The U.S. Department of Defense (DoD) conducts humanitarian assistance missions under the Overseas Humanitarian Disaster and Civic Aid program for the statutory purposes of training military personnel, serving the political interests of the host nation and United States, and providing humanitarian relief to foreign civilians. These purposes are undertaken via the humanitarian assistance (HA), humanitarian and civic assistance, and excess property donation programs. DoD conducts over 200 such projects annually at a direct cost of approximately 27 million dollars in fiscal year 2001. Although varying by year and command, as many as one-half of these projects involve aspects of health care. These range from short-term patient care to donation of medical supplies and equipment excess to the needs of the DoD. Despite the considerable resources invested and importance of international actions, there is presently no formal evaluation system for these HA projects. Current administrative staffing of these programs by military personnel is often by individuals with many other duties and responsibilities. As a result, humanitarian projects are often inadequately coordinated with nongovernmental organizations, private volunteer organizations, or host-nation officials. Nonmedical military personnel sometimes plan health-related projects with little or no coordination with medical experts, military or civilian. After action reports (AARs) on these humanitarian projects are often subjective, lack quantitative details, and are devoid of measures of effectiveness. AARs are sometimes inconsistently completed, and there is no central repository of information for analysis of lessons learned. (The approximate 100 AARs used in the conduct of these studies are available for official use in the Learning Resources Center, Uniformed Services University of Health Sciences.) Feedback from past humanitarian projects is rare and with few exceptions; DoD-centric projects of a similar design are often repeated. Critical reviews to determine whether other kinds of projects might be more effective are rarely conducted. Recommendations for improving the effectiveness of DoD HA under Overseas Humanitarian Disaster and Civic Aid programs include: ensuring adequate staffing to meet the complex, dynamic nature of humanitarian missions and measuring the effectiveness of each project in mandatory, standardized AARs. For medical HA projects, application of public health strategies would compliment the patient care approach of the majority of medical projects to date. This offers possibilities for enhancing host nation infrastructure, allowing improvements beyond the short period of most military humanitarian projects.

Although perspectives of military and civilian humanitarians may differ, they share common goals and parallel efforts for more effective humanitarian assistance. Effectiveness measures for military or civilian humanitarian assistance are discussed. Whereas examples cite military medicine, findings and recommendations are widely applicable to all forms of humanitarian assistance especially developmental relief. Humanitarian effectiveness is improved by a straightforward, standard approach to planning and evaluation, such as the logical framework process. Given successful application by a wide variety of private volunteer, nongovernmental, and international humanitarian organizations, the logical framework process is recommended for adaptation by the Department of Defense. More effective humanitarian assistance requires: developing specific, written purpose, criteria, and quantifiable measures, coordinating the purpose, criteria, and measures with all involved, including donor and host nation officials, all other providers (expatriates, private volunteers, nongovernmentals, international organizations), and beneficiaries, and documenting then analyzing results to compare outcomes with project purpose and international consensus standards for minimal performance in humanitarian assistance (i.e., Sphere project, see http://www.sphereproject.org/).

Although the purpose of the Department of Defense humanitarian and civic assistance (HCA) projects is training, there is no system to evaluate HCA training or humanitarian effectiveness. Few after-action reports (AARs) document the number of personnel trained, skills taught, or proficiency before and after HCAs. Nevertheless, HCAs are positively viewed by participants and offer great potential for training service personnel as well as donors, expatriates, and host nation representatives. Linking unit training calendars with HCA projects and vice versa, would improve both projects and training. Mission essential tasks should be incorporated into HCAs, and conversely, HCAs into training. Training objectives should be clearly stated early in the planning and shared with all participants (subject to security). Proficiency to training standards and performance to international humanitarian standards should be documented in after-action reports. Mandatory after-action reporting (ideally, in a standardized, easily retrievable format that supports postproject analysis) should be implemented. Reported training benefits of medical HCAs include a large number of patients treated in a short amount of time, often under austere conditions, and the opportunity to treat diseases of military importance that are not endemic in the United States. The vast majority of medical HCAs have involved direct patient care, but this scope should be expanded to include public health-oriented developmental and infrastructure-building projects that would provide lasting humanitarian benefits and training for additional personnel and units.

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Telecommunications from telephone and radio to two-way audio, video, facsimile (fax), and digital imaging via satellite transmission have been used in responses to disasters. Current and rapidly emerging communications technology offers the prospect of enormously expanded and more efficient application in predisaster, acute, and postdisaster rehabilitation activities. A survey of present and potential roles for telemedicine in disaster medicine will be presented with particular focus on initial on-going medical needs assessment, prevention programs, and emergency assistance for provision of emergency care of victims, care for other survivors, and public health and sanitation services. Attention will also focus on telemedicine in education and training, disaster response exercises, development of comprehensive plans, and research. Finally, the essential relationship between the routine utilization of telemedicine in predisaster health care and effective employment in disaster situations will be discussed.

Threshold of Toxicological Concern (TTC) decision-support methods present a pragmatic approach to using data from well-characterized chemicals and protective estimates of exposure in a stepwise fashion to inform decisions regarding low-level exposures to chemicals for which few data exist. It is based on structural and functional categorizations of chemicals derived from decades of animal testing with a wide variety of chemicals. Expertise is required to use the TTC methods, and there are situations in which its use is clearly inappropriate or not currently supported. To facilitate proper use of the TTC, this paper describes issues to be considered by risk managers when faced with the situation of an unexpected substance in food. Case studies are provided to illustrate the implementation of these considerations, demonstrating the steps taken in deciding whether it would be appropriate to apply the TTC approach in each case. By appropriately applying the methods, employing the appropriate scientific expertise, and combining use with the conservative assumptions embedded within the derivation of the thresholds, the TTC can realize its potential to protect public health and to contribute to efficient use of resources in food safety risk management.

Casualties incurred during the assault on Punta Paitilla Airfield during Operation Just Cause were evaluated through reviews of records and interviews with the participants. There were eight initial casualties. One-half of all subsequent casualties were wounded trying to move to these men while still under effective hostile fire. Consistent with other studies, the most common cause of death was internal hemorrhage; the second most common was catastrophic brain injury. Rapid control of external exsanguination was the technique most likely to prevent death. Tourniquets were applied to three lower extremities for two casualties, without sequelae.

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