Health care in insurgency and counter-insurgency: Some lessons from others

By Col Aizen J Marrogi, U.S. Army;
Capt. David Tarantino, U.S. Navy;
and Lt. Gen. Robert L Caslen Jr., U.S. Army

In their counterinsurgency efforts against ISIS, policymakers ought to consider deploying one more tool in the arsenal: healthcare for the affected population and battlefield medicine for the embattled troops fighting the militants.

Yes, we have all seen the DoD photographs of troops caring for Arab children. But our efforts in medical engagement lack sustainability, purpose and trained personnel. Despite the photos, real success stories are few and far in between. Serious, sustained humanitarian and relief efforts are initial steps necessary for changing attitudes toward reconciliation and acceptance, and this assistance helps to restore order and legitimacy within local and national governments.

We believe that a sustained Heath Engagement Program that shows respect for the local culture is a strategic enabler when properly implemented by U.S. professionals. It will not only win people’s affections, but deprive the enemy of its base, which is a critical element of winning the ideological battle against an unconventional foe.

To be effective, the right doctrine, policies, and trained medical personnel are needed. Health engagement that trains and resources local medical personnel within and outside the Security Forces can invigorate these forces by not only enhancing battlefield health care, but also by establishing a legitimate local authority within the eyes of its citizens. During the outbreak of cholera in the late summer of 2012 in Iraq, we realized that working alongside local Iraqi health authorities built trust and mutual respect among the health officials and local population alike, a key tenet of any counterinsurgency strategy.

Prior to 2011, the U.S. had provided training and education to the Iraqi military health services, utilizing scores of deployed U.S. medical mentors, with great success. These U.S. mentors trained Iraqi personnel in areas of trauma, operational and battle field injuries, medical logistics, leadership, aerospace and navy medicine, infectious and communicable disease, and disaster medicine. Although these personnel and capabilities have diminished since the departure of U.S. forces, the Iraqi Security Forces medical personnel have continued to provide significant health service support under very trying conditions. Included in their work is the care they have provided to more than five million Internally Displaced Persons (IDP) and refugees that threaten to overwhelm the local and regional health systems with their basic needs for water, sanitation, and hygiene; public health and control of communicable diseases such as Leishmaniasis, polio, childhood diarrheal and respiratory conditions; and general clinical, trauma and mental health care needs.

U.S. government institutions such as National Institutes of Health (NIH), Uniformed Services University (USU) in Bethesda, MD and others are well equipped to lead and execute medical engagement missions. For example, were they to support the on-going Iraq mission, collaborations in health education and capacity building with local health care authorities and medical educational institutions in key Sunni population centers like Ramadi, Fallujah, Tikrit, Mosul, Kirkuk, and Baqubah would positively impact the heart of the restive population. Further, an effective Iraqi Security Forces health system, especially battlefield medicine, can boost the morale of security forces fighting ISIS.

General Obeidi, the former Iraqi minister of defense, in a recent interview with Foreign Policy emphasized that the ISF resolve and determination in battles against insurgent elements between 2003 and 2011 was bolstered simply by knowing that US medical services were available to attend to their needs when injured. Recent reports from Iraqi health ministry and ISF medical services clearly indicate a significant lack of advanced trauma, reconstructive surgery, physical medicine and rehabilitation, and prosthetic care for their forces involved in difficult fight against ISIS. As of 2013, Iraq had more than sixty thousand combat veterans waiting for appropriate rehabilitation care, representing a difficult and complex socioeconomic burden.

Health engagement that includes adequate resources and qualified personnel who understand the history, culture, language, and psychology of the host nation population and their leaders will enable a counterinsurgency strategy.  Embedding medical officers as health liaisons within our commands can enhance our counterinsurgency objectives.  Further enabling these officers are the collective efforts of the interagency cooperation of DOD, DOS, HHS, and other stake holders. Collectively, they will ensure competence within the indigenous health system.

Finally, a health care strategy that implements civilian population care in public health, epidemiology, child and maternal health, training and education, communicable diseases surveillance and community resiliency and behavioral health will have significant and dramatic effect. As an example, in the fall of 2012, the excitement displayed by ISF medical personnel who attended English language classes in Baghdad in preparation for their upcoming medical training in the United States was inspiring. The training emphasized U.S. commitment to the local population and reinforced the message that United States really cares about them, which goes to the core of counterinsurgency doctrine.

As the United States develops strategies to confront emerging radical movements, particularly in Iraq and Syria, lessons learned from regional actors such as the Muslim Brotherhood (MB), Hamas, and Hezbollah can be educational. The delivery of health services, regardless of from which side, built trust within the local population by delivering essential services to the population through competent, transparent, and professional medical personnel.

As we analyze why radical theocratic ideologies quickly gain popularity among the people in this part of the world, we should recognize these groups’ efforts to provide social and essential services especially in education and health care, filling a gap where nascent governments fall short in delivering even the most basic services. We learned over the last twelve years of counterinsurgency efforts in both Iraq and Afghanistan that the key to a population-centric approach and host nation legitimacy is the ability to provide security, essential services, and rule of law. When such governance falls short, and radical groups recognize the gap and fill it, popular support can shift towards those who meet the most basic needs of the populace. In Iraq, we have also witnessed the crushing impact to both the populace and the indigenous security forces when previously effective health care systems fail to provide this essential service under the newly emerging government.

Hezbollah, the Muslim Brotherhood (MB), and Hamas groups have all used Chinese leader Mao Zedong’s revolutionary war doctrine to win local support. In addition to a formidable armed guerrilla force and media outlets, Hezbollah boasts an extensive health network of hospitals and clinics throughout Lebanon. By establishing legitimacy through its repeated wars with Israel (Mao 1st principle) and benefiting from the prestige of inflicting IDF casualties and political blows (Mao 2nd principle), Hezbollah is now a major power broker on the Lebanese political stage, forging a broad national alliance with main stream Lebanese political groups (Mao’s final principle). Hezbollah’s popularity is bolstered by its ability to provide much needed social services neglected by the Beirut government. Counterinsurgency strategy targeting this group without considering its social services outreach will accomplish limited success, as Hezbollah remains firmly enmeshed in Lebanese society while also extending its influence into Syria and Iraq, remaining a persistent challenge for U.S. and Israeli policy makers.

The Egyptian MB, Palestinian Hamas, Indonesian Jemaah Islamiyah, and Iraqi and Syrian Badr, Al-Sadr, and Islamic Supreme Council Shia groups are adapting and implementing the Hezbollah model of social services, especially in the health care sector. Of the 5,000 NGOs working in Egypt, greater than 20 percent of them are MB affiliates operating dozens of hospitals and clinics countrywide. The MB has focused on recruiting physicians and educators to serve in their highest leadership echelons, including the recently appointed Dr. Mahmoud Ezzat, the MB movement general counsel. Unlike state-run institutions, MB-managed facilities are rarely the subject of fraud or corruption allegations. MB health care efforts are touted as “getting closer to God through medical work.” The MB’s effective response to the devastating Cairo 1992 earthquake provided them with much sought-after legitimacy. As is the case in Hezbollah’s legitimacy among people, it is becoming more difficult to remove the MB from the political scene.

In summary, the U.S. and coalition partners face a significant challenge confronting ISIS and other extremist ideological groups in Iraq, Syria and elsewhere. Health engagement that bolsters civilian and military capabilities and provides essential health services is an important line of effort in the overall strategy

Col. Marrogi is a member of the Division of Global Health, Department of Preventive Medicine and Biometrics, Capt. Tarantino is at the Center for Disaster and Humanitarian Medicine, Uniformed Services University, Bethesda, MD.; Lt. Gen. Caslen is superintendent of the U.S. Military Academy, West Point, N.Y. The views expressed are those of the authors and do not necessarily reflect the official views of the United State Military Academy, Uniformed Services University of the Health Sciences, or the Department of Defense.

Image credit: U.S. Navy