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Ee Afghanistan Ast: Medical Logistics Mentoring in the Afghan National Army

As part of a joint medical logistics embedded training team (ETT), I spent a year in Afghanistan mentoring members of the Afghan National Army (ANA). Our 10-member team, which included 4 U.S. Soldiers, 4 U.S. Airmen, 1 Afghan civilian, and 1 ANA medical logistics officer, was assigned to the Combined Security Transition Command-Afghanistan (CSTC–A) Command Surgeon’s Office in Kabul. The CSTC–A provides mentors to assist the Afghan Ministry of Defense in training, equipping, and employing Afghan National Security Forces (ANSF) so that they can defeat insurgencies and provide security for the citizens of Afghanistan.

Our mission was to facilitate the operation of the ANA Medical Stocks Command in order to ensure that its regional medical depots received proper health services materiel support, including materiel management, stock control, storage, shipping and receiving, and biomaintenance support. As mentors, we were there to train ANA personnel in the art of medical logistics so that one day they would be able to run the depots without assistance.

In a typical week, our ETT would brief the ANA Force Modernization G–4 at the Ministry of Defense, conduct classes on managing temperature-sensitive medical supplies (cold-chain management) at the Medical Stocks Command, conduct convoys throughout the city (and quickly navigate to alternate routes when improvised explosive devices changed our plans), referee disputes with antagonistic commercial vendors at the medical depot, and facilitate the development of products like the Afghan first aid kit.

Techniques for Success

Adhering to the tenets of multinational operations in Joint Publication 3–16, Multinational Operations, was critical to our success in Afghanistan. Although the manual is written from the perspective of working with allies in a joint and multinational campaign, we applied it to our role as mentors to the ANA. Respect, rapport, knowledge of partners, patience, and making the most of interpreters proved to be keys to our success.

Respect. Respecting our Afghan colleagues came from seeking to understand their culture, history, religion, values, and customs. Since very little of this knowledge was provided in a formal educational setting, we gained it through extensive reading and experience. I read a multitude of books exposing me to Islam and Afghanistan’s rich history and culture. For example, I learned that proverbs and metaphors are valued in Afghan society because of their simple conveyance of a deep idea or thought. In the West, we tend to marginalize proverbs as simple, but when one masters a proverb in Dari, the world is open to his influence. Understanding and a healthy dose of mutual respect go a long way toward creating an environment where partners can achieve great things. When U.S. mentors have disdain for their Afghan colleagues, it is often evident in their lack of mission achievement.

Rapport. Building rapport is an investment and therefore takes times. Greeting with a kiss and humble hand to the heart allowed me to gain the confidence of many Afghans. Family is very important to Afghans, so I showed them pictures of my immediate and extended family and inquired about theirs during our first conversations. Small talk over several cups of chai tea built a foundation for future dialogue. The teamwork that ensued was invaluable to our mutual accomplishments.

Knowledge of partners. Just as a good leader should know himself and a good commander should know his enemy, a good mentor should know his partners. Our Afghan brothers were part of our team. We sought to use their knowledge and cultural views to help us accomplish missions. Understanding their perspective and abilities allowed us to concentrate our efforts to produce effects with the most long-term benefits.

Patience. Patience is a required skill in mentoring Afghan soldiers. In general, Americans tend to be very results-oriented and expect immediate gratification—in essence, impatient. One could easily tell that our Afghan colleagues did not operate with a sense of urgency. Their work habits were developed within their cultural views, not ours. Yes, the Americans probably could have quickly produced near-perfect products by doing it themselves, but that was not the point. Since everything we did was designed to mold a self-sufficient organization, it had to be a group effort. And partnerships take time to develop.

Making the most of interpreters. The most important asset we had in training the Afghans for success was our interpreters. Interpreters should be treated well because they hold the knowledge required to build better partnerships with the mentees. We were blessed to develop habitual relationships with very competent and hardworking interpreters. Mission continuity, better situational awareness, and technical understanding resulted from continuously using the same interpreters. When it was feasible before a meeting or daily mission, an interpreter and I would go over the subjects I planned to discuss with the ANA. This helped to build upon previous coordination and minimize the possibility of miscommunication.

Challenges

Working in a joint environment was something new for each of the U.S. Soldiers. Since half of the medical logistics ETT personnel and half of our surgeon’s cell leaders were Air Force, I learned a lot about working with our sister service. Their expertise was exceptional, but Airmen generally tend to complete projects differently than Soldiers. Our Air Force teammates previously had operated in environments where they managed projects as individuals; the Army tends to operate in teams. Although this was not a huge sticking point for us, we did pause to discuss the differences and how we would proceed with our tasks.

From an Army perspective, it concerned us when we realized that the echelons-above-corps and corps-and-below ETTs were filled with non-Army mentors. Navy and Air Force personnel have begun to occupy Army-centric slots in Afghanistan as “in lieu of” fillers. Yes, healthcare is healthcare in a garrison setting, but land warfare doctrine training for a land component force (which the ANA happens to be) is very different from air and sea doctrine. This observation can be applied to all mentoring missions currently operating in Afghanistan—not just medical mentoring missions.

Another challenge was balancing our time between the requirements of staff work inherent in a joint environment and the actual hands-on mentoring of our Afghan colleagues. Without a doubt, facilitating ANA hospital and clinic openings, conducting logistics staff work, and providing staff assistance visits to the regional medical ETTs were critical. Our challenge was prioritizing our mentoring and infrastructure-building responsibilities and our staff work. We wrestled with it daily. Eventually, we sorted out the differing roles in our staff lanes. However, we observed that equipment and materiel fielding may be better accomplished by a separate team dedicated to equipment fielding and deployment.

Taking time for ourselves and putting everything in perspective was essential to avoiding burnout. Constantly being asked to solve problems or provide materiel every time we stepped outside the wire became very draining. Everywhere we went, Afghan civilians and military personnel would crowd around and seek something. They reminded me of crowds closely following some celebrity healer and wishing to merely touch his cloak so that they may be healed. We commonly heard, “You are Americans and will solve our problems.” Sure, maybe we could fix everything immediately, but that was not our mission. After pleas for help, we had to take a step back, encourage self-help, and provide tools to accomplish the task. It was the slow way but also the right way. To combat the potential for burnout, we tried to incorporate some down time. The Afghans celebrate the Sabbath on Fridays, which were also our lowest battle rhythm days. The ANA was off on Fridays, so we had no one to mentor. Using this time for individual recuperation and protecting it for the team became critical.

Lack of continuity and different funding streams often created situations where we had lots of money for supplies, but no money for a building to store them. The American tendency to put the cart before the horse was a constant challenge. The Afghans have a proverb that loosely translates as “Before you buy an elephant, you must build the elephant’s house.” We helped prevent future homeless elephants by focusing on the big projects’ second- and third-order effects. Creative ideas and resource sharing helped alleviate a lot of the problems.

Seed Sowing

That year in Afghanistan was marked by the emerging independence of the ANA Medical Stocks Command. Borrowing from the Afghan practice of creating metaphors and proverbs, I will explain our efforts to guide the ANA toward independence using a farming metaphor. As mentors, our team sowed seeds for future development and accomplishment in the ANA medical community. Our success at seed sowing can be measured by the fruits of the medical logistics ETT and our Afghan colleagues’ labor. We planted many seeds for future success, like when we opened the regional medical depots and the regional military hospitals. The most strategic measures—nation-building measures—are focused on outcome rather than input.

The Mazar-e-Sharif Regional Medical Depot and Military Hospital were opened in March 2007. The medical logistics ETT fielded hospital furniture, medical equipment, and supplies (including consumables) valued at $6.5 million for the hospital. They also established and trained the Afghan commander and quartermasters on their first-ever property book and key control system for their $2 million inventory. Within the depot, the quartermasters were trained in establishing supply accountability and hand-receipt management.

The Kandahar Regional Medical Depot became operational in June 2007. In preparation for the opening, the medical logistics ETT also established a property book with corresponding hand receipts for $2 million worth of inventory. As in Mazar, Kandahar’s $6.5 million fielding package consisted of furniture, medical equipment, and consumable medical supplies. The Kandahar Regional Military Hospital also opened a few months later.

Numerous clinics throughout Afghanistan were fielded that year. The National Military Hospital received its first-ever computed tomography (CT) scanner, valued at $1.1 million. The biomedical maintenance experts from the medical logistics ETT facilitated its installation. The Medical Stocks Command depot received pallet risers for the “clamshell” shelter (see photos below) and shelving for CONEX (container express) containers.

In addition to the medical supplies and equipment required for garrison support, we continued to field corps medical equipment sets (MESs) throughout the year. Together with the Medical Stocks Command, the medical logistics ETT received, segregated, and shipped 400 combat medic bags for the 5 ANA corps across Afghanistan. The ANA went from having 32 percent of the required authorized sets on hand to 100 percent. Another 939 MESs, made up of dental, ground ambulance, patient holding, preventive medicine, sick call, and trauma supplies, were ordered and scheduled for delivery in the next fiscal year. These sets would fill the remaining requirements for each ANA corps and separate commando battalion so that they would have 100 percent of the authorized sets on hand.

The ETT also launched training classes held every other Thursday at the Medical Stocks Command headquarters. The classes covered fundamentals of materiel management and inventory control. These courses became the model for further local training at regional hospitals throughout the Medical Command.

Blossoming Fruit

The most important changes that occurred that year involved the ANA’s independence from its U.S. and coalition partners. The ANA no longer depends on its partners to coordinate many common tasks. For example, cold-chain-managed items (such as blood, vaccines, and lab reagents) can now be rapidly distributed using fixed- and rotary-wing assets from the ANA Air Corps. Responsibilities like scheduling and coordinating deliveries and palletizing equipment for air shipment have been passed from U.S. and coalition forces to the ANA.

The ANA now handles ground deliveries as well. All medical supplies and equipment are routinely coordinated and shipped using the ANA Logistics Command’s (LOGCOM’s) Central Movement Agency vehicles, which pick up the supplies and transport them in LOGCOM convoys to each regional medical depot and forward supply depot.

Routine vehicle services and special coordination for contracted maintenance teams are now arranged between the ANA maintenance contractor and the Medical Stocks Command transportation officer. ANA Medical Stocks Command staff members coordinate with contractor personnel to receive, sign for, and distribute equipment and supplies at the off-site overflow warehouse at Camp Dogan. All ANA MESs arriving from the U.S. Army Medical Materiel Center-Europe in Germany are accounted for and distributed to each corps within ANA channels.

The medical logistics ETT made nine specific recommendations for medical logistics improvements within the ANA Medical Command. On 9 October 2007, the ANA Surgeon General approved the following recommendations to revamp class VIII (medical materiel) management within the Medical Command—

  • Appoint wardmasters on orders, and train them on logistics procedures.
  • Create pre-approved stockage lists of items and quantities at the ward level within each hospital, and review them quarterly.
  • Differentiate the duties of the pharmacists and medical logistics officer.
  • Establish document numbers, a signature card system, and a customer dueout system according to the Ministry of Defense (MOD) Logistics Decree 4.0.
  • Track customer order history, and establish 30 days of supply at each hospital and 60 days of supply at each depot.
  • Approve and distribute standing operating procedures for the Medical Stocks Command.
  • Use the newly formed Medical Support Command’s vehicles to pick up and deliver medical supplies within the Kabul area on a weekly basis.
  • Designate the ANA Surgeon General to either assume management of the class VIII depot at LOGCOM or rebuild the Medical Stocks Command (which is currently just a clamshell and a few CONEXs) so that it can function as a true warehouse operation.
  • Designate the ANA Office of the Surgeon General’s Directorate of Medical Logistics as the approving authority for MOD Form 14, a materiel and request document, and MOD Form 9, an issuing and turn in document. Give the surgeon general oversight through the annual command inspection program. MOD Form 9s should be signed and reviewed quarterly.

The emerging independence of the ANA is significant. The process was painstaking, but future generations will benefit. We often said that our success will be measured by whether or not our children would be in Afghanistan mentoring the ANA. When the ANA can function without our assistance, we can be called successful and my children can be tourists and not mentors.

Strategic Future

The current Medical Stocks Command headquarters has no warehouse on location. The headquarters, which has been storing supplies in a clamshell shelter and CONEXs that have reached their storage capacities, began construction of a warehouse. The new warehouse will accommodate biomedical engineering and materiel management functions and will have administrative and classroom space. The ANA also will remove the materiel from “the pit” that is adjacent to the incomplete structure at the depot. The pit was originally a graveyard that had been excavated by the Soviet Army to build a KGB hospital. The Soviet Army abandoned the construction and left behind their ruined medical equipment, and the construction site became a dumping ground for unsalvageable materiel. (See photo below.)

A performance work statement (PWS) has been written for the future ANA Medical Logistics Course. The course will consolidate information from current ANA regulations found in MOD Logistics Decrees 4.0 and 4.2 and from the approved program of instruction for the U.S. Army’s Health Services Materiel Officer Course. The Biomedical Maintenance Course PWS has also been written. The largest obstacle in this endeavor will be the purchase of training equipment and its subsequent storage.

Our Afghan colleagues were very receptive to recommendations for better business practices. Our mentees have been fighting for the last 30 years. They are tired of fighting and are seeking better ways to manage materiel and distribution. The Medical Stocks Command commander, whom I personally mentored, informed his staff that when I spoke, I spoke with his authority. When my Soldiers spoke, they spoke with my authority. Of course, the Afghan ways were not always our ways. Sometimes the ANA would do something a little differently than we had desired, but the objective was still accomplished. Regarding his work with the Arabs, T. E. Lawrence remarked in The Arab Bulletin, 20 August 1917, “Do not try to do too much with your own hands. Better the Arabs do it tolerably than that you do it perfectly. It is their war, and you are to help them, not to win it for them.” Even though Lawrence warns in the preface to his “Twenty-Seven Articles” that these words are only meant to apply to that specific context, the spirit of his truth became one of our guides for working with the Afghans. We were not in the United States; we had to remember the phrase, “Ee Afghanistan Ast,” which translates to “This is Afghanistan.”

I always had an appreciation of how blessed we are as Americans, but seeing the poverty and destruction in a developing country up close every day for an entire year really hit me. Visions of children standing inside large trash containers and burning refuse to stay warm have stayed with me. I do not remember ever seeing an Afghan building that was not missing a part of its edifice—a roof, a wall, a window, or a door. A satellite television dish attached to the outside of a store that used only kerosene lanterns for light seemed ironic at first, but I got used to it.

Most of our strength came from the maturity of the ETT; the lowest ranking members were staff sergeants. The team was hand-picked because of the special skill sets we each possessed. The independent and self-motivated nature of each member was a testimony to his personal devotion to duty and the team. Frankly, we envisioned working ourselves out of a job. Our mantra was the old proverb, “Give a man a fish and you feed him for a day; teach a man to fish and you feed him for a lifetime.” Serving on an ETT was the best job I have ever had. The combination of the team, our Afghan colleagues, and the results we reaped together was extraordinary.
ALOG

Major Scott C. Woodard is a health services materiel officer in the Army Medical Service Corps at the Army Medical Department Center and School at Fort Sam Houston, Texas. In his last assignment, he served as the officer in charge of a medical logistics embedded training team with the Afghan National Army. He has a B.A. degree in history from The Citadel and an M.A. degree in military medical history from the Uniformed Services University of the Health Sciences.

The author dedicates this article to the medical logistics embedded training team personnel with whom he had the privilege of serving and those in the Combined Security Transition Command-Afghanistan who were wounded or paid the ultimate sacrifice while deployed.