Humanitarian Mission at Home: Walter Reed National Military Medical Center’s Experience in Operation Allies Refuge and Operation Allies Welcome

ABSTRACT

BACKGROUND

After two decades of war in Afghanistan, on July 14, 2021, the White House announced Operation Allies Refuge (OAR), to support Special Immigrant Visas for eligible Afghan nationals and their families who supported the U.S. Government (https://www.northcom.mil/OAR/ accessed on November 9, 2021). On August 26, 2021, a suicide bombing at the Hamid Karzai International Airport in Kabul, Afghanistan, killed at least 183 people, prompting emergent medical evacuation to the United States via Landstuhl Regional Medical Center (LRMC) in addition to the ongoing airlift efforts to designated immigration processing centers, known as “safe havens.” Walter Reed National Military Medical Center (WRNMMC) was alerted on August 27, 2021, to prepare to receive up to 63 injured patients in 48-96 hours. Following the initial medical evacuations, more travelers continued to arrive over the following months in support of Operation Allies Welcome (OAW) (https://www.dhs.gov/allieswelcome accessed on November 9, 2021).

Although thousands of evacuees were sent to various military bases throughout the United States, WRNMMC received those with more complicated injuries and illnesses along with their respective families. This mission represented a complex and coordinated effort to ensure medical care for acute and chronic issues, prevention and control of infectious diseases (ID), support of immigration medical screening requirements, safe passage, housing, and meals in addition to extensive psychological and social support. We present a synopsis of the resettlement support mission the WRNMMC military treatment facility provided as part of the nation’s response to the United States’ withdrawal from Afghanistan.

MISSION OVERVIEW: CASUALTY RECEIVING AND CARE

WRNMMC is a tri-service tertiary care military medical center and is historically regarded as the flagship of U.S. Military medicine. Located on Naval Support Activity Bethesda (NSAB), in Bethesda, MD, along with the USU and multiple tenant commands, WRNMMC has a 244-bed capacity and provides care and services to more than 1 million beneficiaries annually (https://walterreed.tricare.mil/About-Us/Facilities/Facts-at-a-Glance accessed on November 10, 2021). Comprehensive medical, surgical, dental, and ancillary services are available, as well as a wide range of medical training programs for a variety of health professional programs. Although OAR was primarily led by the DoD, the Department of Homeland Security was the primary lead for OAW, and WRNMMC was designated as the sole continental U.S. Military treatment facility for care of significantly wounded and ill Afghan evacuees.

Between August 27, 2021, to November 13, 2021, 18 Active Duty U.S. Service members and 277 Afghan evacuees, comprising 20 individuals and 50 families, were received by WRNMMC via the LRMC to Joint Base Andrews medical evacuation (MEDEVAC) pipeline (Table I).¹ The initial WRNMMC casualty response in the first 5 days consisted of 18 active duty service members and 38 Afghan nationals. Of active duty admissions, 14 were inpatient trauma, 3 were outpatient trauma evaluations, and 1 required outpatient medical evaluation. Of the initial 20 Afghan inpatients, 13 were adults. Eleven adults experienced blast or gunshot wound-related injuries, two adults with inpatient medical needs, and five pediatric patients required inpatient trauma care. In all, over 3 months, WRNMMC received 72 Afghan inpatients, 8 outpatients, and 197 nonmedical attendants (NMAs), many who required outpatient services while housed on NSAB. NMAs were often family members. In general, the wounded personnel and evacuees were received following a 24-48 hour evaluation and stabilization at LRMC.

A multidisciplinary medical and logistical response was coordinated to support the arrival of all evacuees at WRNMMC. Numerous specialty and subspecialty services were involved in Afghan care, to include infectious disease, internal medicine, pediatrics, general surgery and surgical subspecialties, obstetrics and gynecology, psychiatry, dental, nutrition, radiology, laboratory, pharmacy, immunizations, and physical and occupational therapy. The American Red Cross, patient administration, social work, and hospital operations were critical in coordinating much of the nonmedical services, logistics, and other requirements. As evacuees were received, admissions were grouped together on medical-surgical or surgical intensive care units with in-person interpreter support. Family unit integrity was prioritized when needed for pediatric patients or families with multiple members admitted. It was common for medical services to admit stable trauma patients with complex medical problems. Nonmedical attendants were provided on-base accommodations in barracks settings, meals via hospital nutrition support, and 24-hour access to active duty escorts to facilitate efficient and safe movement throughout the hospital and about the campus.

The majority of the Afghan patients arrived with their NMAs and remained on NSA Bethesda during their acute care needs. Family units had a median of four members (range, 2-12). Duration of support for an Afghan family aboard the base was a median of 10 days with a range of 1 day to ongoing care. One individual remains on base as of March 11, 2022. Evacuees routinely required a full range of consultative services, and their associated NMAs also commonly required outpatient care or additional services. Consultation and referral of care to outside hospitals for expert care were made when necessary, particularly for pediatric care needs. Evacuees were eventually transferred off NSAB via Department of Health and Human Services (HHS) pathways to identify safe havens for ongoing resettlement. A few evacuees required direct resettlement from WRNMMC to long-term care and inpatient rehabilitation facilities at their final destinations. Upon initial discharge from WRNMMC to local safe havens in the Maryland and Virginia area, several evacuees continued to require follow-up physical therapy, occupational therapy, and subspecialty care at WRNMMC.

MEDICAL RESPONSE

A multidisciplinary approach was required to address the immediate needs of the medical and nonmedical evacuees, requiring interdepartmental, inter-directorate, and interinstitutional coordination. Upon receiving the mission, regional, hospital, and service-level leadership prepared the regional military health system hospitals of Walter Reed and Fort Belvoir Community Hospital (FBCH) to see a surge in census and allow for better organization of patients and required resources. Furthermore, resources were made available to train staff in culturally sensitive topics, and housing and nutrition services were coordinated to support the family units and outpatients who would not otherwise be admitted.

Initial efforts included sending stable medical patients via ambulance and military aviation assets to FBCH bolstered by a graduate medical education (GME) medicine team. Under ID guidance, GME trainees assisted with implementation of required immigration health screening and assessments of all inpatients, outpatients, and NMAs. This required extensive coordination of immunization, pharmacy, laboratory, radiology, and translation services support. Immigration health care was conducted in family units with assistance from pediatrics and either an internal medicine or an ID provider and with consideration for providing gender-appropriate staff. Initial assessments included screening for active health concerns, evidence of immunity to vaccine-preventable infections (e.g., measles, mumps, rubella, viral hepatitis, and varicella), and screening for tuberculosis and sexually transmitted infections. Initial assessments were completed typically within 48 hours of arrival with close adherence to CDC guidance (https://www.cdc.gov/immigrantrefugeehealth/civil-surgeons/vaccinations.html; ARNORTH SF600 pdf). All travelers were also screened for coronavirus disease 2019 (COVID-19) and offered vaccination as clinically indicated. Pediatric patients also received treatment for ectoparasites and soil-transmitted helminths using ivermectin and albendazole in addition to catch up administration of age-appropriate vaccines.

Inpatient efforts leaned heavily on institutional experience with trauma care from two decades of Operations Iraqi and Enduring Freedom. The DoD’s Joint Trauma System guidelines (https://jts.amedd.army.mil/index.cfm/pi_cpgs/cpgs) serve as the basis for initial surgical management, Infection Prevention and Control, as well as complex infection management. Multidrug-resistant organism infections and to a lesser extent invasive fungal infections were diagnosed in several patients who presented with severe trauma injuries. Stable trauma patients were frequently cared for by medicine teams with a census between 8 and 12 daily. Psychiatry support as well as bedside care was supported by both fluent providers as well as 24-hour interpreter support and access to telecommunication resources for family communication.

Pediatric care proved to be especially challenging in both the in- and outpatient care settings. Many of the inpatients were victims of complex polytrauma from the airport bombing. Others were transferred for the management of acute exacerbations of chronic complex medical issues. Care and disposition from WRNMMC were driven by family decisions, access to civilian specialists, and conjunction with the Office of Refugee Resettlement within the Department of HHS.

Initial management of high-risk pregnancies was also challenging and required extensive collaboration between obstetrics and pediatrics services to leverage resources and rapidly triage pregnant patients at the flight line upon arrival into the United States. Cultural and language barriers were a common impediment to performing obstetrical exams and obtaining accurate histories of prenatal care received in Afghanistan. On a few occasions, groups of 7-10 pregnant travelers would require after-hours obstetrical evaluations immediately upon arrival and subsequently be dispositioned to NSAB housing or local safe havens within 12 hours of entering the United States. One patient was admitted directly to the obstetric service for hypertensive emergency diagnosed during the medical evacuation. Another patient was admitted directly for induction of labor due to newly diagnosed selective growth restriction of dichorionic-diamniotic twins. All other pregnant travelers were evaluated and did not require admission.

Wrap-around clinical and logistics support proved crucial to the efficient reception, housing and care, and final disposition of these travelers. Active duty escorts were provided with translators in housing areas on NSAB. Red cross and community non-governmental organizations assisted with clothing and supplies, while nutrition services provided an excess of 11,000 culturally appropriate meals, along with consultative services, to most travelers. Behavioral health resources ranging from psychiatrist, psychologists, counselors, and social workers interfaced daily with patients and family units in an effort to aid in the processing of both the trauma and chaotic cultural shift that these travelers faced. A joint effort also ensured that essentials such as housing, clothing, shoes, toiletries, laundry pods, eyeglasses, snacks, meals, baby formula, strollers, and car seats were made available to all evacuees.

Throughout the entire mission, medical services flexed to accommodate the needs of the Afghan patients. Lab, immunization, nutrition, and counseling services were often provided to the families either in temporary clinic spaces on underutilized wards or within the designated lodging areas in an attempt to ensure efficient and comprehensive care. As medical conditions allowed, coordination with HHS enabled transfer of patients to medically fragile housing to allow for close follow-up in the community.

WRNMMC’s OAR medical response included care for common and uncommon conditions (see Table I), and the majority of patients and NMAs were received from August 26, 2021, to February 28, 2022 (see Fig. 1).

FIGURE 1.

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WRNMMC Afghan traveler response from August 26, 2021, to February 28, 2022.

NSAB—Naval Support Activity Bethesda, Bethesda, MD; WRNMMC—Walter Reed National Military Medical Center.

DISCUSSION

The military has a long history of medical humanitarian missions in response to natural disasters, humanitarian assistance, and disaster relief and as planned humanitarian and medical civil action projects.^2–5 Prior examples include 2017 Hurricane Maria in Puerto Rico, 2010 Earthquake in Haiti, 2004 Tsunami in Indonesia, USNS Mercy’s Pacific Partnership, USNS Comfort’s Continuing Promise and various health programs in participation with nongovernmental partners, U.S. Agency of International Development, or the U.S. CDC in multiple countries.^6–10 Amidst the final withdrawal of U.S. forces from Afghanistan in August 2021, the military medical system was activated on short notice to support humanitarian crises involving thousands of Afghan evacuees.

In one of the largest resettlement efforts in recent U.S. history, WRNMMC rapidly mobilized to provide care to 80 Afghan patients and 197 NMAs as part of OAR and OAW. As a country with a low human development index, Afghans have higher health hazards, to include malnutrition, high mortality from infections and inadequate sanitation, and low access to health care and vaccinations (http://hdr.undp.org/en/countries/profiles/AFG accessed on November 9, 2021).¹¹ During OAW, there was a measles outbreak in September at several sites in the United States, which caused a pause in evacuations, quarantine, and vaccination requirements for over 49,000 evacuees. In addition, several outbreaks of COVID-19 infections occurred at identified safe havens for Afghan evacuees both overseas and within the United States throughout OAR and OAW.

At WRNMMC, multiple departments and services actively played key roles in assisting in the care and screening of the evacuees. The coordination of all the different services required frequent communication and willingness to adjust processes to optimize the experience and efficiency of resource use while avoiding impact on other hospital services and MHS beneficiaries. The processes were constantly modified and adapted to meet the changing needs.

Operation Allies Welcome represented a very unique, short suspense mission set for WRNMMC that posed a number of challenges. Within a 96-hour notice, immediate access to extensive interpreter services was required, to include an appropriate mix of Dari and Pashto interpreters, as well as a few other less commonly spoken languages. As previously mentioned, gender assignments were maintained to the extent possible for both interpreter and medical services, and nutrition contracts had to be quickly constructed to allow for culturally appropriate meals. With extensive assistance from American Red Cross and eventually Department of Homeland Security services, mechanisms were constructed for obtaining much needed clothing, baby formula, car seats, strollers, and other personal needs for Afghan evacuees. One of the most challenging aspects of the mission set involved ensuring the successful disposition of Afghan inpatients with extensive ongoing medical needs into the outpatient community. A significant increase in case management support was required to assist with identifying appropriate insurance mechanisms and outpatient medical and surgical care services in the local civilian community around WRNMMC as well as in identified resettlement areas across the country. A local hotel nearby to WRNMMC was utilized as a “medically fragile” outpatient facility that allowed discharged Afghan outpatients to continue to access WRNMMC for following up outpatient medical, physical therapy, and occupational therapy needs until eventual resettlement. Amidst an ongoing COVID-19 pandemic, many larger metropolitan areas were deemed to be oversaturated and unable to support the medical and surgical needs of some Afghan evacuees, which prompted eventual relocation and resettlement into other regions less heavily impacted by the pandemic. Throughout the operation, family unit integrity was prioritized to the maximum extent possible. Successful relocation of Afghan evacuees with extensive medical needs along with their family members required extensive coordination between WRNMMC leadership, case managers, social workers, and multiple government agencies.

The recent successful care and disposition of hundreds of Afghan evacuees at WRNMMC once again demonstrates the ability of the DoD to draw on its uniformed providers and support staff on short notice to accomplish a “no fail” mission set. No other medical system in the world has the ability to pivot manpower, expertise, and resources in support of humanitarian crises, to the extent which the United States has demonstrated as part of OAW. This mission, similar to those before it, is a testament to the value of having a ready medical force with the depth and breadth that allow for flexibility and competence in the most challenging and complicated situations of national and strategic importance.

ACKNOWLEDGMENTS

The authors would like to thank MAJ Rebecca O. Clark, MC USA and COL Michael Y. McCown, MC USA for their support.

FUNDING

None declared.

CONFLICT OF INTEREST STATEMENT

None declared.

REFERENCES

Author notes

The views expressed are solely those of the authors and do not reflect the official policy or position of the U.S. Army, U.S. Navy, U.S. Air Force, the DoD, the U.S. Government, or the American Red Cross.