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Chapter 39

POPULATION-BASED PROGRAMS AND 

HEALTH DIPLOMACY APPROACHES OF 

THE US PUBLIC HEALTH SERVICE

JON T. PEREZ, PhD*; JEFFREY COADY, PsyD†; KEVIN McGUINNESS, PhD‡; and MERRITT SCHREIBER, 

PhD§

INTRODUCTION

THE INDIAN OCEAN TSUNAMI AND RELIEF EFFORTS

THE MERCY MODEL: “LEADERSHIP OF THE OPEN HAND”

THE US PUBLIC HEALTH SERVICE MERCY MISSION: “GO WEST AND DO 

GOOD THINGS”

Initial Assessments and Collaboration

Program Development and Delivery

Final Preparations and One Last Hurdle

SUMMary

ATTACHMENT 1: EARTHQUAKE DISASTER RELIEF

ATTACHMENT 2: THE MERCY MODEL

*Captain, Scientist Corps, US Public Health Service; Team Leader, US Public Health Service Disaster Mental Health Team II, Department of Health and 

Human Services, 801 Thompson Avenue, Suite 300, Rockville, Maryland 20852

†

Commander, Scientist Corps, US Public Health Service; Deputy Team Leader, US Public Health Service Disaster Mental Health Team II, Department 

of Health and Human Services, 233 North Michigan Avenue, Suite 600, Chicago, Illinois 60601

‡

Captain, Scientist Corps, US Public Health Service; Director and Medical Psychologist, HRSA/BCRS National Health Service Corps, Ready Responder 

Program, Department of Health and Human Services, c/o La Clinica de Familia, 510 East Lisa Drive, Chaparral, New Mexico 88081; formerly, Senior 

Clinical Scientist, Health and Human Services, US Department of Justice, Bureau of Prisons, Federal Correctional Institution La Tuna, New Mexico

§

Captain, Scientist Corps, US Public Health Service (Inactive Reserve Corps); Senior Program Manager, Center for Public Health and Disasters, University of California at Los Angeles Center for the Health Sciences, 1145 Gayley Avenue, Suite 304, Los Angeles, California 90024; Operations Lead, 

USPHS Mental Health Team II
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Combat and Operational Behavioral Health

Go to the people

Live with them

Learn from them

Care about them

Start with what they know

Build with what they have

But with the best leaders

When the work is done

The task accomplished

The people will say

“We have done this ourselves”

—Lao Tzu (700 BC)1

INTRODUCTION

The Commissioned Corps (Corps) of the US Public 

Health Service (USPHS) is an all-officer corps of approximately 6,000 members.2

 The Corps is capable 

of providing highly trained and mobile healthcare 

professionals to carry out programs that promote the 

health of the nation and, when needed, furnish health 

services and expertise in times of war or other national 

or international emergencies. 

As demonstrated in its healthcare relief response to 

the Indian Ocean tsunami of December 26, 2004, the 

Corps provided distinct leadership approaches and 

methodologies that proved useful to that extraordinary 

international effort. Several of the key leadership precepts and approaches are now known as the “Mercy

model” and constitute an important guide for USPHS 

health diplomacy efforts worldwide.3

THE INDIAN OCEAN TSUNAMI AND RELIEF EFFORTS

The Indian Ocean tsunami, also known as the 

“Sumatra tsunami,” was the result of a massive earthquake, with a magnitude of at least 9.0 on the Richter 

scale, that occurred when the India tectonic plate 

subducted beneath the Burma plate.4 Waves reached 

a height of 35.5 feet, and killed an estimated 230,000 

people, 168,000 in Indonesia alone. (When earthquakes 

occur in landmasses above sea level, their initial effects 

are felt immediately and precautions can be taken in 

anticipation of follow-on tremors and structural collapse. Attachment 1 to this chapter provides a description of land-based earthquake disaster relief.) 

Operation Unified Assistance (OUA) was an 

unprecedented undertaking to support victims of 

a massive natural disaster. The USNS Mercy sailed 

from San Diego on January 5, 2005, less than 3 days 

after being ordered to assist, and arrived in Banda 

Aceh, Indonesia, on February 6, 2005. From that point 

through to its departure on April 29, 2005, the ship 

and crew treated over 17,500 patients in the region. 

It brought together an untested capability (the USNS 

Mercy as a humanitarian service platform) and an 

untested mix of uniformed and civilian personnel to 

accomplish an overarching humanitarian mission that 

was not clearly defined until well into its eventual 

execution. 

The OUA teams were sent into an area of extraordinary human devastation where there was active 

military conflict, devastated healthcare infrastructure, 

and an uncoordinated mix of governmental and 

nongovernmental organization (NGO) programs 

with widely divergent approaches and capabilities. 

Logistics of ship-to-shore lift, security, unknown 

length of time on station, limited understanding of 

and commitment to population-based programs by 

key leadership personnel, and initial relief agency 

reticence to accept US help, limited preliminary 

activities and very nearly stopped them completely. 

Ashore, the Mercy team was met with suspicion by 

many who questioned the sincerity of the overall US 

commitment to tsunami relief and, in particular, the 

team’s commitment. It was in this environment that 

the eventual collaborations, programs, and successes 

were achieved, and it was the Mercy leadership approach that helped build them. 

Although not especially unique or groundbreaking 

in many of its individual specifics, the overall intervention approach developed and implemented by 

the USPHS behavioral healthcare team was seen as a 

marked advance for behavioral health programming 

in multinational relief efforts. The people and agencies 

of Aceh Province embraced this approach, as well as 
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the larger international relief community supporting 

them. It significantly altered the view of the United 

States’ ability to work in an integrated, international 

behavioral health relief effort. 

At its most basic level, the Mercy model represents 

a public health leadership approach, not a program 

or a product. That approach is composed of specific 

knowledge, attitude, and collaboration precepts that 

guide efforts to create teams and programs. Relief 

personnel face operational environments that vary 

in nature, severity, and complexity. The basic Mercy

approaches have proven themselves to help relief 

leadership maximize what resources are available, 

and mobilize systems far larger than the coordinating team itself to create large-scale, population-based 

recovery programs. 

The precepts are highly adaptable to international 

and domestic systems. In its tsunami relief form, the 

Mercy model was composed of 21 general precepts that 

fostered collaborative interaction among diverse organizations and stakeholders (detailed in Attachment 2 to 

this chapter). Most recently, virtually the same precept 

set was used with substantial success in the Hurricanes Katrina/Rita (in 2005) response where it was 

shared with the Louisiana Department of Education 

and ultimately directly contributed to the successful 

development of a psychosocial recovery program for 

over 200,000 displaced schoolchildren.5

The Mercy model precepts have been applied most 

effectively to facilitate delivery of population-based 

behavioral health interventions. However, they have 

also been adapted for use across an array of disciplines 

from biomedical engineering to primary care medicine. 

Given the scope of hazards that the United States faces 

in the world as a nation, in which very large numbers 

of the population may develop enduring mental health 

consequences as a result of disaster exposure,6 Mercy

model percepts are particularly needed.

The Mercy model is designed to effect large-scale, coordinated change in damaged or fragmented systems 

following major disasters by providing collaborative 

leadership to help the system regain operational status. 

The model is called “Leadership of the Open Hand,” 

in deference to the Lao Tzu quotation that opened this 

chapter. It details the means and methods to work in a 

response environment where US agencies are neither 

completely in control nor have the resources to effect 

unilateral action or mission accomplishment. Instead, 

the strategy in such cases is to increase response impact 

through effectively harnessing collaborations with 

other agencies, forces, NGOs, international organizations, and even nations. 

This is accomplished by 

	 •	 addressing, first and foremost, public health

and system-level interventions;

	 •	 providing essential health system leadership

support for damaged systems during highly 

chaotic and difficult times;

	 •	 seeking and promoting collaborative approaches, not unilateral action;

	 •	 assessing system needs rapidly and determining the best placement of limited resources to 

maximize system effects;

	 •	 partnering with the most promising and resourceful agencies;

	 •	 providing partner agencies with capacitybuilding tools;

	 •	 working with partner agencies from program

conception through implementation; and

	 •	 accomplishing it all in time frames measured

in days, not weeks or months.

In Indonesia, the model was utilized to help coordinate relief agencies and the Indonesian government’s 

disaster relief effort to provide specific infrastructure 

and program support for children’s services. Through 

this effort an array of population-based services was 

created in the posttsunami relief environment that 

was eventually delivered to all 200,000 school-aged 

children in Aceh Province. Equally important, the 

approach taught local agencies methods to independently develop and deliver their own programs 

without any outside support. 

In the post-Katrina recovery efforts, the Mercy

model was used to help the Louisiana Department of 

Education regain its operational footing and create a 

statewide system of behavioral health interventions 

for students affected by the hurricane. In Indonesia, 

the process, from initial conception to implementation, 

was completed in just 9 days. In Louisiana, it took 12 

days. There were seven officers directly assigned to 

population-based operations in Indonesia; there were 

four officers assigned to the Louisiana Department of 

Education. This chapter will focus more specifically 

on the Indonesian mission, but the reader should 

understand it represents many missions with similar 

leadership challenges. 

Far from a closed fist, “my-way-or-the-highway” 

leadership approach, the Mercy approach is openhanded leadership, designed to help pull people 

and systems back up and forward following major 

THE MERCY MODEL: “LEADERSHIP OF THE OPEN HAND”
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Combat and Operational Behavioral Health

catastrophic disruption. It utilizes the leadership 

approaches described in the WICS (“wisdom, intelligence, and creativity, synthesized”) model by Robert 

Sternberg,7 to achieve this collaborative partnership 

for the common good. Future relief situations will 

have many of the associated leadership challenges 

present in the OUA response, as well as others not 

even imagined here. Thus, understanding the transitions from chaos to clarity, and suspicion to collaboration are critical to understanding the ultimate 

mission successes. In particular, decisions were made 

and approaches were adopted at several key junctures 

that, if carried out differently, would have resulted in 

mission failure. For future planning, it is important 

to fully appreciate how fragile the situations were 

and how easily the missions could have failed. It is 

the team’s belief that the leadership approach embodied in the open-handed Mercy model precepts 

contributed to these significant transitions and was 

critical to the ultimate successes of the international 

team missions. 

Another important aspect of the leadership approach involved the OUA team aboard the USNS 

Mercy and around the world working to support novel 

programming outside of their traditional operating 

spectrum. International relief organizations, many of 

which had never worked with or were suspicious of 

US uniformed services support, were also of critical 

importance because these organizations provided 

many of the resources that were crucial to successful 

program implementation. Also, research and program 

institutes from around the world provided significant 

amounts of information, often in real-time, via email 

and other digital technologies in support of the team’s 

training efforts, despite the significant time zone differences.8

In a related Department of Health and Human 

Services effort, a team at the Centers for Disease Control and Prevention Emergency Operations Center 

facilitated the use of the novel, rapid mental health 

triage platform—PsySTART (psychological simple 

triage and rapid treatment)—that enabled use of a 

population-based rapid triage platform in an affected 

area. This work began empirical validation of this 

non–symptom-based approach to rapidly determine 

levels of risk in mass casualty events. When the results 

of the PsySTART triage “tags” are aggregated to form 

population estimates, they can be used as a common 

metric for Mercy model population approaches using 

evidence-based risk indicators.9.10 The Mercy model 

and the PsySTART rapid mental health triage system 

are now key competencies of a training initiative for 

new federal disaster response assets—the USPHS 

Disaster Response Teams—created after Hurricane 

Katrina.

The Mercy model approach did not begin with all 

of these pieces in place. How the people and processes 

were assessed, understood, and guided forward is the 

real leadership success story of the Mercy effort by the 

USPHS team; this effort continues to evolve. 

THE USPHS MERCY MISSION: “GO WEST AND DO GOOD THINGS”

The overall mission order was to “go west and do 

good things.” It meant that actual operations would 

be developed and based, in no small measure, upon 

what was encountered when the USNS Mercy arrived 

on station. Mission definition depended to a large degree upon the resources already in place in the region, 

the priority needs of the local Indonesian people, and 

resources that the USNS Mercy and her crew could 

bring to bear in the relief effort. Mission clarity was 

only that which could be conjured or inferred, not what 

was provided, nor even what could be seen or verified 

until arrival in the area of operations. 

The USPHS team took the mission order as a mandate to develop its own mission contingencies and 

integrate them with the larger Navy mission as it 

developed, sometimes minute by minute. To meet its 

own developing mission demands, the USPHS team 

prepared several operational capabilities. Contingency 

planning included direct clinical services for the ship’s 

personnel and those patients who would be received 

on station; environmental health missions; biomedical 

engineering missions; and population-based behavioral health missions. The first three mission capabilities 

were immediately discernible and clearly understood. 

The last was not. Among the USPHS team there developed a desire to take services “beyond the boat,” 

meaning going to shore-based operations and moving 

beyond direct-service provision to include large-scale, 

population-based public health missions.11

While the USPHS team brought direct clinical 

service capability, it also brought unique expertise to 

help local agencies create service programs in relief 

environments, methods to work collaboratively with 

a wide range of relief operations, and the ability to 

integrate seamlessly with operating relief systems and 

structures already in place. However, these capabilities 

were seen as novel by much of the leadership, and even 

useless by some of them. Indispensable support for 

these capabilities came from Rear Admiral William C 

Vanderwagen, commander of the USPHS team and the 

Secretary of Health and Human Services representative on station, and Captain DM Llewellyn, the medical 
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Population-Based Programs and Health Diplomacy Approaches of the US Public Health Service

treatment facility (MTF) commander. Early on, they 

communicated their support for the population-based 

approaches12 recommended by the USPHS behavioral 

health team. Trusting the team’s expertise and advice, 

they enabled the mission to go forward despite the fact 

that such methods were outside the normal operating 

spectrum of the MTF and untested in previous deployments. Rear Admiral Vanderwagen, in particular, saw 

the approach as critical to any large-scale response, 

directed the team to develop it, and advocated for it 

across the leadership lanes from Washington, DC, to 

the MTF itself. 

Initial Assessments and Collaboration

USPHS personnel were on the first helicopter in to 

Banda Aceh from USNS Mercy and began assessment 

and collaboration efforts at that time. The operational assessment and initial collaboration efforts for 

population-based services lasted 5 days. During that 

time, individual meetings were scheduled with over 

a dozen NGO and governmental agencies engaged in 

psychosocial recovery activities, local schools were 

visited to determine the needs as expressed directly 

by local school teachers and head masters, and USPHS 

team members participated in various meetings with 

representatives of over 50 NGOs and agencies that 

provided behavioral health services in the province. 

Very quickly the assessment indicated: 

1. The needs were beyond anything any of the 

team members had ever seen before. 

2. There were over 200 agencies/forces/NGOs 

operating in the theater with widely varying 

capabilities, only limited coordination, and 

very divergent approaches to relief efforts. 

3. The USPHS team would be in this immediate 

area of operation for an unknown, but presumably very short, length of time, possibly 

only days.

4. Of 17 USPHS officers initially available for 

shore-based operations, only seven officers 

were available for population-based behavioral health services; the remaining personnel 

were needed for other healthcare missions 

and to provide direct services on the ship.

The behavioral health personnel, unlike other capabilities shipboard, faced an ambiguous situation and 

three key initial decision points, only the first two of 

which were under their direct control: 

1. What can reasonably be done in days, not 

weeks, given the enormity of need? 

2. What should be offered and to whom?

3. Will anyone want what the behavioral health 

personnel have to offer?

The behavioral health climate was sensitive, particularly for the USPHS team members from the Mercy. The 

prevailing feeling among the NGOs in Banda Aceh was 

that the USNS Mercy was late to the response, would 

be there only long enough to take part in a public relations event, and would probably look to “take over” 

as opposed to “work with” programs already in place. 

It was also expected that western psychological/psychiatric interventions would be used with little regard 

for deeply held spiritual and traditional belief systems 

that may not be congruent with them. This was not an 

open or initially welcoming operational environment, 

but one that viewed Mercy personnel and their offers 

with cool distance.

It was also a situation that began to change with 

a critical exchange that has since become known by 

international colleagues of the US team as “the diplomatic pants incident.” In this particular incident, the 

open-hand leadership approach was demonstrated, 

with particular attention paid to mission success, not 

personal success. 

The United Nations Children’s Fund (UNICEF) and 

the Australian Agency for International Development 

(AusAID) were the organizations with which the Mercy

personnel saw the most potential for collaboration and 

at-scale impact for programs. Highly professional, 

experienced, and respected throughout the relief area, 

they had resources, infrastructure, and personnel, and 

were there for the long haul. Three meetings were 

held with various personnel from those agencies over 

the course of the first few days after arrival. The first 

two meetings appeared to be very encouraging, with 

many ideas shared and possibilities for collaborations 

discussed. At the third meeting, however, there was a 

distinctly disquieting change, particularly with respect 

to UNICEF response to the USPHS personnel.

The USPHS team was confronted with an impromptu, but mission-critical, decision point. It proved to be 

a moment of leadership awareness that substantially 

changed the overall behavioral health mission outcome. In retrospect, the US team’s recognition of the 

potentially course-changing implications of subtle 

changes in vocal tone, physical posture, and interpersonal distance proved to be as important to mission 

success as the actual words exchanged between team 

members and their international partners. The following case study demonstrates the importance of followup conversations in these circumstances. 

Case Study 39-1: After the formal meeting completed, 
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when just a couple of the Mercy USPHS team members 

were together, the obvious question that hung in the air 

was asked: 

Did the USPHS team do something to offend? 

The UNICEF colleagues politely replied, “Why are you 

wearing uniforms today?” 

It was explained that the team members were uniformed 

officers of the United States Public Health Service. The behavioral health team leader went on to explain that although 

the team had worn civilian attire to previous meetings, they 

were wearing uniforms on this particular day because the 

team leader’s only pair of civilian pants had been permanently 

stained with helicopter hydraulic fluid the day before and, not 

wanting to be disrespectful, he opted to wear a clean uniform 

instead of the soiled civilian pants. The rest of the team had 

followed suit. The answer to the question that followed was 

a bit more complicated, however. 

“Are you military?” 

It was explained that, although the team was assigned 

to the US Navy for this humanitarian mission, as USPHS 

officers, they were part of the US Department of Health and 

Human Services and generally prefer to fight disease, not 

people. 

The UNICEF partners responded with smiles of relief. 

“We would much prefer the dirty pants,” they commented, 

“as it is against our [UNICEF] charter to work with military 

forces unless it is absolutely necessary.” 

“Then dirty pants it shall be.” 

After this exchange, the tension evaporated. Assurances 

were made, collaborations sealed, and operations began in 

earnest. Understanding that they had become a symbol of the 

collaboration, the USPHS team leader wore the “diplomatic” 

(ie, dirty) pants ashore for the remainder of the mission. 

Good-natured humor and self-effacement were 

embodied in such behaviors and approaches, and, 

although seemingly secondary to specific program 

delivery, it was exactly these processes that created 

the interpersonal environment that allowed the programs to be delivered at all. For the US personnel to 

be seen by the international relief community, and the 

Achenese in particular with the fears they associated 

with US involvement, as approachable and capable 

of personal humility and self-effacement was critical to their accepting US content and programmatic 

support. The importance of these approaches and 

processes cannot be overstated. The United States was 

seen with human faces and supportive, helping hands 

through these approaches, which spanned the breadth 

of services provided by the entire MTF. Those friends 

with expertise, in the case of the population-based 

programs, were readily welcomed when expertise 

absent such personal connection was not. 

Program Development and Delivery

The next critical leadership decision was to integrate

the USPHS behavioral health team of seven into the 

initial UNICEF and AusAID planning team of five, 

to create a single management team. That team, in 

turn, chose to develop programs and train a cadre of 

individuals to deliver psychosocial interventions for 

school-aged children in every school in the province. 

The collective plan called for the USPHS team, 

within 1 week’s time to: 

	 •	 develop a training curriculum;

	 •	 train the UNICEF/AusAID staff in its delivery; 

	 •	 prepare and distribute associated documentation; and 

	 •	 administerto 45 governmental and NGO staff

the final training program of 40 contact hours 

covering 43 content areas. 

The Indonesian colleagues were unsure whether 

the USPHS team was capable of developing and 

delivering such a program within such a short time 

frame, especially with Indonesian interpreters. The 

team provided assurances that it could do so. The 

program would create a network of trainers to carry 

on long after the Mercy mission was completed, and it 

could be delivered in a short period of time, although 

some thought privately that it was an impossibly short 

period of time. 

The first critical step in the development of the program involved collecting, evaluating, and preparing 

the necessary materials. Using e-mail, the Internet, and 

a large international virtual team from academic and 

NGO organizations, the US team relied almost completely on the information provided to it electronically 

from these sources around the world. That information 

was received within 24 hours of the first request and 

amounted to over 500 pages of training and intervention documentation. 

The next critical decision point came during a planning meeting when the USPHS/UNICEF/AusAID/

Aceh team was evaluating training information. 

Originally, the mission concept called for USPHS 

personnel to provide the training with Indonesian 

translation. The Indonesian members of the planning 

team, however, included professors of psychology and 

other human-service subject-matter experts. Most of 

these personnel had advanced degrees, were residents 

in the province, and were highly capable trainers and 

facilitators. The conversation during the meeting suggested that the quantity of training information might 

need to be cut by half to provide adequate time for 

translation during the presentations. The specter of 

such a loss of information yielded a substantial change 

in approach: what if the collective international team 

gave the Indonesian members all the information, 
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partnered with them as they created their own training program, and mentored them as they delivered it 

in Indonesian to Indonesians?

This was perhaps the most important and powerful shift in approach throughout the entire mission. 

The “Black Wave” devastated the people of Aceh. 

Lives, property, infrastructure, and ways of life were 

destroyed. Following the physical destruction, community confidence was also damaged as armies of 

personnel and foreign assistance descended upon the 

province and began “doing things for” the victims 

rather than “doing things with” the community. Until 

members of the US team took an important second 

look at their own approach, they were engaged in the 

very same damaging process. 

With this new strategy, the long-term power of the 

program began to grow and the US team members 

were accepted as colleagues, not outside “experts.” The 

new approach provided a vehicle for the Indonesian 

people to take charge of their own and their province’s 

psychosocial recovery, beginning with their children. 

The shift put the Indonesians on the team in charge 

of everything. The international team—meaning 

everyone else—became their support team. The US 

team members were now seen as trustworthy, and 

thus transitioned from intruders to welcome advisors 

and collaborators.

Two days were added to the preparation time to 

allow for this change in approach. Two more Indonesian facilitators were contracted by UNICEF to assist. 

This international group then began developing what 

eventually became known as the “assembly line” for 

choosing program content and having it immediately 

translated and packaged for delivery. The entire training program content was developed in this manner in 

less than 5 days. 

The most important aspect of the health diplomacy 

model that emerged from this mission was that the 

model facilitated a diverse group of people, from all 

over the world, to become an integrated team. It was 

promoted, in no small measure, as a direct result of 

this change in approach. Consensus became the standard for program development—roles were created 

and people filled them based on program needs, not 

necessarily professional credentials, and those team 

members who would soon leave stepped back and 

supported those who would remain. 

Final Preparations and One Last Hurdle

When the second Mercy precept was formulated 

(“We are not ‘the pros from Dover’”),13 it was with the 

USPHS team members in mind. It was modified to 

include “We are not the pros from Djakarta” after the 

final Indonesian members of the team arrived from the 

capital and the whole training curriculum came close 

to unraveling 2 days before it was to be delivered. One 

of the new members wanted to try a very different approach to several aspects of training. The Indonesian 

members met with the international team for advice 

about how to proceed. They then met as a team to address the concerns, educate the new members about 

why the program was as it was, and welcomed them 

into the process. It worked; consensus was achieved, 

only minor and very beneficial adjustments were made, 

and the program was finalized for delivery with everyone’s roles clearly delineated and agreed upon. Most 

importantly, the team integrated new membership, 

incorporated new ideas without losing the overall approach, and did it without altering the consensus approach that was the hallmark of the entire process. 

The trainings themselves were the culmination 

of a short but intense period of development filled 

with deep emotion and renewed spirit of hope for the 

training staff and the approximately 90 people from 

throughout Aceh Province who would themselves 

become trainers. The training brought together a wide 

range of both governmental and NGO personnel from 

across northern Sumatra, gave them detailed content 

and a network of people upon whom they could rely 

to help them, and instilled confidence that they could 

deliver this training themselves upon their return 

home. As of this writing, the programs are still operating and the Abidin University Hospital in Banda Aceh 

has dedicated space for the programs there to support 

their ongoing operation. 

SUMMARY

The program described in this chapter developed 

from a USPHS leadership approach. It was then modified into an international collaboration among several 

agencies in the middle of the chaos of the relief effort, 

and transitioned from a program given by outside 

“experts” to one ultimately formulated and delivered 

by the people of Indonesia themselves. The development team included many who were directly affected 

and suffered significant personal losses, while others 

knew only what they saw reported via news media 

prior to their arrival. Several team members had no 

previous relief experience, although others had years 

of experience in such efforts. Several of the relief agencies represented had never before worked together, nor 

worked directly with the US Navy or USPHS; the initial 

levels of suspicion about motives and capabilities in 
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Combat and Operational Behavioral Health

the response were high. That they all ultimately came 

together in a spirit of common cause is a testament to 

the best of what is possible in times of great human 

need, and when personal interests are subsumed to 

support the greater good and provide large-scale successes for others.

The success of this program also demonstrates the 

significant benefits that can result when quiet, but 

informed leadership principles are understood and 

acted upon. Absent the open-handed leadership approach, there would have been no collaboration and 

no subsequent program. Future missions and their 

commanders will face similar chaos and unknowns, 

but some of the precepts developed in the Mercy

model may prove useful in developing the clarity 

and collaborations necessary to effect change at-scale 

in health systems following major conflagration or 

catastrophic emergencies. Attachment 2 to this chapter 

contains these precepts, exactly as they were written by 

the USPHS team during relief efforts and as reported 

in their after-action report. Emerging operational approaches such as the PsySTART rapid mental health 

triage platform can also be used as tools to further 

these aims. They are particularly effective when the 

relief and response lanes are shared among agencies 

and forces, rather than wholly “owned” by a particular 

command structure. Because these cases make up the 

vast majority of international relief efforts, the Mercy

approaches appear to maximize effectiveness via better 

collaboration where command and control would be 

either counterproductive or rejected outright by the 

other agencies involved in the response. 

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2006;296:549–559.

10. Schreiber M. Learning from 9/11: toward a national model for children and families in mass casualty terrorism. In: 

Daneli Y, Dingman R, eds. On the Ground After September 11: Mental Health Responses and Practical Knowledge Gained. 

New York, NY: Haworth Press; 2005: 605–614.

11. Coady J, Perez J, Schreiber M. The way forward: innovations in disaster mental health. Calif Psychol. 2007;40(2):41–44.

12. Schreiber M, Gurwitch R, Coady J, Perez J, Wong, M. Toward a National Model for Children and Families in Mass Casualty 

Events. New York, NY: Springer Publishing; in press.

13. Hooker R. M*A*S*H. New York, NY: Simon & Schuster; 1969.
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ATTACHMENT 1: EARTHQUAKE DISASTER RELIEF

Major earthquakes have the potential to be one of the most catastrophic natural disasters affecting humanity, 

as evidenced by the recent earthquakes in Bam, Iran, Pakistan, and Peru. Earthquakes of significant size set off a 

chain of events that significantly affects the public health and medical infrastructures of the region. Accelerated 

urbanization in seismically active parts of the world dramatically increases the vulnerability of these regions. 

Worldwide, more than a million earthquakes occur each year, with nine countries accounting for 80% of earthquake fatalities (China, Japan, Pakistan, Chile, Russia, Turkey, Peru, Iran, and Italy1–6). In the United States, the 

state experiencing the most earthquakes is Alaska.1,2

Numerous factors influence earthquake mortality and morbidity, including natural factors, structural factors, 

and individual factors. Aftershocks are a particular concern and may occur for a prolonged period of time. For 

example, during the Northridge, California, earthquake more than 14,000 aftershocks occurred in the region over 

the next 5 years.3 Landslides and mudflows after earthquakes account for significant morbidity and mortality. 

Hazardous materials (chemical, biological, radioactive) are an increasing risk after earthquakes due to accelerated urbanization. Following the Loma Prieta earthquake in California in 1989, toxic materials were responsible 

for about 20% of after-earthquake injuries. Flooding from dams with structural damage and fires continue to be 

additional causes of mortality and morbidity after earthquakes.7–9

Structural factors affecting injury or death rates include trauma caused by building collapse. In fact, approximately 75% of earthquake fatalities are caused by collapse of buildings that were poorly constructed or 

not earthquake resistant.10–12 Individual risk factors include age, health, and emotional stability. Demographic 

factors associated with increased risk for death and injury are persons over the age of 60, children between 5 

and 9 years of age, and chronically ill persons.12 The increased vulnerability of these groups is because of lack of 

mobility, exacerbation of underlying diseases, and inability to withstand major traumatic injury. Entrapment, the 

occupants’ locations within a building, their behavior during the earthquake, and time until rescue, constitute 

the factors affecting mortality and morbidity. 

Logistical support is an essential element of disaster relief and an area in which the military excels. The mass 

casualty response to earthquakes includes four essential elements of disaster medical response: (1) search and 

rescue, (2) triage and initial stabilization, (3) definitive medical care, and (4) evacuation.13 The requirements for 

search and rescue and definitive care, and the need for outside assistance from military and civilian teams, are 

significantly increased in earthquake disasters compared to other natural disasters because of the severity of 

wide-spread damage and the complexity of injuries.

Psychological trauma and other adverse psychological sequelae are frequently the side effects of earthquake 

disasters for a number of reasons. Earthquakes occur with little or no warning compared to hurricanes (several 

days of storm tracking) or even tornadoes (often with several hours of meteorological information). This lack of 

warning deprives victims of time to take psychological and physical protective action, and exacerbates a sense 

of loss of control over the destructive event. Earthquakes expose victims to serious threats to personal safety, 

increasing their vulnerability to future psychological symptoms. One of the important lessons learned in disaster 

medical response is the necessity to configure teams based on functional capacities, not professional titles. A 

capacity for mental health interventions is critical, and mental healthcare teams are now incorporated into most 

civilian and military disaster response teams in the United States.

Earthquakes are a major cause of the full spectrum of traumatic injuries, both physical and psychological, and 

frequently require outside medical and public health disaster assistance. Ultimately, disaster mitigation will be 

the most significant factor in decreasing mortality and morbidity from earthquakes.

Acknowledgment

This attachment was prepared by Susan Miller Briggs, MD, MPH, Associate Professor of Surgery, Harvard Medical 

School; Director, International Trauma and Disaster Institute, Massachusetts General Hospital, Boston, Massachusetts.

REFERENCES

1. Noji EK, ed. The Public Health Consequences of Disasters. New York, NY: Oxford University Press; 1997.
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2. Hays WW. Perspectives on the international decade for natural education. Earthquake Spectra. 1990;6:125–143.

3. Prager EJ. Furious Earth: The Science and Nature of Earthquakes, Volcanoes, and Tsunamis. New York, NY: McGraw-Hill; 

1999.

4. Perez E, Thompson P. Natural hazards: causes and effects. Lesson 2–earthquakes. Prehosp Disaster Med. 1994;9:260–

271.

5. US Geological Survey. Scenarios of Possible Earthquakes Affecting Major California Population Centers, With Estimates of 

Intensity and Ground Shaking. Menlo Park, Calif: USGS; 1981. Open-File Report 81-115.

6. Blake P. Peru Earthquake, May 31, 1970. Report of the CDC Epidemiologic Team. Atlanta, Ga: Centers for Disease Control 

and Prevention; 1970.

7. Showalter PS, Myers MF. Natural disasters in the United States as release agents of oil, chemicals, or radiological 

materials between 1980–1989: analysis and recommendations. Risk Anal. 1994;14:169–182.

8. Durkin ME, Thiel CC, Schneider JE, et al. Injuries and the emergency medical response in the Loma Prieta earthquake. 

Bull Seismological Soc Am. 1991;81:2143–2166.

9. Hayes BE, Freeman C, Rubin JL, et al. Medical response to catastrophic events: California’s planning and the Loma 

Prieta earthquake. Ann Emeg Med. 1992;21:368–474.

10. Colburn AW, Murakami HO, Ohta Y. Factors Affecting Fatalities and Injury in Earthquakes. Engineering Seismology and 

Earthquake Disaster Prevention Planning. Hokkaido, Japan: Hokkaido University; 1987. Internal Report.

11. EQE Engineering. The October 17, 1989 Loma Prieta Earthquake: A Quick Look Report. San Francisco, Calif: EQE Engineering; 1989.

12. Coburn AW, Spence RJS, Pomonis A. Factors Determining Human Casualty Levels in Earthquakes: Mortality Prediction in 

Building Collapse. Reston, Va: US Geological Survey; 1992.

13. Briggs SM, ed. Advanced Disaster Medical Response Manual for Providers. Boston, Mass: Harvard Medical International; 

2003. 
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ATTACHMENT 2: THE MERCY MODEL

The Mercy (ship and concept) was an untested capability arriving at the site of an unprecedented event. 

Extraordinary devastation, great chaos, much need, little information about overall response, and, of equal 

importance, little information on the ground and among agencies there about us, who we were, and what we 

might do. We did not know ourselves what we might be capable of doing. There was fear, particularly among 

the international mental health community, that we were going to interfere or otherwise act unilaterally without 

cooperation or coordination. The international relief community, including our own US organizations, viewed 

us with suspicion. Western psychological methods were not widely understood, or greatly accepted, and our 

reputation—real or conjured—was that we would come in for a few days, see a limited number of patients (more 

to use as props for media opportunities than genuine assistance), get our pictures taken, congratulate ourselves, 

and then leave. As a team, we assumed this going in and swore we would do nothing of the sort. The Mercy

model began with that promise. The precepts as they were formulated were: 

1. “Go West and Do Good Things...” This was essentially the mission order until the ship arrived on station: our overarching precept was to promote the greater good, not our particular role in the effort. 

2. We are not “the pros from Dover”—borrowing the line from the book M*A*S*H.1 The principle here is 

collaboration, not independent action. Egos and personal ownership of information and approaches 

are checked at the helicopter door. 

3. We are here as students of the people and culture we are here to assist, because the better we understand, the better we can serve. 

4. We work for and with agencies ashore, not the other way around. We do not work independently, unless we have capabilities that are useful, support those that are already in place, or are desired by the 

agencies with whom we work. 

5. For behavioral health, given limited time, personnel, and resources, we will focus on public health and 

population-based approaches to maximize program development, penetration, and effects. Responding to the area’s behavioral health relief systems and infrastructure needs is our primary concern, not 

direct service. We are responding to a disaster of unprecedented proportions. We could limit our overall 

impact by only delivering direct services, or we could take our limited personnel resources and seek 

to maximize potential impact by working with systems programmatically. Somewhat novel, but not 

at all unprecedented. 

6. Initial work will be assessing the mental health infrastructure, programming, agencies, and services, 

then developing relationships with agencies, not developing programs independent of them. The 

building of the relationships with other agencies is the most critical step in the entire process; without 

the relationship, there is no program. New relationships with agencies may be met with suspicion; we 

should approach this as an opportunity, not a threat. 

7. Collaborative leadership, consensus approach: coordination not control, development not ownership, 

shine spotlight on others not ourselves, and collaboration among the team and the teams with whom 

we work. Seek consensus wherever possible and defer to others when conflict arises or differences 

threaten the process. Adopt local approach when such exists. Simple concepts, though extremely difficult to execute and should neither be overlooked nor undervalued. 

8. We will not promise anything that we can’t deliver, period. 

9. Team members do what needs to be done regardless of position or professional background. 

10. Promote respect for divergent people, professions, worldviews, and spiritual beliefs. 

11. “Wisdomkeepers” must be sought and welcomed—language and cultural guidance are essential. We 

will learn as much as we teach. 

12. International team formation is critical; positive interpersonal relationships, group formation, promotion, and collaboration are primary goals. 

13. Focus on facilitation for program development, not instruction, so the process of program development 

is taught by doing. Through this process new leaders are developed and the people are empowered. 

14. Create tools for program development and show how to use them: don’t just provide the programs 

themselves. 

15. Focus on approach for paraprofessionals and nonprofessionals, not professionals...because there aren’t 

any, or at least not enough to make any substantive difference. The “paraprofessionals” are both the 
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experts of the culture and the facilitators of the programs. They bring valuable and essential skills to 

the trainings and must be empowered to implement programs.

16. We are an international team with a local presence. We are, in a very real sense, a local presence for an 

international team and knowledge trust, including many of the finest disaster recovery people around 

the world. Utilizing digital and other technologies, we are in this together and will work together as a 

worldwide virtual team. 

17. Programs will need to be formulated with great speed, will be discrete and time limited—we do not 

know how long we will be on station in any given place and we will not start something we can’t finish. Thus, we will work as quickly as possible to provide stand-alone programming. 

18. Mobilize local expertise and capability, wherever possible, then support it with programming and disseminate the overall process widely, particularly where there has not been such an approach before. 

This was particularly true in Aceh, where there was limited infrastructure, and what infrastructure was 

there developed posttsunami. This offered an opportunity to support the new network and capability 

in ways that might not otherwise have been possible. 

19. Use a program assembly line approach to maximize collaboration and speed of program production. 

It is during this process that the relationships and trust developed between organizations and people. 

We did what we said we would do and we promoted active collaboration, not passive acceptance, for 

the program’s development: 

a. Team consensus on program specifics; we began by asking the question: “If we could do anything, 

what would the program look like?” Taking that ideal, we then asked, “How can we do this?” and 

mobilized the network, both in Aceh and internationally, to try to get as close to the ideal as possible. 

This we learned from AusAID [Australian Agency for International Development] and UNICEF 

[United Nations Children’s Fund]. 

b. Content gathering: gathering as much information as possible as quickly as possible in the areas 

requested, then reduce that information to a usable set of reference materials from which to choose 

final products.

c. Logistical and resource support: where, how, who, funding, mechanisms of support, travel, security, 

local transportation and housing, etc. Completely UNICEF and AusAID managed. 

d. Editorial/programmatic: consensus collaboration on what content, from all that was received, would 

finally be used in the presentations. 

e. Media preparation: taking the selected information and putting it into the proper format, PowerPoint, reference documents, etc, for participants. 

f. Translation: taking the final training products and translating them, primarily from English into 

Indonesian, and placing them into the day’s presentation curriculum and reference documentation. 

g. Trainer preparation: review materials with trainer and promote input on feasibility of content and 

method. 

h. Presentation: as much as possible, use local trainers and program people. We will support and 

supervise as needed, but this is their show, not ours. We helped produce, but they star.

20. Evaluation: current evaluations are being completed by members of UNICEF, AusAID, Karinivasu, 

and Women’s Crisis Counseling. The evaluation will cover other international agencies’ experiences 

in working with the behavioral health team and its role in the collaboration.

21. Ongoing collaboration: while the programs might be time limited, the relationships are not and the 

potential for ongoing support and collaboration is very real, particularly with technology and digital 

capabilities to maintain and support it. Plan for and promote it. 

REFERENCE

1. Hooker R. M*A*S*H. New York, NY: Simon & Schuster; 1969.