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Operation Iraqi Freedom 05-07 Medical Civil–Military Operations: Lessons Learned in Humanitarian Assistance

Chapter 37

OPERATION IRAQI FREEDOM 05-07 

MEDICAL CIVIL–MILITARY 

OPERATIONS: LESSONS LEARNED IN 

HUMANITARIAN ASSISTANCE

JEFFREY S. YARVIS, PhD*

INTRODUCTION

BACKGROUND

PARTNERING WITH NONGOVERNMENTAL ORGANIZATIONS AND GOVERNMENTAL ORGANIZATIONS

SUMMARY

*Lieutenant Colonel, Medical Service Corps, US Army; Chief, Behavioral Health, Department of Psychiatry, Borden Pavilion, Walter Reed Army Medical 

Center, 6900 Georgia Avenue NW, Washington, DC 20307; formerly, Director of Social Work, Uniformed Services University of the Health Sciences, 

Bethesda, Maryland
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INTRODUCTION

The primary mandate of Task Force 30th Medical 

Brigade (TF 30) is force health protection. During 

Operation Iraqi Freedom (OIF) 05-07, TF 30 saved the 

lives of an unprecedented 96% of the wounded soldiers 

entering its facilities. Also historic was the way in 

which the task force commander employed behavioral 

health assets and their unique skills for the brigade’s 

civil-military operations. 

Medical brigades, with their organic clinical operations section and civil-military operations staff, represent a robust public health team capability unsurpassed 

by even the public health teams organic to a civil affairs 

brigade. Nearly half of the casualties seen in coalition 

hospitals were Iraqi; to transition these medical cases 

back to the Iraqis, Iraqi military and civilian medical 

capabilities must be enhanced.1 TF 30 Medical CivilMilitary Operations (CMO) joined together with the 

Department of State, Multi-National Force–Iraq (MNF–

I), nongovernmental organizations (NGOs), private 

companies, and the Focused Stabilization Task Force of 

the Multi-National Corps–Iraq (MNC–I) to accomplish 

this goal. TF 30 also facilitated humanitarian assistance 

to vulnerable populations in Iraq. 

In fiscal years 2005 and 2006, TF 30 assisted in 

securing more than $70 million to support humanitarian needs, including establishing emergency health 

services; enhancing water treatment and sewage 

plants, clinics, hospitals, and schools; and facilitating 

agricultural projects through effects-based planning 

with local and regional host-nation government officials. These efforts bolstered the legitimacy of the 

local medical officials, opened lines of communication 

between local individuals and local leaders with the 

Iraqi national government, created access to care, and 

promoted livelihoods. Due to the highly fluid nature 

of the internally displaced person (IDP) population in 

Iraq, TF 30 also supported ongoing preventive medicine operations for humanitarian assistance for IDPs. 

This chapter will discuss the medical civil-military 

lessons learned by TF 30 during OIF 05-07.

BACKGROUND

 The US military routinely executes medical humanitarian missions. These missions encompass 

everything from medical support, to civic action, to 

capacity development or enhancement projects, to 

major theater wartime operations. The public affairs 

benefit of military medical forces providing support to 

another nation in conflict seems apparent. Assisting the 

injured, sick, and wounded, and providing access to 

care to displaced peoples seems beneficial. However, 

as Ritchie and Mott2

 point out, many pitfalls are associated with providing assistance. Past literature on the 

pitfalls of military humanitarian assistance was largely 

concerned with the ethical issues of providing care that 

cannot be sustained by the host nation, resulting in 

“doing more harm than good.” This harm is often associated with the medical rules of engagement that are 

tied to the amount of resources the US military brings 

to support troops in a theater of operations. However, 

often overlooked are how the medical humanitarian 

assistance missions are tied to the strategic end state of 

an operation and how these missions may contribute 

to or detract from a mission.3

To frame military humanitarian assistance missions, it is necessary to go back to the purpose of all 

operations: to create a secure environment in which 

political and economic development can proceed. 

Therefore in Iraq, the end state of all missions, to 

include medical civil-military missions, is to create 

legitimate local and provincial Iraqi governments 

capable of continuing political and economic development. Furthermore, to stabilize the Iraqi government, 

the effect of the insurgency must be minimized. Insurgency is both a political and a military phenomenon. 

Insurgents will be frustrated if the government has a 

competent and capable administration that dispenses 

services and effectively coordinates a multitude of political, economic, and security policies. In Iraq, access 

to and delivery of medical care represents a tangible 

reminder that the government is functioning. These 

functions are also exploited by the insurgency. If the 

insurgency or those sponsoring it control serviceoriented ministries, then the Iraqis will believe that it 

is the insurgency that is providing this care to them. 

In other words, healthcare is something that can be 

utilized by both the US military and the insurgency. 

The perceived Iraqi government response to the 

medical needs of its people is thus a key variable in 

achieving US political-military objectives. 

President George W Bush recognized the importance of healthcare in achieving US political-military 

objectives when he said, 

America is now threatened less by conquering states 

than we are by failing ones....The United States 

should invest time and resources into building international relationships and institutions that can help 
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Operation Iraqi Freedom 05-07 Medical Civil–Military Operations: Lessons Learned in Humanitarian Assistance

manage local crises when they emerge....We will 

use our economic engagement with other countries 

to underscore the benefits of policies that generate 

higher productivity and sustained economic growth, 

including...investments in health and education that 

improve the well-being and skills of the labor force 

and population as a whole.4

Tommy G Thompson, the former US Secretary 

of Health and Human Services, noted that military 

missions must include medical strategies. He stated 

that the “[m]ost effective arsenal against terrorists 

[contains]: education, compassion, and medicine.”5 He 

also said that the “[b]est chance to defeat the terrorists 

[is] by enhancing our medical and humanitarian assistance.”5

 History demonstrates the effectiveness of 

such strategies. During World War II, the US employed 

military humanitarian assistance in the Philippines. 

It has continued to do so in places such as Haiti and 

Bosnia because of a moral mandate in support and 

sustainment operations.2

The military operations other than war and peacetime engagement projects that represented the bulk 

of military humanitarian missions in the 1990s were 

inherently different than the missions occurring 

today in Iraq and Afghanistan. In Iraq, for example, 

the war began with kinetic fighting—attacking the 

enemy with weapons and destroying infrastructure 

along the way. As the United States approached the 

transition phase of operations during OIF 05-07, 

efforts were refocused on building projects. The 

various projects were undertaken to restore basic 

health services and address public health concerns 

to mitigate the health effects that were the result of 

the kinetic fight. 

Now as the shift continues to the nonkinetic fight, 

the aim is to preserve existing structures, develop 

capacities, and target key structures critical to transitioning the health “battlespace.” After three to four 

rotations in Iraq, medical civil-military operations 

were incorporated into all transition operations from 

the start and in all levels of planning—strategic, operational, and tactical. Waiting until the kinetic fight 

is over to plan and execute civil-military projects is 

not a workable concept.6

 Simultaneous integration of 

civil-military operations represents a shift in the operational effort following combat operations to a nonkinetic main effort. As the transition phase proceeded, 

the civil dimension became a part of the main effort. 

Following security gains, constructive engagement to 

repair damage and build on security success must begin in earnest. This is where longer-term success and 

true transition to civil control will become possible. 

The civil dimensions noted in Ritchie and Mott2

—rule 

of law; facility/critical infrastructure assessment and 

repair; critical needs assessment (health, safety, and 

so forth); and local governance/leadership—all had 

to be focused. In addition, the TF 30 medical civilmilitary operations included nontraditional actors in 

the planning and execution process, such as NGOs 

and international organizations.

As mentioned earlier, medical civic action programs 

(MEDCAPs) and other medical military humanitarian assistance projects have apparent benefits such 

as “winning the hearts and minds.” However, the 

contrary was true in Iraq; the apparent benefits of 

“tailgate” medicine were not realized because these 

missions were not tied to lines of operation and the 

strategic political-military objectives. Furthermore, 

the value to US medical personnel was not apparent. 

The need to transition patients back to an independent and capable host nation medical system was 

burdened by MEDCAPs. The medical civil-military 

end state defined by the XVIII Airborne Corps during 

OIF 04-06 was defined as: “To conduct coordinated 

cooperative medical engagements at the provincial 

level to strengthen governance and transition lines of 

operation in support of campaign plan and overall US 

objectives in Iraq.”7No clear end state was identified in 

this mission statement. Past operational civil-military 

operations and plans did not effectively develop governance capacity in provinces. Furthermore, no standing 

organizations existed for coordination and support 

to medical civil-military operations at the national 

level. By OIF 05-07, it was clear that what was needed 

were fundamental changes in behavior, structure, and 

organization to address gaps in medical civil-military 

staffing and skill sets at the operational and strategic 

level. Inattention to these gaps led to inconsistent and 

“stovepiped” MEDCAPs that offered little long-term 

benefit and could not be quantified in terms of measures of effectiveness.

To implement the national strategy at the transition 

phase of operations in Iraq to achieve the politicalmilitary objectives set forth by the commander of the 

MNF–I, the following seven assumptions were made 

by the US medical civil-military operations team:

1. Increased governance capacity building and 

assistance is necessary to develop sustained 

capability of provincial governments. 

2. Existing organic civil affairs public health 

teams will maintain current capability in 

provinces until their efforts are tied to the 

operational main effort, which when established will represent fully coordinated, joint 
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Combat and Operational Behavioral Health

medical civil-military teams. 

3. A need exists to develop a formalized mechanism for coordinating provincial activities 

and support at the Department of State and 

MNF–I. 

4. Capability to provide enhanced health support to provincial governments must persist 

beyond elections. 

5. The Iraqi national government will need to 

support increased medical outreach at the 

provincial and district levels. 

6. Coalition resources necessary to support any 

new medical civil-military operations efforts 

will be available. 

7. Medical civil-military efforts can be tailored 

to meet the needs and security situation 

existing in each province. Substantial capability of provincial governments will be 

developed in 2 years, allowing transition to 

more traditional US Agency for International 

Development (USAID), international organization, governmental organization, and NGO 

assistance delivery mechanisms to provincial 

and local governments for an additional 2 

years. 

Given these assumptions, the following mission 

statement for medical civil-military operations was 

developed:

• To assist Iraq’s provincial director generals 

of health with developing a transparent and 

sustained capability to promote public health 

and provide provincial administration necessary to meet the basic health needs of the 

population. 

• To provide timely and relevant assessments 

of health infrastructure and political developments in the Ministry of Health at the local 

level, and to promote Coalition governance 

and capacity development goals.

To implement the mission statement, the following 

eight tasks were identified: 

1. Facilitate achievement of Coalition goals in 

Iraq by enhancing the capabilities of the Iraqi 

health sector from the district level within 

the Ministry of Health and the battalion level 

within the Ministry of Defense. 

2. Promote health reform at the provincial 

level. 

3. Assist local ministry representatives and Iraqi 

Army surgeons with developing a comprehensive strategy that results in a capable and 

accountable local government. 

4. Assist provincial governments with identifying and prioritizing the needs of their citizens 

and with addressing those needs via the Iraqi 

government, Coalition, donor, and NGO 

resources. 

5. Assess health capabilities of provincial governments and develop a joint plan of action 

to increase these capabilities, with emphasis 

on sustainability. 

6. Assist provincial governments in developing 

short- and long-term goals for public health 

programs, and assist with their implementation.

7. Coordinate with other major subordinate 

commands to synchronize medical governance efforts with stability operations. 

8. Coordinate with civil affairs assets to assess 

health sector developments at the local level, 

and to advocate Coalition goals and objectives. 

These tasks were augmented with some of the 

peacetime concepts for civil-military operations noted 

in Ritchie and Mott2—train, coach, and mentor local 

government medical entities to develop their capacity to: 

• develop core competencies and standards of 

care; 

• establish effective linkages with ministries and 

central government; 

• help Iraqi health officials plan and prioritize 

direction and activities; 

• prepare critical needs lists, identify funding 

needs, and identify resources; and

• determine facility staffing requirements and 

assist medical officials to address these with 

their next higher minister or officer. 

The G-5 (civil-military operations officer) of TF 

30 also addressed systemic gaps through resource 

development activities for the MNC–I. Specifically, 

TF 30: (a) coordinated support by donors and NGOs; 

(b) communicated with stakeholders via effective 

public affairs and information operations activities; 

(c) provided and enhanced the delivery of provincial 

and municipal health services to include emergency 

medical services; (d) developed subordinate medical civil-military operations working groups; and 

(e) involved host-nation medical contacts in medi-
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Operation Iraqi Freedom 05-07 Medical Civil–Military Operations: Lessons Learned in Humanitarian Assistance

cal reconstruction activities to ensure the cultural 

relevance of all TF 30 projects. All of these efforts 

had to be observable in some meaningful way, 

therefore qualitative and quantitative measurements of success against established benchmarks 

were provided.

The involvement of Iraqi healthcare officials in TF 

30’s medical civil-military operations planning seems 

obvious, however, it had been routinely ignored by 

previous rotations. Upon implementation of the TF 30 

medical civil-military engagement strategy, Iraqis were 

part of meetings at all levels of planning. This involvement was key to the paradigm shift from MEDCAP as 

the main thrust of medical humanitarian assistance 

to a more comprehensive process called “cooperative 

medical engagements.” Cooperative medical engagements are specific humanitarian assistance opportunities led by Iraqi civilian or military medical personal 

for which US involvement is incidental to the overall 

engagement. Each cooperative medical engagement 

must focus on assisting the Iraqi medical system and 

the Iraqi Security Forces to provide for its civilian 

population. The projects must advance operational 

security goals; improve access (to regions and to the 

people); reinforce security and stability; and generate 

good will to enhance the US ability to shape the operating environment. Projects must be humanitarian in 

nature and must compliment the strategic goals and 

objectives of the Ministry of Health. Addressing the 

medical rules of engagement and misuse of MEDCAP, 

cooperative medical engagements do not allow for 

direct care to the Iraqi people unless it is a life, limb, or 

eyesight issue. The corps surgeon is the coordinating 

and approving authority for all cooperative medical 

engagements.

On August 18, 2005, then Secretary of Defense 

Winkenwerder stated that, “[t]he primary goal of the 

US Governmentin matters of world health is to build 

capability and capacity so that societies may address 

their healthcare needs.” Cooperative medical engagements promote this concept. Initial reconstruction 

efforts had been designed to create entire healthcare 

systems for, and not with, the Iraqis. According to the 

Department of State,7

 $786 million from international 

and US sources was provided for health-sector development. However, few substantial gains were made 

in terms of transitioning healthcare back to the Iraqis 

or increasing access to care. TF 30’s goals were more 

modest: building on existing platforms, identifying 

medical systems that could assist with the transition 

to the host nation through partnerships with the Iraqi 

Security Force and TF 30 facilities, or assisting medical 

systems key to stabilizing Iraq. Department of Defense 

Directive 3000.5 states, “Integrated civilian and military efforts are key to successful stability operations.”8

Executing this directive meant implementation at the 

local and regional levels, and allowing lower-level officials to communicate needs in a culturally acceptable 

way with the National Ministry of Health. Such open 

lines of communication and systemic cooperation 

across the country enhanced the legitimacy of all the 

health officials involved. Involving Iraqis through 

cooperative medical engagements addressed issues 

created by MEDCAPs. Ritchie and Mott2 describe 

pitfalls of peacetime engagement projects. Some of 

the pitfalls that they identified—short-term focus, 

inadequate planning, disruption of local healthcare, 

and raising expectations for care—were all real problems that undermined long-term political-military 

objectives in Iraq. For instance, many medical civil 

affairs public health teams conducted “a MEDCAP 

a week,” without any apparent reason. In addition 

to the problems discussed by Ritchie and Mott,2

MEDCAPs also created parallel systems, vacuums 

of care when medical assets were moved around the 

battlefield, and resentment among Iraqi officials who 

often did not have an opportunity to vet these projects, 

determine if there was need for US interventions, or 

simply have the means to sustain US efforts once care 

was withdrawn. TF 30 and the corps surgeon’s office 

were determined to achieve small, sustainable, and 

observable efforts. 

Small sustainable humanitarian assistance projects 

created tangible results, increasing the legitimacy of 

Iraqi medical care and governance with potential for 

growth of Iraqi systems in a culturally relevant way. 

Using Natsios’ “Nine Principles of Reconstruction 

and Development”9 and considering the dimensions 

of nation building, TF 30 had highly successful cooperative humanitarian assistance operations, engaging 

Iraqis at the tactical, operational, and strategic levels 

(Exhibit 37-1).

These nine principles should guide medical planners in the targeting and execution of medical CMO 

and humanitarian assistance missions. Such planning 

is consistent with the effects-based planning conducted 

by military planners representing the full spectrum 

of battlefield operating systems and is not limited to 

medical planners. When employing these principles, 

the objectives of all CMO efforts should be to gain 

targeted effects that support the mission of the higher 

command, the commander’s stated lines of operation, 

and the national strategy for the intervention for Iraq. 

It is also important, however, to understand that these 

concepts represent a departure from civil-military 

doctrine.10
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Combat and Operational Behavioral Health

EXHIBIT 37-1

NINE PRINCIPLES OF RECONSTRUCTION AND DEVELOPMENT

In 2005, Natsios1 delineated nine principles that guide the US foreign assistance community, which includes the US 

military, in the provision of aid to a variety of war-torn countries:

In a time of increasing collaboration between the two organizations [military and USAID], it is important that 

the military gain a better understanding of how USAID [US Agency for International Development] and development agencies generally approach their work, and how the two communities can beneficially build on 

this cooperation. . . .When a foreign assistance agency adheres to the Nine Principles, this greatly enhances the 

likelihood of success. Conversely, failure to take the Nine Principles into account when designing and managing a program increases the risk of program failure. . . . Just as a particularly skilled battlefield commander can 

violate one or two of the principles of war and still prevail, a development officer may violate one or two of the 

development principles and still succeed. But generally development agencies ignore these principles at great 

risk, particularly in countries like Iraq, Afghanistan, and Sudan, where major reconstruction efforts are under 

way.1(p5)

This table presents the nine principles for successful collaboration between the US military and other agencies, and 

the US military experience in Iraq with the utilization of the principles. The first two columns are from the Natsios 

article; the third column delineates how TF 30 interpreted and employed the “Nine Principles” in Iraq.

Principle Description Experience in Iraq

Principle 1: Ownership—

Build on the leadership, participation, and commitment 

of a country and its people.

The first principle of development 

and perhaps the most important is 

ownership. It holds that a country 

must drive its own development 

needs and priorities.

Leadership, participation, commitment of host 

nation.

Activities should enhance legitimacy of host 

nation.

Principle 2: Capacity 

Building—Strengthen 

local institutions, transfer 

technical skills, and promote 

appropriate policies.

Capacity building involves the 

transfer of technical knowledge 

and skills to individuals and 

institutions so that they acquire the 

long-term ability to establish effective policies and deliver competent 

public services.

Activities that enhance legitimacy of local 

professionals through accredited training 

models and certification programs.

Activities that allow self-sustaining operational capability such as training in use of 

budgets and logistical systems.

Activities that promote personal accountability 

and ownership of product and process.

Principle 3: Sustainability—Design programs to 

ensure their impact endures.

The core of the sustainability principle is that development agencies 

should design programs so that 

their impact endures beyond the 

end of the project.

Impact must endure, for example: TF 30 created the first self-sustaining Iraqi medical 

association in Iraq.

Risk if ignored: alienation of local population.

Principle 4: Selectivity—

Allocate resources based on 

need, local commitment, and 

foreign policy interests.

The selectivity principle directs US 

bilateral assistance organizations 

to invest scarce aid resources based 

on three notions: humanitarian 

need, the foreign policy interests of 

the United States, and the commitment of a country and its leadership to reform.

Needs assessment plus political-military 

objectives need not be expensive or time 

consuming.2

 Example: disease nonbattle 

injuries (DNBIs) at Iraq Security Force camps 

increased during the Ramadan holiday. Targeted Iraqi camps (nodes) were given handwashing campaign posters and water-testing 

strips for under $50/camp. In 2 months, 

DNBI from food- and water-borne sources 

went from approximately 300 Iraqi soldiers 

per month to zero. Lesson learned: did not 

have to create an entire preventive medicine 

program to address some immediate shortand potentially long-term problems.3

 (Exhibit 37-1 continues)
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Operation Iraqi Freedom 05-07 Medical Civil–Military Operations: Lessons Learned in Humanitarian Assistance

Principle 5: Assessment—

Conduct careful research, 

adapt best practices, and 

design for local conditions.

One of the most important tasks a 

development agency must undertake before designing and implementing a program is to conduct a 

comprehensive assessment of local 

conditions.

Research best practices, design for local conditions.

Nongovernment orgnizations (NGOs) may 

already have this information. Example: 

International Medical Corps has been doing 

medical humanitarian assistance for nearly 

30 years in Iraq.

Principle 6: Results—Direct 

resources to achieve clearly 

defined, measurable, and 

strategically focused objectives.

The principle of results is an outgrowth of the assessment principle. It means that before a donor 

agency even enters a particular 

country, it first determines its strategic objectives.

Results measured by standards, indicators, 

and effectiveness. 

Measures of standards; qualitative or quantitative. Example of qualitative standards: 

increased use of host-nation ambulances to 

clear battlefield and increased transportation of Iraqi casualties directly to host-nation 

facilities.

Performance (process) indicators: decreased 

length of stay by Iraqi patients at targeted US 

facilities (nodes) by as much as 70% in one 

year’s time.

Impact indicators: increased host-nation care 

for burn patients through capacity enhancement projects with Iraqi hospitals.

Measures of effectiveness: combination of key 

indicators, interdependent and multisectoral; 

more useful in longer missions; useful to 

determine transition criteria; need to partner 

with civilian agencies to do these right.

Principle 7: Partnership—

Collaborate closely with

governments, communities, 

donors, nonprofit organizations, the private sector, 

international organizations, 

and universities.

The partnership principle is a 

central element of USAID’s business model and holds that donors 

should collaborate closely at all 

levels with partner entities, from 

local businesses and private voluntary organizations to government 

ministries.

Collaborate not only with the health attaché 

and host-nation minister of health, but also 

NGOs and international organizations. 

Principle 8: Flexibility—

Adjust to changing conditions, take advantage of 

opportunities, and maximize 

efficiency.

Development assistance is fraught 

with uncertainties and changing circumstances that require 

an agency to continuously assess 

current conditions and adjust its 

response appropriately.

Adjust to changing circumstances.

Be aware of cultural, political environment.

Principle 9: Accountability—Design accountability and transparency into 

systems and build effective 

checks and balances to guard 

against corruption.

There are two important aspects 

to the accountability principle: 

donors should work to fight corruption in the countries where 

they operate, and donors must also 

ensure that the actual programs 

they implement are transparent 

and accountable.

Transparency (within security restrictions).

Avoid corruption.

Perception is everything.

(1) Natsios A. Nine principles of reconstruction and development. Parameters. 2005:5–20. (2) Bonventre G. Capacity-building in the health 

sector. Presentation to the Combatant Command Surgeons Conference. December 2005. Washington, DC. (3) Yarvis JS. Social workers as 

civil affairs officers: medical civil affairs in Iraq. In: Actionable strategies for caring for our warriors, veterans and our country. Presented 

at the 112th Annual Meeting of Association of Military Surgeons of the United States (AMSUS). San Antonio, Tex. November 2006.

Exhibit 37-1 continued
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Combat and Operational Behavioral Health

PARTNERING WITH NONGOVERNMENTAL ORGANIZATIONS AND 

GOVERNMENTAL ORGANIZATIONS

TF 30 could not achieve optimal results without 

coordinating and synchronizing efforts with NGOs 

such as the International Medical Corps and Assisting Marsh Arabs and Refugees, and US governmental 

organizations such as USAID. These organizations are 

experienced in managing the second-order effects of 

combat and have substantive relationships in Iraq that 

often began well before OIF. Lacking a Commander’s 

Emergency Response Program of its own, TF 30 relied 

on the resources of the MNC–I as well as the NGOs. In 

turn, the NGOs relied on the technical expertise, security capability, and networking ability of the military 

to effectively develop partnerships between the Iraqi 

military medical community, Iraqi civilian medical 

community, and the Coalition medical community 

to accomplish humanitarian assistance missions. For 

example, TF 30 facilitated the identification and movement of over $60 million in humanitarian assistance 

medical supplies for Iraqi hospitals and primary 

healthcare centers from Humanitarian AssistanceKuwaitand US donors (via the Denton Amendment11). 

TF 30 was the lead on medical issues for the MNC–I 

Humanitarian Assistance Working Group, working 

to match the needs of the Iraqi medical systems with 

available medical supplies and to focus the medical 

efforts being conducted by agencies working in the 

health sector. This coordination by the TF 30 CMO staff 

gave visibility to the “ground truth” from the tactical 

level of the health sector, thereby giving actionable 

intelligence to the health attaché for the US Department of State as it coordinated with the Iraqi National 

Ministry of Health. 

The partnerships were not just focused on the 

delivery of tangible medical goods. Tangible goods, 

although extremely important in terms of demonstrating that Iraq can provide for its own people, are 

but one of many issues. Partnering with NGOs also 

involved sharing technical expertise and systems that 

enhance health promotion and delivery of services. 

Some of the enduring projects were the creation of 

three burn centers and a national trauma-training 

center, with an approximate cost of $2 million. These 

programs would allow Coalition hospitals to train 

and share expertise with their Iraqi counterparts 

while simultaneously developing the capacities of key 

Iraqi facilities. This will enable the Iraqis to gradually 

take over healthcare for critical neighborhoods and 

thus allow Coalition forces to transition out of caring for seriously ill and wounded Iraqi citizens and 

soldiers. An example of success in the area of Iraqi 

capacity was evidenced in their ability to “clear” or 

evacuate their own casualties from operational and 

civilian areas independent of Coalition evacuation assets. For example, during rotation 05-07, Iraqi medical 

facilities took over the health “battlespace,” increasing the clearing rate from 41% to 81% and caring for 

casualties directly without the help of the Coalition 

medical assets, meaning the Iraqis were now clearing 

81% of their casualties themselves. Another example 

of success was the decrease in the “length of stay” of 

Iraqi military and civilians in US medical facilities. 

Length of stay was defined as the number of days 

occupying a bed. In 7 months of capacity building, 

the length of stay in US beds decreased by an average of 6 days. This significant decrease occurred because Iraqi hospitals could now accept an increased 

number of patient transfers due to better Iraqi facilities, evacuation assets, and trained providers. Such 

capacity-building indicators were now being used 

by the MNC–I surgeon as measures of effect toward 

operational and strategic goals.

NGOs were well established in all 18 Iraqi provinces and therefore had relationships and credibility with 

the host nation. Because NGOs are neutral they can 

reach less approachable members of the health sector 

in the Iraqi Ministry of Health. NGOs must maintain 

the appearance of neutrality to be effective; military 

partnerships with them are less formal and not used 

as part of a military public affairs campaign. While 

humanitarian assistance activities make for good 

photo opportunities, the best public affairs stories 

come from programs that actually succeed. The worst 

example of health sector failures are structures that 

were built by the United States for Iraq, but sit empty 

or are used for other purposes by the enemy. Such 

failures can undermine US information operations. 

Typical focused humanitarian assistance partnership 

programs in the health sector are successful because 

the projects involve local contractors and workers, 

train local officials to staff programs and facilities, and 

are typically resourced at a degree that the community 

can maintain with its current level of financial, natural, 

and human resources. Furthermore, US medical CMO 

projects were linked to other civil-affairs projects to 

make them more comprehensive. TF 30’s preventive 

and veterinary assets were heavily involved in sewer, 

water, electricity, and trash (SWET) projects. When 

SWET projects augment humanitarian efforts, the 

insurgency was diminished in those “Beladiyahs,” or 

Iraqi districts. The key lesson learned from the NGO 

partners is that it takes much more than money and 

infrastructure development to be successful. 
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Operation Iraqi Freedom 05-07 Medical Civil–Military Operations: Lessons Learned in Humanitarian Assistance

SUMMARY

TF 30 had highly successful civil-military operations and successfully transitioned its operations to 

the 3rd Medical Command for OIF 06-08. Recognizing 

the importance of CMO and humanitarian assistance 

in stability, security, transition, and reconstruction operations, the 3rd Medical Command deployed a more 

robust CMO capability to capitalize on the successes 

of TF 30. However, to date very few Army medics 

are trained in humanitarian assistance, and there is 

no proponent in the Army Medical Department for 

medical CMO or humanitarian assistance. The civil 

dimensions of war must be planned for. To facilitate 

medical planners’ cognizance of the importance of 

CMO, doctrine and courses must be developed to 

meet needs of the operational commanders on today’s 

battlefields. 

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Military Medical Ethics. Vol 2. In: Textbooks of Military Medicine. Washington, DC: US Department of the Army, Office 

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suppl):14.

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globe/editorial_opinion/oped/articles/2005/10/24/the_cure_for_tyranny/. Accessed July 28, 2010.

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8. Department of Defense. Military Support for Stability, Security, Transition and Reconstruction (SSTR) Operations. September 16, 2009. DoD Directive 3000.05. Available at: http://www.dtic.mil/whs/directives/corres/pdf/300005p.pdf. 

Accessed July 28, 2010.

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carlisle.army.mil/usawc/parameters/Articles/05autumn/natsios.pdf. Accessed July 28, 2010.

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11. Information on the Denton Amendment is available at: http://www.usaid.gov/our_work/cross-cutting_programs/

private_voluntary_cooperation/dentonguidelines.html. Accessed July 26, 2010.
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