Today, Conflict Health welcomes a guest post by Captain Crispin Burke. CPT Burke is a US Army Aviator with assignments with the 82nd Airborne Division during Hurricane Katrina, Joint Task Force-Bravo in Honduras, and the 10th Mountain Division in Iraq. He is a contributor to Small Wars Journal and runs his own blog at Wings Over Iraq.

Every commander has his or her particular pet peeves. Mine revolved around immunizations and preventive medicine. So much so that, to this day, I still carry around my yellow shot record in my wallet.

I used to persuade soldiers to get their regular immunizations by claiming that that wars have been lost as a result of poor preventive medicine, with infectious disease, poor sanitation, and immunizations crippling many an army. In fact, as I read last night, it’s quite possible that America might not have won its independence had the British actually took steps to ensure the health of their sailors.

Most Americans know about the American Revolution from grade-school history books, where we learned of thrilling battles at Bunker Hill, Trenton, Saratoga, and finally, at Yorktown. Yet, like many insurgencies, the war was not won on the battlefield; Washington’s Continental Army lost more military battles than they won.

True, the Continental Army owed much of their success to the strategic posturing of France, and overextension on the part of the British armed forces. After all, the Royal Navy in particular was far too small to cover the breadth of the British Empire. Tasked with protecting assets stretching from the home waters of the English Channel, the Carribbean, and the Mediterranean, the Royal Navy was hard-pressed to sustain a blockade off the American coastline, while simultaneously containing the Bourbons (then the ruling power in both France and Spain).

Although Britain successfully undertook a prodigious ship-building effort, her real difficulty lay in recruiting and retaining enough sailors to man ships-of-the-line, frigates, and corvettes. In October 1778, over ten percent of the Royal Navy’s ships-of-the-line lacked the sufficient manpower to put to sea.

These difficulties were compounded by the fact that, though the Royal Navy drafted some 170,000 sailors into service, over 40,000 deserted. Furthermore, another 18,000 sailors–fifteen times the number which perished in battle–succumbed to disease, with scurvy being one of the primary culprits.

Europeans had known of a correlation between the consumption of citrus fruit and the prevention of scurvy since the time of the explorer Vasco de Gama in the late 15th Century. Later, in 1747, the physician James Lind formally documented the link between citrus and scurvy, even proposing a method of preserving lemon juice for long voyages. Indeed, in 1775, as war was breaking out in the Americas, Captain James Cook of the Royal Navy circumnavigated the globe without losing a single man to scurvy, relying on sauerkraut as a source of Vitamin C. Yet the British were slow to adopt regular Vitamin C consumption, and their naval operations suffered greatly. Nearly one-third of British sailors were hospitalized in 1779.

Scurvy hamstrung the Royal Navy’s operation. Upon France’s entry into the war, the British Channel Fleet was thoroughly unable to venture from their home port and provide a consistent blockade of the French port of Brest, a mere 150 miles from Britain. Scurvy caused horrendous attrition among the sailors of the Royal Navy, forcing the British to conduct their blockade from anchorage off the southern coast of England. This permitted a convoy of French frigates and troop ships, led by Charles Hector, Comte d’Estaing, to slip past the British blockade and land a sizable force in the Colonies.

In 1795, over a decade after the British surrender at Yorktown, Sir Gilbert Blaine petitioned the Admiralty to regularly issue lemon juice to British sailors. Within a few years, sickness in the Royal Navy dropped precipitously, with hospitalization rates dropping from one in three in 1779 to one in twenty by 1807.

A healthier force was able to leave Britain and seal off the French coast through long-standing blockades. It was the ability to stay at sea longer, according to British historian Piers Mackesy, which allowed the British to break the naval power of Napoleon.

Which raises the question: would we be living in a far different world had the British had simply taken their vitamins?

Always a sucker for a good war and health related graphic, I can’t help but post about Nightingale’s Rose. The Rose is a graphical representation of William Farr’s mortality data on the Crimean War, drawn by the one and only Florence Nightingale. The chart visualizes infectious disease (in blue), battle casualties (in red), and other deaths (in black).

While interesting, the Nightingale Rose is, for three reasons, far from my favorite visualization of casualty data. First, the wedges are measured from the center (and therefore overlap), however this is not intuitively derived from the graphic itself and thus can easily lead to misinterpretation. Second, as with pie charts, I find it difficult to accurately compare wedges of similar size. Take, for example, the August 1984 1854 and November 1984 1854 blue wedges. Which is larger? Third, the area of each wedge represents its numerical value, however, since this is accomplished by increases the radius of the wedge, the representation takes on an exponential property. For instance, a wedge representing twice as many deaths as another wedge would not have twice the radius. Again, this takes away from the intuitive interpretation of the graphic. Not to say it isn’t still very cool.

This graphic is republished with permission from its creator, Hugh Small.

Note: This is an old post from 2008 that was reposted by accident. But, given that I enjoy visualizations, I am going to call this a fortunate accident.

Edit: Special thanks to Michael for pointing out that the Crimean War did not occur in the year of Reagan’s election.

Last week, the US Navy deployed USNS Mercy on a humanitarian deployment in the Pacific. The news prompted Kyle Mizokami of War Is Boring to rue Japan’s lack of soft-power humanitarian cruises of its own:

Here’s a question: why doesn’t Japan have its own version of the Pacific Partnership? Why doesn’t Japan have two former supertankers, converted to 1,000 bed hospital ships, and sail them from Africa to the South Pacific, delivering non-emergency humanitarian assistance? With its aversion to hard power and immense reservoirs of talent, technology, and cash, Japan should be the absolute king of soft power. Despite that, it displays an utter lack of imagination and a hesitation to copy even highly effective ideas. Yet again it prefers to just lend a hand to the Americans than do anything on its own.

Japan’s lack of hospital ships has nothing to do with a limited imagination or a hesitation to import good ideas from overseas. In fact, many would argue that historically Japan’s power came precisely from its willingness to adopt good ideas from other societies. No, the reason for no Japanese hospital ships rests squarely in Article 9 on the Japanese constitution.

Amongst other things, Article 9 requires that “land, sea, and air forces, as well as other war potential, will never be maintained” by the island nation. In other words, it is illegal for Japan to have a military. The nation’s Self-Defense Force is a civilian organization, with its members even allowed to quit at any time. Article 9 is a security guarantee to Japan’s neighbors. Without a standing military, the thinking goes, Japan can never threaten other countries with war.

What do hospital ships have to do with military aggression? Nearly everything. Hospital ships are an old concept and until a decade ago they had only one purpose: to provide medical supports to military forces on campaign. Floating hospitals are a requirement for amphibious operations. This is precisely the reason USS Kearsarge and USS Boxer, ships built to conduct amphibious landings, are excellent soft power providers: they contain massive medical facilities. These onboard hospitals were not originally designed to provide free surgeries to Nicaraguan children, but to give first rate trauma care to Marines storming the beach.

The building of a Japanese hospital ship could very easily be seen by its neighbors as preparation for a more militarily aggressive foreign policy. Many would argue the same should be said about China’s new hospital ship. Yes, it could conduct soft power operations, but it could also provide vital medical services during any amphibious invasion of Taiwan.

This is the third in an excellent series of guest posts by Paul Rexton Kan. The first and second articles explored drugs in warfare and peak insurgency. Kan also recently contributed to a special issue of Small Wars and Insurgency.

The ongoing drug cartel violence in Mexico took an ominous turn last month. While the killings of two Americans who were consular employees in Ciudad Juarez was a serious escalation, even more troubling was an event that took place several miles away and several days later. Thirty people of the small Mexican town of El Porvenir walked the 860 yards to the US border, crossed it and went to a small Texas town of Ft. Hancock to seek political asylum from an explicit cartel threat. The threat was simple as it was cruel—leave before the outbreak of a gang war or your children will be targets…unless you provide 5000 pesos per child for protection. The gang was able to purge the town of human obstacles and earn money for weapons from those who could afford to pay the extortion money.

Political asylum cases are not new, but those who qualify are targeted for their political beliefs or ethnicity in countries that are typically repressive or coming apart. Mexico is neither and the reason people are being targeted in Mexico by cartels and gangs is not for what they believe or for who they are, but for what they do—police who investigate crimes; mayors who govern towns; journalists who write about the violence. And now people are being targeted merely because they are in the way, because of where they live.

If such acts of criminal cleansing are repeated and sustained, US communities will feel an even greater burden on their systems of public safety and public health from “narco-refugees”.

Given the ever increasing cruelty of the cartels, the question is whether and how the US should begin to prepare for what could be a new wave of people like those whose hometown of El Porvenir is Spanish for “the future”.

The Department of Defense is releasing a new handbook [pdf], but inside you will not learn how to transport a tank, plan an ambush, or jump out of a C-130. Instead, this publication is “a primer for the military about private, voluntary, and nongovernmental organizations operating in humanitarian emergencies globally”. In other words, “humanitarians 101”.

The guide is meant to help familiarize servicemen on the in’s and out’s of NGOs, in turn promoting amicable relations between the two, which have traditionally varied between mild curiosity to outright hostility. The guide’s eighteen chapters cover the gambit of NGO topics from “What is an NGO?”, to non-profit bureaucracy, to humanitarian logistics, to international NGO coordination, to physical security. Overall, the primer offers a fair and largely positive assessment of NGOs and their capabilities, portraying them as nimble, creative if underfunded groups and the “the driving force in deploying humanitarian assistance programs”. Where NGOs stumble says the primer, is logistics and large-scale operations. The most NGOs lack the capacity to manage large, international movement of goods and equipment. Limited resources force NGOs to use off the shelf transportation solutions, cheaper but often unreliable in emergencies. Second, the limited resources of NGOs prohibit most from running country-size programs. While there are coordinating bodies, the fragmented nature of the greater humanitarian community means that “[no] matter how much coordination occurs, NGOs are still individual entities, often both small and private, that act independently during emergencies”, preventing unified, cohesive action.

The primer offers lengthy discussions of ‘typical’ NGO personnel. To its credit, it counters the long held stereotype of aid workers as unprofessional do-gooders, observing that “[t]he days of witnessing untrained and young ‘humanitarians’ attempting to get involved are not over, but now more than ever value is placed on professional operations, experience, protocol, training, and capacity to handle extremely technical tasks in difficult working environments. Advanced degrees and program specialties are major rank indicators and most NGOs found operating in humanitarian emergencies can be trusted to meet their objectives”. NGO personnel are portrayed as professional, experienced and independent. They are free agents operating in a loose organizational structure, “often tasked with responding to the needs of NGO beneficiaries before that of the NGO”. Yet, while highlighting the independent nature of humanitarians, the guide cannot resist offering a laughable guide to the aid worker ‘uniform’:

“That is, there is no easy way to identify NGO personnel. Instead, and to generalize grossly, many NGO personnel wear what has become seemingly if informally standard — multi pocketed vest (normally tan or black), khaki pants, chukka boots, and sometimes a badge with an ID card or insignia. Medical personnel often wear or tote fanny-packs filled with essential tools or medicines, and engineers and logisticians often carry small tool belts.”

Where the guide does falters is in local NGO personnel. Local aid workers are only briefly discussed, yet play a major and growing role in NGO operations. Locals are often hired for their ability to move and operate amongst the population (i.e. no fanny-packs). Thus, in many cases they will be the primary points of contact in the field.

The last chapter contains the primer’s core message: that there are areas of potential, value-added cooperation between humanitarians and the militaries. Specifically, the military can support NGO operations by offering physical security, logistical capacity, and communications. In those three areas the military’s capacity dwarf those in the NGO sector. The primer also explains NGOs reluctance to work with the military, highlighting the value of the USAID OFDA as a civilian middleman between the two sides. NGOs are not going anywhere. The number of humanitarian groups has skyrocketed since World War II. In the foreseeable future, the military is going to have to work closer with NGOs, whether during combat operations in Central Asia or disaster relief in the Caribbean. This new primer is both an acknowledgment that NGOs cannot be ignored and an argument for greater cooperation.

You can download a pre-release draft here [pdf].

On May 14th, 1943, AHS Centaur, an Australia hospital ship sailed off the coast of Queensland towards Port Moresby in Papua New Guinea. The ship had 332 medical personnel and crew on board. She was marked with large red crosses and sailed without military escort as per the Geneva Convention requirements. The vessel would not survive to see dawn. The Japanese submarine I-177, commanded by Hajime Nakagawa, torpedoed AHS Centaur in an early morning attack, taking 268 lives. Now, the discovery of her wreck on December 20th has resurfaced the sensitive issue between Australia and Japan.

The sinking of AHS Centaur violated international war law and is considered one of Australia’s worst wartime tragedies. Her demise turned the vessel into a martyr for Australians, confirming the brutality of the Japanese in the public’s mind. General Douglas MacArthur claimed the attack showed the “limitless savagery” of the Japanese. The Australian government used the sinking to enrage public opinion and rally Australians in support for the war effort.

I-177’s captain was never tried for the sinking, but was convicted on other war crimes by the Allies. The attack has long been a sore subject for the Japanese, who only acknowledged in 1979 that I-177 did indeed sink the hospital ship, after denying involvement since 1943. Furthermore, Tokyo claims it never ordered the attack, a fact if false would likely lead to Australian pressure for additional war crime charges. In a statement on the search for AHS Centaur, Japan said it “made the greatest efforts for world peace and prosperity as a responsible member of the international community and has also developed a close relationship with Australia.” To their credit, the Centaur Association, the RSL, and the Department of Foreign Affairs and Trade have all made statements that Japan does not need to apology for the sinking of AHS Centaur. Apparently 66 years of good relations is enough time for some countries to let history be history.

For decades demographers and epidemiologists have observed a peculiar phenomenon during and after war. In these times, the ratio of male to female newborns shifts ever so slightly towards the former. In other words: more boys are born during and soon after wars. The change is slight, MacMahon and Pugh’s 1954 study finds one sex ratio shifted from 51.406 to 51.481 after WWII.

A number of theories explaining this ‘returning shoulder effect’ have been posited. One in particular has potential broader application in conflict research. Satoshi Kanazawa of the London School of Economics and Politics argues that the phenomenon is a “byproduct of the fact that taller soldiers are more likely to survive battle and that taller parents are more likely to have sons”.

Kanazawa tests his theory by examining the height of a non-random sample of British enlisted men serving in WWI. More specifically, Kanazawa draws his sample from only one of the 23,608 reels of microfiche at the UK National Archives. Since the reels are organized by last name, his sample contains only soldiers with the names Ababreltom to Ablett. Methodological problems of a non-random sample aside, the author finds supportive results: “The surviving soldiers in my sample have a significantly higher mean height than fallen soldiers”. Since height is positively related to the probability of having a son, war would have a positive relationship on the number of male births after intense conflict.

While Kanazawa resists providing a theory on why taller soldiers are more likely to survive warfare, he does offer some possibilities. First, taller and larger soldiers are more resilient to disease and wounding. Second, since height is related to intelligence, taller soldiers would be more likely to rise in the ranks and avoid the most dangerous duties. Third, and my personal favorite:

Dominic D. P. Johnson suggests another interesting hypothesis. If vital organs in the body do not increase in size linearly with the body size (height and weight), then it means that taller and heavier soldiers, while they may be more likely to be shot because of their larger body size, have nonetheless more room in their body where they can be ‘safely’ shot and still survive the injury.

Beyond explaining the returning soldier effect, the article is a reminder that even among similarly aged enlisted soldiers, war does not try men equally. Armies are not unitary objects, but organizations of individuals facing individualized risk. The same argument can be applied to civilian populations. Warfare’s effect and risk is unique to the person. Populations face war as individuals.

Update: Eduardo Leoni points out that a data scientist I respect very much has serious questions about Kanazawa’s statistics in this and similar papers.

Sources

Kanazawa, Satoshi. 2007. “Big and tall soldiers are more likely to survive battle: a possible explanation for the ‘returning soldier effect’ on the secondary sex ratio.” Hum. Reprod. 22(11): 3002-3008.

Last week, President Obama announced the deployment of 30,000 additional troops to Afghanistan. The troop surge is part of a new strategy set forth by General Stanley A. McChrystal. The strategy shifts focus from kinetic to non-kinetic operations: protecting civilians, development projects, and winnings hearts and minds. It will be central to America’s operations in Afghanistan for years to come, and even the basis for an American endgame there. Army, Marine, and Air Force roles in the McChrystal approach are clear. The former two are boots on the ground, while the latter provides logistical, intelligence, and combat support. The Navy, however, appears to have little place in this new strategy. The Navy’s primary contribution so far has been combat air support. But, airstrikes have fallen out of favor in Afghanistan as of late due to mounting civilian casualties. McChrystal’s new strategy should worry the Navy leadership, since Secretary of Defense Gates has demonstrated a strong preference for funding programs with applications in current conflicts, and a willingness to cut programs failing that criteria (and more importantly: to fight legislators’ attempts to block cuts). Does the Navy have a place in McChrystal’s war? Yes, but not without some soul-searching.

The Navy can play a significant role in McChrystal’s strategy. Every year, thousands of sailors deploy on humanitarian, development, and disaster relief operations around the world. Sailors have repaired schools in the Pacific, organized health clinics in South America, and delivered disaster aid in the Caribbean. These operations are outside traditional military education and have required developing a new set of skills, notably the ability to plan and work side by side with different services, agencies, governments, and NGO partners. The missions have given the Navy hard won experience adapting military resources to humanitarian, development, and disaster relief challenges. This is particularly true of short term, high impact programs, the type of military involvement in development envisioned by Secretary of Defense Gates. The Navy could have precisely the type of soft-power experience McChrystal’s Afghanistan strategy requires.

The main obstacle to a major Navy role in Afghanistan is not material, but cultural. The Navy’s leadership is dominated by line officers. This perpetuates an institutional culture valuing warships and warplanes. However, the enemy has neither fleet or coastline. All the carrier strike groups in the world will not find victory in the mountains of Afghanistan. To win over the hearts and minds, McChrystal’s strategy requires a surge of a new sort: of nurses, doctors, dentists, engineers, and civil-affairs units, the domain of the staff corp officer. While staff corp officers have a secondary role in the Navy’s traditional warfighting focus, they have played a major part in the Navy’s humanitarian and development cruises. Staff corp officers might not be able to plan a defense of the North Atlantic, but they can run health clinics, manage construction projects, and coordinate with NGOs. They are America’s soft-power specialists. If the Navy is going to take advantage of the humanitarian and development institutional knowledge of its staff corp officers, it must overcome its cultural biases towards the interests of line officers. In the 1980s, the Soviet Army learned that Afghanistan was not the Fulda Gap. Now, the US Navy must accept it is not the Taiwan Strait either.

Last week, Jeremy Scahill of The Nation claimed Blackwater (Xe) contractors run covert snatch and grab missions out of Karachi for the US military. It is a great piece to read over turkey leftovers. Scahill’s claims of private black operations in AfPak has inspired comment by every pundit with a tangental relationship to national security. In addition, the article has triggered a second firestorm in the humanitarian and development communities over allegation that Blackwater employees “work undercover as aid workers”. Una Vera, a good friend in the aid community, responded to the story this way: “This is going to be ruinous. I’m so angry I’m literally at a loss for words now”.

Personally, I am amazed either of Scahill’s claims surprised people. First, PMC contracting is a common method of working under the radar. Granted, the majority of these contracts involve training and not ‘tip of the spear’ missions, but still there is little doubt they happen. Second, and relevant to this site, who else is an undercover team of burly westerners going to pose as? Tourists? Exchange students?

The truth is that posing as aid workers is a nothing new. During a daring hostage rescue of FARC hostages, Colombian special forces dressed up as members of a fake NGO, “Mision Internacional Humanitaria”. Some accounts even claim the special forces wore ICRC armbands, a clear violation of the Geneva Convention. In 2006, Kruma Yaya posed as an Afghani aid worker setting up a computer science training during an attempted suicide assassination of the regional governor. Even journalist admit posing as aid workers.

This is not to say posing as aid workers is right. The practice has real dangers for humanitarians in the field. But, it is not a revolutionary tactic, or even a new one.

Update: Una Vera has more at Change.org.

Two former Zambian Air Force officers are suing the country’s military, claiming to have been tested for HIV without their knowledge. Military HIV testing is voluntary in Zambia. The military argues they discharged the two officers for other medical conditions (cancer and TB).

Both were put through medical tests in 2001 that they believed were routine check-ups, after which they were put on medication.

Much later, both men volunteered to be tested for HIV and claim it was only then that they were told that the drugs they had been taking were anti-retrovirals.

The case is bringing the debate over mandatory HIV screening in Zambia back into the public debate. Opponents claim mandatory screening is a violation of human rights. Proponents argue it is a public health necessity.