TY - JOUR
AU - Dembek, Zygmunt, F
AB - Abstract Introduction: A systems perspective was used to describe U.S. Department of Defense (DoD) Global Health Engagement (GHE). This description was based on DoD instructions and higher-level documents related to DoD GHE. A complex system of systems such as health care can benefit from using modeling approaches to help understand the interactions among major components. Models (conceptual, computer-based programs, realistic simulations, or training exercises) can be used to help stakeholders prioritize options and to identify important components and gaps for making performance improvements. Based on the cited documents, we identified major DoD GHE components to create a conceptual model. Materials and methods: Components were selected from DoDI 2000.30 for DoD GHE. Definitions of these interacting components are given and assigned to our network model that consists of three levels: strategic, operational, and tactical. These levels are linked by critical nodes (decision points) that allow feedback to previous levels for modifying appropriate components. A network that is reminiscent of this structure is Boyd’s observe-orient-decision-act diagram. Acceptable strategic and operational plans are linked to the tactical level. Acceptable tactical components lead to the desired outcome of accomplishing the DoD GHE goals. Complex systems also have feedback loops to allow for component evaluations and modifications. Accomplishing DoD GHE goals need to have adaptable components in dynamic permissive environments. Results: The network that we considered is multicomponent and interdisciplinary. The network uses DoD GHE goals as the input (observing in the observe-orient-decide-act loop) to provide relevant information. It consists of three levels of adaptable, interacting (orienting) components that are linked by critical nodes (decision points) involving the evaluation of plans and desired outcomes. Strategic components (eg, sharing, personal interactions, agreements, planning, readiness, etc.) are required to develop strategic plans, the first critical node. If these plans are acceptable, the information is passed on (feed forward, action) to the operational components (define problems, understand strategic direction and guidance, understand the operational environment, etc.). At the second critical node, the decision is made about moving the operational plans to the tactical components (eg, evaluation, data, training, etc.). Tactical components are essential to provide further information to the third critical node, desired outcomes, in accomplishing DoD GHE goals. Feedback from all critical nodes is essential to allow modifications of various components and to attain health-related interoperability in supporting security policies and military strategies. Conclusions: Examining the composition of DoD GHE and creating a defined model can help identify interacting features of this complex system. All of the identified components have been associated with gaps, such as the need for monitoring and measuring tools, and standards. The current state of this system is dynamic and is evolving when confronting gaps. DoD GHE represents an intersection of global health and security in supporting U.S. national security objectives by establishing access and influence with partner nations and among health care-related government and non-government organizations, and as a result, improves the readiness, health, and safety of our military personnel. Agreements, communication, evaluation, performance improvement, planning, readiness, standardization, trust INTRODUCTION This review focuses on identifying components shared by the U.S. Department of Defense (DoD) Global Health Engagement (GHE) initiative, as well as those of other national and international civilian communities. Historically, health engagement policies originated and have been built upon that which was first established during the Vietnam War. In 2010, the DoD established policies to help stabilize fragile states using DoD medical assets. Specifically, the instruction directed the U.S. Military Health System (MHS) to establish health-related capabilities for indigenous populations.1 DoD Instruction 2000.30 further defined DoD GHE activities as fostering productive communication among DoD, other U.S. Government agencies, and partner nations’ military and civilian authorities.2 The outlined goals are “to build trust and confidence, share information, coordinate mutual activities, maintain influence, and achieve interoperability” in “DoD GHE health-related activities in support of U.S. national security policy and defense security strategy.” Overall, the activities of the GHE are, mainly, improving the capacities of the partner nation military and civilian health sector and, from the perspective of the DoD, doing so with a focus on national security.2 Health care itself has been described as a complex system of systems, and DoD GHE is no exception when analyzing its interacting components. In fact, reports from the Center for Strategic and International Studies have highlighted concerns arising from the magnitude and the scope of the complexities of DoD health care in stabilizing operations.3 Without establishing expectations, these insufficiencies led to unintended consequences including unrealistic expectations by local populations of receiving health care services. The analysis of health care systems can help with expectation management among all parties involved and, consequently, improve relations. Given the complexity of DoD GHE, analyzing it using a systems approach will provide the means necessary to tackle the nuances and, ultimately, allow us to gain a better understanding of organization, interactions and functions. This begins by deconstructing a complex system, examining its components in isolation, and then integrating this information to gain insights about productive interactions. Typically, systems methodologies generate models (conceptual, computer-based programs, simulations, or training exercises) that can be used for comparison to real-life observations to improve our understanding of the overall mechanisms of how a complex system works. The challenge for having such models in the health care domain is obtaining relevant data from the field and integrating them to make timely and more informed response decisions. Models of health care systems are complex and are defined by the characteristics of their components. Complex systems in general systems theory also have the attribute of chaos which, in the mathematical sense, implies that they are deterministic, contain feedback loops, and depend on initial conditions.4 Small changes in variables are sometimes associated with large changes in outcomes that represent non-linear behavior. Making predictions from complex systems models are difficult when some of the essential components are unknown or only partially understood. These outcome uncertainties may appear to emerge and to cause unintended consequences or adverse events. Bill Gates reported in 2018 on the failure by the civilian health care community of having insufficient progress in pandemic preparedness, including bioterror events.5 Gates emphasized the military’s general use of mathematical modeling and other simulations in planning and decision-making. The purpose of such models is to make predictions that are testable in which problematic components can be identified and improved. In this review, we describe a conceptual model of DoD GHE that was developed based on documented DoD needs in order to envision these interactive components within a system and to help focus on the interactions and the critical issues of strategic and operational plans and desired outcomes. DoD GHE is associated with other systems that are described in high level DoD documents. The Joint Operations document includes “A Network of Networks”, in which “a threat will use and/or exploit” members of the medical network (local population, government, and demographic groups) that have the continually sustained function of protecting against threats in their local regions.6 With regard to Joint Health Services, the Force Health Protection (FHP) officer should “establish and foster liaison relationships, to include, but not limited to” “civilian and multinational personnel as required to facilitate support to CMO” (Civilian-Military Operations).7 The Joint Concept for Health Services document proposed the development of the Globally Integrated Health Services (GIHS).8 One of several operational considerations included medical military-civilian engagements while new approaches and capabilities involved non-state and transnational partnerships.9 The GIHS appears to be a conceptual forerunner of the DoD GHE. The policy of “Comprehensive Health Surveillance is an important element of FHP programs to promote, protect, and restore the physical and mental health of DoD personnel throughout their military service and employment, both in garrison and during deployment.”10 Although DoD GHE activities do not directly affect U.S. forces, positive security cooperation outcomes should, in an indirect manner, positively impact their health. This directive also states that a responsibility of the Armed Forces Health Surveillance Center is to “maintain and operate” “the Global Emerging Infections Surveillance and Response System.” In addition, this Comprehensive Health Surveillance Directive is referred to by DoDI 2000.30 in which a responsibility of the Assistant Secretary of Defense (Health Affairs) is oversight of the Defense Health Agency (DHA), including the Armed Forces Health Surveillance Branch. In Figure 1, DoD GHE refers to five other documents, none of which have a reciprocal reference, because they are either earlier versions or have the same 2017 publication date. Figure 1 Open in new tabDownload slide A selection is shown of high-level DoD policies that are associated with DoD GHE. The dates refer to either those of the original publication or to the most recent update. Dashed lines link references to earlier versions of a document. Figure 1 Open in new tabDownload slide A selection is shown of high-level DoD policies that are associated with DoD GHE. The dates refer to either those of the original publication or to the most recent update. Dashed lines link references to earlier versions of a document. MATERIALS AND METHODS Conceptual Model Models of complex systems can be constructed by multiple representations or diagrams. We have subjectively categorized selected terms from the 2017 DoDI into three levels of components: strategic (eg, sharing, personal interactions, agreements, planning, readiness, etc.), operational (eg, operational environment, strategic guidance, planning, etc.), and tactical (eg, evaluation, data, training, etc.) (Fig. 2). The interconnectedness of, what we considered to be, the more important components within both categories is shown. Note that budget considerations are beyond the scope of this review. Figure 2 Open in new tabDownload slide A graphic representation of DoD GHE levels with their components (labeled small hollow circles). Decision points (diamonds and boxed text) link the levels together and direct the flow of information. Unacceptable decisions are fed back to one or more previous levels for component modification. Acceptable decisions direct the flow of information to the next level or to the final state of goals accomplished. The * denotes names taken from the DoDI 2000.302. Corresponding terms in parentheses are from Boyd’s observe-orient-decide-act diagram.11 Figure 2 Open in new tabDownload slide A graphic representation of DoD GHE levels with their components (labeled small hollow circles). Decision points (diamonds and boxed text) link the levels together and direct the flow of information. Unacceptable decisions are fed back to one or more previous levels for component modification. Acceptable decisions direct the flow of information to the next level or to the final state of goals accomplished. The * denotes names taken from the DoDI 2000.302. Corresponding terms in parentheses are from Boyd’s observe-orient-decide-act diagram.11 The observe-orient-decide-act diagram of Boyd (OODA) employs feedback to modify observations.11 These loops represent a multidimensional, on-going set of processes. Our system concept (Fig. 2) is similar because it begins with DoD GHE goals in which information (observations at two levels) is linked to interacting (orienting) components in a tri-tiered arrangement.6 Critical nodes (decision points) in our model are represented by diamonds,11 and the lack of any node will disrupt system operations requiring the modification (via feedback) of one or more components before undertaking the forward movement of information (action).12 The first critical node, strategic plans, occurs between strategic and operational levels. Leveraging access to medical resources and influencing multinational partners who do not necessarily accept U.S. standards of care will require operational plans, the second critical node, that define, establish, and sustain roles and commitments of our medical partners.8 The third critical node, desired outcomes (ie, accomplishing DoD GHE goals), is accepted following evaluation of planning and other components at the tactical level. Results (observations) from the set of strategic components form a strategic plan. A decision is made to determine (act) whether or not that plan is acceptable. If not, then one or more of the strategic components will need modification (via feedback of information). The information from an acceptable strategic plan is, in turn, sent to the operational level where the components lead to an operational plan. If the operational plan is decided to be acceptable, it is sent to the tactical level. If the tactical components lead to obtaining the desired outcomes, the initial goals are accomplished. If the information from the tactical components is determined not to be achievable, feedback information is sent to modify the components at either the strategic or the operational levels. This conceptual model refers to real, dynamic events that can occur in a permissive environment, ie, an “operational environment in which host nation military and law enforcement agencies have control, as well as the intent and capability to assist operations that a unit intends to conduct.”6 Even when a desired outcome is a success, it would be under continuous evaluation as operational conditions are not static. Definitions The terms used in Figure 2 are defined in this section. As in any analysis of components, definitions of terms may be numerous and overlap.13 Strategic level terms The agreements component consists of formal regulations, memoranda, treaties, policies, and both formal and informal diplomatic documents. Although informal agreements can support the conduct of DoD GHE activities, more formal actions are likely to be required, eg, memoranda of agreements and understandings, regulations and diplomatic treaties and notes.1,2,5,14–18 Analysis decomposes the system to understand it “from its component parts, behavior, and activities.”19 Interactions reference personal associations dependent upon subject matter experts at all levels within an organization, ie, clinical specialists and support staff, logisticians, diplomats, and other services.17 Depending on the interactions, results can be supporting, complementing, or conflicting. Planning is required to enable the tactical components shown in Figure 2 in addition to other components that could include sustainment and maintenance of health care activities. Readiness is a major concern that includes the potential rebuilding of host nation infrastructure, integration of DoD and other health-related agencies, communications and coordination, understanding of local customs, training, and oversight. Readiness measures (for mitigation, response, and recovery) can be taken in advance of future global health care issues.”12 In this review, the term preparedness is associated with civilian health systems. Sharing of data and other multidisciplinary information leads to transparency that should provide a deeper understanding for improving the making of decisions and priorities, as well as maximizing resources and reducing duplication of effort. Sharing is built upon collaboration, cooperation, coordination, and transparency. The strategic components of agreements and sharing are linked to planning and policy development, which leads to readiness, sustainment, trust, and relationships among interacting individuals and health care agencies. Synthesis assembles system components and evaluates the entire system to understand how it functions in a specific environment.19 Operational level terms Operational environment includes items such as physical areas (eg, geographic), physical factors (eg, air, maritime, land, space, weather, and population), information environment, and in a medical context, intelligence that will mitigate against health threats.6 Strategic guidance may change rapidly and may not reflect most current strategic directions that are governed by federal and internationally recognized law.6 Operational approach is a commander’s initial description that should be continually reviewed and modified as changes occur in the operational environment, in the goals, or in the problems to be addressed.6 Tactical level terms Education and training are focused on providing guidance to DoD personnel on the design, development, implementation, and evaluation of instruction and instructional materials.20 Training is the act of teaching a person a particular skill or type of behavior. Education is a process for giving or receiving systematic instruction. Overall, a skilled population cannot exist without either. Evaluation is a judgment, assignment, or an assessment of the worth of processes, actions, knowledge, or materials. Evaluation extends to various parts of education and training, eg, a course, its operation, and performance of instructors and students. The evaluation component consists of information, the instrument, the plan, and the program.20 Evaluation includes oversight and measuring and/or monitoring, and represents analytical processes that quantify the desired outcomes.21 Data consists of monitoring, collection, analysis, evaluation (using standards for identifying areas of performance improvement), and information sharing.2 This could include clinical records, patient history, and data collected for the Joint Trauma System Clinical Practice Guidelines for performance improvements.22 There does not appear to be any major inconsistency among the definitions given in DoDI 2000.302, the DoD Dictionary of Military and Associated Terms12, and the DoD Handbook, Glossary for Training.20 It is expected that the above general definitions will need more details to accomplish goals and objectives, or to develop performance measures in outcomes-based research.2,12,20 RESULTS We chose the critical node of strategic plans as a key link to the Operational level of components. Strategic plans rely on information from the interacting strategic components of sharing, personal interactions, agreements, planning, readiness, etc. In support of these objectives, DoD GHE training is available from several sources.2,23 For the “Fundamentals of Global Health Engagement” course, the participants may include personnel from the Military Health System and Public Health Service, U.S. Government agencies, International military and civilian partners, and representatives of academic and health institutions from non-governmental organizations. The strategic component of sharing denotes transparency that is the foundation of achieving cooperation and partnering. Developing plans and guidance at the operational level involves defining the problem, in using an operational approach for developing options, understanding the strategic environment (policies, diplomacy, and politics), and understanding the operational environment.24 A systems perspective of the operational environment includes interorganizational and multinational partners that involve, among others, economic and political components.6 Operational considerations for DoD GHE are referenced in DoDI 2000.30.2 Sustaining operational skills of partner nation personnel is part of the policy to enhance the readiness of DoD medical forces (Section 1.2.c.(1)). The Chairman, Joint Chiefs of Staff (CJCS) “monitors the execution of DoD GHE operations” (Section 2.10.a.). The Geographic Combatant Commands (GCCs) will “ensure a united effort for all GHE activities by synchronizing and integrating component GHE operations and activities” (Section 2.12.d.) and “measure effectiveness and evaluate the outcomes of command GHE operations in accordance with DoDI 5132.14”25 (Section 2.12.h.). DoD GHE activities include “stability operations, in accordance with DoDD 3000.0526 and DoDI 6000.161 as applicable” (Section 3.b.(6)). In contrast to the operational considerations for DoD GHE, those of the Tactical Combat Casualty Care (TCCC) effort appear to be more mature and better defined with regard to Operational guidance and planning. For example, this effort is overseen by the Committee on TCCC and the Joint Trauma System (JTS).27,28 Trauma data are entered into the DoD Trauma Registry29 that is used by the JTS in compliance with the DHA.30 The operational environment is focused on under-fire conditions.31 On a detailed operational level for planning, more than 45 clinical practice guidelines have thus far been published.22 Achieving desired outcomes depends, at a minimum, on tactical components that can be enacted such as education and training, data, and evaluation to achieve competency. The importance of standards for assessing monitoring and measuring those components that lead to desired outcomes has been previously emphasized.2,21 These actions reinforce the essential concept that avoiding known problems requires continual evaluation.32 The knowledge component (education, training, and clinical practice guidelines) implies that it has been shared and understood by all partners. We do not, however, assume that knowledge is equivalent to understanding or competency. Depending on the outcomes, feedback is essential for building necessary plans and establishing performance improvements in measurable actions. DISCUSSION A case-based approach may help exemplify the interacting components of our model system (Fig. 2).33 An entire health care system responded to the massive 2006 food-borne botulism outbreak that confronted the public health in Thailand. The cooperative global health response included embassies and industry.34,35 The primary outcome was that lives were saved. Thus, all three of the model levels of planning can be aligned with these events. The strategic environment included policies and diplomacy that involved personal interactions that led to agreements among regional health ministers on sharing data and on conducting joint outbreak investigations. There was guidance on developing coordinated, logistical activities from cooperating agencies in Canada, Japan, Switzerland, Thailand, the United Kingdom, and the United States for delivering life-saving mechanical respirators and antitoxin.35 For Operational planning, the problem of how to save lives was obviously defined. The Operational environment for developing plans again relied on collaboration and dialog throughout all three planning levels.24 On a Tactical level, response preparedness validated existing investments in epidemiology training in Thailand. After analyzing, synthesizing, and evaluating the new data, the processes involved, and the clinical outcomes from this outbreak experience, at least five policy issues were identified that could help plan for prompt responses to future disease outbreaks. This example of feedback defined the need for improved detection, response, and reporting procedures in preparing for future emergency situations. Gaps Many of the components included in Figure 2 have been associated with gaps, such as the need for specific medical devices and process standards.5,21 For example, a transportable device is needed that uses technology to reduce pathogens in whole blood in combat environments. As for standardized medical processes, the U.S. MHS has the U.S. Army Institute of Public Health’s Food Safety Surveillance Program21, the Joint Trauma System36, and the Joint Pathology Center (JPC)’s accreditation by the College of American Pathologists (International Standard ISO-15189).37 Without devices and standardized processes, functional interoperability is difficult to attain.38 An example of a gap in medical interoperability is the extent of care given to patients that may be based on a patient’s nationality.39 Specialized treatment of local nationals may need to be considered.40 Lessons Learned The assumption that improved health care and life saving procedures allow for better outcomes for “geopolitical, military, and operational readiness”21 requires more quantitative monitoring and evaluation of health outcomes data.36 These data should be continuously collected and objectively examined. A common pitfall of GHE is to underestimate needs at the start of a health crisis and overestimate outcomes once the crisis ends.41 Rejection of sanitary measures imposed without explanation, abuse of power and imprisonment, border closures, riots, and murdered health care staff are all events that could have been minimized by combining expertise and interventions.41 Ongoing military medicine practices have produced valuable lessons.36,42 Using monitoring and evaluation processes of archived combat casualty care data within the JTS will help future policies, processes, and standards become part of DoD GHE. The organization and prioritization of the DoD GHE programs may also benefit from the experiences of Cuba’s health diplomacy program17 and from operational considerations involved with previous and current Ebola crises.41,43 Forgotten lessons have in the past delayed improvements in the initial treatment of combat wounds.44 The JTS and other data resources can help mitigate this loss of information.36 Adapting knowledge from military wartime experiences of civilian medical communities is another approach to prevent loss of medical knowledge. This transition occurred, for example, with the concept of phased wound management involving treatments applied beginning at the point of injury to subsequent higher levels of care. Although prevention is difficult to measure, the importance of the loss of medical information was recognized by the World Health Organization (WHO) and the Ministries of Health of Iraq and Kurdistan. Emergency medical responses in “fragile and failed nation states” need to include “evidence-based practices derived from military medical experiences.”45 The loss of medical knowledge is related to the cautionary remark by LTG Schoomaker regarding the importance of the maintenance and legacy of the Army “Medical Department’s trusted reputation” that is currently being “overlooked in current ranks of Army Medical Corps and other AMEDD officers, enlisted Soldier-Medics, and civilian professionals.”46 On a strategic level for deployed U.S. military personnel (health care providers, patients, support staff, and others) in permissive environments, a functioning DoD GHE infrastructure will be a valuable asset. Successful outcomes will depend on collaborative/cooperative efforts with government and non-government personnel from partner nations and their ability to provide useful medical and non-medical support. Establishing and maintaining security at these deployment sites would also increase readiness in-garrison. Postdeployment DoD GHE-experienced personnel could assist or lead in training predeployment personnel, teaching them the lessons learned in developing hard-earned skills while on duty and serving with partner nations.33 Important skills include strengthening team-building efforts that require inter-personal respect, establishment of trust, and the production of cooperation. All of these and other components mentioned in this review provide a framework for enhanced readiness both at home and in permissive settings. Although some personnel may not perceive any benefits from this effort, those who serve on DoD GHE teams will no doubt experience a sense of contributing to U.S. military readiness and to the security of our country and to that of partner nations. CONCLUSIONS Decomposing DoD GHE into a defined model has helped identify interacting features of this complex system. Its current state is evolving by addressing known gaps.16,21 Gaps will be overcome with improvements in cooperation, collaboration, and data sharing, components that are being considered by the DoD GHE Council, especially when interacting with other U.S. Government agencies, government agencies of partner nations, private institutions, and commercial pharmaceutics industry, the WHO, and health care-related non-government organizations.2,5 Another example of intergovernmental cooperation is the 2014 U.S. partnership with WHO and other countries that launched the Global Health Security Agenda to provide assistance in developing a responsive worldwide prevention and detection network to infectious disease threats.2,47 The required trust among stakeholders has also been recognized in relation to large-scale research collaborations.48 On the other hand, several criticisms of global health have dealt with the health systems of developing countries.49 Host countries may be required to develop more efficient administrative procedures, expand the authority or participation of existing leadership, maximize local stakeholder engagement, acknowledge cultural values, and strengthen communication and trust.50 The recent Ebola outbreak in the war zone of the Democratic Republic of Congo, in which health care facilities have been attacked by armed militia groups, exemplifies the mistrust experienced by suspicious local populations where avoiding violence is considered to be more important than treating diseases.51 The above examples could provide guidance for enhancing the present DoD GHE system by continual monitoring and evaluation of standardized clinical practice guidelines, data collection, storage and data retrieval standards, and current relevant medical publications. “Collecting, analyzing, and publishing data from GHE provide better guidance regarding the true impact and effectiveness of the health engagement rather than the mere noting of process measures and singular personal observations typically written in after-action reports.”52 At a higher level, several international policy activities have been recommended for improving responses to public health emergencies: establish local health care infrastructures in partnering nations to institute communication and response systems; construct stockpiles (medications, equipment, and supplies) with transparent logistic “procedures for release and transport”; create a standard decision support system for alerting WHO; and educate stakeholders that an “international response to public health emergencies” is a foreign policy health issue.34 According to the MHS, DoD GHE will “improve the health and safety of our warfighters, expand our medical readiness, building trust and deepen professional medical relationships around the world, and advance U.S. national security objectives.”53 In this manner, the GHE effort by the DoD recognizes the intersection of global health and security. “In addition to ensuring force health protection and medical readiness, DoD GHE efforts also address other DoD and U.S. government priorities that include enhancing interoperability by helping partnering nations build health capacity, countering global health threats, and supporting humanitarian assistance and disaster relief initiatives.”53 FUNDING This work was supported by core funds provided by the U.S. Army Medical Research and Materiel Command. Funding identifier: http://dx.doi.org/10.13039/100000182. The views, opinions, and/or findings contained in this report are those of the authors and should not be construed as official Department of the Army positions, policies, or decisions, unless so designated by other official documentation. Citations of commercial organizations or trade names that may be named in this report do not constitute official endorsements or approvals by Johns Hopkins University, the Uniformed Services University of Health Sciences of the products or services of these organizations. References 1. Department of Defense Instruction 6000.16 Military Health Support for Stability Operations. 2010 Available at https://www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodi/600016p.pdf; accessed November 10, 2019. 2. Department of Defense Instruction 2000.30 Global Health Engagement (GHE) Activities. 2017 Available at https://fas.org/irp/doddir/dod/i2000_30.pdf; accessed November 10, 2019. 50. 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TI - A Systems Perspective of DoD Global Health Engagement
JF - Military Medicine
DO - 10.1093/milmed/usz461
DA - 2020-08-14
UR - https://www.deepdyve.com/lp/oxford-university-press/a-systems-perspective-of-dod-global-health-engagement-1w6iDR3kSb
SP - e1024
EP - e1031
VL - 185
IS - 7-8
DP - DeepDyve
ER -