Humanitarian surge

EDITOR'S NOTE: More than five years into the war, most Iraqi municipalities lack basic emergency care like ambulances and trained firefighters. That's one reason that in 2007, as part of the U.S. surge strategy, the State Department working with Gen. David Petraeus formed Provincial Reconstruction Teams (PRTs) across Iraq's 18 provinces to rebuild political, social, and material structures. When Petraeus first commanded troops in Mosul, his well-known imperative was, "What have you done for the people of Iraq today?" PRTs resulted from his insistence that the first step to ending the insurgency is protecting the people and improving their lives.

Composed of military, civilian, and diplomatic experts, both Iraqi and American, the units are in many cities the leading face of the U.S. presence in Iraq, particularly with the retreat of combat units from urban areas earlier this summer. PRTs can include city planners, public-health experts, or school specialists, as well as military officers, and most teams include about a dozen people. "The essential mission of PRTs now is to build the capacity of provincial and local officials to govern and to provide services. That is mostly being done with Iraqi funds and working within the Iraqi government, as opposed to the earlier model of reconstruction where coalition forces planned, built, and paid for everything," noted one PRT member who spoke to WORLD last year.

In January 2009 the Obama administration launched a review of PRTs, sending a questionnaire to members in each of the provinces and removing from its website a State Department counterinsurgency guide that concluded PRTs were an essential tool to battle militant groups and terrorism. Now, as part of the overall drawdown of troops in Iraq set to continue to 2011, the teams are scaling back, with many already based only in Baghdad and perhaps as few as six throughout the country by August 2011. The following is a recent snapshot of one PRT's work in Karbala, one of the holiest cities in Islam and considered a center of learning by Shiite Muslims.

KARBALA-With five Iraqi surgeons in tow, U.S. Army Col. John Schriver moved quickly between Iraqi patients awaiting surgery in Al Hussein General Hospital. For Schriver, a general surgeon with extensive experience in some of the world's best medical facilities, it was his first time in an Iraqi hospital. "What is going on with this patient?" he asked the group. "Who is presenting this case?" Dressed in coats and ties, the doctors took turns-using slow but clear English-explaining each case. "This is what I see," said Schriver, who gave them a rapid diagnosis and tips on how to approach the surgery. "Do you need me in the operating room on this one?"

Schriver's presence-and that of the other 11 team members who accompanied him on a recent medical tour to Iraq's central province of Karbala-is one of the far-reaching effects of the "civilian surge" launched in early 2007. The surge expanded the Provincial Reconstruction Team (PRT) program that now includes about 450 civilians spread among 26 PRTs in Iraq. The teams consist of Iraqis and U.S. officers who include military and civilian experts. The PRT in Karbala, a city of over half a million 60 miles southwest of Baghdad, moved into its small base on the outskirts of the city in May 2008. Since then, its small convoys with civilian and military experts have become a familiar sight.

The 10-day medical training was the fruit of months of work between PRT officials on the ground in Karbala, U.S. military medical units throughout Iraq, and local Iraqi authorities. Here's how it came about: Two PRT members first approached the Karbala Provincial Council Health Committee in November 2008 to inquire about the needs of Karbala's medical community. The following week the committee presented to U.S. officials a long list of medical equipment they wanted to have repaired or replaced. "We knew that was a non-starter," said Major John Gerald, a registered nurse who leads the PRT's small health team: "Medical equipment, in addition to being extremely expensive, is notoriously difficult to maintain [here]."

After several additional meetings, the U.S. advisers and the Iraqi health-care authorities agreed instead on training. Iraqi medical standards are largely out of date because of the country's international isolation under Saddam Hussein's regime. Gerald contacted U.S. medical units around Iraq to see if any could spare doctors and nurses, and he found enthusiastic allies in two U.S. Army captains from the 172nd Brigade Combat Team (BCT), Michael Cahill, the Brigade Surgeon, and Christina Buchner, the medical company commander. Along with the local public-health director and a team of local doctors, Gerald, Cahill, and Buchner designed a training program: a four-day course for ambulance First Responders at the PRT base outside Karbala, followed by four days of medical training in Karbala's main hospital.

For the hospital phase, Cahill requested a forward surgical team from the 10th Combat Support Hospital (CSH) in Baghdad, which included Schriver, an orthopedic surgeon, an anesthesiologist, three nurses, and an operating room technician. Cahill brought along a family practice physician, a nurse, and two physician's assistants from the 172nd Brigade.

What became immediately clear, particularly during ambulance training with first responders, is that the Iraqi medical personnel had a high level of expertise compared to the basic level of the curriculum. "We went through four days of curriculum in three hours," Gerald said. The U.S. trainers-all medics from Charlie Company of the 172nd BCT-quickly recovered and spent the remainder of the course teaching hands-on skills, which the Iraqi medics enthusiastically absorbed.

During the hospital phase, there was a similar disconnect with some of the classroom instruction for the doctors. The U.S. nurses discovered that they had no real equivalent in the Iraqi health-care system, where nurses provide little patient care. And the Iraqi doctors hoped that the U.S. surgeons would bring along their much better equipment. "What they want is for us to take them to the next level," said Schriver, who performed two operations during four days of training. "They can do the easy stuff, but they need advice for the more complicated procedures."

Locals regarded the brief training session as a success, and it received wide coverage in local media as well as praise from Karbala officials. But the evaluation of the patients is perhaps what counted most. Iraqis brought one young woman, 30 years old, to the doctors with severe damage to her jawbones, damage she sustained from a traumatic injury at the age of 2. She could barely open her mouth, and Iraqi doctors had been unable to operate because the surgery required a special procedure to administer anesthesia through her nose, which they were not equipped to do. With an anesthesiologist on hand, Major Christopher Hutson, the operation went forward, giving the woman hope for a more normal life. During one of Schriver's operations, he successfully treated a blind man with gastrointestinal reflux disease. "You should have seen his family" said Salaam Wendy, an Iraqi who works for the PRT. "The brothers were all shaking Colonel Shriver's hand, and the father, he just shed tears."

-Richard G. Miles is a U.S. diplomat serving with the Provincial Reconstruction Team in Karbala, Iraq