By Matt Pueschel
Posted: 30-October-2007

WASHINGTON-The U.S. Naval Ship COMFORT's four-month humanitarian health care mission through Latin America from June-October signaled the coming together of federal entities on a grand scale.

The Navy's other hospital ship, the MERCY, had some Public Health Service (PHS) personnel onboard when it responded to the Indonesian tsunami a couple of years ago, but not as many. "This is the first time this amount of PHS people are onboard a Navy ship," said Cdr. Ulana Bodnar, MD, USPHS, a CDC medical officer and an infectious disease physician who served on the Latin America mission for a month. "I think this has been the biggest deployment of PHS people that PHS has ever done, so I think in many respects this kind of was a first experience for the military with this large amount of people from PHS and also for us. Just from my perspective, it was a great experience. I thoroughly enjoyed working with people [in a] no-nonsense, mission-first, how do we get this done [approach]. That's a great attitude to go into any sort of experience."

Furthermore, Cdr. Bodnar said she did not see any leadership clashes while she was on the mission. "My attitude and I think the attitude of others from PHS was, 'well, we're here at the Navy's request. We're here to augment the Navy,'" she said.

For example, Cdr. Bodnar felt that her Navy counterpart on the mission, fellow infectious disease specialist Lt. Cdr. Todd Gleeson, MC, USN, should serve as the ID lead on the mission, even though his rank was lower, because he was going to be with the ship for the entire four months, whereas PHS sent four supplemental teams each for a month long. So Cdr. Bodnar felt that she was there to back Lt. Cdr. Gleeson up and do what was needed. "And I think that was pretty much everyone else's approach to the situation," she said. "We're there to help, we're there to augment in whatever manner and fashion we can, so what needs to be done, we'll do it if we can. Plus, it was so mission-driven, which was also the amazing thing for me. It was all about the mission [and], 'how can we do this to the best of our ability? We're here to help you in whatever manner we can with the expertise that we have.'"

When asked if she has a sense that they made an impact while they were there, Cdr. Bodnar said, "I think we did. Not just us, [but] all of the Services together. But, I think also us as PHS-we were the only people that have veterinarians on the missions, so they were seeing pets [and] livestock."

The PHS veterinarian who served on the first leg of the mission with Cdr. Bodnar's group felt like things got established to make it easier for the next groups that came onboard to make an impact as veterinarians, Cdr. Bodnar advised.

As far as infectious disease work, Cdr. Bodnar said she thinks she was useful. "I think what needed to be done on that ship with only one infectious disease physician would have been extraordinarily difficult, and having two I think was very well-planned," she advised.

And when they were onshore, they were seeing patients pretty much non-stop, Cdr. Bodnar added. "It was basically like running a regular clinic," she said.

Cdr. Alfred Shwayhat, MC, USN, who served as the mission's division leader for adult medicine, agreed. "The coordination, the teamwork, and the collegiality between all of them, it's a very joint mission, and I got to tell you in my career I've never seen such teamwork," he said. "It's been absolutely wonderful. It really, really has. I've learned so much about the other organizations."

The various military and public health groups complemented one another's skill sets very well. "Without question," Cdr. Shwayhat advised. "They all show up here, including the volunteers for Project Hope and Operation Smile [both NGOs], and within 24 hours literally everybody is on the same team and you know, as a doctor, I came here wondering if that would happen and I was convinced within minutes of arriving here [that] everybody's on the same page, everybody's excited to be here and everybody is just really excited to be a part of the team. It's really a great feeling."

Cdr. Bodnar said after having established relationships with the host countries, as well as one another, it should help toward having a smooth re-entry into the area in the event there is a future crisis that requires interagency help. "I know within the military, among the different Services, they talk about integration," she said. "And I think you can also talk about integration for PHS. We are a uniformed service, so we're there to support our sister services in any way we can. And I do think the PHS is unique because of what we bring to the table. We're health care providers, and that includes physicians, nurses, dentists, [and] like what we had on our team, an engineer, environmental health officers. It's such a broad spectrum of health care providers that we have within the PHS. So I do think we're very unique compared to other Services. And I think because we all work at different agencies, we all have different experiences and different niches within those agencies. I've done a tremendous amount of protocol writing. I did a document also for surveillance, prevention and control of influenza-like illness on cruise ships for the cruise industry a couple years ago."

So, when Cdr. Bodnar arrived on COMFORT, she knew she would have to address flu-like illnesses there, too, but she only had to tweak the document she had used in her previous experience. "Everyone has a niche within their agency, and I've been in two different places at CDC, so that just enhances one's experience in what they bring to the table," she said.

Another aspect of the mission was to send environmental health specialists and environmental engineers out to the field mission sites. "They inspect water treatment facilities, sanitation disposal facilities, they discuss local measures, they provide some education and tips on pointers to improve the host nation measures that they have for these modalities and to treat their sewage and treat their water supplies," Cdr. Shwayhat said.

Surpassing Language Barriers
Communication with the locals was eased through translators. "We do have translators that are with us and the locals had the host nations provide translators to us, as well, and each provider and each specialist, whether or not they are a provider, has a translator present with them to be able to interpret and help us provide care," Cdr. Shwayhat advised.

Spanish was prominent and there were also some indigenous dialects. "Even some of the in-country interpreters had trouble with some of the dialects," Cdr. Bodnar said. "In one instance they actually grabbed another patient who knew not just that particular dialect, but also regular Spanish, so it became like a three-way conversation."

Making sure the questions and answers got translated correctly, and that the patients understood was the key challenge.

The overall medical/humanitarian presidential initiative to aid the people in Latin and South America seemed to have resonance with Cdr. Bodnar. "It's part of the world we live in," she said. "Humanitarian training and I'd say community relations and hopefully [more]."

An Air Force lieutenant colonel that Cdr. Bodnar met on the ship hoped that what they did would foster cooperative solutions in health care for years to come and that the mission would leave a 'lasting footprint,' Cdr. Bodnar said. "I thought that was a nice way of wording it. The bigger question is 'well, we have this humanitarian mission and then what will happen after that?' Hopefully there will be more of these types of humanitarian missions down the road, so it will become more of an opportunity for other people, as well. For me, what was interesting was not just the medical perspective and what the mission was all about, but also just the cultural context, the living circumstances of the people, and the people themselves. So it was a really very multi-faceted experience," she added.

Interacting with the military personnel and the NGOs, the PHS providers all worked to deliver quality medical care as the common goal. "When I first saw the notice about [volunteering for] it, it caught my eye because it's just so different, it's so unique," Cdr. Bodnar advised. "And it sounded so absolutely interesting and fascinating. I think any time you travel to a foreign country, there is an enriching experience, not just from what you take away from the country by what you've observed, but also the interactions that you've had with the people. I think I came away with a lot. I think I'm a better person for it."

In some of the more rural places they visited, like Morales, Guatemala, it was more difficult for people to access medical care. Cdr. Bodnar said she read an account of one local woman during the mission where it took her two days to get to one of the clinics. "The environment was hot and humid, tropical," she added.

More Missions?
As far as future humanitarian missions, PHS public affairs staff said in August that the agency was also collaborating with COMPACFLT (Navy Command of the Pacific Fleet) by supplying USPHS commissioned officers to the USS PELELIU, a Navy gray hull amphibious assault ship that has significant surgical and emergency medical capabilities, even though it is not a hospital ship. "In a novel approach, PACFLT is using the ship to deliver public health and medical services to several Pacific Rim and Pacific Island countries," said Rebecca Ayer, communications director for the Department of Health and Human Services (HHS) Office of Public Health and Science, in an e-mail to U.S. MEDICINE on Aug. 6. "These include several locations in the Philippines, Vietnam, Papua New Guinea, the Solomon Islands and the Republic of the Marshall Islands. Because it is designed to move people ashore, it is an excellent platform from which public health, medical, dental, engineering and environmental health projects can be launched."

In addition, Ayer said that HHS secretary Michael Leavitt has tasked the commissioned corps with supporting a similar COMFORT mission next summer.

As for the Navy, when asked if there were any future COMFORT missions planned to return to the Latin America region or any other similarly planned humanitarian missions, Lt. Cdr. Jon Spiers, a public affairs officer for U.S. Naval Forces Southern Command, provided no specifics, but seemed to leave the possibility open. "The Southern Command has a long history of humanitarian assistance in its area of focus, a history that includes not only the deployment of USNS COMFORT, but also the deployment of individual medical teams that provide health services for an average of 200,000 patients per year," Lt. Cdr. Spiers wrote in an e-mail to U.S. MEDICINE on Oct. 11. "We will continue to explore innovative ways in which we can help partner nations improve conditions across the Americas. USNS COMFORT has proven itself a valuable asset in helping us achieve this goal, and we will certainly consider this option in the future."