Corporate Travel Medicine—Priorities & Models - Panel Discussion, April 27, 2000

Sudershan Narula, MD, Deputy Medical Director, United Nations

DR. LIESE: Dr Narula has been dealing with medical evacuation, field staff and the United Nations peacekeeping operations for the last year. We have very close contacts here at the Bank with the UN and we all know Dr. Narula very well.

Sudershan, it is yours.

DR. NARULA: Thank you.

I really don't know why I am here because my presentation is very, very different than what everybody has talked about. You have excellent research papers and mine is not a research.

What I am going to say is what we do on a daily basis as a Medical Service Division at the United Nations. Among many other functions, we provide medical support to all of our peacekeeping missions.

So, basically, I am here to summarize what our Division does there. At the end, if you have any questions, please confine them to medical or medical policy questions and not political or legal questions.

As we say in New York at the United Nations, as soon as the Security Council adopts a resolution that we are going to have a new peacekeeping mission and that is the country where, we, the Medical Services, have to start planning for medical support.

Our division is responsible and we ensure that all personnel deployed to all the peacekeeping, humanitarian and political missions have adequate medical support before they are deployed there. As of 31 March 2000, the UN had 32 field missions though not all of them are peacekeeping missions, we in Medical Services provide equal support to all of them.

We have a total of about 60,000 personnel who have been authorized, as of 31st March to be deployed or have already been deployed as peacekeepers. If we try to break down and see what these components are, they can be divided into three major components, though every mission doesn't have all of them. You will find that we have many missions with troops and at present we have about 34,000 troops that are all UN troops and these are troops provided by troop-contributing-countries. These are the member states who provide us troops.

Then, we have the second component (military observers and civilian police monitors), which is over 10,000 who are coming individually as experts. The troops are coming with their formed medical units, but the experts are coming as individuals contributed by different member states. Then we have the civilian component, which is about 15,000 UN staff members.

These 15,000 are actually assigned in those missions. Their assignment is usually from six months to two years or maybe sometimes until the end of the mission. So, basically, we have to prepare all of these peacekeepers to go to those missions, not only prepare them but we also have medically speaking to prepare those missions, to make sure that peacekeepers have some kind of medical support before they are deployed there.

What you are talking here in this Travel Symposium is the frequent business traveler. For the UN, the staff members who will be visiting these missions frequently for short periods from New York, including physicians from our own division, could fall into that category. But most of the staff members are going to be assigned there, as I said, at least for a minimum of six months.

We can put in these five groups—the role that our division plays in support of these peacekeeping missions. First and foremost is planning of the medical support. We are involved right from the planning stage of the mission and our role continues long after a mission has been closed.

The first role is planning the medical support; second is our advice on different levels of medical support that the UN itself should provide; third, we prepare the vaccination schedule and malarial prophylaxis specific to that particular mission. Then, we determine the medical fitness of all civilians, military observers and civilian police experts to be deployed to those missions. Finally we also provide services to personnel leaving from or through UN headquarters.

What planning entails is, as soon as the mission has been decided, a technical survey team goes to each of the mission sites to decide what kind of medical support the UN has to provide to them. I recently returned from one technical survey, as part of a technical survey team to the Democratic Republic of Congo, which is going to be our next big mission.

So, one of us visits that mission area as part of the technical survey team, and we also collect all possible information.

So, when we go to visit any of those mission areas, we are looking at all medical facilities that are already available in that country. We don't want to duplicate; we don't want the UN to provide medical facilities if there are host nation facilities that we can use. So, that is where we start from.

We look at the host nation facilities such as government facilities, military facilities or even from some NGOs, with whom we can have some paid service arrangements or some kind of an understanding. So, we try to get the maximum from the host nation if the host nation has the capacity to provide it.

During that survey, we not only look at that country, but we try to look at the countries around it. If we can find one good city where they have adequate medical facilities, then peacekeepers can be evacuated to the city and receive medical care beyond the capabilities of what we have provided them in that mission area.

Once we have gone in and once we had looked at the medical facilities and collected all the information—that information could be from WHO, from the local doctors, or from any source—then we come up with what kind of medical support the UN is going to provide before the UN peacekeepers are deployed.

This medical support planning will be different if our mission has its own troops or if this is a mission without troops. If we have a mission with UN troops, the troops are going as formed military units that are going to carry with them the medical capability that they are supposed to have with them wherever they go. So they donÕt depend on the local facilities for that level of medical care.

If we have any missions with troops—and good examples of missions with troops at present are those in East Timor, Sierra Leone, South Lebanon, and then we are going to have one in the Democratic Republic of Congo.

When troops are coming, they will bring a level one medical facility if they are coming as UN battalions. Level one means capability of providing the basic care plus resuscitation.

They will bring this for themselves; that is the battalion will have enough level one capability for themselves and they should also have support, logistic support, to transfer their troops from level one to a level two facility.

Even though they bring this level one facility only for themselves, the UN ensures that they also provide medical support to any civilians who are posted in that area, because this civilian component is to support military in performing their functions, basically the peacekeeping function.

Then, if the military is coming at brigade level, they will be bringing level two medical facility. Level two has level one, plus surgery for emergencies, as we call it surgery for life or limb saving. Then, we have level three. Level three is either provided by the host nation or the UN goes to all the member states requesting for a level three hospital, and this level three hospital is deployed at the mission headquarters.

As you all know, peacekeeping has expanded since 1992, and initially these level three field hospitals were mostly staffed by doctors specializing in trauma. Mostly, they were surgeons and anesthesiologists. But over the years, we have realized that we needed more broad specializations in those areas. So, the UN has requested for tropical disease specialists, psychiatrists, and general physicians. And now, at the request of our female staff members, even female gynecologists are being added to the staff of these level three field hospitals.

So, this is what the planning entails when we have a mission with troops. But then, we have many missions where there are no UN soldiers; there could be NATO soldiers, there could be soldiers from other countries, but no UN soldiers. These are mostly referred to as observer missions. Bosnia is a good example of such a mission.

So, in these observer missions we are not getting any of the formed units. So, nothing is coming, especially for level one medical care. So, the UN provides a few physicians. We open small civilian clinics in mission, one could be at the headquarters and a couple of them could be at the sector headquarters of that mission. We ensure level one by providing them with our own physicians and nurses. Level two and three could be provided by the host nation or the UN can again request for a level two or three hospital from one of the member states. Level four, which is to a definite care, in both of these situations, is usually provided by their own countries, if the country has that capability.

So, while we are planning on the kind of medical support the UN is going to provide, we simultaneously identify the kind of immunization and malaria prophylaxis we are going to come up with for that particular mission. As I said earlier, this is done in consultation with WHO country office, WHO Geneva, and also with CDC, and through our own personal visits where we talk to local physicians.

Once we have come up with the mission-specific list of what immunization and malaria prophylaxis we are going to recommend to those missions, we send that list through the UN permanent missions to all troop-contributing nations that ensures a standardized policy for vaccinations that are being given.

Member states/the troop-contributing countries can give more than what we recommend Š we require only the minimum requested. Then, we use the same list of vaccinations for staff who are going from New York or are passing through New York. So, this is all still at the planning stage.

The other responsibility we have at the Medical Services Division is to determine medical fitness of all those who are going to be deployed to those peacekeeping missions. We determine medical fitness for all civilians, all military observers and all civilian policy monitors. Many of these civilians we examine ourselves if they are going through New York or they are going from New York. But, for the second and third component we only base our judgment on the medical exam reports that are forwarded to us. So it is mostly clearance on papers based on whatever medical information we get.

When determining medical fitness, we take into consideration the medical facilities of that peacekeeping mission, other hardships of that mission, and endemic diseases. When a mission is well established and its medical support is well functioning, we are not very strict in providing medical clearance. But, in the beginning of the mission, when there is usually nothing available, we are very, very strict about that.

We do not provide medical clearance to UN troops. They are cleared by their own nations, but we do provide them what we call UN medical standards; that is the least they should comply with. As I said, they can have their stricter standards. Not that every country is complying with those standards, but we do provide them with the standards, and that is still in the planning stage.

We also have an HIV/AIDS policy for peace-keeping missions and this question is asked periodically from us as to how we are dealing with this issue. Do we let peace-keepers with HIV positive status, be deployed to these missions?

As a UN policy we don't ask for testing. There is no mandatory testing, whether you are going to be recruited for any UN position or you are going to be a peacekeeper with the UN or for the UN troops going to those field missions.

But there are many troop-contributing-nations who test their soldiers before they go to these peace-keeping missions and subsequently exclude those who are positive. But, as I said, it is their own national policy, not the UN policy.

But if they are found to be positive while serving in the mission, we don't repatriate them unless they have AIDS or some other medical condition which was a reason for them to be medically repatriated.

But the UN is involved in a big way in the HIV/AIDS awareness/prevention training program, to sensitize all the peacekeepers. The Department of Peacekeeping Operations conducts these training programs for troop-contributing-countries, and also provide training material if necessary. Once the peace-keepers are being deployed, they are provided with personal pocketbooks, which has health educational material on how to protect yourself from getting HIV infection.

So far I have discussed our planning issues. What are we doing on a daily basis when we are sitting in New York and staff are traveling from New York, following are the services we provide to them? We can divide them into five categories.

Firstly, there are mission readiness workshops. These workshops are although organized by our Training Division, a physician is always included in the workshops. The mission readiness workshops are conducted periodically. They could be held once in three months but they are not mission-specific. These are intended for people who are planning to go to these peacekeeping missions or they have been on a few missions and they want to be better prepared for the next one.

The mission readiness workshop deals with many different issues, since many of these travelers are not frequent travelers but once they travel they will have to be staying in the mission for at least six months. So, they are being prepared how financially to look after themselves and their families in their absence when they are away on those missions. So, there is an exhaustive check list that they go through, and thus they are really well prepared before they leave. And we look after the medical component of that readiness workshop. We let them know about the kind of medical exams they should undergo before they leave, what they should carry with them and also tell them what medical facilities to expect in those missions and also to somehow assure them that a medical evacuation will be carried out if there is a medical problem while they are out there.

I think once they know there is an established system, somehow, it does give them a sense of relief that they can go and somebody in New York can be called and an air ambulance will be sent if there is a serious accident/illness.

Then, we have individual briefings which are to the staff going to a particular mission. So, these are very mission specific briefings. Again, we talk about the similar issues but pertaining to that particular mission and we give them health education materials and also how to protect themselves from sexually-transmitted diseases, among many other things.

We also provide them vaccinations and medical kits.

Once the mission has been established and the peace-keepers have started working there, what role are we playing? Whether they can keep peace or not, I mean, that is not our job. As I said earlier, there should not be any political questions to me. But once they are there, what role does the Medical Services Division play?

We are largely involved in medical evacuations and repatriations from those mission areas. Repatriation is the word used when the troops/ military observers/civilian police cannot function because of an illness/injury and we send them back home. Once we know that they will not be able to return to duty for the next 28 days or the type of medical care that they need cannot be provided by in the mission area, they are repatriated, and otherwise all peace-keepers are medically evacuated to one of the region's medical evacuation centers.

And I think on average we have about ten medical evacuations a day, which are not only for peacekeeping but also from other UN agencies posted in field duty stations.

We advise on compensation claims. These are work-related compensation claims due to injuries or illnesses peacekeepers develop when they were working for the organization.

We also perform post-mission medical checkups of those who are returning from the missions and, as and when requested, we travel to those missions.

These two bars tell us about medical evacuations and repatriations that we had in 1998 and in 1999. As you can see, number one is trauma. Most of the cases that we evacuated or repatriated because of trauma, which can be a motor vehicle accident, a gunshot wound, a helicopter accident, and so on.

Then, we had a good number of evacuations for psychological reasons, and a big number of cardiovascular diseases. These are the people who had pre-existing conditions.

But basically, when you are you looking for the prevention part of it, where we can really have an input if we want to prevent is going to be in trauma, where we can minimize the harm, or in the psychiatric cases.

And I think that should be our focus. If we really want to minimize, that should be our focus.

Okay. This is my last slide, just to let you know that most of the claims that we get are because of the accidents and because of the post-traumatic stress disorders.

Thank you.

[APPLAUSE]

DR. LIESE: Thank you very much, Sudershan, for this very different perspective of people who are traveling into real hardship areas. They are not business travelers in that sense. They are different business travelers; let me put it this way.

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