greatly increased, the Army hospital staff began seeing an increasing number of U.S. casualties. These changes led to a great deal of anger and resentment among the medical staff and to considerable debate about continuing to treat Somali nationals. A further problem involved the placement of Somali patients on the same wards as U.S. soldiers requiring hospitalization.
The experience of the Swedish hospital in Somalia suggests that if civilians are going to be treated in these types of OOTW, separating civilian and military patients may be a good idea to minimize potential conflicts among the staff and patients. To do so requires having enough ward beds on hand to effect the separation. However, the Army is well positioned to do this, given its modular equipment that is part of Medical Force XXI.
Besides separating civilian and military patients, the Swedes also elected to provide a different level of care to civilian patients--one more in line with the existing medical standards of the host country. Such a policy would be useful for the AMEDD as well.
Benefits of the Somalia Mission for TrainingWhile the Somalia mission clearly presented problems for the AMEDD in structuring its support and in treating civilians, it also had a high training value, especially in the initial phase of a rotation. Specifically, the deployment gave AMEDD personnel valuable training in field medical skills. By providing care to the civilian population, the medical staff were able to treat conditions and operate on wounds they would not normally see stateside, which, in turn, made AMEDD personnel better prepared to deal with the combat casualties they saw later on.
Medical personnel also gained invaluable experience in triage and in handling a mass-casualty situation. The Somalia deployment, for example, proved invaluable in the recent aircraft crash known as the Green Ramp incident. On 23 March 1994, a U.S. Air Force F-16 fighter aircraft collided with a C-130 Starlifter transport aircraft at Pope Air Force Base, North Carolina, as the two aircraft both tried to land on the same runway. At the time, U.S. Army soldiers from the 82nd Airborne Division, XVIIIth Aviation Brigade, and other units from Fort Bragg were standing on the tarmac preparing to board an aircraft for a routine training exercise. The debris and fireball from the collision plowed into the group of Army soldiers, killing 20 and wounding 80 others. The wounded were transported to several military and civilian hospitals, including Womack Medical Center, Fort Bragg. CPT Mango, one of the nurses interviewed, had just returned from Somalia, and made the observation that as a result of the AMEDD's experience during the Ranger firefight incident, the medical staff at Womack Medical Center who had just returned from Somalia were much better prepared to handle this mass-casualty incident. The staff worked well as a team, were able to make the necessary triage and treatment decisions called for, and in general were psychologically better prepared to deal with the kind of injuries they saw from the aircraft crash. On the other hand, the medical staff who had not deployed to Somalia had more difficulty in dealing with this incident.
In addition, this operation provided an opportunity to field test the telemedicine capability--Remote Clinical Consultation System (RCCS). RCCS is an "on-site" system linked to Walter Reed Army Medical Center (WRAMC) that allows providers in the field to consult in real time with medical experts at WRAMC. The telemedicine capability was utilized in the Ranger firefight incident to assist the surgeons in the 46th CSH.
Finally, commanders gained important experience with multinational coalition operations, including the opportunity to evaluate other coalition forces' medical capabilities. All this experience directly contributed to the AMEDD's combat readiness mission.
 U.S. Army Forces, Somalia--10th Mountain Division (LI) After Action Report Summary, dated 2 June 1993, p. 19.
 In this case study, we focus specifically on the medical mission. For an overview of ORH and OCH, we refer the reader to the two after-action reports on Somalia completed by the Center for Army Lessons Learned (CALL): Operation Restore Hope Lessons Learned Report, 3 December 1992-4 May 1993; and U.S. Army Operations in Support of UNOSOM II, 4 May 1993-31 March 1994.
 The Somali nationals received the bulk of their care from the Swedish hospital. The Swedes provided two levels of care: one for U.S. troops and UN forces, and another for Somali nationals that was more commensurate with the level of care within that country.
 Specifically, it was a fourteen-hour flight from Mombasa, Kenya, to the Army hospital in Lanstuhl, Germany. In Mombasa, an international joint task force had an air transportable clinic (ATC) set up to provide support to the U.S. and coalition troops in Somalia requiring evacuation out of the theater. This clinic only had outpatient capabilities but had also contracted with the local hospital. The Mombasa operation ended around mid-March 1994 for all intents and purposes and remained closed for three months. Following the October 1994 Ranger incident, the Mombasa operation reopened to support the U.S. and UN forces in Somalia. Source: Interview with LTC Courtney Scott, M.D., JTF Surgeon for OPR, serving in the U.S. Air Force.
 The figure shows officers only. Although there were some enlisted PROFIS personnel in-theater, they were relatively few and not typical of the kinds of PROFIS personnel who usually deploy. Enlisted personnel are excluded from Figure 4.2 as well.
 The provider category includes surgical, primary care and medicine, mental health, and dental specialties. The "other officers" category includes administrative and health services specialties, preventive medicine, and ancillary support specialties (e.g., pharmacy, laboratory science, infectious disease, diagnostic radiology, dietetics, optometry, and pulmonology). The nursing category includes operating room, medical-surgical, and clinical nurses.
 The division's organic medical assets were supported by a Navy Corps Collecting and Clearing Company and by the USS Tripoli. An Air Force air transportable hospital (ATH) had also been established in Cairo to serve as the intermediate link in the strategic aeromedical evacuation chain. Source: "Operation Restore Hope Medical After Action Report," DASH-HCO-P, MAJ Michael Gunn.
 Three types of hospitals were deployed to Somalia: an evacuation (EVAC) hospital, a field hospital (FH), and a combat support hospital (CSH). The EVAC is designed to provide hospitalization to all classes of patients in the combat zone. At its maximum capacity, an EVAC consists of four intensive-care wards, eight intermediate care wards, and ten minimal-care wards. Note that the nominal bed capacity of a hospital (104 beds in this case) can be misleading, since not all of its wards may be set up.
 The policy was for the U.S. forces to treat whomever they injured (e.g., if an Army truck ran over a Somali citizen). There was some fratricide by Somalis; individuals would push relatives underneath the wheels of a Army vehicle in order to obtain monetary compensation from the Army for an injury or death.
 A field hospital is designed to provide hospitalization for patients within the theater of operations who require further stabilization prior to evacuation and convalescent care to patients who will be returned to duty with their field unit. It can accommodate up to 504 patients. At its maximum capacity, a field hospital includes two ICU wards, seven intermediate nursing care wards, one ward for neuropsychiatric care, two minimal-care wards, and seven patient support sections providing convalescent care. A field hospital is typically staffed with 19 Medical Corps officers and 57 Nurse Corps officers.
 A combat support hospital is the most comprehensive hospital unit within a theater, being designed to provide hospitalization for up to 296 patients within the combat zone. At its maximum capacity, a combat support hospital comprises eight ICU wards, seven intermediate nursing care wards, one ward for neuropsychiatric care, and two minimal-care wards. A combat support hospital at its maximum capacity is staffed with 33 Medical Corps officers and 120 Nurse Corps officers.
 The third rotation was also plagued by other morale problems that were related either to the rotation policy or to the fact that the 46th CSH was scheduled to deactivate upon its return to OCONUS.
 Grouping U.S. military and U.S. civilian personnel together in one category did not affect any of the results reported herein. One could argue that U.S. civilian contract and federal employee personnel would tend to be older, more likely to have chronic conditions, and more likely to be in poorer health than U.S. military personnel. However, their numbers were few and so did not affect any of our results.
 One of the nurses interviewed from the 46th CSH corroborated this suggestion. She made the observation that at one point, the Somali nationals constituted a relatively small percentage of the total number of inpatients, yet they required 80 percent of the nurses' time, since they were also the sickest patients in the hospital.
 Reasons for the problems in repatriating coalition soldiers included the country of origin lacking MEDEVAC capabilities, among others. The problem of repatriation is discussed more fully in Chapter Three.
 As noted earlier, the high proportion of providers during the initial rotation may have been due to the expectation of being tasked to provide medical care to civilians and humanitarian relief volunteers as well as U.S. troops.
 Although it is not shown in the figure, when we broke the surgical specialties down further into their various components (i.e., ob/gyn, general/thoracic/ orthopedic, and other surgical specialties), we found that the mix of surgical specialties in-theater remained fairly constant over the deployment, even though the percentage of providers who were surgeons initially increased, leveled off, and then decreased over time. Of the 184 surgeons in-theater over the 17 months of this deployment, approximately 45 percent were general/thoracic/orthopedic, another 45 percent fell into the "other" category, and less than 10 percent were ob/gyn.
 This was due partly to ORH representing the first deployment of the combat stress teams, before the permanent assignment of personnel to the 528th Combat Support Company (CSC) could be completed. The 528th CSC has noted that a key lesson learned from the Somalia deployment was the need to send a smaller rapid deployment assessment team over first to assess the mental health threat and to tailor the combat stress support.
 For the first rotation, a twelve-person prevention section was deployed to Somalia, so that the mental health team initially comprised thirteen officers and one enlisted personnel. For the second rotation, this number dropped to one officer and one enlisted personnel, too few given the increase in violence within the theater during this period, per CPT Eric Cipriano. The 528th Medical Detachment (Combat Stress) noted in its after-action report that a minimal mental health team of two officers (one prevention and the other restoration) and two enlisted personnel was required during the second rotation, as was the flexibility to augment the staff as the threat level increased.
 Interview with MAJ Winton Carter, 257th Dental Detachment, first rotation into Somalia. As in Somalia, the dentists in Zagreb, Croatia for the UNPROFOR mission were in high demand by the coalition forces.
 Because the Americans and the Swedes had set up weekly case exchange meetings to facilitate standards of care in-theater and encourage a professional dialogue, the 46th CSH knew well in advance that the Swedes would be able to handle these cases.
 The decision about which unit to deploy is also a subjective one and often involves the input of a number of different entities. For example, for Somalia the planning sequence included the command elements of CENTCOM, FORSCOM, the 3rd Army, 18th Airborne Corps, and the 44th Medical Brigade. The 44th Medical Brigade developed the operation plan (OPLAN) for ORH and then briefed the 62nd Medical Group, which developed the actual execution plan.
 The Army force structure determines what units doctrinally will be required to supply deploying forces. The organization is designed to support a certain level of intensity (e.g., fight a war in Europe), and the force modernization process was aimed at making changes necessary to have units with enhanced capabilities to achieve this. For example, under MF2K, the new combat support hospital (CSH) has much more intensive-care capabilities, and the mix of providers for this hospital will reflect this design factor. In OOTW, however, this means that if a brigade deploys, for example, the level of medical support it may require will not necessarily be at the same level of intensity a brigade may require in a full-scale war. Thus, if a slice of a hospital (e.g., CSH) is deployed for OOTW, then by definition one will have a higher capability than what one might actually believe is the level of intensity associated with this particular operation. The difference between the level of intensity a hospital is designed for and the level of intensity one actually may see in an OOTW is what results in excess capacity in these operations. Interview with COL David Nolan, 4 January 1996.