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The Changing Face of Medical
Logistics in Afghanistan

With each succeeding rotation to Operation Enduring Freedom in Afghanistan, troops are assuming more of a support, stability, and nation-building role and less of a combat operation. As a result, processes are in place for organizations sent to Kandahar Airfield to support a more clearly defined nation-building mission. While combat patrols still are dispatched periodically to austere locations such as Deh Rawod, Qalat, and Kandahar City to search for the remnants of the Taliban and Al Qaeda networks, the garrison environment is being improved for the personnel assigned to Kandahar Airfield.

At first glance, all of the construction and changes at Kandahar Airfield yield an impression of chaos. In fact, the chaos is part of a larger plan implemented in a timely and efficient manner. Chang- es within the medical community are part of a plan to create an environment that provides optimal health care for as many people as possible. This plan was embraced by the chains of command of the
Airfield Support Task Force, Brigade Task Force units, and coalition forces operating in and around Kandahar Airfield. Commensurate with the changes to combat health support are changes to the medical logistics support provided at Kanda-har Airfield.

Medical Logistics Organization and Operations

Units assigned or attached to Kandahar Airfield acquire their medical supplies through a medical logistics cell that is staffed by a handful of personnel. From July 2003 to May 2004, the Division Medical Supply Office (DMSO) of the 10th Mountain Division (Light Infantry) Main Support Battalion from Fort Drum, New York, served as a single integrated medical logistics management agency that provided the medical logistics node at Kandahar Airfield. This complement consisted of one senior noncommissioned officer, two medical logistics specialists, and two medical maintenance technicians. This small group was responsible for over 400 lines of supply, including various types of medical materiel ranging from infant medical and surgical supplies to hospital equipment.

The DMSO also managed the logistics requirements of approximately 20 diverse military organizations, including several Army National Guard, Army Reserve, and Active Army and Air Force units; civilian organizations; and independent contractors. Several international forces, such as French and Romanian units, also received medical logistics support through acquisition and cross-servicing agreements (ACSAs). (An ACSA is a legal agreement that establishes a binding contract between U.S. and coalition forces. Title 10 of the U.S. Code prohibits coalition nations from receiving free logistics support from the United States. The ACSA serves as a tool for the United States to be reimbursed for logistics support and services.)

Medical materiel was used frequently in support of humanitarian and civil assistance missions throughout southern Afghanistan, where coalition troops were operating. Routinely, soldiers would travel into communities around Kandahar to provide medical assistance to local people who ordinarily would not have received such care. The medical rules of eligibility for Afghanistan operations, which were established in 2002 by Joint Task Force 180, state that medical materiel can be provided to local nationals under the following conditions—

• Units must obtain approval from the chain of command operating in Afghanistan before using military medical supplies for civilian relief. Exceptions are authorized as emergency measures to relieve starvation and hardship, restore law and order, protect public health, reestablish public services, or restore civil administration. Civil affairs units may distribute medical supplies for civilian relief.

• Minimal expenditures may be incurred for incidental humanitarian medical services provided on a limited basis in conjunction with contingency operations. An example of limited humanitarian medical assistance is a unit medic or doctor examining villagers for a few hours, administering several shots, and issuing some medicine to villagers during a visit.

Strategy for Improving Services

James B. Ayers states in his book, Handbook of Supply Chain Management, that logistics is the part of the supply chain that plans, implements, and controls the efficient, effective flow and storage of goods, services, and related information from the point of origin to the point of consumption in order to meet the customer’s requirements. This requires a strategy for distributing materiel accurately. The failure to implement some form of strategy implies that none exists.

Too often medical logisticians try to be everything good to all of their customers. However, to provide the correct method of delivery of resources, different levels of accessibility must be available for customers. For example, the DMSO allowed units to request supplies in a variety of ways that were not part of their operating procedures, to include paper and pencil orders, email requests, and in-person requests. As Ayers states in his book, “Thinking in terms of supply chain management instead of individual operations or departments [units in this case] leads to more competitive strategies.”

The plan implemented by DMSO to improve the ser-vices it provided was based on four basic steps: obtain storage space, organize existing stocks, identify shortfalls, and order needed materiel.

Obtaining storage space.
Improving available assets and resources became a DMSO priority. The first step was to obtain more storage space. The class VIII (medical materiel) receiving and distribution area was a concrete slab surrounded by a 1,000-square-foot dirt lot. One 60-by-20-foot tent, four 20-foot MILVANs (military-owned de-mountable containers), and two ISU–96 refrigeration units were available for storage. The refrigeration units were unreliable, so parts were being salvaged from one to keep the other running. These storage units provided the only available shelter for storing everything being used by the medical staff. Oxygen, litters, exam gloves, and other supplies were stored outside of these storage units with no protective covering, completely exposed to the elements and the intense heat of Afghanistan, and with no security measures in place for pilferable items.

No tents were available for a warehouse, so DMSO requested six additional 20-foot MILVANs and two 20-foot refrigerated MILVANs. The existing concrete slab was used as a receiving area, and the MILVANs were placed in a row to facilitate access to supplies and improve organization and security.

Organizing existing stocks
The second step was to organize existing stocks. After acquiring the additional MILVANS, one of the logistics soldiers used his carpentry skills to build shelving units inside each of the MILVANS. All chemical defense medications, fluids, and medications requiring cool, dry storage were placed inside the two refrigerated units. Next, all supplies were organized by category of use, such as surgery, fluid management, airway management, and extremity injury management.

In the process of realigning the stocks on hand, many of the supplies were packaged for delivery to a local hospital as part of a humanitarian assistance initiative. Expired drugs and supplies, such as rubber exam gloves that were severely degraded because of prolonged exposure to harsh weather, were identified and packaged for destruction. Other supplies were identified for one-for-one exchanges through the U.S. Army Medical Materiel Center, Europe (USAMMCE) and other organizations. Finally, other supplies were identified for use during local humanitarian assistance visits to villages in support of ongoing brigade-level combat missions.

Identifying shortfalls
. As DMSO personnel filled each MILVAN with available stocks, they identified shortfalls and critiqued the requirements for a variety of physician-preferred items. As First Lieutenant Donald J. McNeil stated in his January–February 2004 Army Logistician article, “A Conventional Class VIII System for an Unconventional War,” “Lack of physician-preferred brands does not constitute a patient risk.”

However, not knowing what stocks are available and what lines of supply are needed within the clinical environment does constitute patient risk. A patient’s death caused by the unavailability of appropriate and necessary supplies is unacceptable. In this respect, the class VIII manager becomes a crisis manager. As McNeil said, “. . . it is okay to have stocks on the shelves; combat health logistics is not just-in-time logistics. A CHL [combat health logistician] does not have the luxury of a 24- to 72-hour turnaround time using a prime vendor, as the medical logistician does in garrison. To avoid becoming a crisis manager, the CHL should establish realistic reorder points to ensure he does not run out of supplies.”

By identifying and having the proper supplies on hand, even if they are viewed as excess by other commodity managers, the medical logistician can help avert crises before they occur. Beneath every seemingly routine medical plan is the possibility of a mass casualty (MASCAL) episode during which the medical system may become overwhelmed with a large number of casualties, stretching routine healthcare assets to the limits. CHLs play a pivotal role in preparing for this type of scenario.

Ordering needed materiel. Shortfalls were defined as depleted supplies, the absence of which would impede the daily operation of the clinic. Included in this list were items such as blankets, intravenous solutions, bandages of various sizes and types, and a variety of bandaging tapes. The DMSO noncommissioned officer in charge also looked at the most recent orders made by maneuver units to determine items needed at forward bases. Their needs included items such as casualty blankets, spine boards, specific drugs for treating various ailments endemic to that region of the world, as well as other durable and expendable goods. Once all shortfalls had been identified, a massive order was entered into the Army Medical Management Information System Customer Assistance Module.
When supply operations in Kandahar became steadier, the support infrastructure and the supply chain management being employed by logistics personnel became more solid. While awaiting the arrival of replenishment stocks, DMSO personnel conducted location surveys and rearranged materiel within the storage facilities, placing items according to available space. When the replenishment stocks began to arrive, materiel was stored according to established locations on file in the medical supply office. Reorder points and stock objectives for replenishments of materiel also were established.

Improved Flow of Class VIII
The flow of medical materiel is becoming more consistent and predictable in Afghanistan and the Kandahar area of operations. Resupply currently flows primarily through Al Udeid, Qatar, or Karshi-Khanabad, Uzbekistan. However, many supplies flow through a medical logistics forward distribution team in Bagram, Afghanistan. The forward distribution team passes stocks flowing from Europe into Southwest Asia for both Operations Enduring Freedom and Iraqi Freedom.

When an order is submitted for replenishing stocks, the CHL can expect to receive the supplies in 2 weeks to a month. Thus, a constant cycle of replenishment is established.

In January 2004, the possibility of a MASCAL became reality when 28 local national victims of an improvised explosive device in Kandahar City came to the Kandahar Airfield clinic for treatment. Ground ambulances brought 21 of the casualties, and medical evacuation helicopters brought in 7 casualties with serious injuries. A MASCAL plan was activated, and medical soldiers treated the casualties—mostly children—with little concern about the types or quantities of materiel being expended.

No area of the clinic ever experienced a shortfall because of a lack of adequate supplies. As soon as the MASCAL ended, the shelves were restocked and the clinic was operational even as the last casualty was being evacuated to the next level of care. CHLs were critical to the success of the event.

Sharing the Plan

The importance of command emphasis to the CHL role at Kandahar Airfield cannot be overstated. As the units assigned to Kandahar Airfield prepared for transition, they shared information with incoming units about the need to include medical logistics personnel in the task organization. Without the proper emphasis by incoming nonmedical chains of command, the CHL system could fail. This would present a serious shortfall for the medical community supporting Kandahar Airfield.

Many changes are still underway for the CHL personnel at Kandahar Airfield. Recently, the medical logistics personnel saw the biggest modification to their normal business operation when 15 pallets of medical supplies arrived at the supply yard on a host-nation tractor-trailer truck in-stead of a military aircraft. After giving this delivery method due consideration, USAMMCE became an advocate of using third-party logistics to expedite the receipt of medical supplies in the theater of operations. From its point of origin in Pirmasens, Germany, materiel flowed by Menlo Worldwide Trucking to Frankfurt, Germany, where it was loaded on an Ariana Afghan Airlines flight to Kabul, Afghanistan. From Kabul, the supplies were loaded onto a truck and brought to Kandahar Airfield. The total shipping time involved from order submission to delivery was approximately 14 days, eliminating approximately 7 days from the delivery process.

Change is happening faster than the CHL personnel expected. Change is good, though, and the CHL community is adapting to the change.A basic concept taught to soldiers is to always leave a place better than you found it. This concept also should hold true during a deployment. The DMSO of the 10th Mountain Division’s Main Support Battalion did just that. They improved the medical logistics area of Kandahar Airfield by organizing and increasing storage facilities and establishing a system for replenishing supplies when they are needed. ALOG

First Lieutenant Jerry D. VanVactor is a Medical Service Corps officer who served as the combat health support officer for the 1st Brigade, 10th Mountain Division (Light Infantry), while deployed to Kandahar, Afghanistan, during Operation Enduring Freedom. He has a bachelor’s degree in health science from Athens State University and a master’s degree in healthcare management from Touro University International. He is a graduate of the Army Medical Department Officer Basic Course and the Support Operations Officer Course.