The Role of Pediatric Care in Conflict
By Christine Morrice
Photo by Brian Miyamoto
Dr. Mark Burnett, a Lieutenant-Colonel in the U.S. Army, was interviewed on March 18, 2008 at his office at the Pediatric Department of Tripler Army Medical Center, Hawaii, USA. Dr. Burnett recently published an article in the journal Pediatrics in February 2008 on pediatric care by the U.S. Army Medical Mission in Afghanistan and Iraq, stating the treatment of children is a “moral, ethical and doctrinal” obligation1 during war. He emphasized that pediatric care is key in the effort to bridge the gap between civilian communities and military medical personnel deployed to areas engaged in building health sector capacities. Dr. Burnett was also involved in another program initiated by a U.S. military doctor to donate updated medical textbooks to Iraqi doctors.2
Christine Morrice: Your experience in the U.S. military has included deployments over the past 10 years to Kosovo, Afghanistan, and Iraq. How have conflict zones changed over the years for you?
Mark Burnett: In Kosovo we could roll out in soft-skinned Humvees. In doing [Medic Civic Action Programs] MEDCAPS in Iraq in 2006 or 2007, we required secrecy. It felt surreal when there were helicopters flying overhead providing security as we saw patients. The security concerns made it more difficult to provide humanitarian care.
We had more interactions with NGOs in Kosovo because it was a safer place – there were more of them around. In Iraq, we rarely had any interaction because they did not feel it was a secure environment. We had interactions with USAID and the International Medical Corps (IMC) in the Kurdish-controlled areas.
On a side note, one of the first things I teach about humanitarian missions in the military is that there is no medical mobile clinic worth getting soldiers killed. That is why these things should not be patchworked together at the last minute. Research must be done to make sure the site is safe, and to ensure that all return safely.
CM: In the Pediatrics article, you mentioned that the U.S. Army found itself treating children as they made up a significant portion of patients being admitted to military-run hospitals in Afghanistan and Iraq. Although it has provided adequate care, the military is trained primarily for warfighting operations, and not support operations.
This represents the classic dilemma discussed in this journal of balancing security concerns versus capacity-building functions in conflict situations, for both civilians and military personnel alike. Why do you think military-trained pediatricians are suited to strike this balance accordingly?
MB: There are many children out there in conflict zones. The military pediatrician can serve at the battalion aid station taking care of acutely wounded U.S. soldiers, and they can also take care of the children, who unfortunately make up the mix whether combat-related or non-combated related.
I think what makes military pediatricians unique is that we can transition from taking care of a 22-year-old soldier, to providing care for a four-month-old baby and still feel comfortable.
Iraq's population has a median age of 18 years, so there were many children around. Iraq has many well-trained doctors; they just need the resources and security to do their job. However, from time to time, we were the only immediate healthcare available for the children. Unfortunately, a number of these clinics in the aftermath of the war were looted, and many supplies disappeared.
I developed the idea for the [Pediatrics] article when I was deployed to Afghanistan, as I did not think there was an appreciation for the numbers of children requiring care. I was struck by how many children I saw in the wards of the Combat Support Hospital there.
One of the hardest things to convey was how sick these children often were by the time they arrived at the hospital. In Afghanistan, children would often travel for days before being seen. In Iraq, care might be delayed due to security concerns, resulting in a more ill child by the time that they did arrive.
Military pediatricians are well suited to serve in environments, such as Iraq and Afghanistan, as they have extensive training in resuscitative care, infectious diseases, as well as the humanitarian assistance aspects of medicine.
CM: Speaking of which, the article mentions that unlike other military healthcare practitioners, military pediatricians are trained specifically in humanitarian assistance and disaster management, such as in the Military Medical Humanitarian Assistance Course (MMHAC) at the Uniformed Services University of the Health Sciences (USUHS) in the U.S. Why do you recommend humanitarian assistance and disaster management training for all pediatricians, both in civilian and military organizations?
MB: Humanitarian Assistance (HA) is a fact of life in military operations. More low-intensity conflicts will occur where there are scattered areas of fighting. I could be sitting here one day in the office, and a month from now I can be sent halfway around the world working on a HA mission. And often times, there is no time for a train-up.
In terms of the U.S. military in low-intensity conflicts, we are there, we are amongst the local people, and we should be good neighbors. This is what it comes down to, in my opinion.
CM: There is also your recommendation for uniformed military forces around the world to consistently integrate the care of children injured during combat and non-combat events, who have no other recourse. Why is this so?
MB: As an example, the care of one child helped us to do the rest of our jobs. One of our units’ combat patrols was driving back to base. Several people ran out and waved them down because there was a child who had gotten burned and was having trouble breathing. My medic, a young soldier, recognized that this child needed
more care than could be quickly
The medic made a split-second decision that the child needed more care than he could give. So the child was taken into the base, cared for and medevaced to the Combat Support Hospital (CSH) in Baghdad. Surgeons there worked on him, including some skin grafting. The child was pretty sick for a while. But he had a good outcome and went back to the local population.
The locals did not wave us down for minor things. They understood that they needed to go into their own medical clinics. But in this particular instance, the child had a good out-come, and his family was very grateful. And the mood changed in that area; people who were previously indifferent or really did not care became more helpful. It wasn't quid pro quo – not “we are going to take care of your kids so you better do something for us.” It just came down to common sense, and being good neighbors.
CM: How has the US Army Medical Command improved its pediatric care in overseas conflict response?
MB: Pediatricians have been serving at Combat Support Hospitals; for instance, the chief of our department at Tripler Army Medical Center and a pediatric intensive care physician from Walter Reed Army Medical Center [Washington, D.C.], have both served in Afghanistan specifically caring for children.
More pediatric-specific medical supplies have also been coming in, such as endotracheal tubes small enough to intubate a child, and ventilators for smaller patients. Another aspect has been the ability to contact around-the-clock [via cellular phone or the Internet], the critical care specialists of pediatric intensive care units in the U.S. Often, the children have unbelievably good outcomes. Military doctors overseas already have had the ability to consult with adult intensivists in the U.S. and ask them specific questions on how to manage patients.
CM: In terms of capacity-building, you were also engaged in the donation of used medical books and journals by U.S. military medical personnel to Iraqi doctors during your latest deployment to Iraq. How did this idea come about and how is it important?
MB: The program was started by Dr. David Gifford, a retired Army Colonel and a rheumatologist working at Darnell Army Medical Center at Fort Hood, Texas. Dr. Gifford's son was a medical service officer in Tikrit [Iraq] early in the war. Local Iraqi leaders asked if he could find a way to get some medical books from the US since clinics were looted after the invasion in 2003. In 2004, Dr. Gifford had a book drive at his hospital, then he mailed them over to his son and received tremendous feedback.3 Dr. Gifford then put the drive up on Medscape [online resource for healthcare professionals] and also received an enormous response.
I was very interested because I had donated books that went to Afghanistan. Talking with the Iraqi doctors, I would hear over and over again that they did not want us to do their job. They just needed help in getting the resources to help them do their job. Nowadays, U.S. doctors often turn to the Internet. But for a medical population that often times does not have much or limited access to the Internet, books are the mainstay.
We delivered a big load to the clinics, and the doctors were extremely appreciative. One doctor was a radiologist with very limited resources. We gave him radiology journals that were about five months old, and he was turning them over in his hands like they were gold. Their textbooks were 15 years old, but we dropped off books from a year or two ago, or brand new.
Dr. Gifford asked if I would mind writing a note on the reactions. So I wrote how incredibly appreciative the Iraqi doctors were. They were some of the most apolitical people I knew, and they could care less about ethnic backgrounds; I found they were just interested in taking care of their patients. Dr. Gifford said the following weekend he had hundreds of people e-mailing him with requests on how
I still receive e-mails from doctors back in Iraq, expressing appreciation.
All Iraqi doctors read English very well, even if a few do not speak it well, because that is how Iraq doctors are trained. So even with limited communications, they could all read the textbooks well.
In our second area of operations, just north of Baghdad, there was a large highway running through the middle. The western side was mainly Sunni, and the eastern side was mainly Shia. There was a large clinic on the main road, where we dropped off the books and said that this was where the medical library was going to be – to encourage the doctors to again work together. The doctors had no problems working with each other, but they had to deal with the threat of providing care for someone of another background.
Another great program was the Wheelchairs for Iraqi Kids program4 [begun in 2005 by U.S. Army Lieutenant-Colonel David Brown], in which hundreds of wheelchairs went to children with cerebral palsy and other conditions. The wheelchairs encouraged independence, and the children could use their arms or be pushed around by their relatives. This was another simple program but with a great outcome [see Interview].
CM: What would you suggest to military readers (U.S. and otherwise) if they are interested in
launching a similar program in
conflict areas such as Iraq?
MB: Keep it simple. Do not make promises because your unit can
be moved to a different part of the country or to a different country altogether. Just setting up things takes such a long time. It’s not like
you can pick up the phone and call, and meet someone down at a corner. There is a lot of legwork involved. Understand that the more complicated and the more steps one has to do to get something up and running, the more chances of failing. But if one does not try at all, then there’s a one hundred percent
chance of failure.
CM: Any last thoughts on your experiences or on capacity-building that you would like to share with your readers from your perspective?
MB: It's hard but not hopeless. People hear every single day that it’s a hopeless situation. But people are often times surprised when I tell them stories of the very brave people there, and of how things had been improving.
There was an Iraqi doctor I worked with who received death threats, but he would still work with me because he believed in fixing up his clinic, which was a government-run clinic – not even his own. Trying to do the best for his people was the most important thing for him. I can't imagine calling a meeting with my colleagues, saying that there could be a chance that you will be killed just for attending. I don't think I would have very good attendance. I think we have to give the Iraqis credit because they have certainly lost a lot more than we have.
I was also struck by the incredible bravery of the medics that I had. They would put themselves in harm's way to care for others – knowing that they were being targeted by the enemy. The pre-hospital training they received, as well as the new tools they have to work with, made them indispensable members of our unit.
I tell people, “I wish you had the chance to see what I saw, and I wish you had a chance to meet the people that I met.” Unfortunately, with the constant barrage of negative stories in the mainstream media the hopeful stories of Iraq are seldom told.
According to Dr. Gifford, the medical textbooks program continues to garner interest and is possibly expanding into the Philippines. For mailing address, instructions, and specifications for the medical textbook donations, please contact Dr. Gifford at: email@example.com
1. Burnett, M.W, Spinella, P.C., Azarow, K.S., and Callahan, C.W. (February 2008). Pediatric Care as Part of the US Army Medical Mission in the Global War on Terrorism in Afghanistan and Iraq, December 2001 to December 2004. Pediatrics. 121 (2), 261-265.
2. Cupp, J. (Staff Sgt). (September 21, 2007). Iraqi Doctors Get New Medical Books. DefendAmerica. U.S. Department of Defense. Retrieved April 26, 2008 from: http://www.defendamerica.mil/articles/sep2007/a092107ls2.html
3. See Miller, M. (July 1, 2004). Fort Hood Doctor Helps Bring 21st Century to Iraqi Health System. DefendAmerica. U.S. Department of Defense. Retrieved April 26, 2008 from: http://www.defendamerica.mil/articles/jul2004/a070104a.html
4. Wheelchairs for Iraqi Kids. Retrieved April 28, 2008, from: http://www.wheelchairsforiraqikids.com/
Gifford, D.B., MD. (January 16, 2007). The Power of an Idea: Help for Iraqi Medical Professionals. Medscape. Retrieved April 26, 2008, from http://www.medscape.com/viewarticle/550427
Donations of Medical and Nursing Books and Journals Arrive in Iraq. (June 26, 2006). Medscape. Retrieved April 26, 2008, from http://www.medscape.com/viewarticle/557426
Dufresne, G.W. (December 10, 2007). More Donations of Medical and Nursing Books Arrive in Iraq. Medscape. Retrieved April 26, 2008, from http://www.medscape.com/viewarticle/567027
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