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New zealand defence force: deployment to east timor – performance of the health support services

In November 2001 we issued a report on the New Zealand DefenceForce's (NZDF) deployment to East Timor, which took place in 1999.
That report looked at how the NZDF planned for the East Timoroperation, prepared a joint force, and subsequently deployed that forceto East Timor.
We said in the November 2001 report (page 4) that we would be reportingon a second examination of the roles performed by two particularelements of the New Zealand force in East Timor – helicopters andmedical support. This report contains the results of the final part of ourexamination. It examines the contribution of the variety of professionalsfrom all three Services (Navy, Army and Air Force) who providedHealth Support to the East Timor Deployment.
Our examination considered the medical preparations that were necessaryfor the deployment, how military personnel were supported while inEast Timor, and what procedures and services were necessary in gettingthem back to New Zealand at the end of a tour of duty.
As with our earlier examination, the professionalism and helpfulness ofthe NZDF personnel in preparing this report have impressed us. I wouldlike to thank in particular the Health Support personnel from JointForces Headquarters and Army No. 2 Field Hospital for their willingnessand co-operation.
I hope that Parliament will find this report of interest, and that it willgive the NZDF a basis to improve the health support servicescurrently provided.
K B BradyController and Auditor-General

Summary and Recommendations
Overall Findings and Conclusions In-theatre Services Part One: Background
The East Timor Operation The Importance of Health Support Services Focus of Our Examination How We Carried Out Our Examination Part Two: How Are Health Support
Structure and Composition Non-operational Services Operational Services Part Three: Arrangements for Keeping
Why Medical Records Are Important Personnel Medical Information for Deployment Arrangements for Medical Records During Deployment Analysing Information for Health Surveillance Developing a Computerised Medical Information System

Part Four: Health and Medical Aspects of
Getting Ready for East Timor
Planning for a Possible Deployment Preparing General Military Personnel for Deployment Checking that Personnel Being Deployed Are Medically Fit Training Health Support Services Personnel for Deployment Training Civilian Volunteers for Deployment Part Five: Establishing Health Support Services
in East Timor
Levels of Health Care Setting Up the Company Aid Posts Setting Up the Regimental Aid Post Setting Up the Forward Surgical Team Medical Evacuation Treatment of Military Personnel Part Six: Maintaining Health Support Services
in East Timor
Maintaining Good Environmental Health Providing Sufficient HSS Personnel for Each Battalion Rotation Getting Medical Supplies to East Timor Recognising the Need for Psychological Services Dealing With High Levels of Dental Problems Treating the Local Timorese Civilian Population

Part Seven: Looking After Returning Personnel
The Force Extraction Programme Part Eight: Lessons Learned for Next Time
Collection of Lessons Learned Data Operational Lessons Learned Strategic Lessons Learned Glossary of Terms Structure of the NZDF Dimensions of NZDF Health Support Services HSS Professionals in the NZDF HSS Command Structure HSS – Who and Where? Regular Force HSS Personnel 1990-2002 Levels of Health Care Structure of Army No. 2 Field Hospital Linton Contents of a Medical File Arrangements for Medical Records During Deployment Pre-deployment Health Preparations Summary Time-line of Batallion Rotations Pre-deployment Medical Examination Process (INTERFET) Pre-deployment Health Training for All Personnel Pre-deployment Training For HSS Personnel

Time-line for Setting up the HSS in East Timor FST Ground Layout and Staff Location of Health Support Services in the Field HSS Structure - NZ BATT 4 Responsibilities and Activities of the Environmental Health Team The "Foggy" at Work Work Being Done Without Protective Footwear Waste Disposal at Tilomar The Medical Supply Chain Psychological Support Activities 26. Force Extraction Programme Force Extraction Team – NZ BATT 4 Psychological De-briefing Process Post-deployment Transition Model HSS Sources of Lessons Learned Data

SUMMARY AND RECOMMENDATIONS
Summary and Recommendations
A capable and well-prepared NZDF requires personnel who are atall times fit, healthy and motivated to carry out a range of assignedmilitary tasks. Keeping personnel in good health and medically readyto deploy at short notice is the task of the NZDF's Health Support Services(HSS). While HSS are a small part of the NZDF, they have a critical role inthe preparedness of NZDF personnel.
The morale and commitment of every military member will also beinfluenced by the confidence they have in the network of services forpreventive health care, medical treatment and (where necessary)evacuation. It follows that an effective and efficient medical supportsystem is vitally important for the NZDF to achieve its operational goals.
Overall Findings and Conclusions
The HSS played a crucial role in the East Timor operation by: • assisting in the preparation of personnel for deployment; • providing health care and support in theatre; and • providing post-deployment health care and support when personnel returned to New Zealand.
In performing their various roles, the HSS met four main challenges: • short times within which to prepare large numbers of deploying personnel within limited resources; • working in difficult environmental conditions; • the need to adapt to changing needs and circumstances over the period of the deployment; and • the difficulties inherent in sustaining operations over a long period that were essentially planned for the short term.

SUMMARY AND RECOMMENDATIONS
We conclude that the HSS played their crucial role and met thesechallenges with a high degree of success. However, the pressures createdby the scale and duration of the operation highlighted some poorsystems and practices that made the job of the HSS more difficult than itneeded to be.
Issues for consideration by the NZDF include: • upgrading the poor medical records system; • addressing shortages of health care personnel; • reviewing the supply system for medical items; and • improving the focus on preventive and environmental health.
Some of these issues were well known to the NZDF before thedeployment to East Timor, but little action had been taken to rectify them.
The NZDF began to address issues with environmental health in thecourse of the deployment. The outstanding matters need to be addressedas a matter of priority.
The HSS undertook effective and timely planning for the deployment to
East Timor.
The HSS produced a Health Services Support Plan that provided effectivesupport for the preparations by: • taking account of the health hazards that deploying personnel would • identifying the numbers of medical personnel and equipment needed, mission tasks and training requirements, and the key tasks to becompleted before deployment; and • providing the basis for the development of health-related training programmes for military personnel, and training for the HSSthemselves.

SUMMARY AND RECOMMENDATIONS
Health information about East Timor was used in training programmesfor all deploying personnel who received comprehensive briefings onenvironmental health risks and ways to maintain their own health.
Shortcomings in the training of HSS personnel were noted early on, and
were addressed as the deployment continued.
Pre-deployment training for medical staff – such as hands-on experience inhospitals – gave them a practical grounding in the trauma situations thatthey might encounter. However, early in the deployment they lackedsome necessary basic soldier skills and training in tropical medicine.
The NZDF recognised these shortcomings and has gone some way tomodifying training programmes accordingly.
We recommend that –
1 The NZDF reviews HSS personnel training programmes in the light
of the East Timor deployment, to ensure that basic soldier skills,
specialist medical skills (such as tropical medicine) and skills
associated with the provision of humanitarian aid are sufficient to
support future deployments.
Medical Fitness Checking medical fitness before deployment was a huge undertaking.
The NZDF's medical screening system is based on an assessment of risk,and takes account of the operational environment, the expected role andduties of the individual on the mission, and the likely risks to theindividual and their unit.
Everyone deploying to East Timor had to have an up-to-date assessment oftheir medical fitness. Large numbers of medical examinations wererequired immediately prior to the deployment, which placed a very heavyworkload on clinical staff and health administrators.
We recommend that –
2 The NZDF reviews the frequency of regular medical examinations in
cost/benefit terms to assess whether it would be worthwhile increasing
the frequency in order to reduce the numbers of examinations
required to prepare large numbers of personnel to deploy.
SUMMARY AND RECOMMENDATIONS
The numbers of personnel without the expected standard of protection
from vaccination led to a large workload to get all deploying personnel up
to the standard.
Personnel being deployed overseas are often at increased risk from diseases.
The NZDF has a standard ongoing level of disease protection fromvaccination (known as Protocol A) that all its regular forces are required tohave, so that they can be ready to deploy at short notice. The extent towhich NZDF personnel actually meet Protocol A is an importantcomponent of force preparedness and individual readiness to deploy.
Not all NZDF personnel met Protocol A at the time of preparing for theEast Timor deployment. The additional work needed to bring allpersonnel up to Protocol A at short notice added to the burden of activitiesto be performed as the NZDF trained and mobilised its force within therequired response time.
Compliance with Protocol A continues to vary across units. But the NZDF'scurrent medical information systems cannot identify how many personnelmeet the standard at any particular time. This represents an importantgap in the NZDF's ability to monitor and report on force preparedness.
We recommend that –
3 The NZDF ensures that all Regular Force personnel meet the
Protocol A vaccination standard.
Vaccination against Japanese encephalitis virus was a challenge and
could have put the timing of the deployment at risk.
For East Timor, in addition to meeting Protocol A, personnel needed to bevaccinated against Japanese encephalitis virus (JEV). The JEV programmewas an important logistical project, because the time required tovaccinate personnel was key to formulating options and time-scales fordeployment. While sound intelligence and early contingency planningidentified the need for vaccination, there were difficulties with obtainingsupplies of the vaccine for the initial deployment. Intensive managementof the vaccination programme minimised the adverse impacts on meetingthe response time.
We recommend that –
4 The NZDF considers setting up an arrangement with suppliers in
order to facilitate ready access to JEV and other vaccine supplies at
short notice when required.
SUMMARY AND RECOMMENDATIONS
Shortcomings in the NZDF's medical records system undermined the
HSS's ability to help achieve the NZDF's readiness to deploy.
Medical records need to provide accurate and readily accessibleinformation about the health history and status of all personnel, andinformation about the medical fitness of the NZDF as a whole and itsreadiness to deploy. The current arrangements in the NZDF do notachieve these aims – the main system is paper-based, and records have tobe updated and analysed manually.
Using such a system made it more difficult for HSS personnel to checkthe health status and prepare personnel for the East Timor deployment.
For example: • Information on the fitness ratings and medical history was cumbersome to retrieve, and often incomplete.
• Unit commanders were not able to readily establish whether their personnel met the Protocol A vaccination standard.
• Updating medical records prior to deployment, preparing summary records for use in East Timor, and later putting the information backinto the main file and replicating the backup files for storage purposes,was an extremely time-consuming process.
• Medical records could not readily be used to compile health data across the NZDF – such as to help predict likely treatment demands ofthe deploying force. (The NZDF is currently testing an alternativesystem to collect data for cross-Service analysis, but this places anadditional data collection load on HSS staff.) The NZDF also had no overall information about injury, disease ortreatment patterns for the period of the deployment. Such analysis wouldprovide valuable data to inform future training, health service planningand resourcing – particularly for military operations in a similar tropicalenvironment.
A patchwork of electronic records systems or medical databases hasevolved – at each Service's or treatment centre's own initiative – operatingin parallel to the manual system. The NZDF has considered establishingcomputerised medical records, which it has noted would bring a numberof benefits – including increased patient safety. Proposals have beenprepared, but no decisions have been made on funding or implementation.
SUMMARY AND RECOMMENDATIONS
We recommend that –
5 The NZDF puts in place a single electronic medical records system
for the whole of the NZDF, that will support both individual patient
management and wider planning of operational and non-operational
health care provision.
Shortage of Personnel The East Timor operation put into sharp focus known shortages of
health care personnel.
The NZDF has over a number of years been aware of the difficulties ofattracting and retaining HSS personnel. For example, there are knowndifficulties in recruiting and retaining doctors, surgeons, and othermedical specialists. There are also reported shortages of medics whoprovide the backbone for health care in operations like East Timor.
The preparation, deployment, and sustaining of the East Timor force wasa challenging test of HSS capability. However, it was difficult to measureand assess the ability of the HSS to meet the challenge because only oneoperational health support unit (No. 2 Field Hospital) reports itspreparedness directly through the NZDF's operational preparednessreporting system (OPRES). All other units report as an integral part of alarger unit. Therefore, the NZDF does not have any clear picture of theHSS capability to deploy staff or to prepare other personnel for deploymentat any one time.
We recommend that –
6 The NZDF further develops the operational preparedness reporting
system to enable it to report on the preparedness status of the HSS.1
Personnel shortages became increasingly visible as HSS personnel dealtwith the extensive preparations (particularly medical checks andvaccinations as noted above) for the deployment.
See our earlier report – New Zealand Defence Force: Deployment to East Timor, November 2001,
ISBN 0-477-02886-1 – available on our web site www.oag.govt.nz – which contained this
recommendation for all NZDF units (page 26, paragraph 2.30).
SUMMARY AND RECOMMENDATIONS
Sustaining the force for successive rotations in East Timor placed furtherpressures on the HSS. The Forward Surgical Team (FST) was not designedto deploy and operate for an extended period. HSS planning for thedeployment envisaged an operation that might last about six months,but in fact the FST was in East Timor for nearly two years from October1999 to August 2001. As a result, the NZDF had to rely on civilianspecialists to help sustain the FST.
We recommend that –
7 The NZDF reviews Government expectations of the Forward
Surgical Team – in terms of response times, length of deployment,
and the consequent personnel, equipment and funding implications.
The HSS had to go to great lengths to identify sufficient civilianpersonnel willing to be deployed (and employers willing to release them)for short periods to sustain the FST over the operation. The NZDF hadno formal agreements – such as between the NZDF and the Ministry ofHealth or District Health Boards – to facilitate finding personnel.
Achieving the full complement of the FST resulted mainly from a hugerecruitment effort and good fortune in civilians who willingly offeredto serve in East Timor.
We recommend that –
8 The NZDF explores with the Ministry of Health and District Health
Boards how a more reliable arrangement can be established for
seconding specialist clinical staff to support a range of extended
NZDF operations as required.
The structure and delivery of HSS have been reviewed a number oftimes since 1988, and a further major review of the structure andresourcing of HSS is under way. We found little in terms of positiveoutcomes from these reviews. In our view, the ongoing uncertaintyassociated with these reviews has affected morale and the ability torecruit and retain staff.
We recommend that –
9 The NZDF urgently completes the review of the HSS's structure
and resourcing, in order to provide a more certain environment in
which to recruit and retain HSS personnel.
SUMMARY AND RECOMMENDATIONS
Supply Problems There were ongoing problems with the supply of medical items to East
Timor.
Health personnel operating in East Timor needed regular and reliablemedical and pharmaceutical supplies. Difficulties with supply includeddelivery of incorrect items, delivery of the wrong quantities of items, anda growing list of items to be supplied as the deployment progressed.
These difficulties were caused by a number of factors: • logistics staff responsible for handling requests had little training or experience in dealing with medical supplies; • civilian medical personnel were unfamiliar with the NZDF medical • requirements expanded as the FST developed a humanitarian aid role; • the NZDF was called upon to provide supplies for other nations.
The NZDF recognised and reported on these difficulties early in thedeployment, but supply problems persisted. When we visited East Timorin July 2001, the FST was still experiencing difficulties with accurateand timely re-supply.
We recommend that –
10 The NZDF improves the supply of medical items by ensuring that:
• logistics personnel are suitably skilled and experienced in the management of medical supplies; • supply processes can adapt to meet changing requirements; and • civilian medical staff understand the constraints of NZDF supply processes and can operate within them.
SUMMARY AND RECOMMENDATIONS
Environmental Health Personnel and Equipment A shortage of trained or experienced environmental health personnel
and equipment limited their effectiveness, and the NZDF is increasing its
environmental health capability as a result.
Creating and maintaining a safe environment for deployed personnel wasa priority for HSS. The East Timor deployment revealed gaps in theNZDF environmental health capability. For example, the shortage ofenvironmental health officers, environmental health technicians, andequipment resulted in: • repeat deployments for environmental health officers; • limitations on the quality and quantity of preventive and environmental health activities that could be undertaken; • limited monitoring of compliance with occupational health and safety • additional environmental health responsibilities being allocated to Flexibility of Response Changes in the focus of the HSS during the deployment illustrated
the flexibility to respond to changing circumstances.
The HSS adjusted its response during the course of the deployment inline with the changing military and political environment. Initially focusedon the possibility of battle casualties and trauma, the emphasis wasshifted to providing primary care and treating military personnel for avariety of tropical diseases and minor surgical conditions.
• Military operations put military personnel in stressful situations. The HSS made more extensive psychological support services available toNew Zealand military personnel to help them manage the stressesassociated with deployment.
• Early evidence of dental problems for deployed personnel led the NZDF to recognise the need to provide in-theatre dental services. A dentalteam made regular visits to East Timor to maintain the dental healthof NZDF and other personnel.
SUMMARY AND RECOMMENDATIONS
The NZDF viewed humanitarian aid as important in building andfostering a strong relationship with the local community and winningacceptance of its role. As part of this, the FST treated a large number ofTimorese people. This required HSS to allocate resources with carefulregard to competing demands of New Zealand personnel and the localpopulation.
Moreover, its work for the local population called for a different andwider mix of skills and training among medical personnel. The experiencehighlighted some useful lessons for HSS planning for future deployments.
Continuing Health Care There has been an effective process for providing post-deployment
health care for personnel returning to New Zealand.
The NZDF has effective arrangements for assessing the health of personnelreturning to New Zealand, and for providing any necessary ongoingtreatment. Its comprehensive end-of-tour assessments include healthchecks and psychological de-briefs. The latter, in particular, have helpedpersonnel to make the transition back to everyday life in New Zealand.
Lessons Learned The NZDF has identified lessons for personnel management, training,
and logistical support. In some cases, it has already amended procedures
and practices, but other lessons still require action.
The matters that most urgently require action have been noted above,namely: • medical records; and • early completion of the review of HSS structure and resourcing.
The East Timor Operation
On 15 September 1999 a resolution of the UN Security Council authorisedthe establishment of a multinational force – known as INTERFET – torestore peace and security in East Timor with authority to use armed forceif required.
INTERFET comprised a coalition of 23 contributing countries with over11,000 personnel, led by Australia. It was New Zealand's largest overseas military commitment since the Korean conflict. At its peak, theNew Zealand Defence Force (NZDF) committed around 1,100 Navy,Army and Air Force personnel.
In February 2000, INTERFET was replaced by a United Nations peace-keeping operation known as the United Nations TransitionalAdministration in East Timor (UNTAET). Under its United Nationsmandate, UNTAET provides security and maintains law and order inEast Timor. As part of this operation, New Zealand was givenresponsibility for about 1700 square kilometres to the south-west of thecountry (including a long section of the border between East andWest Timor) with the township of Suai as the base (see map on page 26).
This area was characterised by poor infrastructure, difficult supplyroutes, limited communications, and considerable destruction by theretreating militia.
Figure 1 on the next page shows the structure of the NZDF, illustratingthe positions of the three Forces and the Joint Forces HQ. In the East Timordeployment, the Joint Forces Commander had responsibility for thedeployed forces, including deployed Health Support personnel.
Figure 1Structure of the NZDF New Zealand Defence Force
Chief of Defence Force
The Chief of Defence Force retains overall responsibility for all New Zealand military forces Air Force
Joint Forces HQ
est. July 2001
Naval Staff
Air Staff
In peacetime the three Chiefs of Staff are responsible Commander Joint Forces New Zealand
for raising and maintaining force elements at the The Joint Commander has responsibility required level of capability.
for deployed forces. During peacetime the Joint Commander is responsible for directing the joint/combined activities of the three Services.
Each Service has a representative as part of the Joint Forces HQ. They facilitate information flows between the single Services and the Joint Forces HQ and The New Zealand Battalion was withdrawn in November 2002.
The withdrawal had been factored into the United Nations' downsizingplans, which had confirmed that the United Nations had no requirementfor any NZDF combat force elements to remain in East Timor afterNovember 2002.
The Importance of Health Support Services
A capable and well-prepared NZDF requires personnel who are at all times fit, healthy and motivated to carry out a range of assignedmilitary tasks. Keeping personnel in good health and medically readyto deploy at short notice is the task of the NZDF's Health SupportServices (HSS). While HSS are a small part of the NZDF, they have a criticalrole in the preparedness of personnel.
The morale and commitment of every military member will also beinfluenced by the confidence they have in the network of services forpreventive health care, medical treatment and (where necessary)evacuation. It follows that an effective and efficient medical supportsystem is vitally important for the NZDF to achieve its operational goals.
Focus of Our Examination
In November 2001, we produced a report on our examination of theNZDF deployment to East Timor. The report described and assessed thesystems used by the NZDF to plan, prepare and deploy a force as part ofthe INTERFET operation.
The focus of this report is our examination in greater detail of therole performed by the HSS as part of INTERFET and UNTAET betweenmid-1999 and late-2001. It describes and assesses four maindimensions of that role (see Figure 2 on the next page): • maintaining the primary health of Regular Forces personnel; • medically preparing personnel for the East Timor deployment; • delivering health support services in theatre and sustaining those • providing post-deployment health care for returning personnel.
Figure 2Dimensions of NZDF Health Support Services Peacetime Services Individual and Group Readiness to Conduct In-theatre Services We also examined the NZDF's own systems for reviewing HSS practicesand processes in the light of the East Timor experience.
We examined the capability of the HSS to perform the various rolesexpected of them in the context of the East Timor operation to: • maintain the capability and readiness of NZDF personnel to deploy; • provide for the health-related planning, training and other preparations • assist in prevention of disease and non-battle injuries; • collect, triage, treat, and evacuate or return fit for duty, sick, injured or wounded soldiers in order to maintain combat strength; and • sustain the ongoing capability and readiness of personnel after their return to New Zealand.
These expectations are set out in more detail in Appendix 1 on pages133-134.
How We Carried Out Our Examination
The scale and complexity of the East Timor deployment made it necessaryto limit the scope of our examination. We therefore did not assess: • the provision, efficiency or effectiveness of medical treatment centres in New Zealand; or • the potential future role of the Territorial Force in supplementing Regular Force HSS personnel.
We interviewed a very wide range of NZDF personnel about the health- related planning, preparation, deployment and sustainment aspects of theEast Timor operation. The personnel were of different ranks and werebased at locations including: • Defence Headquarters; • Joint Forces Headquarters; • No. 2 Field Hospital and the Medical Treatment Centre at Linton • the Medical Treatment Centre at Burnham Army Camp; • Medical Treatment Centres at Air Force Base Whenuapai and Air Force • Naval Health Service Hospital Devonport.
We sought and analysed relevant documentation from Army, theNavy and the Air Force – including (but not limited to) plans, DefenceForce Orders, command directives, correspondence, situation reports andpost activity reports. The NZDF facilitated access to all documents,including classified material where required.
In May 2001 we travelled to East Timor and interviewed HSS personnel,gathered documentary evidence, and observed operational activitiestaking place in Dili and Suai and at the Infantry Company location inTilomar (see map on page 26).
Map of East T
2Part TwoHow Are Health Support
HOW ARE HEALTH SUPPORT SERVICES ORGANISED?
Health care is provided to all serving Regular Force members of theNZDF, as a condition of service. Members of the Territorial and ReserveForces are eligible for medical treatment while engaged in militaryservice. The NZDF provides health care to its personnel because: • they need to be medically fit to perform their operational duties if the NZDF is to achieve its outputs; and • providing health care in peacetime is a means of helping to develop, preserve and exercise sustainable medical capability (medicalpersonnel and equipment) for the support of military operations.
Health care for serving personnel is provided through the NZDF's Health Support Services (HSS), which is made up of a variety of doctors,nurses, environmental health officers, and other health professionals.
(See Figure 3 on the next page.) The 300 Regular Force HSS personnel areresponsible for the 8700 uniformed NZDF personnel, and are the basis of support for any military deployment. In addition, about 50 civilianmedical staff are employed at medical and dental treatment centresthroughout the country.2 The HSS are set up to support: • operational deployed force elements – such as the Battalion group in East Timor or ships at sea; and • non-operational personnel through base medical facilities – such as the Medical Treatment Centres3 at Linton, Burnham, Devonport andOhakea.
And the services that HSS provide are designed to ensure that personnelare: • fit to be deployed; • protected from avoidable hazards to health; and • provided with appropriate medical care to assist the sick and injured to return to duty.
Getting accurate information on personnel numbers over time has proved difficult. These are thefigures that NZDF gave us in May 2002. Establishment figures are currently under review.
We use the term Medical Treatment Centre to cover all treatment facilities within the NZDF – theNavy and the Air Force use different names/terminology for such centres.
HOW ARE HEALTH SUPPORT SERVICES ORGANISED?
Figure 3HSS Professionals in the NZDF Historically recruited as a trade within the NZDF with no priormedical experience. Medics are trained in-house on a time andrank based career progression and with qualification in the Diplomaof Military Medicine. On a deployment the medic is the first personin the chain of treatment classified as a medical person under theGeneva Convention. The function of the medic is to provide initialprimary care, enhanced first aid including immobilisation of fractures,IV therapy (drips), and insertion of airways. The medic starts medicaldocumentation and prepares patients and casualties for evacuation.
MEDICAL OFFICER (DOCTOR)
Generally recruited as qualified practitioners who then proceed to specialise in their Service-specific medical environments.
The NZDF has more recently taken steps to recruit under-graduate doctors and to contract them to work within the NZDFafter qualifying. Doctors within the NZDF are either GeneralPractitioners (Army) or occupational health specialists (Air Force and Navy). They have separate remuneration and employmentconditions that differ from other specialists in the NZDF, such assabbatical leave for professional development. Most doctorsundertake a large proportion of the non-operational routineprimary care in medical treatment centres. They are subject toexternal regulation by their professional bodies.
Registered Nurses are recruited to fill a number of different specialistroles. Nursing Officers work in the medical treatment centres.
They undertake operational roles within the Regimental Aid Posts.
Specialist operating theatre, intensive care, acute surgical andemergency department Nursing Officers work with the FST andare based with 2 Fd Hosp. Registered Nurses are subject toexternal regulation by the Nursing Council of New Zealand.
HEALTH INTELLIGENCE OFFICER
Provide Environmental Threat Assessments for areas of potentialinvolvement of NZDF personnel. They help manage and update amedical internet database about the environmental hazards incountries throughout the world.
HOW ARE HEALTH SUPPORT SERVICES ORGANISED?
ENVIRONMENT HEALTH OFFICERS
Provide public and occupational health support to the NZDF duringpeacetime and on operations. This involves advice on threats tohuman health arising from environmental and workplace sourceswith an emphasis on measures that prevent disease and injury.
Duties include collection of health-related data to profile operationalrisks for deployments; technical support and advice to the commandon disease control, food safety, drinking water treatment and waterquality standards, waste disposal; occupational health and safety;pest and vector control and environmental health educationand training.
The Army has two specialist surgeons on contract positions.
This means that the surgeons work and train full time in a publichospital but are on 28 days' notice to be deployed should they berequired and must meet NZDF training commitments throughoutthe year.
Professionally qualified and registered dentists provide a fullrange of general dental services to keep NZDF personneldentally fit. Some dental officers who have obtained postgraduatetraining and qualifications are able to provide more complexcare, e.g. oral surgery, periodontal advice/treatment and restorativeadvice/treatment. Orthodontic services are seldom provided.
Uses X-ray and other equipment to take images of people. Tasksand duties include work with the radiologist and other medicalprofessionals; provision of information to patients about what willhappen during their examination; preparation of patients andequipment for examinations; and producing the image andchecking for quality. They may specialise in areas such as ultra-sound, nuclear medicine, CT scanning, vascular radiology andmagnetic resonance imaging, which require postgraduate training.
HOW ARE HEALTH SUPPORT SERVICES ORGANISED?
In this part of the report we discuss: • the structure and composition of the HSS; • services for non-operational personnel; • services for operational personnel; • progress on ongoing reviews of the HSS; and • funding of the HSS.
Structure and Composition
A small group led by a Director General of Defence Medical Services (DGDMS – see Figure 4 on the opposite page) handles HSS policy matters.
The DGDMS is the principal health adviser to the Chief of Defence Forceon: • NZDF health policy; • the professional control of medical services; and • the professional standards of the treatment regimes applicable to Alongside this centralised advice and policy, Army, the Navy, and the
Air Force control their own medical services. Each directs the numbers
of health support personnel required and trains and prepares them to
support their own operations.
For the purpose of military operations, the Health Operations Section ofthe Joint Forces Headquarters (see Figure 1 on page 22) is responsible fororganisation, administration and support to deployed health supportpersonnel of all three Services. However, individual HSS personnel onoperations are under the direct control of the Commanding Officer of theService unit they are based with.
Figure 5 on page 34 illustrates the HSS in more detail and shows wheresome of the various personnel were based in May 2002 when not deployed.
HOW ARE HEALTH SUPPORT SERVICES ORGANISED?
Figure 4HSS Command Structure Chief of Defence Force
of Naval Staff
of General Staff
of Air Staff
HOW ARE HEALTH SUPPORT SERVICES ORGANISED?
Figure 5HSS – Who and Where?(May 2002) Chief of Defence Force
Chief of General
Chief of Naval
Chief of Air Staff
Joint Forces
of Defence
Director of Defence
Officer Navy
Officer Army
Joint Forces HQ
2 Field Hospital
HMNZS Te Mana
HMNZS Te Kaha
*Excluding Dental staff
Precise numbers of HSS staff have proved difficult to determine – weattempted to examine the numbers of such personnel available fordeployment leading up to East Timor, but the data was not reliable andestablishment figures were outdated. This made it difficult to form aview on whether there were sufficient HSS personnel available to supportNZDF operations.
Using the annual historical data that the NZDF provided, Figure 6on the opposite page illustrates the changes in Regular Force HSS staff forthe three main clinical staff groups (doctors, nurses and medics), comparedwith changes in NZDF personnel numbers since 1990. It shows that theproportion of HSS personnel has remained steady at about one HSS staffmember for every 34-38 members of the Regular Force.
HOW ARE HEALTH SUPPORT SERVICES ORGANISED?
Figure 6Regular Force HSS Personnel 1990-2002 NZDF Doctors
NZDF Nurses
NZDF Medics*
Total HSS
Total NZDF (RF)
* There were no figures available for Army medics from 1990 to 1995 – this distorts the total HSS figures for those years.
However, there are well-reported difficulties with the recruitment andretention of HSS personnel, including shortages of: • medics (reported in 1999); • environmental health officers and technicians (reported in 2000); • Army doctors; and • medical specialists to deploy and sustain the Forward Surgical Team (see paragraphs 6.28-6.38 on pages 100-102).
HOW ARE HEALTH SUPPORT SERVICES ORGANISED?
Primary health care for NZDF personnel makes up the majority ofnon-operational health services.
Medics provide first-line primaryhealth care in the course of their The HSS provides primary health
normal duties in sick bays on ships care – secondary health care
or at aid posts in Army units.
is provided by the public
They are trained to diagnose and treat a wide range of afflictions –ranging from headaches, colds,sprains and strains, through to trauma and resuscitation. Medics alsoplay an important part in helping to maintain the morale of personnel.
They are frequently well respected in their unit and usually regarded as a person who can be trusted and confided in.
The procedures and guidelines for treatment by medics are set out in theMedical Treatment Protocols. While on deployment, medics may workalone without supervision from a nurse or doctor. While in New Zealand, however, medics will usually work alongside other nurses and doctors ata medical treatment centre (MTC) (see Figure 5 on page 34) which,typically, provides for: • sick call/parade – where personnel will present themselves at a
standard time of the day if they are unwell (The general treatment ofcoughs, colds, bumps, bruises and injuries is very similar to a generalpractitioner's daily surgery. More complex conditions are referred toparticular specialists in the public health system where appropriate.) • medical fitness testing – attending to the medical examination of
personnel to ensure that they retain the required level of fitness formilitary operations; and • safety coverage – for hazardous training activities like flying, diving,
parachuting, demolition and live firing.
Linton Army Camp MTC has 18 beds and the Naval Health ServiceHospital at Devonport has 20 beds, to undertake limited secondary care orto isolate personnel if they have a contagious condition. The Naval Hospitalalso acts as a training facility for Navy medics and has a specialisthyperbaric chamber unit for the care of divers. All other secondary careis provided by the public health system.
HOW ARE HEALTH SUPPORT SERVICES ORGANISED?
Dental Services The Defence Dental Services is an NZDF-wide organisation run by theDirector of Dental Services based in Wellington. It is designed to provideall the routine dental care that would be provided by a civilian dentalpractice.
There are nine dental centres throughout the country providing dentalservices to all NZDF personnel. There are four regular force dentists(Dental Officers), with the remaining centres staffed by civilian dentistsand a mix of regular force and civilian oral hygienists and dental assistants.
All Regular Force personnel undergo an annual dental check – receivingtreatment work as required – and are assessed and graded as "dentally fitfor deployment".
Military clinical support is required to be on hand to support NZDF deployments. There are five levels of operational health care.
Each incorporates the capabilities of the lower levels, expanding on thatcare (see Figure 7 on page 38). At the operational level, HSS are integratedinto the units they support and provide primary health care and emergencysecondary health care.
Army is capable of providing an in-theatre "life saving" surgical facilitywhile the Air Force is responsible for aero-medical evacuation. Specialisedsurgery, advanced care, hospitalisation or rehabilitation capabilities arenot provided for operational deployments.
The Navy requirements for health support are maintained in much thesame configuration for peacetime training as when deployed on militaryoperations. Sickbays are maintained on all ships other than minorvessels. Medics generally run the sickbays, but doctors can be deployedwhen the risk of battle casualties or other injuries is considered apossibility.
Unlike Army and the Navy, no standing operational health support existswithin the Air Force. Operational resources are drawn from non-operational medical facilities as required. Air Force deployable healthsupport normally comprises a doctor and/or medics accompanyinga deployed force where dictated by the operational environment.
HOW ARE HEALTH SUPPORT SERVICES ORGANISED?
Figure 7Levels of Health Care4 Level One
Location and removal from danger of casualties and provision of immediatefirst aid. Self or "buddy" aid, examination and emergency lifesaving measuressuch as maintenance of airways, control of bleeding, prevention and control ofshock, and prevention of further injury. Treatment at a Company Aid Post, aRegimental Aid Post or some similar facility with trained medical personnelwhere treatment could include restoration of airway, use of intravenous fluids,antibiotics, and application of splints and bandages.
Level Two
Collection, sorting, treatment and evacuation of casualties, and provision ofresuscitation procedures where appropriate. Provided at a minimal care facilityand can include basic laboratory, pharmacy and temporary holding facilities.
Surgical support not normally provided. At this level, medical examinations and observations can be conducted in a more deliberate manner. Focus onsustaining care and evacuation, resuscitation and stabilisation.
Level Three
Initial wound surgery performed and hospitalisation provided for medium-and high-intensity nursing of the wounded, sick and injured. Facilities staffedand equipped to provide resuscitation, initial wound surgery and post-operativetreatment. Care may be the initial step towards restoration of functionalhealth, as distinct from procedures that stabilise a condition. Treatmentprovided with greater preparation and deliberation. Preparation for evacuationof those patients who require care beyond the scope and management ofthe unit.
Level Four
Specialised surgery, rehabilitation and hospitalisation are provided within thelimits of the holding policy. Normally the highest level of care provided in anarea of operations.
Level Five
The highest level of care, which is not normally provided in theatre.
Includes specialised and sophisticated management and care associatedwith the most advanced range of medical capabilities. Research facilitiesare provided.
United Nations levels of medical treatment are defined slightly differently – a Level Two UN facility is a Level Three NZ facility.
HOW ARE HEALTH SUPPORT SERVICES ORGANISED?
Standards of Operational Care Defence Force Order 18 (DFO 18)5 defines the primary role of the HSSas being to develop, preserve and exercise a sustainable medical capabilityfor the support of military operations. DFO 18 requires medicalpersonnel to be adequately trained, and medical professional expertise tobe available to treat and rehabilitate both battle and non-battle causalities.
DFO 18 does not specify operational standards or policy. The operationalactivities of individual HSS units are set out in the NZ Army MedicalSupport for Land Operations document Standard Operating Procedures(SOPs).
The level of medical care provided in East Timor was determined by: • the NZDF medical protocol document; • other New Zealand professional standards for medical practitioners; • the standards set out in the Medical Support Manual for United Nations New Zealand HSS and other United Nations medical support are alsorequired to comply with the: • International Convention for the Treatment of the Sick and Wounded; • Geneva Convention and its Protocols; and • Laws of War as they pertain to medical units and their personnel.
No. 2 Field Hospital The primary operational medical unit in the NZDF is Army's No. 2 FieldHospital (2 Fd Hosp) located at Linton Army Camp. 2 Fd Hosp isdesigned to provide a range medical support for all NZDF operationaldeployments. This includes: • a Forward Support Section comprising medics6 for Company Aid Posts and medics, nurses and doctors for Regimental Aid Posts; Revised 2000.
Though allocated to 2 Fd Hosp, the majority of medics are not usually physically located there butare on active service with other units.
HOW ARE HEALTH SUPPORT SERVICES ORGANISED?
• medics, nurses, doctors and other medical specialists for the Forward Surgical Team on deployment and for another retained in New Zealandfor training and exercises; and • environmental health officers as required.
In addition, 2 Fd Hosp is responsible for the training and provision ofother non-medical personnel, such as command and administration staff,required to run any health support facility.
The structure of 2 Fd Hosp is shown in Figure 8 below.
Figure 8Structure of Army No. 2 Field Hospital Linton No. 2 Field Hospital personnel: doctor, HOW ARE HEALTH SUPPORT SERVICES ORGANISED?
Readiness to Deploy The NZDF's Operational Preparedness Reporting System (OPRES)measures the preparedness of individual force units at regular intervals.
The only operational health support unit to directly report through OPRESis 2 Fd Hosp. This unit has consistently (since 1996) reported its failureto meet the desired level of capability due to shortages of personnel andequipment.
The operational preparedness of other health support components is notgenerally visible through OPRES because they report as an integral part ofa larger unit. NZDF's Joint Forces Headquarters noted that the OPRESsystem did not give any clear picture of HSS capability to deploy staff orto prepare other personnel for deployment at any one time.
The structure and delivery of HSS have been subject to a succession of reviews going back to 1988. These reviews have focused upon a numberof issues, including: • the structure for delivery of operational and non-operational HSS for the whole of NZDF; • the options for delivery of non-operational health care – including Regular Force personnel or contracting out services to civilian personnel; • separation or integration of operational and non-operational health support establishments; and • numbers of HSS personnel required in the Regular Forces to support potential operational requirements.
HSS are still under review in 2002 as part of the Manpower Required inUniform review. The revised establishment – how many HSS personnelare required to meet operational and non-operational needs – has yet tobe determined.
In our view, the protracted nature of these reviews and the associateduncertainty are adversely affecting the morale of NZDF healthprofessionals and NZDF's ability to attract and retain key healthprofessionals into the HSS.
HOW ARE HEALTH SUPPORT SERVICES ORGANISED?
The NZDF estimated in 2001 that total HSS expenditure was about $26million each year, representing about 1.8% of the total annual appropriationfor NZDF at that time.
Of this sum, $14.2 million of costs are directly identifiable to HSS.
The balance falls into other categories of expenditure.
The only directly identified costs that appear in the NZDF's AnnualReports are those attributed to Output Class: D9.2 Land Combat ServiceSupport Forces. These represent the costs of 2 Fd Hosp, and haveamounted to just over $10 million in each of the last two years.
The NZDF is an Accredited Employer under the ACC PartnershipProgramme. ACC forms were prepared in theatre at the Regimental AidPost in East Timor, as appropriate, for any injury and illness, and were returned to New Zealand monthly.
3Part ThreeArrangements for Keeping
ARRANGEMENTS FOR KEEPING MEDICAL RECORDS
Why Medical Records Are Important
Health professionals need access to comprehensive, accurate healthinformation in the form of individual medical files that record a person'shealth status. Without such records,patient care – and even patient A medical records system
safety – may be put at risk. The HSS also require collective healthinformation about the current • accurate information about
deployment readiness of personnel, the health status of each
and about the diseases, injuries and treatments they need to plan • collective information about
to provide for.
the health and deployment
Early in our examination, we readiness of the NZDF.
identified medical records as a keyarea requiring improvement, becausethe current poor state of medical records affects a number of dimensions ofHSS provision. We have therefore drawn all our findings in relation tomedical records into this part of our report in order to give a clear overviewof the problem.
The Medical File
The NZDF uses a standard paper-based medical file for all personnel.
The medical file is started when someone joins the NZDF, undergoes a Part Three
comprehensive medical examination, and is given a medical fitnessgrading. The medical file, called an MD910A or Enclosure, is referencedby the person's name and service personnel number – which acts as aunique identifier. From that point, records of all medical examinations,treatments, laboratory results, X-ray reports, and vaccinations are addedto the file. The file also contains a working sheet about any currentcondition or treatment. (Figure 9 on the next page illustrates the contentsof a medical file.) ARRANGEMENTS FOR KEEPING MEDICAL RECORDS
Figure 9Contents of a Medical File
treatment form) Record Part Three
The NZDF also maintains a duplicate file (MD910B) for each person.
The Navy maintains its duplicate files on optical disc, while Army andthe Air Force hold photocopied files at their respective ServiceHeadquarters. This "B" file must be updated on a regular basis to keepit current.
All original files (both A and B) of discharged NZDF personnel are storedand never destroyed or disposed of.
While the NZDF has policies requiring standardised management ofmedical files, we found variations in the way files were used and managedbetween different MTCs and between the different Services.
ARRANGEMENTS FOR KEEPING MEDICAL RECORDS
Completeness of the informationon medical files can be a problem Medical files have been found to
– as illustrated by the finding of a review undertaken by one MTCthat, of 35 patients seen in one day,only one medical file was complete. Missing items included: • misplaced (in the wrong file) lab results; and • recall dates for vaccinations.
The review identified a risk of medical misdiagnosis or incorrecttreatment that could result from incomplete medical records.
Personnel Medical Information for Deployment
HSS needed medical information about personnel being deployed toEast Timor. These personnel wererequired to meet four basic healthrequirements: All NZDF personnel deploying to
East Timor were required to:
1. pass a medical examination; • pass a medical examination;
2. have their vaccinations up • have their vaccinations up
to Protocol A standard, and to Protocol A standard, and
be vaccinated for Japanese be vaccinated for Japanese
encephalitis virus; • be dentally fit; and
3. be dentally fit; and • pass a physical fitness test.
Part Three
4. pass a physical fitness test.
A person's medical grading is recorded on their medical file and on theNZDF electronic personnel system known as ATLAS. HSS staff foundthe ATLAS system cumbersome and slow to respond. In addition,information held on the system was often found to be incorrect orincomplete.
As a result, it was necessary to access each person's medical file to reliablycheck their current fitness grading. In fact, the check also revealed somepoor quality information on individual medical files. And the medicalexaminations of some key personnel revealed that they were awaitingtreatment or carrying injuries not recorded on their medical file orreflected in their medical grade.
ARRANGEMENTS FOR KEEPING MEDICAL RECORDS
In order to be sure about the health of deploying personnel, HSS stafftherefore reviewed all medical files. In addition, a large proportion ofpersonnel were given medical examinations. These tasks createda large workload for HSS staff.
All NZDF deploying personnel must be vaccinated to a standard knownas Protocol A (see paragraphs 4.25-4.31 on pages 62-64). For the East Timordeployment, most personnel were also required to be vaccinated againstJapanese encephalitis virus (see paragraphs 4.32-4.41 on pages 64-66).
Details of the vaccination status of each person is held on their: • individual medical file; • immunisation card; and • Clinical Summary Sheet for deployment.
This information is not held on ATLAS. The NZDF has for some time beenattempting to upgrade ATLAS to include vaccination status, but theupgrade has not yet been implemented.
In the absence of an NZDF-wide computerised medical records system,some medical treatment centres have developed stand-alone systems inorder to keep track of the health and/or vaccination status of personnelunder their care. For example, Air Force Base Whenuapai and the WaiouruMTC use general practice management software which includes utilitiessuch as appointments scheduling, screens for recording examinationresults and referrals, immunisation schedules, prescription forms andprescribing data. And because the Linton Medical Treatment Centre hadno comprehensive information about the vaccination status of personnel,staff created a computer database to assist the management of the Part Three
A post-activity report about the INTERFET deployment concluded thatthe overall inability of the medical information system to provide consistentadvice and to adequately track the medical status of deploying personnel must beresolved. ARRANGEMENTS FOR KEEPING MEDICAL RECORDS
Arrangements for Medical Records
During Deployment
When a person is deployed, the full medical file is not sent with them.7Instead, a summary medical history (summarising the person'smedical history and all other relevant information – such as blood group,hepatitis status, vaccination status, and allergies) is prepared and sent tothe senior medical officer in theatre – to the Regimental Aid Post in thecase of East Timor. If any diagnosis or treatment is conducted in theatre,this is added to the summary. On return to New Zealand, the summaryis returned to the MTC, and the main A file is manually updated asnecessary. The same process is repeated for the B file. An illustration ofthis process is provided in Figure 10 below.
Figure 10Arrangements for Medical Records During Deployment Part Three
The Navy does send the full medical files on deployment with personnel.
ARRANGEMENTS FOR KEEPING MEDICAL RECORDS
Administering medical document-ation for personnel deployed to East Timor has been a time-consuming documentation was onerous and
process – updating medical files prior to deployment, preparationof a summary sheet to accompanydeployed personnel, and updating of information on both the mainmedical file and the B copy. Administrative staff had to work very longhours on occasions – sometimes through the night – in order to meetdeployment timelines.
Opinions were divided about the usefulness of medical summary sheetsin theatre. Some nursing and administration personnel felt thatproducing and returning them was unnecessary and inefficient,because treatment in theatre did not usually require immediate access tothe medical records and most summaries were not referred tothroughout the deployment. Some other nations deploying with theNew Zealand force did not bring medical files. However, MedicalOfficers (doctors) felt that the summaries could, in some cases, provideinformation critical to the diagnosis and treatment of a patient, and thatthey were therefore essential.
Analysing Information for Health Surveillance
Health surveillance is defined as the process of data collection, collationand analysis for the purpose of characterising risk groups within thepopulation. It is used to develop prevention and treatments appropriateto the environment. In the context of NZDF, health surveillance is a key Part Three
component of prevention and the management of illness and injury.
HSS staff in East Timor: • gathered daily information on conditions and treatment patterns; • analysed the information, and identified and investigated trends; and • supplied statistics to the United Nations.
However, information was collected in a different form from one Battalionrotation to another, and the statistics gathered for the United Nations didnot show treatment patterns for New Zealand personnel. As a result,the NZDF has only limited statistics about illness, injury and treatmentsfor NZDF personnel throughout the deployment. Such information isonly available from special studies. The NZDF has recognised thisshortcoming.
ARRANGEMENTS FOR KEEPING MEDICAL RECORDS
In 2001, the NZDF adopted a health surveillance system used byAmerican, British, Canadian and Australian armed forces called EPIDATA.
The system is currently (June 2002) being tested in two MTCs beforebeing adopted more widely. It involves the manual collection ofadditional information in parallel to the current medical record system.
Developing a Computerised Medical
Information System
The NZDF has considered a number of proposals for an NZDF-wide computerised medical records system, but no progress has beenmade to date towards funding or implementing such a system.
Reports prepared within the NZDF show that a properly implementedand operated computerised system across the NZDF would: • make accurate individual Service personnel medical files available at medical treatment centres and to appropriate personnel atNZDF headquarters; • assist practice management at medical treatment centres with better health surveillance, appointment scheduling and financial management;and • provide better data to NZDF overall for capability planning, deployment management and reporting.
An NZDF review in March 2002 of options for the computerisation notedsubstantial benefits – including: • an efficient patient recall and follow-up system; Part Three
• improved support for health professionals' audit of their clinical • increased patient safety; and • reduced liability from mistakes and omissions.
ARRANGEMENTS FOR KEEPING MEDICAL RECORDS
Medical records need to provide accurate and readily accessibleinformation about the health history and status of all personnel,and information about the medical fitness of the defence force as a wholeand its readiness to deploy. The current arrangements in the NZDF donot achieve these aims – the main system is paper-based, and records haveto be updated and analysed manually. Using such a system made it moredifficult for HSS personnel to check the health status and preparepersonnel for the East Timor deployment.
Over time, a patchwork of electronic records systems or medical databaseshas evolved – at each Service or medical treatment centre's owninitiative – operating in parallel to the manual system. The NZDF hasconsidered establishing computerised medical records, which it hasnoted would bring a number of benefits – including increased patientsafety.
Part Three
4Part FourHealth and Medical
Aspects of Getting Ready
for East Timor
HEALTH AND MEDICAL ASPECTS OF GETTING READY
FOR EAST TIMOR
Every military deployment is different. The HSS need to plan carefully toprovide effective support to an operation's military objectives. They alsoneed to carry out a range of preparations and training of personnel toensure that the risks of the operation are managed appropriately.
In this part of the report we discuss health-related training of deployinggeneral military personnel, as well as the specific pre-deployment trainingof HSS personnel. We comment on how the HSS: • planned for a possible East Timor operation; • prepared general military personnel for deployment; • trained HSS personnel for deployment; and • trained civilian volunteers.
Planning for a Possible Deployment
From April 1999, the NZDF had access to directives and a variety of otherplanning documentation that outlined the purpose of any likely mission,the mission-essential tasks on which training would be based, and thetime-lines for such training.
HSS planning began as soon as the possibility of a deployment was raised.
At first (April 1999) it was unclear what scale and nature of HSS would berequired. However, the NZDF Health Intelligence Officer, whose role isto produce Environmental Threat Assessments, had identified significantpotential health hazards to deploying personnel. These hazards included: • health and hygiene standards in East Timor, which were generally low; • a number of highly contagious, endemic diseases like malaria and TB; • a high threat to deploying personnel from insect-borne disease; and • high risks from hazardous flora and fauna.
Part Four
HEALTH AND MEDICAL ASPECTS OF GETTING READY
FOR EAST TIMOR
Information about East Timor was gathered from a variety of sources suchas the Internet, health publications and medical detachments of otherarmed forces. This was refined and added to a "Country Brief" thatoutlined the: • location, geography and climate; • social, cultural, economic and political background; and • potential health hazards.
In August 1999, as the possiblelocation, size and type of military The HSS Plan identified
operation became more certain, a personnel and equipment,
plan was prepared. It identified mission tasks and pre-
the numbers of medical personnel deployment training necessary
and equipment, mission tasks and for East Timor.
pre-deployment training required.
It also outlined: • pre-deployment fitness and vaccination requirements; • ground and air evacuation procedures; • a preventive medicine programme to minimise non-battle casualties; • logistical arrangements; and • medical procedures required before returning to New Zealand.
The plan was sent to 2 Fd Hosp tosupport pre-deployment health No. 2 Field Hospital
preparations. Based on the plan, is the primary NZDF operational
two pre-deployment training medical unit and is located at
programmes were set up: Linton Army Camp. It is designed
to provide medical support for all
• a general health programme NZDF operational deployments.
focusing on health issues for alldeploying personnel; and • a programme for HSS personnel – taking account of expected environmental conditions in which they would be working and Part Four
HEALTH AND MEDICAL ASPECTS OF GETTING READY
FOR EAST TIMOR
Preparing General Military Personnel for Deployment
Figure 11 below illustrates the health-related preparations for deployingpersonnel – including: • checking fitness to be deployed (medical and dental); • protection against diseases, including vaccinations and prevention measures against malaria and dengue fever; • provision of general health briefings; and • first aid training.
Figure 11Pre-deployment Health Preparations • Medical Briefings
Heat illness
UV protection
STDs
Personal hygiene
Food and water protection
Protection from biting insects
Stress management
First aid.
• Medical Examination
Age, strength and stamina;
• Dental Examination
Teeth and gums
range of movements in upper Education about oral and lower body; hearing and eyesight; mentalcapacity; and emotionalstability.
• Blood Screening
HIV (AIDS)
VDVL
Hepatitis C;
Hepatitis B;
G6PD; and
Blood Group.
• Vaccinations (Protocol A)
Diphtheria and Tetanus;
Polio;
Hepatitis A and B;
Measles, Mumps and Rubella;
Typhoid; and
Meningitis.
• Vaccinations (Additional)
Japanese Encephalitis
Vaccination (JEV).
Part Four
• Malaria
Prevention measures –
sleeves and bed nets and
uniform dipping. Medical
regime – doxycycline and
primaquine.
HEALTH AND MEDICAL ASPECTS OF GETTING READY
FOR EAST TIMOR
Most medical preparation wasundertaken during the pre- The medical requirements for
deployment training. For the first deployment were possibly the
INTERFET deployment (known as NZ BATT 1), medical preparation of of the whole operation.
approximately 700 Army personnelwas undertaken at 2 Fd Hosp, Linton Army Camp. Preparation of subsequentBattalion rotations (NZ BATT 2 onwards) has alternated betweenBurnham and Linton Army Camps. Figure 12 below summarises the time-line of the Battalion rotations in relation to INTERFET and UNTAET, and themain tasks of the HSS.
Figure 12Summary Time-line of Batallion Rotations training and medical
preparation of all
INTERFET & NZ
Preparation of all
Company Aid Post and Regimental
Aid Post Facilities Provided
Forward Surgical Team/Regimental Aid Post
Combination and Environmental Health Team
Air Force personnel (3Sqn and the crews for the C130 Hercules)were prepared at the Whenuapai Base Medical Flight. Crews for Part Four
HMNZS Canterbury were prepared at the Devonport Naval HealthService Hospital, although some medical vaccinations and examinationscontinued on board the ship while it was travelling to East Timor.
HEALTH AND MEDICAL ASPECTS OF GETTING READY
FOR EAST TIMOR
Fitness for Deployment As it mobilised, the NZDF needed to know that personnel selected fordeployment were medically fit and fully able to carry out their assignedmission task.
Assessing fitness to be deployed involves two components: a medicalexamination (incorporating a physical fitness test) and a dental examination.
Checking that Personnel Being Deployed Are Medically Fit
All Regular Force personnel have a periodic8 medical examination(incorporating a fitness assessment), and their medical grading is reviewed –a process known as a Medical Board or "Med Board". A Med Board is acomprehensive and systematic medical examination to assess: • fitness for initial or continued service in the NZDF; • fitness for a particular branch, trade or duty; • fitness to undergo trial by court-martial and/or sentences of detention • any disability or the extent to which there is a restriction on Service • if appropriate, a recommendation to release an individual on medical The NZDF uses an internationallyrecognised military medical The medical examination is used
examination that is specifically to determine whether a person is
designed to assess whether an physically and mentally fit
individual is physically and mentally for deployment under varying
fit for deployment under varying conditions. It assesses: It is an occupational assessment
• strength and stamina that measures whether the person
(heart and lungs); is capable of doing their
• range of movement in the Part Four
upper and lower body; The medical grading of all Regular Force officers of Colonel equivalent rank and above (and somespecialist trades) is reassessed every year. The medical grading of all Regular Force members ofLieutenant Colonel equivalent and below is reassessed every five years.
HEALTH AND MEDICAL ASPECTS OF GETTING READY
FOR EAST TIMOR
• hearing and eyesight; • mental capacity; and • emotional stability.
Med Board assessments must be confirmed by a second qualified doctorwhenever the assessment results in a significant change to a person'sfitness grading – potentially affecting their employment. The confirmationinvolves checking the medical file, the clinical assessment notes, and are-evaluation of the fitness level. Only doctors with substantial armed-forces experience are qualified to act as a "confirming authority". There areonly six doctors in New Zealand qualified to do this work.
Figure 13 on the opposite page sets out the standard medical examinationprocess for the INTERFET deployment. It required: • a file check by the Medical Officer (doctor) for those deploying personnel who had passed a Med Board in the past six months (nomedical examination of the individual was required unless the filecheck alerted the doctor to a possible health issue); or • a short medical examination for personnel who had not had a Med Board in the past six months; or • a comprehensive medical examination and detailed questionnaire for those personnel who had not passed a Med Board in the past sixmonths and where the file review identified a possible health issue.
The physical fitness component of the medical examination varies in detailbetween the services. Generally, it involves a series of physical tests toestablish the aerobic condition and upper body strength of an individual.
The Army fitness test, for example, includes a 2.4km run, sit-ups, andpush-ups.
For deployment to East Timor, the NZDF set a minimum medical gradingthat each person needed to obtain (or exceed) in order to be considered"fit to deploy".
Part Four
HEALTH AND MEDICAL ASPECTS OF GETTING READY
FOR EAST TIMOR
Figure 13Pre-deployment Medical Examination Process (INTERFET) Check Med Board
File Check
Check Prot A, JEV, G6PD Check Prot A, JEV, G6PD Check Prot A, JEV, G6PD Update Summary Sheet Update Summary Sheet Update Summary Sheet Take Blood Tests
Commence Specific Operational Vaccination Protocols
Update Protocol A
Confirm Med Board if Arrange follow-up Collate information Photocopy results and summary sheets Prepare medical records for deployment The grading system allows for exceptions in the case of people who donot obtain the minimum medical grading. The doctor who carries outthe examination assesses the person and notes the reasons for their failureto reach the minimum grading. The assessment is then consideredby the commanding officer, who weighs up factors such as the person'srole and duties against the possible risks to them and the unit. On average,two or three people in each rotation have been deployed after undergoingthis review or waiver process.
Blood tests for a range of conditions (see Figure 13 above) were a Part Four
standard part of the pre-deployment medical examination.
HEALTH AND MEDICAL ASPECTS OF GETTING READY
FOR EAST TIMOR
Checking That Personnel Being Deployed Are Dentally Fit
All NZDF personnel are required to undergo a full dental examinationabout a month before deployment at a dental clinic in the nearest baselocation, unless they have had a full dental check-up in the past threemonths (and were declared dentally fit). The person's dental fitness tobe deployed is assessed.
The dentist pays particular attention to any condition (such as the presenceof wisdom teeth) that might cause a problem during the deployment,and will carry out preventive work where necessary. A full forensicpanoramic X-ray is taken for identification purposes, teeth are cleaned,and the dentist explains how to take care of teeth and gums during thedeployment.
All personnel who were deployed to East Timor underwent a full dentalexamination, and had to be assessed as dentally fit before they werepermitted to be deployed.
Ensuring That Personnel Have Appropriate ProtectionAgainst Diseases NZDF operations overseas expose individuals to a greater risk of infectionthan civilians in New Zealand. It is therefore in the interests of eachindividual and of the NZDF to protect personnel by vaccination againstknown diseases.
Getting Vaccinations Up-to-date
The NZDF requires that its personnel be vaccinated against a range ofdiseases considered the most likely threat. NZDF vaccination protocolsare designed to meet international and operational requirementsnecessary for Regular Force personnel to be rapidly deployed into awide variety of environmental settings.
Part Four
HEALTH AND MEDICAL ASPECTS OF GETTING READY
FOR EAST TIMOR
All NZDF staff are required to be vaccinated to Protocol A9 standard atall times. The standard requires current vaccinations against thefollowing diseases: • diphtheria and tetanus; • hepatitis A and B; • measles, mumps and rubella; • meningitis.
All vaccinations are done on the basis of informed consent. MedicalOfficers (doctors) are responsible to their Commanding Officers to ensureall personnel are made aware of the importance of the protection offeredby vaccination. The Unit Commander is responsible for the vaccinationstatus of personnel under their command. Should personnel refuse to bevaccinated, they will be disqualified from deployment.
The extent to which personnel at any time actually meet the ProtocolA standard is an important measure of force preparation and readiness.
Protocol A was designed to makeCommanding Officers responsible Not all NZDF personnel met the
for maintaining the vaccinations of Protocol A standard.
their personnel, thereby ensuringthat they were ready to be deployedat short notice. As the NZDF prepared for the East Timor deployment,not all NZDF personnel met the Protocol A vaccination standard.
A combination of factors contributed to this situation, including: • personnel movements between different units, • lack of a suitable information system to track vaccination status (see paragraph 3.15 on page 48); and • the failure of Commanding Officers to give the necessary priority to meeting the standard.
Part Four
Protocol A varies slightly between the three Services to reflect the different circumstances andrisks.
HEALTH AND MEDICAL ASPECTS OF GETTING READY
FOR EAST TIMOR
As a result, the NZDF had to administer large numbers of vaccinationsbefore personnel could be confirmed as deployable. This added to theburden of activities to be performed as the NZDF trained and mobilisedits force.
Because the NZDF is not able to monitor and regularly report onvaccination status, it does not know how many non-deployed personnelmeet Protocol A at any one time. Estimates suggest that compliancewith Protocol A varies widely – with some NZDF units as low as 40%,while in other units 90% of personnel meet the standard. As late as August2001, some personnel were still facing delays in being deployed to East Timorbecause they lacked all the required vaccinations.
Vaccinating Against the Japanese Encephalitis Virus
In addition to the Protocol A requirement, planning for the deploymenthighlighted the need for additional protection for particular diseasesfound in East Timor.10 Early health intelligence pointed to the suspectedpresence of the potentially fatal mosquito-borne Japanese EncephalitisVirus.
Japanese Encephalitis Virus
Japanese encephalitis is a mosquito-borne viral encephalitis in Asia. It ispotentially fatal. Almost 30% of people who survive a serious infection are leftwith serious brain damage, including paralysis.
Vaccination against Japanese encephalitis is considered to be 95% effectiveif the full course of injections is followed. The inoculations require 38 daysfrom the first injection before the person becomes fully deployable.
Three injections are required, on the 1st, 7th and 28th days. Personnel may notbe deployed immediately following the third injection, but must remain near ahospital for ten days, due to the severe side effects for a small percentageof recipients.
A risk analysis prepared by the Health Intelligence Officer determined Part Four
that environmental precautions would not be sufficient to guard againstthe risk of the Japanese encephalitis virus (JEV) and that use of the Japaneseencephalitis vaccine would be necessary.
10 Health intelligence also identified the presence of dengue fever, malaria and rabies.
HEALTH AND MEDICAL ASPECTS OF GETTING READY
FOR EAST TIMOR
In developing a vaccinationprogramme, the NZDF became The JEV vaccination programme
aware that it did not have enough was a key determinant of a
vaccine for all personnel who were timely deployment to East Timor.
likely to be deployed, and thatinsufficient stocks were held in NewZealand. The NZDF was aware that the Australian Defence Force hadpurchased sufficient stocks to vaccinate approximately 11,000 personnel,thereby exhausting immediately available stocks in Australia. The NZDFtherefore had to identify international sources of vaccine and organisesupply.
The NZDF needed to vaccinate approximately 980 NZDF personnel for thefirst deployment. The initial priority was to vaccinate Air Forcepersonnel from 3Sqn and members of Victor Company 1RNZIR ready to bedeployed with INTERFET in late-September 1999. Sufficient vaccinewas obtained from within New Zealand and Australia to complete thistask by mid-September 1999, but because the vaccine was in such shortsupply its administration was placed under the strict control of thesenior medical officer in charge.
For the remainder of the New Zealand Battalion Group undergoingpre-deployment training and preparation at Linton, sourcing supplies,organising delivery, identifying priority personnel and administering thethree-stage vaccination were significant tasks as the NZDF unitsmobilised in preparation for deployment. The NZDF identified aEuropean supplier and the vaccine was ordered in early-August 1999.
The delivery time was 21 days.
The vaccination process was difficult. There were shortages of the vaccineat critical times. The process effectively dictated the timetables fordeployment, and created problems for personnel selection. Moreover,personnel were not permitted to take part in some pre-deploymenttraining activities for a short period after vaccination. This interruptedand constrained pre-deployment training.
Most of the first Battalion Group were vaccinated at Linton together.
NZDF health staff are aware that a small number of personnel weredeployed to East Timor without full JEV protection. This occurred in avariety of circumstances, including when personnel: Part Four
• were directed to be deployed at short notice; and • left New Zealand from different locations and were not brought to the attention of HSS staff.
HEALTH AND MEDICAL ASPECTS OF GETTING READY
FOR EAST TIMOR
The FST in East Timor held stocks of vaccine to meet the needs of thosepersonnel who arrived without having completed their course ofvaccinations.
Navy personnel were required to be vaccinated only if they were goingashore for more than a week. Vaccination was also not requiredfor personnel who were going to be in the risk area for fewer than 30days in total.
As at September 2002, no NZDF personnel had contracted Japaneseencephalitis in East Timor.
Protecting Against Malaria and Dengue Fever
Two types of malaria are common in East Timor, which can be fatal ifthe parasite reaches the brain. Dengue fever is present in a number ofSouth East Asian and South Pacific countries and can cause serious sickness.
All personnel deploying to EastTimor were briefed on precautions Dengue is a flu-like viral disease
they could take themselves to spread by the bite of infected
avoid being bitten by mosquitoes mosquitoes and occurs in most
(carriers of malaria and dengue) tropical areas of the world.
Dengue haemorrhagic fever is a
severe, often fatal, complication
• keeping sleeves rolled down of dengue. There is no specific
during certain parts of the day; treatment for dengue. Prevention
focuses on avoiding mosquito
bites in areas where dengue occurs
treating uniforms and bed-nets or might occur, and eliminating
in a chemical solution.
All personnel were required to takeanti-malaria tablets.
Part Four
HEALTH AND MEDICAL ASPECTS OF GETTING READY
FOR EAST TIMOR
The preventive medicine regime against malaria (chemo-prophylaxis) usedby NZDF personnel in East Timor is Doxycycline (100 milligrams per day).
This is followed by Primaquine (15 milligrams a day for 14 days) after leavingEast Timor.
The alternative drug used by those personnel who are unable to takeDoxycycline is Mefloquine (250 milligrams once a week), followed by the samePrimaquine eradication programme.
These programmes are in line with the recommendations from the AustralianArmy Malaria Institution.
Providing Health Briefings to Help Personnel TakeCare of Themselves Health protection depends heavily upon the actions of individual deployedpersonnel. Much of the health-related preparation and support would beof little value if personnel were ill-informed, or failed to takeresponsibility for their own health and for the health and safety of thoseserving with them.
Health briefings for all deploying personnel, as part of pre-deploymenttraining during late-September and early-October 1999, thereforeprovided important information and encouragement to enable personnelto take these responsibilities seriously. Figure 14 on the next page setsout the briefings prepared and presented by staff at 2 Fd Hosp withsupport from the Health Intelligence Officer.
Part Four
HEALTH AND MEDICAL ASPECTS OF GETTING READY
FOR EAST TIMOR
Figure 14Pre-deployment Health Training for All Personnel First Aid Training
• endemic diseases • identifying signs and symptoms • heat illness (dehydration) • UV protection of the skin and eyes • applying first aid dressing • sexually transmitted diseases • identification of dehydration • personal hygiene • application of a simple splint • protection from biting insects• food and water precautions• stress management• identifying signs and symptoms • applying first aid dressing• identification of dehydration• application of a simple splint First Aid Training First aid training enables people to recognise some symptoms of injuryand disease and give immediate assistance (known as buddy aid) tocompanions where expert medical assistance is not immediately available.
The first aid training for deploying personnel is set out in Figure 14above.
As medical staff might not be present when a soldier is injured in combator becomes sick when on patrol, Army trains some personnel as "combatlifesavers" to provide more immediate aid. These personnel are trained inparamedical skills and must be capable of administering self aid,immediate first aid to sustain life (including resuscitation), and initialIV (intravenous) therapy. Their training is focused on enabling them to Part Four
stabilise the patient until they can be seen by clinical staff or evacuated toa medical facility.
HEALTH AND MEDICAL ASPECTS OF GETTING READY
FOR EAST TIMOR
Around 65 personnel received this higher-level pre-deployment trainingat 2 Fd Hosp, and were deployed as part of the first Battalion Group.
They are predominantly selected from the Engineer and Infantry unitsthat are often located away from immediate medical assistance.
Training Health Support Services Personnel
for Deployment
Preparing HSS personnel for deployment entails: • refreshing basic soldier skills; • upgrading specific health-related competencies; and • focusing on specific aspects of the mission and environment in which they are to be deployed.
Refreshing Basic Soldier Skills HSS personnel all have military training and are expected to maintain corecombat skills. Before deployment, these skills need to be refreshed andreinforced to the required operational standard.
For East Timor, this aspect of preparation involved refresher courses andassessments in core skills as set out in Figure 15 below.
Figure 15Pre-deployment Training For HSS Personnel Basic Soldier Skills
Health-related and Other Skills
• firing live weapons • trauma training and experience • four-wheel driving • certification of medics • navigation and fieldcraft • medical emergency exercises (concealment, target recognition Part Four
and sentry duties) • country familiarisation courses • swimming and marching • familiarity with helicopters• familiarity with ammunition• using radios HEALTH AND MEDICAL ASPECTS OF GETTING READY
FOR EAST TIMOR
Refresher pre-deployment training in basic soldier skills takes about fourweeks, after which pre-deployment training focuses on enhancing healthsupport skills. Personnel who were deployed for short periods of time,such as the Force Extraction and Dental Teams, underwent shorter basicsoldier training for a minimum of three days.
Navy medics are trained in basic skills, such as firefighting and seasurvival, but do not receive training in general sailor skills.
Upgrading Health-related Competencies A standing agreement between 2 Fd Hosp and MidCentral DistrictHealth Board and Massey University provides for medical personnel(doctors, nurses and medics) to gain exposure to trauma situations byworking: • in Palmerston North hospital's accident and emergency department; • with ambulance crews; and • at the veterinary school of Massey University.
Medics undergo a pre-deployment competency and certification processto ensure that they are fully prepared for operational medical duties.
Territorial Force medics have to meet the same standards but generally takelonger because they have to reach the standards for both medical and basicsoldier skills.
Training with military ambulances was not possible after the first rotation,because all the vehicles were deployed in East Timor. This trainingtherefore took place as part of the familiarisation and medical hand-overprocess in East Timor. Navy medics and doctors were able to conduct medical emergency exerciseson HMNZS Canterbury while it sailed from New Zealand to Australia.
This involved conducting different emergency scenarios and preparingthe crew and the equipment for an actual emergency.
Approximately 40 medical and dental personnel from 2 Fd Hosp took part(in May 1999) in a training exercise for the Forward Surgical Team in the Part Four
Solomon Islands called Exercise Tropic Twilight. This exercise was designedto make people more familiar with setting up and working with the Team'sequipment in a tropical environment. It helped them to identify and resolvea number of operational and equipment issues.
HEALTH AND MEDICAL ASPECTS OF GETTING READY
FOR EAST TIMOR
In addition, duties associated with the 1999 Asia Pacific EconomicCo-operation (APEC) Forum had helped to increase HSS personnel'slevel of readiness.
Exercise Tropic Twilight
Exercise Tropic Twilight was conducted as part of the Mutual AssistanceProgramme between New Zealand and South Pacific nations. Each year aselected group from the NZDF is deployed to a South Pacific nation toconduct training in a tropical environment. In May 1999 personnel from 2ndEngineer Regiment and 2 Fd Hosp were deployed to Makira Island in theSolomon Islands group.
The deployment consisted of approximately 80 engineers, 40 medical anddental personnel, 2 Air Force Iroquois helicopters and an Air Force C130Hercules transport aircraft, which transported personnel and equipment toand from the Solomon Islands.
Medical personnel on the exercise carried out programmes for:• minor surgery;• public health education and medical aid;• blood-screening for Hepatitis C; and• education for staff at the local hospital.
At the same time as they werepreparing for deployment them- HSS needed to undertake a great
selves, HSS personnel at Linton deal of work both to prepare
Army Camp were involved in all the themselves for deployment and at
activities described in paragraphs the same time to conduct the
4.8-4.12 (pages 57-59) – providing wide range of tasks necessary
briefings, conducting health-related to prepare all other deploying
training, and carrying out medical examinations and vaccinations.
Part Four
HEALTH AND MEDICAL ASPECTS OF GETTING READY
FOR EAST TIMOR
Preparation for Specific Aspects of the Missionand Environment Medics undertook a nine-day course to familiarise themselves with thesubstantial environmental health issues that they would face – includingpest control, water purification and storage, and tropical health hazards.
All Air Force and some Army health personnel attended a course atAuckland Zoo to familiarise themselves with behaviour of wildlife theymight encounter, such as spiders, snakes, rats and monkeys. They alsolearned how to capture snakes, cats and dogs that might carry diseaseand (therefore) pose a health risk.
Training Civilian Volunteers for Deployment
The NZDF has been able to sustain the FST only through the willingservice provided by volunteer civilian nurses, doctors and medicalspecialists. Pre-deployment preparation for these personnel was muchmore limited than for Regular Force and Territorial Force personnel,although they had to pass a personal medical examination and have thesame vaccinations.
Training of civilian volunteers began with the NZ BATT 2 rotation (seeFigure 12 on page 58). Most received a two-day training course consistingof: • a presentation from a person from a previous rotation about the situation and conditions in East Timor; • an outline of preventive (primary) health, and health hazards; and • information on the layout of the FST and equipment they would use in East Timor.
As the East Timor operation continued, it became clear that the livingand working conditions were more uncomfortable and difficult than thecivilian volunteers had anticipated. From NZ BATT 4 onwards, the NZDFtherefore decided to increase the amount of pre-deployment training totry and assist the civilians in their transition. Volunteers spent a week at Part Four
Waiouru Army Camp and a week at Linton Army Camp. Additionaltraining included: • driver training and four-wheel driving skills; • navigation; and • a briefing on military command structures.
HEALTH AND MEDICAL ASPECTS OF GETTING READY
FOR EAST TIMOR
Completing the required medical assessments, vaccinations and summaryfiles for deployment of the first Battalion Group was a substantialtask. Approximately 700 personnel were examined, assessed andvaccinated during September and October 1999. These tasks were verytime-consuming, complex and critical to the ability of the NZDF to deployin a timely manner. NZDF's own reports have highlighted the scale ofthe work involving: • collecting health intelligence and developing planning documents; • training personnel to deal with health threats they might encounter • preparing personnel for deployment – including conducting medical assessments, administering vaccinations and updating medical files; and • raising the basic military and specialist skills of HSS personnel up to the required operational level.
The NZDF assembled information from a range of sources for trainingprogrammes and a plan to address the health risks that personnel mightface in East Timor.
The NZDF undertakes a comprehensive and internationally recognisedapproach to the examination of military personnel to establish whetherthey are fit for duty. The system takes a risk management approach basedupon potential threats of the operational environment, the role and dutiesof the individual, and risks to the individual and their unit.
Pre-deployment training gave health personnel a practical grounding inthe potential trauma situations that they might encounter, as well asreinforcing the core combat skills that they have as Regular Forcemembers. However, considerable effort was required to bring the basicmilitary skills of HSS personnel up to the required standard.
At the time of preparing for the East Timor deployment, not all NZDFpersonnel met the required vaccination standard. In effect, this meantthat some were not medically fit to deploy.
The NZDF does not know how many of its personnel meet the vaccination Part Four
Protocol A at any one time. This represents a significant gap in its ability toreport on force preparedness.
HEALTH AND MEDICAL ASPECTS OF GETTING READY
FOR EAST TIMOR
The JEV programme was an important logistical project for the NZDF.
The time needed to vaccinate personnel was a key consideration forNZDF planners when options and time-scales for deployment werebeing formulated. Sound intelligence, early contingency planningand effective co-ordination of the programme ensured that the NZDFwas able to largely complete the vaccination programme to meet thedeployment response time.
It is probable that NZDF personnel will continue to be deployed withinthe Pacific and Asian regions. The NZDF did not have contingency plansto obtain vaccine even for a limited number of key personnel.
This resulted in the need to find alternative supply sources at shortnotice – potentially affecting the timing of the military operation. This wasa high-risk approach.
It is important that personnel in theatre remain in good health and fit tocarry out their day-to-day duties. Deploying personnel received acomprehensive briefing on environmental health risks and on waysto maintain their own wellbeing. They also received medication toprevent them from contracting endemic diseases.
The NZDF has itself identified difficulties encountered by the HSSin performing their role, including: • substantial shortcomings in the NZDF medical records system; • the shortage of medical staff needed to carry out large deployments; • low levels of basic soldier skills among HSS personnel.
Part Four
5Part FiveEstablishing Health
Support Services In
East Timor
ESTABLISHING HEALTH SUPPORT SERVICES IN EAST TIMOR
When many people think of in-theatre military medical facilities, theirmain point of reference is likely to be the kind of facility shown by theAmerican TV series M*A*S*H – an established campsite hospital withreasonably high-level surgical facilities.
But the reality is far different in two main ways: Part Five
• As well as being prepared for possible combat casualties, the people who arrive early in a deployment often have to start with nothingexcept what they take with them – which may include supplies as basicas clean water and electricity generators. This was certainly the case asNew Zealand's forces moved from Dili to Suai. In these circumstances,the M*A*S*H-style facility takes a huge effort to establish in the firstplace and to maintain in the longerterm.
• Immediate health-related needs The medical requirements for
on arrival are also much more deployment were possibly the
basic – health personnel must of the whole operation.
work with others (such asengineers) to ensure that safelatrines are dug, to organise effective waste disposal, and to ensure thatsafe drinking water and food are provided. If these environmental healthrequirements are not quickly attended to, no amount of health care –high-tech or otherwise – will prevent serious sickness that will quicklydebilitate the force more surely than any human enemy.
In this part of the report we examine how the HSS deployed and establishedpersonnel and systems in support of INTERFET and UNTAET operations.
Figure 16 on the next page sets out the main events in the time-line forsetting up the HSS in East Timor.
ESTABLISHING HEALTH SUPPORT SERVICES IN EAST TIMOR
Figure 16Time-line for Setting up the HSS in East Timor August 99
10 OCTOBER – 3SQN and VICTOR
COMPANY MOVE CAMP TO SUAI
24 September 3Sqnarrives in Dili: 3Sqn sets up new camp Part Five
 Company aid post Pre-deployment training  1 environmental and medical preparation of all NZDF personnelfor deployment.
Preparation of all HSSpersonnel fordeployment 29 September Victor Company arrives in Dili: battalion group arrives  2 nursing officers  Company aid posts and EHO team set up Levels of Health Care
The HSS Plan for East Timor provided for a system of health care on fivelevels appropriate to the need and location of the personnel (see Figure 7 onpage 38 – Levels 4 and 5 were provided outside of theatre). Should thepatient require more complex care, they are moved up to the next level.
On 8 September 1999 Victor Company was officially notified that
it would be deployed to East Timor. The INTERFET mission
started on 20 September 1999. That day the Company left New
Zealand for Darwin and began the process of acclimatisation.
Special Air Services troops left Darwin by C130 the same morning
to secure the Komoro airport at Dili. When this was successfully
achieved, a succession of C130 aircraft landed and unloaded
further troops and equipment. The Response Force then moved
out to secure the port facilities for use by INTERFET troops.
ESTABLISHING HEALTH SUPPORT SERVICES IN EAST TIMOR
Actual resources provided were based on the size of the force in theatreand estimates of casualty risks. In the first weeks of the deployment onlythe first four levels were provided, until the full Battalion was deployed inOctober 1999 when all five levels were established. In the meantime, theAustralian Defence Force had deployed and set up its own FST in Dili toprovide relatively advanced trauma care if required.
As described in paragraphs 4.47-4.49 on pages 68-69, all NZDF personnelare trained in basic first aid and are briefed about the health hazards ofthe country to which they will deploy. When on a military operation,personnel are issued with a trauma kit that contains basic first aid Part Five
equipment, resuscitation fluids, and morphine auto-inject kits. Many ofthe items can only be used by a person trained as a combat lifesaver (seeparagraph 4.48 on page 68), but each person carries a full kit so that thecombat lifesavers do not have to carry supplies for the whole unit.
Setting Up the Company Aid Posts
Each Company has a Company Aid Post (CAP). In East Timor thisgenerally comprised one senior medic and two junior medics. Companymedics provide first-line medical attention for about 120 personnel. Theyare managed as part of the Company and the Company Commander makesdecisions on deployment.
3Sqn arrives in Dili
21 members of 3Sqn (Iroquois helicopters) flew into Dili on
24 September. They quickly set about establishing a tented camp
next to the runway at Komoro Airport. Initially, three helicopters
and 89 personnel were deployed (six helicopters and 115
personnel by mid-October). A doctor and one medic set up the
initial Aid Post for 3Sqn.
In East Timor, medics were often moved to different locations tocover different operational needs – for example, on patrols or if adangerous situation was anticipated. In the more remote locations, theyhad additional health responsibilities – such as for environmental health,preventive medicine and advice on safety.
ESTABLISHING HEALTH SUPPORT SERVICES IN EAST TIMOR
In the early stages of INTERFET, the medical teams had to be readyto treat personnel who might be injured in conflict. They were alsoengaged in setting up accommodation facilities and dealing with all theassociated environmental health issues. Serious environmental healthrisks in Dili included destroyed infrastructure and contaminated drinkingwater. Waste and rubbish were being piled up and burnt on the ground.
The naval component of INTERFET
The Navy had three major roles: presence, sealift, and guarding
Part Five
the sea lines of communications. Its contribution began on 18
September with HMNZS Te Kaha, which sailed as part of a multi-
national naval escort of ships carrying troops and equipment.
It undertook surveillance, aircraft control and escort duties
until 24 September when it departed. The replenishment tanker
HMNZS Endeavour also took part in the deployment, supplying
much needed aviation fuel and stores to INTERFET participants
HMNZS Canterbury was recalled from training exercise off the
Australian coast to Auckland, re-supplied and deployed.
It carried out routine patrols, protecting the area of sea and airspace
off Dili harbour and escorting supply ships to Suai. When possible,
Canterbury landed shore parties to assist with reconstruction
work and humanitarian aid.
The Air Force's Environmental Health Officer was part of the initialdeployment and provided expertise on fresh water supply and quality,waste disposal, camp location, pest control and hygiene.
Setting Up the Regimental Aid Post
On 22 October 1999 the bulk of the Royal New Zealand Infantry Regimentarrived and set up the Battalion Group at the site of an abandonedhospital in Suai. This became the forward operating base and the BattalionHeadquarters.
Victor Company arrives in Dili
120 personnel – the main body of Victor Company – arrived in
Dili on 29 September 1999. They established their base and started
patrolling their allocated sector. Their assigned mission was
to maintain internal security, support operations, and provide
humanitarian assistance. They provided protection to key assets,
including a rice storehouse, an electricity plant and a water
plant.
… continued on page 81 ESTABLISHING HEALTH SUPPORT SERVICES IN EAST TIMOR
A doctor, two nurses and four medics were deployed to set up a
Regimental Aid Post. In addition, four platoons each had their own
medic. These personnel also collectively supported patrols
of the British Gurkhas.
The Regimental Aid Post (RAP) wasalso set up in Suai, adjacent to the The Regimental Aid Post
Battalion Headquarters. It was was responsible for meeting
the medical needs of the
combined with the FST after it Part Five
arrived, to avoid duplication ofeffort. This arrangement continueduntil the FST returned to New What they found in Dili
Zealand in August 2001. At this It was chaotic. There was
time, the RAP relocated within the filth and rubbish all over the
forward operating base to provide place and fires burning.
onging primary health care and a And the smell was unbelievable.
resuscitation capability to the Faeces all over the place.
Battalion Group. This was a more I'd never seen anything like it.11
traditional RAP formation, exceptthat an additional doctor and nursewere added to the team and the environmental health team was relocatedwith the RAP.
The RAP health services personnel in East Timor consisted of: • a medical officer (doctor); • a nursing officer; • a senior medic; and • four other medics.
Suai is the capital of the Cova Lima district, one of the poorest
regions in East Timor, which includes a wide section of the border
with Indonesia. Suai was a ghost town – it had been completely
destroyed. Every piece of corrugated iron had been removed and
every building was badly damaged, most of them badly burned.12
Operation East Timor: The New Zealand Defence Force in East Timor 1999-2001, by John Crawford& Glyn Harper, Reed Publishing (NZ) Ltd, Auckland, 2001, page 60, ISBN 0-790-00823-8.
12 Ibid, page 92.
ESTABLISHING HEALTH SUPPORT SERVICES IN EAST TIMOR
The RAP was responsible for the management, supervision and allocationof medics to all locations. The doctor was responsible for the training ofall the medics, at the RAP and elsewhere in East Timor.
On 10 October, Victor Company moved from Dili to Suai in order to
secure the area and the airfield. At the same time, two infantry
sections secured the Suai beach area, allowing armoured personnel
carriers, trucks and other supplies to be landed. This was in
anticipation of the arrival of the main Battalion Group from Darwin
Part Five
and 3Sqn from Dili to set up operations in the Suai region.
The RAP was designed as a Medical Treatment Centre to meet theneeds of about 700 personnel – all New Zealand personnel and allother Peacekeeping Forces' military personnel in the area of operations.
It was open from 8am to 6pm each day to provide treatment, but providedmedical services at all times for emergencies. Its mode of operation wasakin to a combined general practice and accident and emergencydepartment.
The Battalion Group included the traditional rifle companies and
support company that make up a New Zealand Infantry Battalion.
The Group also included:
armoured personnel carriers;
a Combat Services Support Company; and
the Forward Surgical Team.
The Battalion Group's objective was to provide security in the
area of operations.
The RAP generally treated between 90 and 130 personnel a week forminor conditions not requiring referral to the FST. It also carried out arange of administrative and other functions for all deployed personnel –including: • maintaining medical records; • keeping vaccinations up to date; • doing blood tests; • carrying out Med Boards; and • providing medical advice to the Battalion Group Commander.
ESTABLISHING HEALTH SUPPORT SERVICES IN EAST TIMOR
In Suai, environmental health was again an immediate priority,
and some of the tasks that had been undertaken in Dili needed
to be repeated.
3Sqn established camp in a muddy maize field next to the runway.
Conditions were very bad with deep sticky mud, and scorpions
were a particular hazard, biting a number of people. The detach-
ment built its own septic tank and got flushing toilets set up.
For personnel who had just spent a month establishing and
improving the camp in Dili, it was something of a trial to go
through the whole process again.13
Part Five
Setting Up the Forward Surgical Team
Between 650 and 700 NZDF personnel were deployed as part of the BattalionGroup at any one time during the first four rotations. Units from othercountries have also formed part of the Battalion Group – including soldiersfrom Canada, Ireland, Nepal, Fiji and Singapore.
The Battalion's FST was contracted by the UN to provide a medical facilityfor approximately 1550 New Zealand and other nations' military personnel.
United Nations Police and Military Observers were also included, but theagreement did not cover any humanitarian aid work with the localpopulation or caring for the international aid workers with various non-government organisations.
The staff who formed the FST were deployed by Air Force Hercules C130aircraft on 20 October 1999 to Darwin for acclimatisation.
The FST is a lightweight trans-portable surgical facility designed The FST is a readily deployable
surgical facility that operates
to be deployed quickly to support close to the area of combat.
military operations or disasterrelief. All the necessary equipmentand personnel (approximately 30) can fit into one Hercules C130 aircraft.
The FST is deployed with sufficient stores to operate independently for48 hours. It can be assembled and ready for operation within 12 hoursof landing.
Some staff and the FST equipment were deployed by air to Suai, and theremainder of the staff arrived by sea on the Australian ship HMAS Tobrukon 29 October.
13 Ibid, pages 95 and 96.
ESTABLISHING HEALTH SUPPORT SERVICES IN EAST TIMOR
The FST provided a platform for stabilisation of serious casualties,emergency surgical care and preparation for evacuation for surgery atoffshore medical centres in Darwin or New Zealand. While the operatingtheatre is basic, it can accommodate a range of surgical proceduresdepending upon the expertise of the surgeon – including limited chestsurgery, neurosurgery, obstetrics and gynaecological surgery, and initialabdominal surgery and orthopaedic surgery.
The FST (see Figure 17 below) comprised: Part Five
• a medical operating theatre; • a resuscitation facility; • intensive care; • X-ray and laboratory services; and • medium- and low-dependency in-patient care.
Figure 17FST Ground Layout and Staff CARE UNIT
2 Nursing officers Anaesthetist tech 2 Nursing officers The FST was also set up to deal with serious tropical conditions (such asmalaria and dengue fever), or people suffering from venomous bites or rabies.
ESTABLISHING HEALTH SUPPORT SERVICES IN EAST TIMOR
Figure 17 illustrates how the FST has a double-cover tent construction.
The inner shells make up the individual units and wards, with a large(800m2) outer shade cloth, which covers the whole area and drops theoverall temperature underneath by about 5-10 degrees. The operatingtheatre, X-ray, laboratory and high-dependency unit areas of the FST areair-conditioned.
The FST has about 30 personnel. Its components include: • an emergency room; • operating theatre; Part Five
• high-, medium- and low-dependency wards; • medical personnel accommodation areas; • X-ray and laboratory areas; • logistics stores; and • administration areas.
Settling In
The RAP and the FST were located in an old church hospital in Suaiknown as the White House. The Environmental Health Team was basedwith them – the work of the Environmental Health Team is discussed inmore detail later in paragraphs 6.3-6.22 on pages 93-98. These combinedHSS units provided: • full preventive and primary health care; • secondary health care; and • a system of land or air emergency evacuation.
In addition to this central facility, medics on patrol or located at aremote CAP provided immediate health care. Seriously injured or sickpersonnel would be moved to where a doctor, nurses and other staff couldprovide a higher level of care or, if necessary, ensure that the patient wasfit enough to be evacuated to Australia or New Zealand.
As NZ BATT 1 became established, HSS personnel in the variouslocations settled into a routine of providing the necessary primary healthcare and support services required by a large number of personnel livingand working in theatre. Figure 18 on the next page illustrates how theseservices were structured at the time of our visit to Suai during the fourthrotation (NZ BATT 4). Figure 19 on the next page shows the structure ofthe various facilities.
ESTABLISHING HEALTH SUPPORT SERVICES IN EAST TIMOR
Figure 18Location of Health Support Services in the Field Company Aid
Aid Skills
Life Savers
Aid Posts
Part Five
Figure 19HSS Structure-NZ BATT 4 CAP = Company Aid PostPAP = Platoon Aid Post Wounded personnel may need to be evacuated quickly to facilities that canprovide appropriate medical treatment. This might be within theimmediate area of operations or the person might need to be stabilisedand evacuated to Australia or New Zealand.
ESTABLISHING HEALTH SUPPORT SERVICES IN EAST TIMOR
Two armoured personnel carriers fitted as ambulances and two truckambulances were located at the Battalion Headquarters. Most locationswithin the area of operations were within one hour's travel by road ofthe nearest CAP. Should the injury be serious, the medical staff couldcall 3Sqn for aero-medical evacuation.
There are three types of aero-medical evacuation (AME): forward, tactical, Part Five
and strategic.
Forward AME involves movement of the patient to an in-theatremedical facility. Prompt evacuation to appropriate medical facilities cangreatly increase chances of survival and recovery. AME from any locationin the Western Sector to the FST took up to 30 minutes by helicopter,depending on the availability of a landing zone, and the aim was to deliverthe patient within an hour of injury. 3Sqn was responsible for providingtrained AME medics for this purpose.
Frequent use of its helicopters forAME flights and the sustained nature East Timor has highlighted a
of the deployment to East Timor shortage of AME trained
highlighted a shortage of AME medics in the Air Force.
trained medics within the Air Force.14 Tactical AME involves stabilising the patient so that he or she can betransferred from one in-theatre medical support facility to another in-theatre medical facility offering a higher level of care. For the purposesof the East Timor operation, medical facilities in Darwin, Australia werealso considered to be in theatre.
Strategic AME involves transferring the patient to New Zealand or ahospital in Australia (other than Darwin). Occasionally, the need toprovide a qualified medical professional to accompany a patient resultedin a shortage of medical staff in Suai.
14 There are also some AME-trained medics within Army and the Navy.
ESTABLISHING HEALTH SUPPORT SERVICES IN EAST TIMOR
Treatment of Military Personnel
Despite the pre-deploymentinformation and training, 64 cases Malaria, heat exhaustion and
skin diseases were a problem
of malaria were treated among for the first personnel deployed
personnel in NZ BATT 1. HSS because they were unfamiliar
personnel considered this was too with the climate and the
high. As a result, all personnel who reported to an aid post with atemperature were given a blood Part Five
test for malaria as a precaution, and additional in-theatre education wasprovided. Cases of malaria and dengue decreased over successiverotations – for example, only two cases of malaria were reported from NZBATT 3.
Tropical diseases, heat exhaustion and skin conditions from living in thehot and humid climate were common in the early stages of thedeployment but, like malaria, their incidence decreased as personnelbecame more experienced with working in the tropical climate.
United Nations statistics show that New Zealand's non-battle casualtieswere low overall compared to the military contingents from other nations.
As well as the usual range of coughs, colds, flu, headaches, bumps,bruises, burns and sports injuries, HSS personnel treated a range ofillness and injury including: The Forward Surgical Team
• viraemia (including dengue); treated military personnel for a
range of minor surgical and
• gastro-enteritis; • soft tissue infections; • neurological problems; • genito-urinary complaints; • soft tissue injuries; • minor skin lesions.
ESTABLISHING HEALTH SUPPORT SERVICES IN EAST TIMOR
Treatment of Naval Personnel The Navy medical team was responsible for: • distribution of anti-malaria drugs to the 240 crew on HMNZS Canterbury; • a regular sick parade at 8am each day for the crew, when personnel could present with any health problems they had; • a 24-hour emergency service; and • conducting regular briefings to the crew about potential occupational Part Five
hazards like dehydration and health risks if they went ashore.
Heat-related illnesses were exacerbated by the breakdown of the air-conditioning on the ship for long periods of time. Most patients neededattention to general complaints like colds, bumps and bruises, and someminor burns. There were also numbers of personnel presenting with skinproblems, due to working in hot sweaty conditions for long periods.
A framework of health services was successfully deployed to East Timorand played a crucial role in support of the operation. As the scale of theoperation increased, appropriate HSS were integrated into the operationto provide a suitable range of care – from primary care through tolife-saving surgery and evacuation where necessary.
The East Timor deployment revealed gaps in preventive health capabilitythat had untoward effects. Despite the efforts of the HSS, 64 personnelfrom NZ BATT 1 contracted malaria. HSS personnel have acknowledgedthat the number of malaria cases might have been reduced if: • more attention had been given to preventive and environmental health matters in basic and pre-deployment training; and • personnel had followed prudent measures for their own protection when in East Timor.
6Part SixMaintaining Health Support
Services in East Timor
MAINTAINING HEALTH SUPPORT SERVICES IN EAST TIMOR
In this part we focus on areas of operations that we found wereparticularly important to the effective maintenance of the HSS in EastTimor. We cover: • maintaining good environmental health; • providing sufficient HSS personnel for each Battalion rotation; and • getting medical supplies to East Timor.
Some of the requirements for the HSS changed as the military operationcontinued. We examine three key changing requirements that we identifiedand how the HSS met them. They comprise: • psychological services; • dental care; and • treating the local Timorese civilian population.
Maintaining Good Environmental Health
In military situations of many types, disease and non-battle injuries havehistorically exceeded the number of battle casualties. Non-battlecasualties15 have a direct impact on the ability of a military force to carryout its mission. Systems and capabilities to minimise their impact aretherefore a crucial component of HSS.
East Timor represented a hostile environment for New Zealand militarypersonnel. The presence of disease, and the hot and humid climate in whichpersonnel had to work, demanded a mix of preventive health caremeasures – including: • provision of safe food and water supplies, and safe waste disposal; • education of personnel about precautions against mosquito bites, heat exhaustion, and other tropical conditions; and • vigorous and effective pest control.
15 Typically, the ratio can be 3 to 1 or as high as 4 to 1.
MAINTAINING HEALTH SUPPORT SERVICES IN EAST TIMOR
As explained in paragraph 5.9 on page 80, much of the local infrastructure(such as fresh water supplies or sanitation systems) had been destroyed,and a great deal of effort was required just to establish basic preventivemeasures.
This work, and the maintenance of effective measures to limit the risks ofillness and disease, was the responsibility of the Environmental HealthTeam. Figure 20 below illustrates the Team's main responsibilities andtypical activities.
Figure 20Responsibilities and Activities of theEnvironmental Health Team Water Supplies All personnel in East Timor used bottled drinking water tested by theUN health personnel in Dili.
NZDF Environmental Health Officers monitored water used for cooking,cleaning and showers – including checks of the chlorine level and testsfor water quality once a week. They also checked the camp water linesand water tanks on a regular basis.
Company groups obtained some fresh water from rain water supplies.
These were monitored less frequently because of their remote locations.
MAINTAINING HEALTH SUPPORT SERVICES IN EAST TIMOR
Food Supplies and Preparation The supply, storage, preparation and distribution of food wasinspected regularly to ensure that the food was safe to eat. EnvironmentalHealth Officers conducted regular checks on cooking and food handlingpractices. Cooks are trained to maintain food hygiene, and undertookmuch of the food hygiene work.
Disposal of Waste Engineers designed and established systems and methods of disposal for: • sullage water (from washing and showers, etc.); • medical waste; and • toxic waste.
Environmental Health Officers were then responsible for inspecting andmonitoring the systems and methods to ensure that they were operatingproperly.
Animal Disease Carrier and Vermin Control Extensive animal disease carrier and vermin eradication programmeswere necessary to minimise disease around camp and work areas. Spiders,snakes, ants, dogs and monkeys are examples of animals that posed athreat.
Jungle, bush and farm areas around the camps are prime locations formosquitoes to breed. In East Timor, mosquitoes carry various diseases –including malaria and dengue fever.
MAINTAINING HEALTH SUPPORT SERVICES IN EAST TIMOR
The Environmental Health Officers did not have the time or equipmentto capture, monitor and carry out analysis on mosquitoes which might haveallowed them to better identify and target the mosquito population andincrease the effectiveness of prevention and eradication. Control ofmosquitoes therefore used a "knock down" approach involving: • identifying potential breeding sites and eliminating them; • killing mosquitoes by thermal "fogging" throughout the camp with a mixture of Peregin (a pesticide) and diesel or vegetable oil (see Figure21 below); and • spraying pesticide around the periphery of the Battalion location.
Figure 21The "Foggy" at Work Maintaining serviceable equipment sometimes presented a major difficulty.
For example, the fogging equipment frequently broke down and neededreplacing. When we visited East Timor, the Environmental Health Officerswe met16 were working with some equipment borrowed from the Australians.
Getting regular supplies of the required pesticides and other chemicals wasalso a problem.
16 July 2001, NZ BATT 4.
MAINTAINING HEALTH SUPPORT SERVICES IN EAST TIMOR
Environmental Health Officers we spoke to believed that manyCommanding Officers were unaware of the importance of basicpreventive health practices, such as keeping areas tidy so as to avoidattracting ants or vermin. In their view, this was reflected in the behaviourof military personnel.
They also pointed to areas wheremore emphasis on preventive A greater emphasis on preventive
health, by Commanders and
health and environmental health in pre-deployment training,
issues during basic and pre- could have reduced risks and
deployment training could have impacts such as the number of
helped prevent problems during cases of malaria.
deployment. For example, theyconsidered that some of thereported cases of malaria might have been avoided had personnel beenmore aware of the consequences of failing to take the necessary precautionsfor their own health protection.
Occupational Safety and Health Where people do not follow Occupational Safety and Health (OSH)standards they expose themselves to unnecessary risk of illness or injury.
The NZDF required that OSH standards should be met in East Timor asif personnel were working in New Zealand. Responsibility for OSH laywith individual Commanding Officers, but compliance was monitored bythe Environmental Health Officers. However, these staff had norelevant training or experience and gave OSH activities low priority –partly also because they felt there were insufficient staff to undertake thework and promote good OSH practices. We found some evidence ofsome unsafe work practices (see Figure 22 on the next page).
MAINTAINING HEALTH SUPPORT SERVICES IN EAST TIMOR
Figure 22Work Being Done Without Protective Footwear Some mistakes were made by the first personnel setting up camp in theSuai area of operations. These largely reflected the early military focus ofthe operation and the need to put facilities in place quickly.
However, at the Tilomar Company location when we visited in July 2001,we noted that human solid waste was still being disposed of by mixingwith fuel and burning in 44-gallon drums (see Figure 23 on the opposite page).
Burns caused by this method of disposal were a result of unneccesaryenvironmental health risks that should have been resolved earlier.
MAINTAINING HEALTH SUPPORT SERVICES IN EAST TIMOR
Figure 23Waste Disposal at Tilomar Providing Sufficient HSS Personnel for
Each Battalion Rotation
Providing sufficient personnel for the successive rotations wasparticularly problematic in two areas of HSS – environmental health andthe FST.
There are three Army and one Air Force full-time EnvironmentalHealth Officers. Territorial Force Environmental Health Officers andsome medics who have been transferred to work as environmentalhealth technicians provided the manpower to support the deployment.
MAINTAINING HEALTH SUPPORT SERVICES IN EAST TIMOR
Initially, only one EnvironmentalHealth Officer was deployed with It is really ludicrous deploying a
force of this size to a tropical
the Battalion Group and it was environment with no existing
realised that subsequent rotations services with only one EHO and
would require more resources. For no staff.17
subsequent rotations, the teamcomprised one EnvironmentalHealth Officer and an Environmental Health technician.
The two-member team also sometimes proved too small to carry out allthe required tasks. For example: • only a basic mosquito control programme could be managed (see paragraph 6.15 on page 96); • one person had to cover all duties in some periods of leave and • the team could visit the remote Company locations only infrequently; • health education and health and safety were accorded low priority.
Medics, who have a basic training in preventive medicine, helped outwhere possible with environmental health activities at the remote Companylocations and while the Environmental Health Team members were onleave.
Forward Surgical Team Due to the geographical location of the New Zealand area of operations,access to the Level Three surgical facility in Dili was uncertain during badweather. As a result, it was necessary to maintain the New Zealandsurgical facility in the Suai area for New Zealand and allied personneluntil the United Nations could find a suitable replacement.
The FST was originally designed to be deployed and operational foronly two weeks – not for any extended period. HSS planning for thedeployment envisaged an operationthat might last about six months. Butthe FST was in East Timor for The FST – designed to be
nearly two years from October 1999 deployed for two weeks – was
deployed for nearly two years.
to August 2001.
17 End of Tour Report: Mike Hunter, Surgeon, November 1999, NZ BATT 1.
MAINTAINING HEALTH SUPPORT SERVICES IN EAST TIMOR
Planning for the initial deployment identified that it would be difficult toprovide enough medical personnel to sustain the FST. Known personnelshortages before October 1999 included a surgeon, anaesthetist andtheatre nurse.
Army is responsible for maintaining the capability and deployability ofthe FST. However, it cannot keep medical specialists like surgeons,anaesthetists or radiographers fully occupied and up-to-date withprofessional training during non-operational periods. Army thereforehas contract positions for specialists whereby the specialist works andtrains full-time in public hospitals. The NZDF pays 60% of their salary tothe District Health Board employer, and in return the specialist is on 28days' notice of deployment and must meet the required NZDF trainingcommitments throughout the year.
Before the NZDF deployment to East Timor, it had two surgeons andone anaesthetist on contract. One of the surgeons and the anaesthetistresigned after being given notice of deployment with NZ BATT 1.
The shortage of specialists was initially overcome by dividing those clinical staff with experience of running the FST into two groups anddeploying them separately over the first two rotations. Other HSSpersonnel were drawn from across the NZDF to fill the gaps. The extendeddeployment of the FST was made possible through the use of: • medical personnel from throughout the NZDF; • Territorial Force health support personnel; and • civilians with the necessary training and experience who were willing to volunteer for deployment.
Though the civilian volunteers were essential to keep the FST fullyoperational, it was difficult for Army to attract civilian specialists becauseof: • the shortage of appropriately skilled individuals within the public health • the reluctance of District Health Boards to lose specialists, even for short periods of time – there are no formal agreements between theNZDF and the Ministry of Health or District Health Boards forsituations of this nature; and • the potential financial losses for specialists unable to conduct private practice while deployed.
MAINTAINING HEALTH SUPPORT SERVICES IN EAST TIMOR
Civilian volunteers also included medical scientists, technicians,radiographers and nurses. At times on the later (NZ BATT 3 and NZBATT 4) rotations, more than half of the FST personnel were civilianvolunteers.
To attract suitable and sufficientcivilian personnel, the NZDF Without civilian volunteers, it
undertook intensive public recruit- would not have been possible to
sustain the FST deployment.
ment and personnel managementprogrammes. This work stretchedthe already busy HSS. Had the NZDF not been able to attract civilianvolunteers, it would not have been possible to sustain the deployment ofthe FST.
Many civilian volunteers were able to be deployed for only a shortperiod (2-6 weeks), creating a "revolving door" of medical personnelthrough the FST. This made it difficult to build the kind of stable teamrelationships that are important in high-pressure environments like anoperating theatre.
Heavy reliance on civilian volunteers also inevitably reduced overallmilitary capability, because civilians cannot carry out the full range ofduties for which Regular Force personnel are trained.
Getting Medical Supplies to East Timor
The deployed HSS require regularand reliable medical and pharma- Medical supplies had priority
ceutical supplies in order to achieve their objectives. Development ofappropriate packages of suppliesas part of the planning for deployment and maintaining appropriatesupplies is therefore essential. Military medical supplies belong to aspecial category – separate from general equipment supplies – called"Class 8" and are assigned a priority delivery status.
Until 1990, medical supplies were the responsibility of the HSS. However,in 1990 the NZDF logistics system was rationalised and medical supplieswere incorporated into overall logistical operations. All NZDF suppliesare now managed within a computerised purchasing system known asSAP, but medical supplies still have priority delivery status.
MAINTAINING HEALTH SUPPORT SERVICES IN EAST TIMOR
Planning for Medical Supplies The HSS Plan envisaged that medical facilities would be deployed with 14days of medical supplies and would maintain permanent stocks sufficientfor seven days. Early planning focused on the need for equipmentand medicines necessary to deal with potential trauma cases associatedwith combat injuries.
The FST initially deployed with sufficient medical supplies to support48 hours of surgery and post-operative care over seven days. A secondsimilar package of medical supplies was sent to keep the FST in operationuntil the full logistics supply chain had been established.
When the military operation changed from INTERFET to UNTAET inFebruary 2000, the United Nations required increased Class 8 supplies tobe held in theatre. In addition, the humanitarian aid work of the FSTmeant that they were dealing with different patient types (e.g. old peopleand children), and a wider range of injuries and illnesses.
This aid work required the supply of additional medical products outside standard military requirements. The need to treat babies, for example, ledto a requirement for smaller tubes, different drugs and nappies, and otherproducts that a military operation does not require. The 2 Fd Hosppharmacist estimated that the range of items needing to be supplied grewfrom approximately 600 to more than 1400 over the full term of thedeployment of the FST. (See also paragraph 6.75 on page 112.) The Medical Supply Chain The system for ordering and delivery of Class 8 items to East Timor wasset up as follows (see Figure 24 on the next page): 1. The FST order was placed on the National Support Element (NSE) 2. NSE Darwin either purchased the goods locally or put an order through to Joint Forces Headquarters (JFHQ) in Trentham. Where possible,the NSE would find a local supplier (in Darwin) of commonpharmaceutical or other supplies like Panadol or bandages so that theorder could be filled quickly.
3. JFHQ would place the order with the Logistics Executive (which is also based in Trentham).
MAINTAINING HEALTH SUPPORT SERVICES IN EAST TIMOR
4. The Logistics Executive would purchase, repackage, and label goods as necessary. They were packed and sent for delivery to EastTimor.
5. Supplies were delivered either as part of regular re-supply flights from Auckland via Darwin or direct to Suai. Special refrigeratedholding facilities were set up at the NSE in Darwin so that bloodproducts could be stored and handled appropriately.
Figure 24The Medical Supply Chain FST (East Timor)
East Timor
Joint Forces
to Logistics Exec.
NSE (Darwin)
forwards order to New Zealand
The expectation of the supply chain was that Class 8 supplies would takea maximum of four weeks to be delivered.
MAINTAINING HEALTH SUPPORT SERVICES IN EAST TIMOR
Difficulties with Medical Supplies Difficulties with the supply of Class8 items were experienced throughout There were ongoing
the deployment to East Timor.
problems with the supply of
Class 8 items to East Timor.
Army investigated and reported onthe problems. The main problemsidentified were: • Initial shortages of Class 8 items: This occurred because the HSS was
obliged, unexpectedly, to provide medical supplies to Canadian, Fijianand Irish personnel within the New Zealand area of operations.
• Difficulties with accuracy of supply: Difficulties occurred with
accuracy of orders, accuracy and quantity of items delivered, and thetimeliness of delivery. In seeking to purchase medical supplieslocally, NSE staff in Darwin frequently had to interpret and identify therequired product from its SAP definition. In addition, the FST wasworking without any SAP computer terminal until the end of NZ BATT2 (November 2000), which made ordering the correct products more • Lack of specialist Class 8
logistical experience: The
The lack of Class 8 training and
problems with accurate supply experience for logistics staff was
a cause of many of the supply
were compounded because staff dealing with orders were generallogistics staff with little or notraining or experience in dealing with Class 8 supplies. They oftenfound it difficult to identify the correct product with confidence. To helpovercome this, a senior logistics officer with training and experienceof Class 8 supplies was deployed from the NZ BATT 4 rotationonwards.
• Expanding requirement for different Class 8 items: As the nature of
the deployment changed, the list of Class 8 items grew to include avariety of non-standard items (see paragraph 6.44 on page 103).
• Familiarity with NZDF systems: Most of the civilian medical personnel
deployed to sustain the FST were unfamiliar with the standardsupplies used by the NZDF, and tended to require particular brandsof supply or types of equipment outside the normal range of Class8 supplies. This further expanded the numbers of items being orderedand added to the delays experienced.
MAINTAINING HEALTH SUPPORT SERVICES IN EAST TIMOR
• Timeliness of supply: While supplies were expected to take up to
four weeks, they generally arrived in 6-8 weeks. This caused considerablefrustration for HSS personnel. Supplies of Class 8 were so limited attimes that even simple but heavily used items (like foot powderand Panadol) ran out.
While the medical supply difficulties were well known to the NZDF,they persisted. When we visited East Timor in July 2001 (NZ BATT 4),the FST was still experiencing difficulties with accurate and timely supplyof Class 8 items.
Supplying Blood The New Zealand Blood Service supplies blood for NZDF personnel. It isprovided in the form of a standard unit load of 25 units (425 ml) of blood18,blood-testing reagents for cross type matching, and various otherpathological lab haematology tests.
Fresh blood has a shelf-life of 42 days from time of original donation.
The blood is treated with a stabiliser that reduces potassium formation,making it safe to use for that period.
The supply contract requires the Army to transport and store the blood inaccordance with the Australian and New Zealand Standard.19 Otherwise,it cannot be safely used. The normal blood chain to East Timor requiredone standard unit load of blood to be supplied every 28 days. This wassubject to flight scheduling, which meant that the blood supplies arrivedbetween 25 and 32 days apart. Blood was sent to Suai by direct Herculesflight from New Zealand. It was transported in a special refrigeratorthat included the necessary alarm and monitoring systems tocomply with the Standard.
At the FST facility, the blood was stored for 28 days from arrival. After the28 days, it was released for use in humanitarian aid cases, prior to beingdestroyed if not used within the 42-day period from time of donation.
18 Comprising approximately 18 units of O+ type blood, with other blood types making up the balance.
19 Within a temperature range of not less than 40C and not more than 60C at all times.
MAINTAINING HEALTH SUPPORT SERVICES IN EAST TIMOR
A total of 29 loads were supplied to the FST throughout its deployment.
Only one load was damaged in transit – through equipment failure. Onepartial load was damaged in theatre – again due to equipment failure.
Recognising the Need for Psychological Services
Operations like East Timor put NZDF personnel in stressful situationsthat have known adverse effects on military capability. The stress maytake various forms: • operational stress arising from danger and experience with death or • environmental stress caused by factors such as heat and noise; and • emotional stress brought about by isolation, boredom, and separation from normal family life.
Personnel placed in stressful situations may need appropriate support tohelp them cope with the effects of the stress – both during deployment and on their return in New Zealand.
The NZDF's psychologists are industrial (not clinical) psychologists.
During the initial INTERFET operation, Army psychologists were onlydeployed to East Timor to deal with critical incidents. However, during therotation of NZ BATT 2 (June 2000), it became clear that a full-timepsychologist was required as part of the operation to provide a full rangeof support activities (see examples in Figure 25 on the next page).
From August 2000, there was one full-time Army psychologist positionin East Timor to work throughout the New Zealand area of operations andin Dili.
MAINTAINING HEALTH SUPPORT SERVICES IN EAST TIMOR
Figure 25Psychological Support Activities Support to Command on psychological
Critical incident stress management
and other human resource matters
This would include responding to critical For example: on individual psychological incidents (like helping individuals to deal health/operation effectiveness issues, issues with the death or injury to a colleague) to do with families, leave recreation, as well as providing advice to Command workload, unit cohesion, team building, etc.
for how to manage the impact upon the The psychologist could also monitor, report unit and setting up peer support networks.
and suggest management strategies for anytrends that might be occurring, e.g. particulardiscipline problems, above average reportingto RAP from particular platoons/sections,etc.
Training
Ongoing training of deployed personnel.
Constructive use of down time for ongoing
training and assessment of personnel for Provides counselling services for those career development (like promotions or personnel who are uncomfortable with changes of trade) while in theatre means seeing a chaplain in this role.
that personnel do not have to put allpersonal or career development on hold forthe time they are deployed. This has becomemore important with repeated deploymentsof personnel in order to sustain the operation.
The most common problems that the deployed psychologist dealt withwere: • Adapting to the environment – especially those on a first deployment
who found it difficult being away from the security of home, family andfriends.
• Welfare issues – arising from problems with relationships or the health
of family members at home that deployed personnel felt powerless todeal with from such a distance.
MAINTAINING HEALTH SUPPORT SERVICES IN EAST TIMOR
Dealing With High Levels of Dental Problems
Dental services were also not part of the original deployed HSS.
Such services were meant to be supplied by other nations as part of theUnited Nations combined force.
Dental examinations and treatmentof some 295 personnel returning All deployed personnel had
been examined and passed as
from the first deployment (NZ dentally fit for deployment.
BATT 1) showed that there was Poor dental health became
inadequate dental provision for evident during the first
deployed personnel, resulting in deployment, which resulted in a
problems such as: loss of force strength
• pain and discomfort – sometimes resulting in absence from duty; • absences due to successive visits to Dili for the same dental problem; • higher eventual costs of dental treatment where personnel deferred seeking treatment for often serious and painful dental problems untilthey returned to New Zealand, because of a lack of confidence in theUN in-theatre dental services.
Dental problems that arose during the deployment were attributed to: • change of climate; • change in diet; and • poor oral hygiene in the field.
The NZDF assessed that, without a change in provision, the dentalproblems identified would be likely to continue for subsequentrotations, and could even increase due to the higher number of TerritorialForce personnel to be deployed.20 It therefore decided to provide its ownin-theatre dental support. From June 2000 (NZ BATT 2), a dentist and adental hygienist21 were deployed to Suai for a two-week period during thethird and fifth months of each Battalion rotation.
20 Territorial Force personnel generally have a lower standard of dental health as they receive less frequent and programmed dental care than Regular Force personnel.
21 Trained within Dental Services from selected Regular Force dental assistants to provide (under guidance of dental officers) hygiene (gum) treatment comprising scaling and cleaning of teeth andoral hygiene instruction.
MAINTAINING HEALTH SUPPORT SERVICES IN EAST TIMOR
All dental equipment and most stores were flown in and stored at the FST.
The dental team and its equipment were sufficiently mobile to be able tooperate from the FST and from the Company locations if required.
An appointments system was set up, and all personnel were given theopportunity to be seen by the dental team during their visits. Between120 and 180 patients were seen during each visit. Routine checksallowed problems that patients might not have been aware of to beidentified, such as broken fillings and gingival gum problems.
Most patients needed treatment for oral hygiene and periodontalproblems. As a result, the dental hygienist was often busier than thedental officer. However, there were also a number of urgent cases,mostly involving problems with wisdom teeth.
Treatment of Other Nations' Personnel UN soldiers and civilian police from other nations in the Western Sector were offered any spare appointments. Personnel from other nationssought treatment from the New Zealand dental team because of theservices they provided.
Treating the Local Timorese Civilian Population
While the primary role of the HSS was to look after the interests of NewZealand and other United Nations military personnel, facilities such as theFST came under pressure to provide humanitarian assistance to the localpopulation. Military Commanders had to consider how best to providesuch assistance without affecting their ability to achieve their militarymission.
The HSS plan envisaged that treatment of the local population would belimited to providing life-saving first aid only. Casualties would then betransferred to local medical facilities.
However, in practice the treatment of the local population was viewed as apart of an important "hearts and minds" campaign that would help developa strong and productive relationship with the local community and winsupport for the peacekeeping role. The contacts could also provide accessto useful local information.
MAINTAINING HEALTH SUPPORT SERVICES IN EAST TIMOR
The main responsibility for treating the local population in Suai restedwith the non-governmental organisation Médicins du Monde (MdM),which was staffed by French and Belgian medical staff who ran a clinic inthe Suai township. However, the clinic had no capability to performsurgery; nor did it have diagnostic or X-ray facilities. As a consequence,the FST was the only surgical hospital facility for a local population of about55,000 people.
As the political and military situation in East Timor stabilised, the FSTagreed to accept patients referred by MdM and referrals from the non-government health agencies in the region. Such referrals had to be ofseriously ill patients requiring intensive care, surgical care, or diagnosticservices that were not otherwise available. In some situations (such as aroad accident) an NZDF ambulance would be dispatched to collectpatients, or they might arrive by helicopter from a remote location.
Such patients (referred to as humanitarian aid cases) represented aboutone in four admissions. For example, there were 93 such admissions outof 362 during the FST's first six months in Suai. Of these, 19 weregynaecological cases and 12 required surgery.
Surgical procedures provided for local people varied depending upon thespecialisation of the surgeon present at the time, but included: • caesarean sections; • treating blood poisoning from wounds; • minor orthopaedic procedures; • treating a head injury from a road accident; • treating an elderly man with a fractured hip; and • cleaning and treating gunshot and machete wounds.
A number of young children with medical problems – including cerebralmalaria, brain abscesses, heart and renal failure – were stabilised at thefacility's high-dependency unit and evacuated to the Red Cross hospitalin Dili.
MAINTAINING HEALTH SUPPORT SERVICES IN EAST TIMOR
The East Timor deployment The humanitarian aid role of the
showed that these kinds of FST had an unforseen impact on
humanitarian aid requirements create demands for different skills,training and other resources.
Civilian patients can sometimes place a strain on the FST's resources,requiring the Commanding Officer to decide whether to continue usingscarce resources to treat local patients, or to conserve them in case theywere needed for the treatment of NZDF or other military personnel.
Blood supplies, for example, were limited, and 15 of the 25 units of bloodin storage were always kept in reserve for United Nations personnel.
The FST followed a policy of transferring humanitarian aid cases back toMdM after a maximum of five days.
Humanitarian aid cases also generated the requirement for the FST torequisition and hold a much greater range and quantity of medicalsupplies than would be required to meet the demands of treatingmilitary personnel. This was particularly the case for the paediatricand gynaecological care provided. Humanitarian aid places demands on supply of controlled drugs, nappies, paediatric food, clothing and foodfor patients and families. Creating and maintaining a safe environment for deployed personnel wasa priority for the HSS. The East Timor deployment revealed gaps in theNZDF environmental health capability. A shortage of trained orexperienced environmental health personnel and equipment limited theireffectiveness, and a lack of specific public health expertise was apparent.
The NZDF increased its environmental health capability as a result.
Sustainment of the military force for successive rotations in East Timorplaced further pressures on the HSS. For example, the NZDF had to relyon civilian specialists to help make up the FST. The HSS had to go to greatlengths to identify sufficient civilian personnel willing to deploy (andemployers willing to release them) for short periods to sustain the FST overthe operation. Keeping the FST at full complement resulted mainly from ahuge recruitment effort and good fortune in civilians willingly offering toserve in East Timor.
MAINTAINING HEALTH SUPPORT SERVICES IN EAST TIMOR
Difficulties that occurred with medical supplies were caused by a numberof factors: • logistics staff responsible for handling requests had little training or experience in dealing with medical supplies; • civilian medical personnel were unfamiliar with the NZDF medical • requirements expanded as the FST took on a humanitarian aid • the NZDF was called upon to provide supplies for other nations.
There were other challenges and changes over the course of thedeployment that illustrated the flexibility of the HSS to respond quickly andeffectively to changing circumstances. Initially, the focus was on thepossibility of battle casualties and trauma, but the emphasis had to beshifted to providing primary care and treating military personnel for avariety of tropical diseases and minor surgical conditions. In addition: • Military operations put military personnel in stressful situations.
The HSS adjusted provision to make more extensive psychologicalsupport services available to military personnel to help them managethe stresses associated with deployment.
• Early evidence of dental problems for deployed personnel led the NZDF to recognise the need to provide in-theatre dental services.
A dental team made regular visits to East Timor to maintain thedental health of NZDF and other personnel.
The NZDF viewed humanitarian aid as important in building andfostering a strong relationship with the local community and winningacceptance of its role. As part of this, the FST treated a large number ofTimorese civilians. This required it to allocate resources with carefulregard to competing demands of New Zealand personnel and thelocal population. Its work for the local population also called for adifferent and wider mix of skills and training among medical personnel.
The experience highlighted some useful lessons for HSS planning forfuture deployments.
7Part SevenLooking After Returning
LOOKING AFTER RETURNING PERSONNEL
It is important that the NZDF oversees the physical and psychologicalwelfare of its personnel returning from deployment. In this part, weexamine how it went about: • assessing and mitigating the impact of deployment duties on • minimising the risk of personnel bringing disease back home; and • maintaining the health of personnel on their return.
The HSS plan outlined the need for returning personnel to undergo arange of health assessments and precautions – including:22 • eradication treatment for malaria and worms; • psychological de-briefs; and • dental care.
The Force Extraction Programme
These comprehensive procedures are known as the Force ExtractionProgramme (see Figure 26 on the next page). A Force Extraction Team(FET) was responsible for checking and processing all returning personnel Part Seven
before they left East Timor, so that no-one was missed before returningand dispersing to different locations in New Zealand. The FET was madeup of about 35 personnel and was deployed to East Timor about fourweeks before the end of each Battalion rotation. It dealt with about 650military personnel leaving East Timor over a 5-10 day period.
Since NZ BATT 2 (May 2000), each FET operated at Hera TransitCamp, an attractive coastal location near Dili where personnel could startto relax before returning to New Zealand.
22 The Navy's post-deployment medical requirements differ in some minor respects but follow a similar pattern to the Air Force and Army.
LOOKING AFTER RETURNING PERSONNEL
Figure 26Force Extraction Programme Force Extraction team Three months later: in theatre (East Timor): return to military de-brief as required Figure 27 below illustrates the work of the FET for NZ BATT 4 (November2001). In this instance, the FET comprised 23 personnel deployed fromNew Zealand, with the balance from medical professionals already intheatre.
Figure 27Force Extraction Team – NZ BATT 4 The team was made up of:• 6 Command and administration personnel• 5 Logistics personnel• 1 Doctor• 1 Nursing Officer• 2 Medics Part Seven
• 9 Drivers• 6 Psychologists• 4 Ministry of Agriculture and Forestry (MAF) personnel.
FET members underwent a brief (3-day) pre-deployment training programmeconsisting of weapons re-familiarisation, an understanding of rules ofengagement, and health and security briefs.
The programme of activities covered:• psychological de-briefs;• medical clearances, blood tests and issuing post-deployment medication;• weapon and ammunition returns;• confirmatory checks on administrative requirements, leave, and pay;• cleaning of clothing and equipment; and• MAF inspections and clearance.* *All equipment and personal effects were cleaned prior to inspection and clearance by Ministry of Agriculture and Forestrystaff before returning to New Zealand, as part of New Zealand's Biosecurity protection programme.
LOOKING AFTER RETURNING PERSONNEL
Medical Checks All personnel were required to have a medical check and receive treatmentto eradicate malaria and worms before leaving East Timor. The medical checkinvolved: • blood tests for a number of diseases – including hepatitis B and C, HIV, and other sexually transmitted diseases; and • a medical check or Med Board (the more comprehensive medical examination) conducted where the person had been ill or injured whiledeployed.
Three months after their return to New Zealand, personnel are required toundergo a comprehensive medical examination including an examination ofeyes and ears, and blood and urine tests. The follow-up blood tests arenecessary in order to identify diseases that may have been contracted but donot appear in test results until after a period of time – usually after theperson has returned to New Zealand.
Army field psychologists are responsible for carrying out one-on-onede-briefings that are mandatory for all personnel. In addition, unit orteam de-briefings give personnel thechance to discuss shared experiences.
Psychological de-briefs are an
The psychological de-briefing important element of the force
process enables personnel to discussreturning to their own country, Part Seven
re-integrating with families, going back to work, attitudes to others,and support systems (see Figure 28 on the next page). While the de-briefing is not counselling or therapy, it gives personnel the opportunityto identify problems that may develop in the future and provide guidanceon where to seek help.
The psychological de-briefing is based on the Post-deployment TransitionModel. The Model – which is described in Figure 29 on page 122 –attempts to explain aspects of the emotional adjustment that people mayexperience on returning from an overseas deployment. It is addressed toindividuals in order to help them understand the emotions and behavioursthat they might experience.
LOOKING AFTER RETURNING PERSONNEL
Figure 28Psychological De-briefing Process Force Extraction Team
Psychological De-brief * Follow-up Sessions can include family members and a clinical psychologist if required Return to New Zealand The Army Psychology Services produce a range of pamphletsfor personnel in different family circumstances (single or married) thatare distributed as part of the FET process. The pamphletsdiscuss the range of issues that personnel might confront on return toNew Zealand.
The de-briefing process aims to: • mitigate the impact of a stressful experience in order to limit the harm to the individual concerned; • accelerate normal recovery processes in those people who have normal reactions to abnormal events; Part Seven
• help personnel to address any immediate symptoms of stress and make it less likely that they will occur in the future; and • identify personnel in need of additional professional assistance.
The NZDF believes that de-briefing sessions provide a number of positivebenefits, including: • reducing incidents of more serious adverse stress reactions (e.g.
alcohol consumption, communications problems, work performanceproblems, marital and family problems); LOOKING AFTER RETURNING PERSONNEL
• giving the individual confidence, self-esteem and a means to recognise symptoms of any future reactions and to seek help morequickly; and • helping the individual to return to their job, family and everyday life While the Air Force conducts similar psychological de-briefing for itspersonnel, the Navy does not conduct post-deployment psychologicalde-briefing.
The period after the return home can be stressful. Accordingly, follow-up de-briefings after one month and three months are part of theprogramme. Follow-up may involve family members and a civilianclinical psychologist if this is considered necessary.
Dental Care Returning personnel report for their regular scheduled twelve-monthdental check up in New Zealand rather than undergo a separateexamination prior to returning from deployment.
The NZDF has effective arrangements for assessing the health ofpersonnel returning to New Zealand, and for providing any necessaryongoing treatment. Force Extraction Teams have carried outcomprehensive end-of-tour assessments that include health checksand psychological de-briefs for Army and Air Force personnel.
Part Seven
LOOKING AFTER RETURNING PERSONNEL
Figure 29Post-deployment Transition Model Stage One: This starts before your return home, with the growing excitement
associated with the expectation of returning home to family friends and
loved ones. For some, the work focus tends to wane and thoughts
increasingly turn towards preparing to return. You may be feeling that you
are running out of time and there is a rush to see and do as many things
as possible.
Stage Two: The honeymoon period experienced on returning to New Zealand.
You find yourself back in a familiar and relaxing environment, enjoying the
comforts of New Zealand, family and friends. You start to unwind, but a degree
of excitement is still present as you catch up with people and events
missed while you were away and fill people in on what you have been doing on
your deployment.
Stage Three: The novelty of being home starts to wear off. While it is good
to be home, you may also have feelings of disappointment or anticlimax, or
a degree of restlessness. You may feel quite unsettled and uncertain about
where you fit in. These feelings can occur as a result of the contrast
between the highly stimulating environment you have experienced during your
employment and your present situation, which may seem boring by
comparison. The feelings associated with this stage can create a state of
dissatisfaction and confusion as you try to sort out your current situation.
Issues may include what you want from life and whether your present
lifestyle or military job can provide those things in the future. Some people
find that they lack motivation at work. This concerns them, as this lack of
motivation is uncharacteristic for them. It is important not to make major career
decisions too early.
Part Seven
Stage Four: Making decisions about what you want from life and how you
might attain it. In the extreme case, it may be that you decide to leave the Army.
Even the decision to stay can be a source of major relief. Once the decision is
made, you can start looking forward and planning for the future.
Stage Five: Looking forward and planning. It could be career goals, family
events, relationship issues, study, or travel. Once you start this planning and
have some direction, you will begin to focus on the future and start to leave
behind the memories of your deployment experience.
Stage Six: Given time, most people will reintegrate into the lifestyle that
they left behind before they went on deployment. This does not mean that
things will be the same as before. It is normal for deployment experiences
to have an impact upon people's values and frame of reference of the world.
8Part EightLessons Learned for
Next Time
LESSONS LEARNED FOR NEXT TIME
Lessons learned refers to the process of using experience forimprovement. A formal lessons learned system is one that ensuresall individual knowledge and organisational experience is gathered andanalysed for future use. Lessons learned systems are used by militaryorganisations around the world to ensure that problems (such as gapsin training or defective equipment) are not encountered repeatedly.
In this part we review how the HSS collect and analyse information tolearn lessons for organisational and operational improvement.
Collection of Lessons Learned Data
We found a variety of systems usedby HSS to compile a record of what HSS lessons learned data is
had happened on deployment (see available from a wide variety
Figure 30 below).
Figure 30HSS Sources of Lessons Learned Data (blue book)
Daily, weekly and
Team reports
NZDF reviews or
Audits of the case
of the operation
UN treatment records
Part Eight
LESSONS LEARNED FOR NEXT TIME
All deployed personnel were given a lessons learned booklet (known asthe Blue Book) for them to note issues they encountered in the course ofthe operation. At the end of the deployment, Commanding Officers wereresponsible for the collation and summary of individual records andadding their own comments from a command perspective. CommandingOfficers were also required to complete a standard questionnaireproviding additional information.
Operational Lessons Learned
Planning and Pre-deployment HSS lessons learned started to emerge as early as December 1999, when areview of the planning and pre-deployment aspects of INTERFET wasconducted. The review noted a number of HSS issues, including that: • management of the medical requirements for deployment was possibly the largest single organisational challenge of the whole deployment; • the current medical record system had serious shortcomings (see Part Three on pages 45-52); • the JEV programme was difficult (see paragraphs 4.32-4.41 on pages • basic soldier skills (such as weapons handling, patrolling and fitness) were low among the health personnel.
A report by the Senior Medical Officer in charge of the first pre-deploymentprogramme also highlighted the failure of routine Med Boards to givean accurate picture of medical fitness to deploy.26 As a consequence, allpersonnel nominated for deployment needed to undergo some kind ofmedical review, thus adding to the demands on HSS personnel.
2 Fd Hosp and Linton Medical Treatment Centre had too few personnelto ready themselves for deployment in addition to preparing and trainingthe Battalion group. As a result, it was necessary to bring in HSSpersonnel from other parts of the NZDF.
Part Eight
26 Closer examinations revealed that some key personnel were awaiting treatment or carrying injuries not recorded on their medical file or reflected in their medical grade.
LESSONS LEARNED FOR NEXT TIME
In-theatre HSS The HSS have prepared reports reviewing a range of operational aspectsof the deployment that have highlighted a number of ways in whichfuture operations might be improved. They fall into broadly three groups– personnel, training, and medical supplies.
Much of the planning and design of the HSS contribution was based on theexpectation that the deployment would last between two and six months.
The personnel requirements of a much longer deployment – allowing forleave, sickness, coverage of Company and Platoon positions and successiverotations – are much higher than for a limited deployment. To meet thesegreater requirements, a sustainment strategy involving Regular Forces,Territorial Forces and civilian volunteers is necessary.
The extended deployment gave rise to personnel issues (see paragraphs6.23-6.38 on pages 99-102) – including shortages in the numbers of: • clinical specialists (surgeons, anaesthetists); • environmental health officers and technicians.
The NZDF has also recognised that an extended deployment like East Timorrequires a wider range of HSS in theatre, including psychologicalsupport and dental care (see paragraphs 6.54-6.65 on pages 107-110).
Health personnel sent to East Timor in 1999 were trained to deal withbattle casualties and trauma. However, as the situation in East Timorstabilised and circumstances changed, they needed a wider skills base todeal with a greater variety of medical conditions and patient types(paragraphs 6.66-6.75 on pages 110-112). They required more training andexperience in tropical medicine, obstetrics, paediatrics and gynaecology.
More language training was also useful.
Part Eight
As a result, the HSS developed a broader pre-deployment trainingprogramme to provide for familiarity with a wider range of patient care –such as paediatric life support skills for some medics.
LESSONS LEARNED FOR NEXT TIME
The NZDF also recognised that a stronger emphasis on preventive healthmeasures and environmental health capability was required to reducethe risk of people getting sick from avoidable conditions. This is aparticularly important aspect of a sustained deployment of large numbersof personnel.
Combat element commanders were not always fully aware of theimplications of the Geneva Convention for HSS personnel. Mandatorytraining on this issue has been recommended.
The deployment also highlighted the shortage of Air Force medics trainedin aero-medical evacuation.
Supplying Class 8 Medical Items
As described in paragraphs 6.47-6.48 on pages 105-106, operational difficultieswere encountered in the supply of Class 8 medical items. A number ofreviews have highlighted, among other things, the need for more Class 8trained and experienced logistics staff, and the need to plan for a widerrange of medical supplies for a sustained deployment.
Strategic Lessons Learned
No comprehensive analysis and reporting of the HSS role in East Timorhas been undertaken. Rather, the NZDF has studied individual lessonslearned, and has considered future deployment options and incrementalchanges to current capability.
Further analysis of the lessons learned for the FST has covered: • options to make the FST more self-sufficient on operations (for example, a bigger mobile generator would enable the unit to operate in isolation);and • options for greater flexibility in the range of HSS for different types and sizes of military force.
Both of these reviews are in line with the NZDF concept of Army 2005,which places a strong emphasis on mobility of all force elements.
Part Eight
The NZDF may also need to review whether some health assets (such as theFST) may need to be kept at readiness to be deployed on as short as 48hours notice rather than the current 28 days notice. This would allow themto be deployed within short response times appropriate for particularoperations, such as disaster relief in the Pacific region.
LESSONS LEARNED FOR NEXT TIME
The NZDF is able to draw on a wide range of sources for lessonslearned, and the HSS prepared a number of reports that review aspects ofthe East Timor deployment.
They identified lessons for personnel, training and logistical support, andin some cases have amended procedures and practices. Many of the keyshortcomings that we identified had also been highlighted in NZDFlessons learned documents. However, in some cases (e.g. medicalrecords), action to rectify the identified deficiency has not yet beentaken.
Part Eight
Appendix 1
Monitoring and Reporting Readiness
We expected that the HSS would know the state of preparedness of personneland equipment, and the tasks, costs and timeframes for addressing knowndeficiencies in capability, including: • the level of health, fitness and immunisation of personnel most likely to • the status of HSS personnel and equipment and what work was required to deploy them.
We expected that the NZDF would have: • established systems and capability to collect, analyse, and interpret health information to inform the formation and deployment of the HSS; • used intelligence to begin early planning for a possible East Timor • used critical path planning to identify those areas of capability which were likely to dictate its ability to respond in a timely and effective way.
Planning the Operation
As each deployment will be different and dictate the nature and extent ofrequirements, we expected that: • planning for deployment would draw on early consultation and information and would be flexible to accommodate a changing situation.
We expected HSS pre-deployment training to: • draw on intelligence about the environment and terrain (so that training would focus on the conditions in which military personnel would beoperating, and medical training would focus on the types of health hazardsthat they expected to encounter); • focus training on those tasks required for the mission; … continued on page 134. • Pre-deployment Training … continued from previous page.
• build on existing skills, and include joint training with other force elements where appropriate operation activities were planned (e.g. airevacuations, or working with infantry on patrol); • make best use of available military and civilian health facilities in order to enhance access to practical clinical training; and • train Regular Force and Territorial Force personnel to the required standards.
Health Support Operations
We expected that the NZDF would provide appropriate HSS in an operationalenvironment in order to effectively: • prevent disease and non-battle injuries; and• collect, triage, treat, and evacuate or return to duty sick, injured or wounded soldiers.
We expected the HSS, as part of the NZDF deployment to East Timor, toreview their: • state of readiness;• preparations and deployment; and• operations in theatre; and to make the necessary improvements to their planning and capability todeal with future operations.
GLOSSARY OF TERMS
Appendix 2
Glossary of Terms
Aero-medical evacuation (AME): Transporting a patient by air to the nearest
appropriate medical facility.
Asia Pacific Economic Co-operation (APEC): The Asia-Pacific Economic Co-
operation meetings are the primary regional vehicle for promoting open trade
and practical economic co-operation. New Zealand hosted the APEC meeting in
Auckland at the beginning of September 1999. Many members of the NZDFwere actively involved in the security arrangements for the meeting.
Battalion: A unit of infantry composed of several Companies. In the case of
the NZDF, usually two infantry Companies, a surveillance and reconnaissance
Company, and engineer, logistics and medical elements. The New Zealand Army
Battalion in East Timor consisted of up to 830 personnel.
Capability: The ability to achieve a specified military objective. The major
components of military capability are force structure and preparedness.
Force structure comprises the personnel and equipment assembled in force
elements for military tasks.
Company: A subdivision of a Battalion, composed of several platoons (each
consisting of between 30 and 40 personnel).
Contingency: An emergency involving military forces caused by natural disasters,
terrorists, subversives, or by required military operations. Due to the uncertainty
of the situation, contingencies require plans, rapid response, and special
procedures to ensure the safety and readiness of personnel, installations, and
equipment.
Deployment: The relocation of forces and material to desired operational
areas. Deployment encompasses all activities from origin through to destination.
Dental Hygienists: Trained within Defence Dental Services from selected Regular
Force dental assistants to provide (under guidance of dental officers) hygiene (gum)
treatment comprising scaling and cleaning of teeth and oral hygiene instruction.
This important but time-consuming treatment greatly reduces incidence of gum
problems which make up a significant proportion of dental casualties and allows
the dental officers to concentrate on other treatment.
Force Element: A unit that directly contributes to the delivery of an NZDF output,
e.g. a frigate or an infantry Company.
GLOSSARY OF TERMS
Gastro-enteritis: Inflammation of the stomach and intestines, typically resulting
from bacterial toxins or viral infection and causing vomiting and diarrhoea.
Genito-urinary: Branch of medicine of or relating to the genital and urinary
organs.
Gynaecology: Branch of medicine concerned with the functions and diseases
specific to women and girls, especially those affecting the reproductive system.
Health Surveillance Systems: The organised purposeful collection and
processing of all civil and military medical, environmental and biotechnological
information (health intelligence), which is immediately or potentially significant
to military planning and operations In Theatre: The area of military operations into which forces have been deployed.
INTERFET: The name given to the multi-national force established on
15 September 1999 by a UN Security Council resolution to restore peace and
security in East Timor. This was later replaced by the UNTAET peacekeeping
operation in early 2000.
Medical Facilities: A generic term that we have used to describe a variety of
locations in which military personnel might seek medical attention. These range
from permanent static Medical Treatment Centres (a term used by Army) in
New Zealand through to the different sized operational locations like Company
Aid Posts and the Forward Surgical Team.
Neurosurgery: Surgery performed on the nervous system.
Occupational Safety and Health (OSH): The Health and Safety in Employment
Act 1992 promotes occupational health and safety in the workplace. It is focused
on the prevention of harm arising out of work activities in the state and private
sectors, including the NZDF. Responsibility is placed on the employer, who has a
general duty to provide a safe and healthy work environment. Employers must
follow a process of identification, elimination and isolation of potential hazards.
If a hazard cannot be eliminated or isolated, the effects of the hazard must be
minimised.
Obstetrics: Branch of medicine concerned with childbirth and the processes
associated with it.
Orthopaedics: Branch of medicine concerned with the correction of deformities
of bones or muscle.
Operational Preparedness Reporting System (OPRES): The mechanism that
the NZDF uses to assess and report the operational preparedness of force elements.
The system takes into account factors such as manpower levels, trained state
GLOSSARY OF TERMS
of personnel, equipment availability, and equipment condition. When thesefactors are put in the context of deployability, combat viability, readiness andsustainability, a full picture of preparedness is obtained.
Paediatric: Branch of medicine concerned with children and their diseases.
Periodontal: Branch of dentistry concerned with the structures surrounding and
supporting the teeth.
Pharmaceutical: Medicinal drugs, their preparation, use or sale.
Pharmacist: A person qualified to prepare and dispense medicinal drugs, and to
advise patients and medical staff on the appropriate use of medicines. Tasks and
duties include dispensing medicines; checking that medicines are given in thecorrect dosage and combinations; counselling patients on how, when and why totake their medication; ensuring that the patient is able to take the medicationsafely; and providing drug information to doctors, hospital staff and patients.
Preparedness: Preparedness is a measure of the ability of force elements to be
employed on military tasks. Force elements must be held at a level of capability
from which they can be raised to an operational status within a specified time,
then deployed for the conduct of a particular type of military task, and be sustained
for a specified period while engaged in that task. The state of preparedness
for a particular military task is specified in terms of readiness, combat viability,
deployability, and sustainability.
Primary Health Care: Essential health care based upon practical, scientifically sound,
culturally appropriate and socially acceptable methods – it is the first level of contact
with the health system.
Psychology: The scientific study of the human mind and its functions,
especially those affecting behaviour in a given context – the mental factors
governing a situation or activity. NZDF psychologists provide professional opinion
in the field of organisational psychology in support of the goals and objectives
of effective personnel management and development.
Purchase Agreement: The Purchase Agreement establishes the level of capability
and preparedness at which the Government expects the Chief of Defence Force
to hold the different components of the NZDF.
Readiness: The current proficiency and effectiveness of a force element or force
to conduct a range of activities. Force element readiness comprises personnel,
trained state, equipment held, and equipment condition.
Regular Force: Men and women who have made the Army their full-time,
professional career.
GLOSSARY OF TERMS
Response Time: The time available to prepare a force for deployment to a
particular area of operations after committal by the Government. The response
time should give the force time to assemble and concentrate its personnel, stores
and equipment; undergo additional individual and collective training; and carry
out specific planning for operations.
Sustainability: The ability to support a force at operating tempo through the
duration of an operation. Sustainability includes the availability of replacement
personnel, equipment maintenance, and the ability to keep force elements
supplied with the necessary stocks.
Territorial Force: Territorial Force personnel are part-time members of Army
who train for a minimum of 20 days per year. The Territorial Force exists to
maintain sufficient trained personnel to sustain and supplement the deployment of
Regular Force Units when required. There are six regionally based Territorial
Regiments.
Trauma: Physical injury.
Triage: The evaluation and classification of casualties for the purpose of
evacuation and treatment.
Vaccination: Treatment with a vaccine to produce immunity against a disease.
A vaccine is an antigenic preparation used to stimulate the production of antibodies
and provide immunity against a disease. Inoculation is simply another term
for vaccination.
Viraemia: The presence of viruses in the blood.
New Zealand Defence Force:
Deployment to East Timor –
Performance of the Health Support Services
Controller and Auditor-General
Tumuaki o te Mana Arotake

Source: http://www.oag.govt.nz/2003/east-timor-health/docs/timor-health.pdf