Lessons Learned from Planning, Assessment, and Immediate Relief in the 2003 War with Iraq

Frederick M. Burkle, Jr., MD, MPH*
Bradley A. Woodruff, MD, MPH**
Eric K. Noji, MD, MPH***

*Senior Scholar, Scientist and Visiting Professor, The Center for International Emergency, Disaster & Refugee Studies, The Johns Hopkins University Medical Institutions, Baltimore, MD, and Professor, Department of Public Health Sciences and Epidemiology, Johns A. Burns School of Medicine, Honolulu, Hawaii, USA
** Senior Epidemiologist, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
*** Visiting Professor, The Center for International Emergency, Disaster & Refugee Studies, The Johns Hopkins University Medical Institutions, Baltimore, MD, USA

Dr. Burkle formerly served as Deputy Assistant Administrator, Bureau for Global Health, US Agency for International Development (USAID) and in that capacity was a major health planner for USAID in the build up to the war with Iraq. He later served as the Senior Medical Officer on the Office of Foreign Disaster Assistance's Disaster Assistance Response Team (DART) and was the first senior health diplomat to enter Baghdad and southern Iraq after the collapse of the health system.
Dr. Woodruff served as senior epidemiologist on the Iraq-DART during the immediate relief phase of the war.
Dr. Noji served as the Deputy Senior Medical Officer on the Iraq-DART during the immediate relief phase, March to May, 2003.
The opinions and assertions herein are those of the authors only and should not be construed as official or representing the views of the U.S. Public Health Service, the U.S. Centers for Disease Control and Prevention, U. S. Agency for International Development, the Department of Defense or the U.S. Government.

Corresponding author:
Frederick M. Burkle, Jr., MD, MPH
Phone: 808-262-2098/fax: 808-262-2538
E-mail: fburkle@jhsph.edu

An earlier version of this article appeared in the Lancet, Vol 364, October 9, 2004: 1371-75

     As the world community entered the 21st Century it faced the reality that more people were being killed by their own country than from outside forces. The outmoded language of the 1945 UN Charter primarily addresses cross border wars, but is clearly ineffectual in dealing with the complicated politically driven internal conflicts and genocide that now dominate the list of human-induced disasters. At the core of debate and dispute is the UN Charter's Article 2 that does not authorize the UN to intervene in matters which are essentially within the domestic jurisdiction of any nation state. Demands by the international community to 'do something' to protect a vulnerable population from grave harm from internal nation state war and conflict has lead to divisiveness among UN member states. Disillusionment over the lack of UN political will to address this problem threatens the future existence of this international body. When the UN Security Council has responded it has done so without a consistent, timely and effective mandate, especially in Africa.
Models of Response
       In 1999, the UN demonstrated success in quelling an internal conflict in East Timor through a multinational action under a UN Charter Chapter VII (Peace Enforcement) Security Council Resolution. This multinational response model approach, albeit evolving over time, is based on the 'right to intervene' and requires military intervention to cease the violence, reduce civilian mortality and morbidity, and strictly monitor human rights and international humanitarian law abuses until safe enough for the UN agencies, NGOs, and other international relief organizations (IROs) to enter the theatre of war. Once a peace agreement or accord is signed, a transition to a Chapter VI (Peacekeeping) force is prescribed.1 However, the multinational model has its detractors who claim inconsistencies from weak UN political guidance, lack of UN operational authority over troops of donor countries, deficiencies of operational command and control, and insufficient logistic, support components, and political will to sustain the missions beyond the end of the initial military intervention.2 The sovereignty-based political will to support the 'right to intervene' or not is re-debated with each Security Council Resolution. The NATO military action in Kosovo was the result of increasing frustration from the West with UN Security Council inaction.  In 2002, this debate led the international community to concur that sovereign states, to remain sovereign, have the responsibility to protect their citizens. Under this model the UN would define circumstances of intervention such as actual or apprehended large-scale loss of life, and genocidal intention where the UN would have the obligation to intervene by authorizing force if necessary. Political will to take action in a sovereign nation state where protection is either not exercised or refused would be based, not on the 'right to intervene,' but rather on the concept of 'responsibility to protect.'3, 4
Political action translates into military action. Both peacekeeping and peace enforcement are inherently political. The non-political component is assumed to represent humanitarian relief. In most situations, the IROs have historically retained overall leadership and control of humanitarian assistance, something that is felt to be essential for maintaining the neutrality of relief workers. However, the frustration directed at UN Security Council inaction spilled over to traditional UN sanctioned IROs that were often perceived by Western observers to be bureaucratically ineffective, inefficient, and were often responsible for prolonging the conflict by unwittingly providing succor to warring factions through their relief programs.
Since the Balkan wars, the military, with increased autonomy from traditional UN approaches to relief, has increased their engagement in humanitarian projects, such as community health and food programs. The IROs feel these programs contribute to insecurity by blurring the lines between civilian and military functions, and falsely associate them with the military forces.1, 5 With increasing security problems worldwide, most will acknowledge the reality that military involvement is often essential in providing intelligence, security, and logistical support to international relief organizations. However, the IROs suggest the military should provide the necessary protection to ensure relief but humanitarian programs should remain with humanitarian organizations.
Since 9/11, the United States (U.S) with its unrivalled military power, reasserted its dominant role in international security by increasing attention to protracted crises and failed states considered bastions for terrorism.4 The U.S. developed a common strategy against Saddam Hussein's regime in Iraq that called for action based on a worst case scenario involving threats of weapons of mass destruction, and a best case scenario if rapid intervention would occur. The U.S., along with coalition partners, disapproved of the political position and apparent lack of support from the UN Security Council and chose a unilateral non-Chapter VII model approach to invade Iraq.6 The U.S. based their intervention on a countries' right to self-defence, and not their right, or obligation, to intervene elsewhere to protect people other than their own.3 In addition, the intervention was first considered a war to remove a hostile regime. A major humanitarian component to the war was considered unlikely. This unilateral action began a worldwide unilateralism versus multilateralism policy debate that exists to this day.
In late 2002, U.S. Government planners, influenced by a State Department led 'Futures of Iraq' program, considered many possible outcomes to an invasion and assumed they might face a humanitarian catastrophe.7  This was based on evidence that civilian health was substantially worse than in 1990, which would be especially critical if WMD were used against already vulnerable populations. Critical indicators that suffered decline over the previous decade were: 1) infant mortality rates rose from 47.1 to 108/1000 live births, 2) under age five mortality rates rose from 56 to 131/1000 live births, 3) acute malnutrition rose from 3.6% to 11% in 1996, then declined to 4% in 2003 because of extensive UN Agency and NGO facilitated Iraqi feeding programs, and 4) increases in reported cases of tuberculosis, cholera, typhoid fever, amoebic dysentery, giardiasis, leishmaniasis, and malaria. This increase in reported cases may reflect improvements in WHO and UNICEF facilitated training of Iraqi health personnel in disease reporting and outbreak investigation. 8-12
Traditionally, in such a humanitarian emergency, the State Department's U.S. Agency for International Development (USAID) and its Office of Foreign Disaster Assistance (OFDA), deploy an operational on-site Disaster Assistance Response Team (DART) in response to natural, technological, and humanitarian emergencies.13 DART is primarily involved in assessment, coordination of technical assistance, development of project proposals, procurement of materiel, liaison with the military, and liaison and funding of UN and IRO programs for immediate relief. In preparation for the war, the DART planned to provide emergency lifesaving health interventions in order to serve as a 'bridge' for up to 30 days until the IROs and Iraqi national technical staff could fully re-engage. Typically, a DART includes fewer than 10 people who are primarily involved in assessment, coordination of technical assistance, development of project proposals, and procurement of materiel. Because of the unpredictable consequences of the anticipated conflict, the DART included 80 people, most with previous experience in complex emergencies. Specific experience included refugee care, human rights abuse and protection, epidemiology, military liaison, information management and communications, public affairs, security, environmental toxicology, and biological, chemical and nuclear threat analysis. All DART members received unprecedented training ranging from chemical, biological and radiation preparedness to human rights abuse and protection procedures and anti-terrorist driving.
Simultaneously, the Department of Defense established a Humanitarian Planning Team (HPT) instructed to conduct prewar planning of the military Central Command (CentCom) humanitarian response (Fig. 1), including health and coordinate those responses during the conflict. Confusion first occurred when the HPT claimed to the IROs that they were the official humanitarian liaison for the U.S. Government. Many non-governmental organizations chose not to work with the military.  This policy resulted in some IROs to question why USAID and other State Department offices, with whom many had established good working relationships, were not being used, and led many to believe that the planning for war might be a hoax perpetrated to drive the Saddem regime out of power. The situation was further complicated by the fact that the HPT, citing secrecy, refused to disclose crucial information needed for planning not only to IROs but also to other US military, governmental, and civilian agencies working on humanitarian relief. Both USAID and the State Department's Bureau of Population, Refugees and Migration (BPRM) had representatives on the HPT, but they could not share any information with their State Department offices. In effect, the HPT became the official liaison, and unbeknownst to USAID, the two planning bodies took increasingly divergent tracks.
With increased buildup of the military in Kuwait, the DoD and Coalition forces established a Humanitarian Operations Center (HOC) in Kuwait City with the assistance of the Kuwait Government. The HOC was to function as a clearing house for 'liaison and coordination' of civilian and military organizations providing humanitarian assistance. HOC activities included providing daily operational and military security briefings, making available office space for organizations providing humanitarian assistance, issuing permits and visas to work in Kuwait and crossing the border into Iraq with humanitarian supplies, and serving as the point of liaison for other military organizations and donor countries. Concerns over neutrality from the military led many IROs to attend HOC operational and security briefings and request the necessary permits; however, only one chose to share office space at the HOC during the war and immediate relief phase.
In January, 2003, under Presidential directive, the Pentagon further broke with tradition and created the Office of Reconstruction and Humanitarian Assistance (ORHA). (Fig.1). Its job was to coordinate the relief and reconstruction efforts in Iraq with other U.S., Coalition, and IROs. ORHA became the central U.S. authority overseeing the efforts of the Coalition Forces (United States, Great Britain, Australia, Poland, Denmark, Spain, and Iraqi Kurdish militia) to provide humanitarian assistance during the crisis. ORHA was in charge of both operational and policy requirements in the areas of humanitarian relief, reconstruction, national and local governance, and external affairs. Concerns immediately surfaced within the State Department and USAID as to the legality, under the Congressional Foreign Assistance Act, that established OFDA13, of bringing the DART under the control of the DoD. The ongoing polemic debate was fed by discussion as to whether this Presidential decision was simply a policy determination or a legal regulation.
Despite the fact that the UN did not sanction the war, IROs, especially those with active programs in Iraq, unofficially began internal planning for preconflict evacuation of expatriate staff and post-conflict recovery of services. There was concern that given the already poor health situation in Iraq before the war, a major relief effort would be needed requiring a coordinated effort of Iraqi nationals and IROs to correct basic public health deficiencies, even without significant combat-related civilian casualties.8-12
The IROs attempted to plan for the likely humanitarian consequences of the war but they faced major obstacles.  First, most organizations could not know if there would be war or not. This made it difficult to invest substantial time and resources in planning for an event which may or may not occur. Available funds for planning and propositioning supplies were limited because many major donor governments refused to commit resources to planning because of objections to the war. Appeals for funds could not be activated until organizations were sure the war would begin. Secondly, much of the humanitarian planning done by the major potential donor, the U.S. Government, was done by military authorities in relative secrecy.  The usual source of U.S. Government humanitarian funds, OFDA and State Department's Bureau for Population, Refugees and Migration (BPRM), were not fully aware of these military plans. This lack of knowledge of the principal donor government's intentions made coordinated planning difficult. Third, because ORHA was a part of the military force which would initiate the war, many organizations, including U.N. agencies and many NGOs, feared losing independence and impartiality if they coordinated with or accepted U.S. Government funds.
By the start of hostilities, the following March, 2003, the DoD had decided to ignore the State Department's 'Future of Iraq' task force findings in favour of thinking that assumed that the war would be short and that it was unlikely that there would be a major humanitarian crisis.14 DoD planners felt there would be little population displacement or public health infrastructure loss. The planners also assumed that reconstruction could be accomplished primarily by the private sector, funded by oil revenues and supported by a cooperative Iraqi population. There would be little need for the IROs.15  The agencies which would provide most of the immediate humanitarian relief were Civil Affairs (CA) units of the US military and the DART. The military's CA units are comprised predominantly of reservists trained to work with US military commanders and local civil authorities to lessen the impact of military operations on the civilian population.  CA specialists, including health professionals, are trained to systematically identify critical services and infrastructure needed by local citizens in war and disaster situations. However, the public health expertise of CA personnel was limited.
As it became clear that an invasion was all but certain, all expatriate UN personnel and their designated Regional Coordinators were evacuated to Cyprus and not allowed to return until the UN Security Coordinator had deemed the environment safe. The International Committee of the Red Cross (ICRC) planned to keep a small core group of expatriate (including the Head of Delegation) and national staff functioning during the conflict in Baghdad, Basra and northern Iraq.  International Federation of Red Cross and Red Crescent (IFRC) Emergency Response Units (pre-packaged 150-bed mobile hospitals or clinics) were prepared for deployment. In general, the types of materials stockpiled and moved to advance positions were supplies that would be useful to treat acute combat and related injuries and illnesses, such as antibiotics, intravenous fluids, and surgical supplies.
On March 19, 2003, coalition forces moved from Kuwait into southern Iraq. By April 14, major combat was declared over in and around Baghdad, and on May 1, President Bush declared that the war was over.
    WHO, which had provided guidance to IROs by convening health coordination meetings in Kuwait City, later provided similar leadership in Basra in southern Iraq. During the war, almost 20 health-related NGOs with more than 250 international staff, with self-contained and staffed clinics and field hospitals, were either in place in surrounding countries or on standby for rapid deployment.
 The conflict did not displace large numbers of people within the country nor create a flood of refugees across its borders. Fighting did not cause extensive damage to highways, bridges, power stations, and other civil infrastructure. Chemical and biologic weapons that U.S. officials had said might be used now appear not to have existed. The U.S. and Coalition military chose not to tally civilian deaths. However, by utilizing a methodology developed for the war in Afghanistan using journalists' reports of war-related civilian deaths, one organization estimated between 5966 and 7661 (January 1-May 1, 2003) civilians were killed in the war.16
Instead, widespread looting and social disorder led to the destruction of public facilities and the disruption of essential public services. In many areas, hospitals, clinics, pharmaceutical stores, public health departments, laboratories, and administrative offices were ransacked, causing the collapse of the already tottering Iraqi health system.17-26 The greatest needs turned out not to be to be supplies to treat acute emergencies that had been stockpiled before the war but medicines for common chronic diseases of the largely urban population, such as cardiovascular drugs, and the critical diagnostic and therapeutic equipment needed to refurbish the looted laboratories and hospitals. In addition, the disruption of such essential services as electricity, water, police, judiciary, public transportation, and communication systems made it impossible for patients to travel to obtain health care and for health workers to perform their jobs.20-21 Lack of funds for salaries exacerbated already acute personnel shortages. The 3 major concerns most often cited by hospital directors and staff were the lack of security, water, and electricity.
As the collapse of the hospital and public health system was occurring, the coalition forces initially maintained they were "liberators" not occupying forces, forcing a debate as to responsibility for restoring essential services or provide security to the hospitals.27
Relief efforts that had begun were hampered because security problems made it difficult for health assessment teams to visit sites safely. As a result assessments were rushed and incomplete. In areas newly open to humanitarian personnel, security constraints prevented assessment teams from remaining overnight or establishing offices, leaving only a few hours in a day to complete the assessment.  Moreover, changing security conditions sometimes made previously accessible areas inaccessible. Even when complete assessments of health facilities could be done, subsequent looting often made them rapidly obsolete.
For a short but crucial period of time, health officials had to depend on reports, often based on rumour, from military personnel within Iraq. CA units that were on the scene unfortunately not trained in health assessment. The resulting information collected on assessment forms adapted from the UN's Office for the Coordination of Humanitarian Affairs (OCHA) varied considerably regarding the types of information collected and the amount of detail which contained little or no information on primary health centers, public health capacity, or civilian health status, such as mortality and morbidity indicators.
    The ICRC and the IFRC continued the services they had provided prior to the war including support for major hospitals.  The Iraqi Red Crescent Society, perceived prior to the war as a potential source of volunteers who could assist in post-war relief, was not functioning during or after the war.
     By the beginning of hostilities the DART was placed under administrative control of ORHA, however, it was to remain operationally independent. ORHA was rushed to Baghdad but soon realized they lacked the expertise in assessment, field operations, security and communications that the DART possessed. Initially, the DART focused on the situation in southern Iraq which was particularly poor. DART personnel, who had extensive communications systems, were deployed to the region and began to coordinate activities with international agencies. WHO assumed the role as lead agency for coordinating the restoration of curative health services in Iraq.  Members of the DART, multiple UN agencies, NGOs, and military civil affairs units participated in WHO-led coordination meetings.  The United Nations Children's Fund (UNICEF) officially assumed lead responsibility for education, nutrition, water and sanitation, mine clearing, child protection, and primary health prevention.  WHO and DART personnel created a standardized health assessment form to assess health facilities and health status in Iraq.     

•    When multi-sectoral and multi-agency participants fail to plan and work in a coordinated fashion mistakes will be made. The military remained 'vertical' in planning as USAID, DART and IROs strived for a broader 'lateral' or 'parallel' decision-making and planning process. What limited preparation was done by IROs occurred in an informational vacuum. IROs also suffered from inadequate funding. As a result, they were unable to respond swiftly.
•    The HPT was unprepared and ill suited to the humanitarian task and appeared to be unaware of the functions, charter, and capabilities of IROs. As a result, the HPT did not work with the IROs to effectively harness their abilities and failed to appreciate the critical role they hold in humanitarian assistance, in transition to sustainable development, reconstruction, and transfer to civilian control as the military exits.
•    The HPT's penchant for secrecy caused confusion and denied IROs crucial information needed for planning.
•     The HPT's insistence that all liaison contacts go through its staff prevented non-military US humanitarian agencies, such as USAID who had a long history of serving as a liaison between the government and neutral IROs from salvaging the situation.
•    During pre-conflict planning, it was USAID that provided for grants to UNICEF, WHO, and for an NGO consortium for health, water and sanitation that proved crucial during the war and the weeks immediately following the conflict. The squabble between DoD and State over who controlled the DART and its assets should have been settled in Washington before deployment. This uncertainty placed the DART personnel in a difficult political and operational limbo that unnecessarily affected performance. 
•    ORHA was primarily staffed by policy experts who lacked requisite relief experience and expertise, and were unfamiliar with critical issues surrounding field assessments. They did not have experience with multi-agency or multi-sectoral (humanitarian sectors of health, water and sanitation, shelter, food, and fuel) decision-making that was essential in understanding the diverse health roles and responsibilities across the IROs and the military.
•    ORHA did not recognize the need to separate politics from relief and more broadly politics from public health. Pre-ORHA planning by the DART and IROs strongly emphasized a decentralized public health approach to health governance. The DART (author FMB) emphasized the critical need for a decentralized health outcome surveillance system approach. There existed four separate regional areas in Iraq (north, south, central and Baghdad) each with unique ethnic, tribal and religious differences, variations in health indices, security, and capacity and expectations for political governance. However, planning by ORHA emphasized a Baghdad centric approach that dismissed the early development of a surveillance system.
•    CA units acted with professionalism and good will and worked well with the IROs. The IROs were fully aware of the critical role these units had as an instrument of the occupying power in restoring essential services.19-20, 27 However,  CA Units, consisting of 96% Reserve forces, were under-supported, under-manned, under-prepared and under-utilized for the 'occupying power' responsibilities they faced.
•    In health, the CA lacked needed public health expertise. For a short but crucial period of time, health officials had to depend on reports often based on rumour from non-public health military personnel within Iraq. CA units on the scene were unfortunately not trained in health assessment.
•    The OCHA assessment form used by the CA units had a brief health section that emphasized structural loss to health facilities. Completed forms varied considerably regarding the types of information collected and the amount of detail and contained little or no information on functional capability of primary health centers, public health capacity, or civilian health indicators. Although CA units sometimes included physicians, nurses, or other healthcare professionals, few had public health training or experience in rapid health assessment or outcome indicators.
•    A standardized health assessment and data collection form created by WHO and the DART only reached a few of the rapidly advancing CA Units. As a result, most of the CA health assessments did not follow a standard format. Some CA assessments were 'classified' and therefore became unavailable to humanitarian organizations.  For those assessments which were available, restrictions on the use of military communications channels made it impossible to contact the CA personnel who performed the assessments to obtain clarification or pose additional questions.
•    CA units should have gone through extensive training with standardized health assessment forms with assurance of a two-way communication link with public health experts in the rear. Rapid assessment, survey and surveillance requirements in humanitarian operations demand a coordinated effort by WHO.
•    Pre-conflict planning did not recognize the impact that delays in obtaining a permissive clearance from the HOC to cross into Iraq from Kuwait would have on the health assessment process. With time this situation did improve.
Immediate Relief:
•    Severe looting should have been anticipated by the DoD planners. Looting by both Iraqi civilians and military had occurred after the first Gulf War in Basra in the south and in Dohuk in the north. International relief workers had predicted that looting would occur but their warnings either never reached high echelon levels or were not heeded. This was symptomatic of a lack of military-civilian communications at levels that would have made sharing these concerns possible and credible. The resulting chaos confirmed that the unilateral U.S. military-led relief operation had "relatively untested capacities," 15 and lacked the expertise and resources for a complicated humanitarian effort.
•    U.S. planners had been wrong to assume they would not need the assessments and assistance of the UN and IROs to restore security and public services after the war. ORHA challenged multi-agency support grants in health questioning their political appropriateness and worth. Only as security worsened and health and water and sanitation delays occurred did ORHA seek the UN as a partner.
•    CA units were consistently unable to meet some of the most pressing needs discovered by their rapid health assessments. CA units did not usually have the orders or the necessary personnel or budget to provide large-scale health interventions.  Also, because coalition forces moved rapidly within Iraq, their accompanying CA units may have conducted assessments only to be moved to a new location before they could take any action. As a response to these difficulties, personnel in the HOC attempted to review assessment reports to identify high-priority needs and match available humanitarian resources to those needs; however, many needs identified initially remained unmet.
•    When the DART was eventually placed under administrative control of ORHA, the consequences to staff time and relationships were often wasteful and damaging. Nevertheless, the DART remained effective and efficient in developing and monitoring relief programs especially in southern and northern Iraq. The DART, UNICEF and WHO rapidly worked to re-establish core public health functions: first surveillance, then disease control measures such as vaccination, outbreak control, and a reliable public health laboratory. Attention to other problems, such as access to chronic disease medications, diagnostic and therapeutic equipment such as dialysis, cardiac monitors, and defibrillators, came slowly.  
•    The pre-conflict 10-year experience of WHO and UNICEF in Iraq proved to be invaluable in jump-starting the health and water and sanitation systems.28 Despite poor funding, WHO training of Iraqi nationals in surveillance and outbreak control and the stockpiling of pharmaceuticals and emergency therapeutic centers by UNICEF proved life-saving. Many others remained in a 'catch-up' mode that delayed their ability to optimize their early participation.
•    Security and social disorder became the overriding concern in dealing with health intervention programs and accounted for the failure to rapid return function to clinical and public health facilities.
•    Public health capacity (disease reporting and outbreak investigation) was severely compromised by lack of security.
•    As IROs moved into Iraq, they found that the HOC failed to provide good threat trend and security analyses on which relief agencies depended on to protect their staff. The HOC were challenged to provide credible intelligence to the IROs once conventional combat activities were over and the evolving asymmetrical guerrilla type of warfare emerged. The HOC needs to be able to adjust to evolving operational and security requirements, and must be prepared to provide this non-battle intelligence and communication as an equal priority. What IROs consider critical to daily security decision making, program and living locations, and the hiring and safety of national and expatriate staff differ from that of the military. For some in the NGO community, the failure of the military to be as 'interested and sensitive' to these non-traditional security concerns of the IROs underscored any lingering mistrust they had in the motives of the military. IROs, who employed their own security personnel, attempted to fill in the intelligence and security planning gaps through their own assessments. It would be useful for military intelligence and security elements to work and learn from experienced IRO security personnel who come from a different operational background.
•    DART training was broad and first thought by some to be wasteful. Because two DART members were ambushed early on in Baghdad, the training in anti-terrorism security, security assessments and security communications in adverse environments proved life-saving.
•    There was a limited number of adequately trained Chemical, Biological, Radiation, Nuclear, and Explosive (CBRNE) support staff, equipment and procedural knowledge. Overall, health professionals serving the humanitarian community were not trained to deal with a CBRNE event. Evacuation from the area was the only operational strategy, one which would have ceased humanitarian relief.
•    Unfortunately, this unconventional war in Iraq as well as future complex humanitarian emergencies may still require IROs to train their staff in CBRNE risk assessment. Response planning must occur before deployment. IROs can only remain operational during a conflict if optimal security, protective, decontamination, isolation, and management assets are available.
•    The media, embedded with the military, was preoccupied with the conduct of the war. Once combat was over, there was no plan for the media to engage with the relief community. The media, essential in getting the word out of a collapsing health care system, often remained pre-occupied with rumours of epidemics, participating in exaggerating the gravity of reports of communicable diseases to the level of 'epidemics' and impatiently failing to understand the critical priority of disease investigation and outbreak control before any public health announcement. An accurate media portrayal of the public health situation is critical, especially when no other information system is available. It would serve the humanitarian community well to educate and embed members of the media in future humanitarian operations. 

In the run up to the invasion in Iraq, the U.S. administration's unilateral model gave the task of planning and the execution of humanitarian relief to the DoD. That relief effort is now widely perceived to have been mismanaged.6 It would be best to keep the military out of the humanitarian business as much as possible and leave this task to U.S. agencies that have traditionally handled humanitarian crises and IROs. It is worrisome that DoD does not recognize and support the critical advantages of having the DART function as the U.S. Congress intended under the Foreign Assistance Act (amended 1961) 13. A military-led model runs the risk of sidestepping both OFDA and the DART and sets one standard for humanitarian assistance for war and conflict and another standard for conventional disasters. Arguably, the DART fulfils an essential role as an impartial broker to the IROs that must be maintained. The military should learn to work with the DART and similar agencies and not try to replace them.
The IROs have participated in various political-military-humanitarian models, all having limited success.24 Controversy centers on the appropriateness of combatants assuming traditional roles of IROs such as community projects and food distribution. In future U.S. military-led operations, the IROs should not be marginalized as they were in Iraq. Much work must be done in asserting and educating for the roles that are performed best by the IROs. Somehow, in the planning for Iraq, these IRO capacities were lost to either history or politics. The IROs possess years of humanitarian experience, understand critical cross-cultural issues, work well in a lateral multi-agency environment, and maintain relief-related and field tested resources such as emergency health kits. Their expertise cannot be replaced by marginalizing the IROs and favouring a private sector not yet functioning. This being said, a strong case can be made for reform in the IRO community. In humanitarian missions important inefficiencies remain unsettled. For example, whereas a strong WHO emergency response and surveillance team were sent to Kuwait during the prelude to the war, it was questioned whether this expertise could be sustained during the immediate relief phase by existing WHO country and regional organization personnel. The operational tempo and tenor of emergency missions requires that WHO commit to educate and train multiple emergency response teams to supplement country teams and WHO Regional Organizations during a conflict, provide country wide surveillance and health program coordination, and maintain the functions of a ministry of health when one no longer exists.
What is lacking in the strategies and sharing of information between the DoD and IROs in a military-led relief operation must be the focus in the future of transparent civil-military exercises and training that takes place before the emergency. Exercise scenarios should promote the advantages of lateral communications among agencies especially those that share sector responsibilities such as health and water and sanitation.29
 U.S. State Department assets have extensive experience with relief operations and liaison duties between civilian and military agencies. Indeed, over the years, OFDA and similar agencies such as U.K.'s Department for International Development (DFID) have served as effective liaisons even between military officials of a belligerent party and the IRO community. Such liaisons are particularly crucial in the role where military officers must understand how IROs operate to provide security and security communications to their organizations. Liaison must stress equal representation of the views from both sides, ensure that those in authority understand the mission, charter and capacity of the organization, and utilize only experienced professionals to complete the tasks.29 
     ORHA lost valuable time in turning around the collapsing health system. People in leadership positions must have previous humanitarian, multi-agency and multi-sectoral policy and operational experience. In addition, the humanitarian community has stressed for years the need to minimize bureaucracy to ensure the efficient delivery of relief. ORHA was an additional layer of bureaucracy designed to be a substitute for existing U.S. agencies and was not successful in adding value to the relief process, failed to serve, and generally impeded immediate relief actions.
If the DoD insists on again taking the lead they must do it right. If the military-led humanitarian response is to be attempted in the future then critical questions remain unanswered. Do these personnel have the appropriate multi-sectoral mix required of humanitarian operations? What transition and exit strategies will exist and who will participate? Will there be accountability for actions and who will monitor these? This past decade minimum standards in disaster response and humanitarian assistance, called the Sphere Project, was developed for use by the IROs and donor agencies.30 Will these standards be followed by the new military-led unilateral model?
DoD needs additional active duty CA units, if not, they are at risk of losing this valuable resource through attrition. A call for a major increase in active duty CA units, first endorsed after Somalia in 1993, never materialized.31-33 It is critical, given the excellent track record of CA assets in World War II, the lesson here is not so much what skills, training and levels of presence are necessary as much as they need to be relearned.
 Re-establishing security must take precedence over replacing looted equipment and supplies. Once security allows access, the first priority is always to rehabilitate the public health infrastructure and provide a surveillance mechanism based on outcome indicators.34-35 Knowing this, the early health planning by the DART identified an outcome based health surveillance system as the major public health priority. This was soon dismissed by the post-Dart ORHA health authorities in favour of reporting health performance indicators that emphasized the reopening and stocking of hospitals and clinics as a measure of success. However, the question remains: can more stringent public health surveillance, critical to mitigating mortality and morbidity, be preserved during conflict? Historically, surveillance during conflict has never been fully supported and remains a gap area. The answer is found in evidence-based surveys successfully adapted to a conflict environment.35-37 Pre-Iraq war excess mortality studies in countries in conflict proved worthwhile in discovery of vulnerable populations and the outcome impact of violence on health indices. The recent application of these independent surveys suggests much greater civilian mortality rates than those portrayed in non-independent reports.37 More qualitative surveillance studies suggest a rise in malnutrition and a near doubling of infant mortality rates.38 In a military-led model the current CA assets cannot fulfil all the evidence based assessment and surveillance requirements required for the population they are entrusted to protect. Whatever the outcome, authority to coordinate surveillance should fall to WHO and their emergency response teams.         
As a postscript to the background section of this article, on October 16, 2003, almost 7 months since the beginning of hostilities, the UN Security Council passed Resolution 1511, setting a UN and international framework for security, political and economic progress in Iraq. This was adopted under the previously avoided Chapter VII of the UN Charter and called for the transfer of power from the Coalition Provisional Authority (that replaced ORHA) to the Iraqi people.39 SG Annan delivered a sharply worded criticism claiming that unilateralism posed a serious challenge to UN principles. If this military model of intervention "were to be adopted, it could set precedents that will result in a proliferation of unilateral and lawless use of force, with or without justification." 40
The authors strongly recommend that without a major UN Charter 'responsibility to protect' concept reform, one that addresses capacity to deal appropriately with genocide and internal conflict, confusion will continue to reign. This will allow for future 'right to self defence' responses to be commonplace and risk the ultimate disappearance of the UN.  Reform will not be successful without first addressing the full implementation of a UN Standing Task Force (under UN Charter Chapter VII, Article 43) 41 that enjoys the recognition, integrity, credibility and support of all UN member states. Public health, in whatever model of response prevails, must be seen by a broader humanitarian community, including the military, as a critical strategic and security priority that takes precedence over politics. In relief operations, public health and humanitarian actions are paramount and must never be driven by political motives and ideologies.
The lessons from this experience will have an impact on how relief operations in complex humanitarian crises will be executed in the future. Specifically, relief should be left to those agencies with the expertise. If the military insists on unilateral control, it must develop the capabilities, from leadership to robust CA units and provide the services, such as assessments and threat trends, which are needed. If IROs decide they are going to relate to the military they are going to have to work with them, decide on the ground rules, and then work to build relationships and the prerequisite lateral communications capabilities in order to avoid the problems experienced in Iraq. Without UN reform no model of response will provide the necessary response to internal conflict and genocide.


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