Abstract
During Operations Allies Refuge and Operation Allies Welcome, over 40,000 Afghans were evacuated to military sites within the US European Command in the fall of 2021. As the evacuees moved through temporary and permanent sites, public health surveillance initiated by the command surgeon general monitored the health of this population to increase health security. A total of 3,974 medical events were recorded among the Afghan evacuee population throughout the operations. The most common categories of disease or medical conditions reported as gastrointestinal (infectious and noninfectious), respiratory, injury, and dermatological conditions. Evidence from this response supports the need to establish rapid public health surveillance during US humanitarian support operations, with coordination among lead and responding agencies.
Introduction
The immediate and longlasting public health consequences of war are a relevant global health security issue, and resultant humanitarian crises highlight the impact of world politics on global health.1-3 Humanitarian crises cannot be ignored, and the tragic impact of conflicts, such as those in Afghanistan, Yemen, and Ukraine, on global health security is a constant concern. These historic incidents show that warfare significantly increases mortality and morbidity for noncombatants. 3 Moreover, vulnerable populations in the region are subject to death due to direct violence, lack of access to healthcare and medicines for chronic illnesses, and increased risk of infectious diseases as national health programs have limited resources or are unable to provide health services. Decades ago, policymakers did not readily associate public health with national and international security concerns. However, as health security events have taken center stage, such as the Ebola epidemic in 2014 and most recently the COVID-19 pandemic, high-level policies, including the US National Defense Strategy, have noted the role of public health in national security.3,4
The entire world watched the humanitarian crisis unfold following the Taliban takeover of Afghanistan in August 2021, which led multiple nations to rapidly evacuate their own citizens and allied Afghan nationals from the country. 5 For the United States, this marked the initiation of Operation Allies Refuge 6 on July 14, 2021 and Operation Allies Welcome 7 on August 29, 2021.
The lead US federal agency for these operations was the Department of Homeland Security; supporting agencies were the Department of Defense (DOD) and the Department of State. The DOD played a key role in these operations because evacuees were transferred to several temporary US military sites around the world before being transferred to 8 military installations in the United States and eventual resettlement into US communities. 7 Providing a sanctuary to the Afghan nationals in the United States involved extensive interdepartmental and international collaboration in order to establish the provision of services before entry: immigration processing, security vetting, and health screening.7,8 The DOD US European Command offered key nodes for transitioning evacuees to immediate refuge in 1 of 6 established DOD European sites. 6 The first 15,000 evacuees arrived at Ramstein Air Base in Germany on August 20, 2021; in total, the 6 sites housed over 40,000 Afghan evacuees throughout the crisis.
Identifying public health issues during crisis situations is critical to avoid the spread of disease between populations and across borders, as well as to ensure those affected receive the healthcare they need. The US European Command surgeon general (ECSG) immediately established a public health surveillance system at the 6 DOD European sites across 4 countries (Italy, Spain, Kosovo, and Germany), providing direct medical support to Afghan evacuees. The experience is considered here as a case study for understanding lessons learned on rapid implementation of public health surveillance for a DOD humanitarian response. As the DOD continues to support humanitarian efforts, it must develop a standardized public health surveillance methodology that considers cultural and global health factors to enhance safety and health outcomes among the vulnerable populations affected by crises.
Health Surveillance for the Afghan Evacuation
The DOD is not usually involved in providing extensive medical care or implementing health surveillance for nonmilitary personnel. To rapidly implement health surveillance for the Afghan evacuee population, a public health surveillance methodology was developed based on guidelines from the US Centers for Disease Control and Prevention 9 and US Armed Forces Health Surveillance Branch 10 on collecting health-related data to aid public health practice during the evacuation crisis.
The list of reportable events and case definitions was developed based on Armed Forces Reportable Medical Events: Guidance and Case Definitions 10 and public health surveillance information for Afghanistan from the World Health Organization. 11 A total of 29 reportable event categories were reported, as reflected in the Table.
Military treatment facilities provided healthcare to the Afghan evacuees on the 6 US military installations in the European region housing them. The facilities reported health surveillance data for all Afghan evacuee medical encounters, and healthcare providers made the diagnoses. The military treatment facilities reported Afghan evacuee health events daily from August 29 to October 13, 2021, for 40,000 Afghan evacuees. These data were submitted to ECSG Force Health Protection for aggregation, analysis, and reporting to leadership.
Key Disease Trends in Afghan Evacuees
A total of 3,794 medical events were recorded among the Afghan evacuee population at US military sites in Europe throughout the operation. The Table highlights the cumulative frequency of diseases and medical conditions of public health concern during the time of the humanitarian operation from August 29 to October 13, 2021. Public health surveillance revealed that the most common categories of disease or medical condition reported were gastrointestinal (infectious and noninfectious), respiratory, injury, and dermatological conditions, as depicted in the Table. In addition, a high number of women and children suffered from infectious diseases, including COVID-19, influenza-like illnesses, and measles, highlighting the importance of surveillance in vulnerable populations. During the reporting period, 241 pregnancies and 19 live births were recorded. Uniquely tropical diseases, such as malaria and leishmaniasis, were also identified in this population, consistent with expected disease risks from the country of origin.
The Figure represents key disease and medical condition trends observed during the humanitarian crisis. Of note, several evacuees needed mental healthcare during the evacuation. Between September 12 and 15, 2021, a high number of diseases related to the large number of evacuees temporarily residing in close living quarters was reported among the sites.
Key disease trends in Afghan evacuees reported by the US European Command, August 29 to October 13, 2021. Disease trends are based on reported diseases. The general disease categories include various reported diseases: gastrointestinal – noninfectious gastrointestinal illnesses, cholera, hepatitis A, and other infectious gastrointestinal diseases; respiratory – COVID-19, pertussis, tuberculosis, influenza, influenza-like illnesses, lower respiratory illnesses, and diphtheria; dermatological – rashes and local cutaneous lesions (not measles); febrile illness – unexplained fevers; psychiatric or other mental health events.
Cumulative Frequency of Diseases or Conditions of Public Health Concern Reported in Afghan Evacuees by the US European Command, August 29 to October 13, 2021
Reportable medical event categories were based on Armed Forces Reportable Medical Events: Guidelines and Case Definitions. 10
All cases were confirmed in a laboratory. cGastrointestinal illnesses include infectious and noninfectious conditions; infectious gastrointestinal diseases were not confirmed in a laboratory.
Lessons From Health Surveillance During the Afghan Evacuation
A rapid public health surveillance response allows for early detection of infectious and noninfectious diseases to achieve necessary disease control and treatment within a vulnerable and high-risk population. A rapid response also protects the personnel directly supporting humanitarian efforts. In addition to public health surveillance, the DOD should include the following steps in policies related to a health response: (1) consider the point of origin of the persons being supported to identify diseases or medical conditions specific to that region; (2) consider culture when applying public health mitigation strategies; (3) provide specific humanitarian training to responding DOD personnel; and (4) use public health surveillance to inform public health policy and practice.
The ECSG used the World Health Organization Global Health Observatory 11 to identify specific disease trends in Afghanistan. This assisted with initiating public health surveillance that corresponded with potential disease risks unique to that population and ensuring relevant data collection, such as the number and types of uniquely tropical diseases and number of pregnancies. Two sites in Germany were the first receivers of Afghan evacuees. The rapid collection and analysis of data helped inform future sites to better understand what disease trends were recorded in the population, thus ensuring better public health planning and mitigation. The ECSG shared the public health surveillance data among interested parties daily; this included medical professionals directly responding to the crisis as well as senior federal leaders. When a military treatment facility identified an infectious disease in the population at risk, contract tracing, quarantine, and isolation took place to reduce the spread of the illness. The US European Command was the first to establish disease surveillance; in turn, that surveillance strategy was adopted by the lead federal agency. Further, the rapid identification of measles resulted in swift decisionmaking for the Centers for Disease Control and Prevention, which instituted a policy regarding vaccination for susceptible individuals and established a quarantine period before the evacuees' arrival in the United States. 8 When the policy was initiated, over 99% of the population was immunized with the measles, mumps, and rubella vaccine.
Recommendations Based on Lessons Learned
We developed public health recommendations for the DOD based on lessons learned during the response to the crisis.
Conclusion
The lessons learned on rapid implementation of public health surveillance for a DOD humanitarian response illustrate the need for a standardized, clearly defined DOD humanitarian response policy. The experience of evacuating Afghans for resettlement in the United States shows how a swift public health surveillance response from the ECSG informed the lead federal agency response and policy, supported future evacuee sites, and informed senior leaders of the current situation. It is clear there is a need for improved public health surveillance that considers cultural norms and global practices to enhance safety and improve health outcomes among the populations affected by crises, as well as a need for effective coordination between lead and responding agencies.
Footnotes
Acknowledgments
The views expressed are solely those of the authors and do not reflect the official policy or position of the US Navy, the US Army, the US Air Force, the US Department of Defense, or the US government. This manuscript has been approved by the US European Command Public Affairs Office and Department of Defense Office of Prepublication and Security Review.