South Sudan 2011 AAR

After Action Report TABLE OF CONTENTS 2. Executive Summary 4. Operation Overview 5. Operation Summary 8. Areas of Analysis 9. Volunteers 10. Logistics 11. Communications 13. Transportation 15. Medical 17. Media

South Sudan 2011

18. Security 21. Mission Statistics 22. Key Lessons 23. Key Actions

South Sudan, 2011

EXECUTIVE SUMMARY In February 2011, Team Rubicon’s (TR) Dr. Glenn Geelhoed led a medical/surgical training mission to the Memorial Christian Hospital (MCH) in the town of Werkok, in the Jonglei province of South Sudan. This area is populated by the Dinka tribe, one of the three dominant tribes in South Sudan (the others are the Murle and Nuer). TR deployed to Werkok to treat patients and teach the local staff physician, Dr. Ajak Abraham, and his clinical officers. Dr. Ajak is a "Lost Boy", an orphan of the 25+ year Sudanese civil war.

Dr. Ajak left Sudan in his youth; studying medicine and living in Cuba and Canada. He voluntarily abandoned the comforts of the west to return to South Sudan and work as a physician caring for the people of his homeland. Another Lost Boy, Jacob Guy, also left South Sudan to study and live in the United States. Like Dr. Ajak, Mr. Guy chose to return home and serve the people as hospital administrator for MCH Hospital Werkok. These two local medical professionals were crucial to the development of the mission.

During Dr. Geelhoed's many trips to South Sudan, and particularly this time in 2011, he witnessed the traumatic results of tribal conflict in South Sudan. For more than 25 years, the tribes of South Sudan focused on the war to gain independence from the north. Now that the war is over, however, their longstanding inter-tribal animosities and struggles for resources have resurfaced, as referenced in Dr. Geelhoed’s journal from his 2009 trip to South Sudan: "AN EMERGENCY CASE INTERRUPTS THESE MUSINGS, AS A MURLE RAIDING PARTY KILLS ONE WOMAN AND ABDUCTS ANOTHER WHO SURVIVES BY FEIGNING DEATH AND BEING CARRIED A FULL DAY LATER TO MCH—FURTHER RE-ENFORCING MY MUSINGS ON CATTLE CULTURE PEACE/HEALTH CARE LINKAGES AND THEIR POTENTIAL OR POSSIBILITY" The intertwined resources at issue are cattle and fertility. The South Sudanese tribes – the Dinka, Murle, and Nuer - are cattle cultures. In these cultures, status, prestige, and wealth derive from the size of one’s herd. And therefore the promise of marriage (dowry) and children is directly linked to cattle ownership.

The Murle have a high infertility rate due to untreated pelvic inflammatory disease and genital infections. In the hope of increasing their ability to propagate, the Murle raid neighboring tribes to rustle cattle and kidnap fertile women. These are the actions of a desperate people facing extinction due to infertility. The Dinka and Nuer respond with counter raids.

After seeing countless victims of these violent raids, Dr. Geelhoed, along with Dr. Ajak and Mr. Guy, decided to take broader actions; not to just treat the victims of these raids, but to stop the raids altogether. The three of them sat down with the leaders of the Dinka Bor and Murle and announced an initiative identified by the slogan “Peace Through Medicine”. This initiative consisted of three components: 1. Dr. Geelhoed and Team Rubicon promised to deliver a full shipping container of medical supplies to Dr. Ajak and Jacob Guy in Dinka-controlled Werkok. The supplies would outfit previously destroyed medical clinics.

2. Dr. Ajak and Jacob Guy would distribute these supplies evenly among the competing tribes.

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3. Dr. Geelhoed would return in one year with Team Rubicon. They would treat patients and train medical officers in Werkok. They would also go to Murle-controlled Pibor to deliver medical supplies, treat patients, and teach clinical officers. The supplies and teaching would focus on the problems of infertility in the Murle.

In return, the tribal leaders pledged to stop the intertribal violence. All of the promised aid was contingent upon this vow to keep the peace. And while the agreement is tenuous, for the time being they did just that. The Dinka and Murle set an example of inter-tribal cooperation, and thereby secured the tools to address the root causes of the violence: “Our overture is based in a biologic needs approach to the potential for a never-ending series of cattle raids and child kidnapping and bride stealing—all of these might have been abstract concepts and far-fetched hypotheticals if it had not been for our first hand observations during the course of multiple trips here to the South of Sudan.”

- Dr. Geelhoed

Jake Wood

William McNulty

John Sutter, MD

Joshua Webster

President

Vice President

Chief Medical Officer

Director of P&R

South Sudan, 2011

OPERATION OVERVIEW OPERATION NAME: DURATION: DATES: LOCATION(s):

OPERATION DIRECTIVE: ELEMENTS: TOTAL VOLUNTEERS: MILITARY VETERANS:

Project South Sudan 27 Days 4 February 2011 – 2 March 2011 Werkok, South Sudan Pibor, South Sudan Juba, South Sudan Surgical Training Mission TR Main Body 7 (Fong, Smith, Smith, Geelhoed, Creiglow, Sutter, Webster) 3 (Geelhoed, Creiglow, Webster)

TOTAL CASH RAISED: LESS: EXPENSES: NET: EXPENSES: TRANSPORTATION: EQUIPMENT: FOOD: LODGING: AUTHORIZED CASH DISBURSEMENTS: TOTAL:

$22,015* $8,667* $13,347

NET OPERATION GAIN/ (LOSS)

($24,663)

$28,002 $6,428 $65 $3,513 $0 $38,009

*NOTE: TR raised $21,345 towards the Sudan mission by hosting two fundraisers in San Diego, CA. These fundraisers collectively cost $8,667 to put on. TR raised $670 over social media while the team was deployed to South Sudan. The negligible amount raised over social media - compared to previous missions - has caused TR leadership to rethink how it pays for proactive missions.

Mission Objectives: 1. Team Rubicon will gather medical supplies, both donated and purchased, secure a shipping container, and send this container of supplies directly to MCH Werkok. This container will travel from Ohio, where most of the donations are housed, to Mombasa, Kenya. From there it will go by truck overland directly to Werkok.

2. Team Rubicon will deploy a team of seven volunteers to Werkok to receive the container and categorize its supplies. In Werkok, the team will work side by side with Dr. Ajak and his clinical officers; treating patients and providing surgical training to MCH Werkok.

3. After the completion of (2), three members of Team Rubicon will leave South Sudan. The rest of the team will go with Dr. Ajak and Jacob Guy to the Murle-controlled town of Pibor. In Murle headquartered Pibor, the team will work side-by-side with Dinka Bor’s Dr. Ajak and Murle clinical officers treating patients and providing training.

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OPERATION SUMMARY PRE-DEPLOYMENT In order to facilitate this mission, a 40-foor shipping container was rented to carry medical equipment into South Sudan. The medical supplies that were packaged into the container were collected by Dr. Geelhoed between 2009-2010. Dr. Geelhoed had been in contact with Dr. Ajak Abrahim, a Dinka clinical health officer in South Sudan, and had developed a friendship over years of working together. They agreed to cooperate in an effort to restore tribal peace through an initiative they named “Peace through Medicine”.

The team formed to execute this mission consisted of both medical staff and military veterans with medical training. The veterans were responsible for security in addition to medical duties. The reasoning here was to mitigate risk by conducting ongoing Operation Risk Management (ORM) analysi as the team traveled to multiple locations with differing security environments.

Supplies for TR’s mission to South Sudan lined up in Ohio

To obtain necessary visas, team member passports were shipped to the Central African Republic (CAR) embassy in Washington, D.C.. They were returned within weeks. Once gear and documents were finalized, the team members were given a rendezvous point and plane tickets to begin their journey.

Team Rubicon volunteer Zach Smith dispatched the container full of donated medical supplies from the United States several months prior to the mission. The container traveled by ship from the U.S. eastern seaboard to Mombasa, Kenya. There, it was loaded onto a truck for the thousand-mile overland movement to Werkok, South Sudan. This journey required multiple entry/exit visas and travel permits, as well as a specialized free-entry permit due to the nature of the container’s contents. Multiple copies of the paperwork were sent with the container.

DEPLOYMENT On February 4, 2011 the team flew to Washington, D.C. to meet and gather last minute supplies from the Team Rubicon east coast storage unit. The Team rendezvoused at a hotel and set out towards the storage unit late at night. The trip to the storage unit proved fruitless as the facility was already closed by the time the team arrived at nearly one o’clock in the morning. Afterwards, the team met with a local volunteer in Washington, D.C. to collect maps of South Sudan.

The next day the team flew to Addis Ababa, Ethiopia, enroute to their final commercial air destination of Nairobi, Kenya. In Nairobi the team was welcomed into the Mayfield Guest House, the hostel of the African Inland Mission (AIM), a religious non-profit that operates in South Sudan and the surrounding countries. There they pre-treated their uniforms with permethrin and conducted final gear inspections.

South Sudan, 2011

The team transferred to Nairobi’s Wilson Airport and met their charter pilot, John Hildebrand.

Mr. Hildebrand was the pilot for a Cessna 208 chartered from AIM. The team loaded themselves and their gear into the aircraft and set out for Werkok, South Sudan on February 8.

In Werkok, the team liaised with the medical staff of the Memorial Christian Hospital (MCH) funded by Partners in Compassionate Care (PCC), a US-based religious organization that funds medical relief efforts overseas. MCH Werkok was staffed by Dr. Geelhoed’s counterpart doctors in South Sudan, former Lost Boys of the Sudanese civil war who had been trained in medicine and were now practicing Clinical Officers (COs). These COs ran the medical infrastructure in South Sudan, and were the most knowledgeable personnel in the area regarding the extent and type of disease processes.

The team spent a week in Werkok studying tropical diseases. They conducted sick call hours in the mornings and evaluated patients that were viable surgical candidates. Patients selected for surgery were kept overnight and had their food and water regulated in preparation for surgery. Patients for sick call were triaged according to their illnesses and evaluated for ongoing care.

TR greeted by local children upon arrival in Werkok, South Sudan

During their stay in Werkok, the team traveled to Juba, the capital city in the Jonglei province, to make an assessment of the hospital there. The hospital facilities were inspected after a brief introduction to the city governance staff. Afterwards the team prepared for a cultural event that Dr. Geelhoed had set up in advance of the teams’ arrival. Dr, Geelhoed and Dr. Ajak had coordinated for an inaugural “Freedom Run” footrace through the town of Juba later in the week. The footrace was intended as a ceremony recognizing the inception of the new country of South Sudan. It was also designed to alleviate tribal tensions through sport; drawing in competitors from multiple tribes. Tribal tensions had increased during the recent infertility epidemic sweeping through South Sudan. The organizers hoped to alleviate some of this while simultaneously creating a bonding moment for the city’s inhabitants.

Chief Medical Officer Dr. John Sutter supervises a

The race was run the following day, and it was a surgery at Werkok Memorial Christian Hospital huge success. Members of Team Rubicon ran alongside Sudanese athletes in a 12-kilometer race through the city. Prizes were awarded to the top four finishers and, ultimately, TR’s Josh Webster placed fourth behind three Sudanese runners. There was a celebration and after the race the Team Rubicon personnel travelled back to Werkok to continue their clinical duties.

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Back in Werkok, the team also oversaw the arrival and unpacking of the shipping container that had be shipped to South Sudan many months prior. The shipping container had to be unloaded into an adjacent storage facility within the PCC camp. The equipment was separated and sorted while Dr. Ajak and Dr. Geelhoed created a plan to distribute the supplies to the outlying cities within the Jonglei province. The team continued their medical duties at MCH Werkok, and visited a Leprosy clinic to treat acute illnesses and inspect their medical capabilities.

The team left Werkok on 18 February, and flew to Pibor, South Sudan. Pibor is controlled by the Murle.

The Murle have been involved in recent tribal clashes with the Nuer and Dinka tribes. Dr. Ajak Abraham, a Dinka Bor physician from Werkok, agreed to accompany the team into Pibor (at great personal risk) for the explicit purpose of healing tribal tensions through an exchange of medical services between tribes.

Shipping container arrives in Werkok

In Pibor the team conducted a sick-call clinic and evaluated patients for surgery. Surgeries were conducted in the local church run by Reverend Oruzuz. Pibor proved to be rife with the diseases that Dr. Ajak and Dr. Geelhoed had expected; including Pelvic Inflammatory Disease (PID) caused by Sexually Transmitted Diseases (STD’s). This type of treatable illness was causing many pregnant mothers to lose their babies; and sometimes their own lives. The team spent the week in Pibor treating these illnesses, as well as any other acute injury or illness that they found. The team also took a trip across town to inspect the bombed-out hospital once known as the Lakonga Clinic prior to the Sudanese civil wars of the 1990’s.

The team departed Pibor on February 21 and returned to Werkok before pressing onto the border of Central African Republic (CAR). The team was delayed in Werkok because the flight clearances for the AIM aircraft needed to be re-authorized before it could enter CAR. The team decided to “pre-stage” themselves along the CAR border in the town of Team Leader Dr. Geelhoed and Paramedic Zach Smith Nzara, South Sudan. In Nzara, the team was met by conduct sick call in PiBor representatives from the Ugandan Peoples Defense Force (UPDF) and stayed in the UPDF camp awaiting aircraft authorization. The stay in Nzara dragged on as the flight clearances were held up by the new government of CAR. In the few weeks that the team has been in Sudan, new flight restrictions had been put in place by the CAR government. All efforts to circumvent these restrictions were met with the utmost resistance; and the team eventually had to abandon plans to travel to the CAR. On February 28, 2011 Team Rubicon ceased medical relief operations in South Sudan and returned home. They left behind all medical gear that they had carried throughout the mission that could be used by the South Sudanese medical personnel.

South Sudan, 2011

AREAS OF ANALYSIS 1.

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Volunteers Logistics Communications Transportation Medical Media Fundraising Expenses Security

Areas of analysis will be presented in the following format: SUMMARY: Summary of issue and how Team Rubicon specifically dealt with it.

RECOMMENDATION: What lessons TR learned, and how it should proceed in future operations.

ACTION: What steps need to be implemented by TR to ensure the recommendation is followed.

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ANALYSIS VOLUNTEERS SUMMARY The volunteers for this trip were chosen primarily because of their medical skills. The secondary criteria were security experience and media skills. Dr. Glenn Geelhoed, the team leader, has years of experience operating in Africa as well as in other crisis zones around the world. He had also been a doctor in the Navy, and was well versed of security threats in the areas that the team planned on operating. His medical counterpart was Dr. John Sutter, a family practice physician and Chief Medical Officer for Team Rubicon. Dr. Sutter has split his medical practice time among New York, Illinois, and Alaska. Kannan Samy, a medical student out of the University of Toledo specializing in general surgery, complimented these two.

Paramedics Zach Smith, Dan Fong, Kirtus Creigow, and Joshua Webster rounded out the crew.

Creiglow and Webster were both prior military, as a Navy Corpsman and Air Force Pararescueman respectively. The journalist chosen for the trip was Brittany Smith.

The team, minus Brittany Smith, poses near MCH in Werkok

RECOMMENDATION In order to fully utilize the strengths and experiences of our volunteers, it has become doctrine within Team Rubicon to ensure 50% of the personnel on missions are veterans. Veterans make up roughly 70% of our volunteers, and while most are not formally medically trained, many of them having medical skills and relevant combat experience. These personnel have been trained in security assessment, threat mitigation, and basic defense. Team Rubicon believes that it is wise to utilize such personnel where appropriate, in order to manage risk and provide an on-scene security advisor.

ACTION  

Specifically identify personnel suited for international deployments in the Team Rubicon volunteer roster.

Develop and maintain a proficiency standard for Team Rubicon volunteers who may be called upon to deploy internationally.

South Sudan, 2011

LOGISTICS SUMMARY The initial logistical piece of the Sudan mission concerned getting a full-size shipping container of medical supplies from the U.S. to South Sudan. This container was filled with medical supplies that would eventually be distributed among all the hospitals and clinics of Jonglei state in South Sudan. It was critical to the overall mission that this container arrive unmolested and at the appointed time (i.e., when the team was there).

The medical gear was donated by multiple medical organizations throughout the year prior to the mission. The donation process was coordinated by Dr. Geelhoed personally, and the collected supplies were stored in his basement. The organizations that donated medical supplies were: Anne Arundel Medical Center; Georgetown Hospital; Georgetown University; Project SAVE (Save All Valuable Equipment); and the University of Toledo MMHOFF (Medical Mission Hall of Fame Foundation).

Eventually, the supplies were sorted and prepared for shipping by volunteers coordinated by Dr. Geelhoed. They then transported the items to the shipping container yard where the supplies were loaded into the actual shipping container. The shipping container sailed to the port of Mombassa, Kenya, where it was loaded onto a truck and driven overland north to Sudan. The truck driver was given multiple copies of the freight documents for use at border checkpoints.

The team learned a great deal about international shipping, and the costs/benefits of doing business in southern Africa.

Other medical supplies were carried over by the team members themselves. These supplies were collected in different parts of the country and then assembled in Washington, D.C. during the team’s layover. The last items intended to be picked up were maps of the operational area and medical supplies from the east coast storage unit; specifically pre-positioned spinal anesthesia trays.

Unfortunately the storage unit could not be accessed at the time the team arrived. The team was compelled to press on with the mission without the spinal kits.

The team unloads personal gear in Werkok

While in country the team carried the bulk of the surgical and pharmaceutical gear around in four specially designed bags. These bags proved to be particularly useful when it came to moving specific pieces of gear to and from forward locations. Their design made it easy to identify and subdivide gear; saving valuable time. The team’s gear was also transported in durable Black Diamond duffel bags which could double as backpacks.

While the team was able to transport much of their food in personal or “team bags”, the weight of water made carrying a full supply unrealistic. For this reason, the team deployed with a two-tiered system for filtering local water. The first tier was a portable water filtration pump that filtered particulates. The second item was a portable ultraviolet light decontamination system for destroying

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viruses, bacteria, and parasites in the pre-filtered water. This system was effective and ensured sufficient supply of water for the team to be able to run smoothly.

Prior to departure from the region the medical equipment was divided into two categories: what would stay in Sudan; and what would be carried out by Team Rubicon utilizing the specially made medical bags.

This ensured that the proper supplies would remain in place for a return trip the following year.

RECOMMENDATION TR learned that equipment cashes in storage units need to be accessible at all times for them to be effective and worth the cost of keeping them. 24-hour access and numerical locks that can be opened by anyone (without needing a key) are essential. They also need to be inventoried and organized in case of a sudden emergency response mission. Local Team Rubicon leaders need an up-to-date itemized list of the contents and directions for entry to pass to deploying team members even while away from a home computer.

Given the extraordinary costs and coordination challenges, the shipping container approach should only be used again with the full support of officials who can ensure protection of the freight. The threats associated with corruption and banditry are simply too great given the value and amount of equipment at risk.

ACTION 

Choose storage units based on accessibility to deploying team members and proximity to major airports. 24 hour access is mandatory. Ground floor location for ease of loading large amounts of gear is preferred.

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Minimize the weight of any items included in international shipments in order to contain costs.

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Ensure that multiple copies of customs/passage forms common to international aid shipments accompany the actual shipment in order to speed its passage through various international choke points.

COMMUNICATIONS SUMMARY Team Rubicon maintained communications while deployed using a host of devices. These were used to: confirm the team’s location; send and receive updates on the stability of the political situation; and update the Team Rubicon website withblog entries.

The team employed the following communication equipment: 

An Inmarsat BGAN satellite terminal

South Sudan, 2011

  

Iridium satellite phone Two Brunton solar panels A laptop computer.

While on the ground the major source of power was the generator within the MCH clinic in Werkok.

When the generator was not available the team relied on the two Brunton solar panels to charge the satellite phone, BGAN, and computer as well as the team’s personal electronic devices. These panels also worked to charge backup batteries that were used to run the team's communications equipment when neither the generator nor the sun were available.

Daily updates regarding the team’s progress were sent back over the BGAN to William McNulty in the United States for approval and posting to the Team Rubicon website. These updates consisted of photographs of the day’s activities, accompanied by written summaries from both the team’s journalist and other members of the team.

RECOMMENDATION The team was able to successfully communicate with the equipment above. However, improvements need to be made prior to the next mission.

Communications equipment assessment:     

BGAN- adequate satellite phone- adequate solar panels- adequate Custom made backup battery- inadequate (greater power and reliability needed) Computer- inadequate (a MacBook Air, with a 13 inch screen and Photoshop software would be better suited for media needs)

The team had an adequate amount of solar panels to run the media equipment. However, difficulty arose when daily news releases and personal reflections needed to be uploaded via the BGAN. This process was fraught with problems and could take an extremely long time. Subjected to extreme heat, the backup batteries lacked the endurance to cover the entire uploading process. The need for a power source for the team member’s personal electronic equipment often interfered with the charging of media equipment. On future missions individual team members should be equipped with small personal solar panels.

ACTION 

Conduct an equipment inspection prior to deployment in order to determine the status of prepaid communication services (BGAN and sat phone).



Establish a partnership with an organization that can streamline information processing for remote devices in order to reduce upload and download time.

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Research batteries designed for use in extreme weather conditions that can be solar charged.

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TRANSPORTATION SUMMARY Team Rubicon personnel from around the country rendezvoused in Washington, D.C. to gather gear, maps, and prepare for transport to Africa via commercial aircraft. They flew directly from Washington, D.C. into Addis Ababa in Ethiopia, and from there connected to Nairobi, Kenya. From Kenya they remained in place for a day before departing on a chartered Cessna 208 aircraft from African Inland Mission (AIM). This aircraft, flown by an AIM pilot named Jon Hildebrand, was contracted to be Team Rubicon’s primary transportation platform for the duration of their stay in Africa.

The Cessna took the team from Kenya into Uganda for a brief fuel stop, and then onto Werkok, South Sudan for the first portion of the trip. While the team remained in Werkok, the aircraft departed for other assignments, but was scheduled to return on February 18 for the second leg of the trip.

Hildebrand was in contact with Dr. Geelhoed while he was away in order to coordinate return time and date.

In Werkok transportation was available most days from a Land Rover that was owned and operated by the MCH. If evacuation was needed, the team planned to rally at the vehicle and depart.

The Cessna 208 returned as scheduled on February 18 and the team loaded their gear into it for transport to the city of Pibor, South Sudan.

Weight was an issue with the load, and the team was limited to approximately 200 lbs of medical supplies. The flight to Pibor took approximately 2 hours, and the team deplaned without incident on a dusty airstrip in the center of Pibor.

Local national transportation used in Werkok.

on

Arrangements made by Dr. Geelhoed ensured that the aircraft would remain with the team for the duration of their stay in Pibor. After five days in Pibor, the team again loaded their gear into the Cessna and returned to Werkok to begin staging for entry into Central African Republic for the third leg of the trip.

The team was delayed in Werkok for a day while paperwork was processed for entry into CAR. This paperwork delay grew into a larger problem for the team over the four following days, and eventually the team was unable to enter CAR at all. During this period, Hildebrand was busy with calls and emails concerning the “permissions” needed by an aircraft to enter CAR airspace.

The team departed the next day for the town of Nzara, an outpost on the Sudan border with CAR, approximately 120 miles from the destination city of Zemio. The outpost was a Ugandan Peoples Defense Forces (UPDF) military base with an airstrip. Here the team would rendezvous with the UPDF and sort out the “permissions” problem while searching for an alternative form of entry should the AIM aircraft ultimately not be able to make the trip.

South Sudan, 2011

The “permissions” problem absorbed the next 72 hours. The government of CAR was processing plane permissions in a new way. Previously, plane permissions could be renewed automatically with a letter and payment. These permissions would grant unhindered access into CAR for the specified aircraft for 6 months. When the permissions for our particular aircraft came up for renewal months before the mission, the paperwork was sent in as scheduled. Unfortunately, the Permission Office in Bangui, the capital of CAR, denied the renewal because of a typo. The office then waited to inform AIM about the refusal, and the team was left scrambling for a fix at the last minute.

The Permission Office asked that the team to fly all the way to Bangui to submit the new paperwork.

This 1000-mile detour would have taken hours, cost the team thousands of dollars in fuel, and, most importantly, set a precedent for every future AIM flight. This was too much of a burden for AIM to take on, and too much of an extra cost for Team Rubicon. The event sorted itself out as, after 72 hours of waiting at the UPDF camp in Nzara, the time window to launch the mission had closed and the team was expected to leave the country.

The team loaded up back into the Cessna 208 and departed Nzara en route to Nairobi, Kenya. The team left Nairobi the following day on commercial aircraft; retracing its original route back through Addis Ababa and on to Washington, DC.

RECOMMENDATION The transportation of the team from the United States to South Sudan and back showed the value of dedicated airlift. While AIM Air was not cheap, it was a highly effective means of moving the team and its gear around areas of South Sudan where ground transport was constrained due to infrastructure limitations and security threats.

Further, the ability of the aircraft (thanks to the pilot, Mr. Hildebrand) to remain flexible and available as we searched for alternate means of travel was vital when operating in multiple underdeveloped countries. In these countries, airstrips become dilapidated, fueling depots close, and roads become useless in a matter of months. It was important that Mr. Hildebrand had worked with the team leader Dr. Geelhoed in the past. Locating fuel, getting through customs, and finding landing strips all required a team effort by people who had actually been there in the past.

Dedicated airlift also greatly mitigated the security threats the team faced. Operating in areas rife with civil unrest due to clashing tribal factions, speed is security. Thanks to our dedicated plane and pilot, the team could move quickly through or around danger and still arrive where its skills and training were most needed.

As far as the “Plane Permissions” debacle, it was primarily a matter of bad luck rather than a lack of planning that led to the failure to enter CAR. No one anticipated the government denying the permissions as they never had over decades of AIM operations. Ultimately, this was an unfortunate side effect of doing business in the underdeveloped world,.

ACTION 

Pre-stage fuel throughout the likely area of operations prior to team deployment.

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

Be prepared for challenges in transferring aviation fuel when traveling in flood plains in the wet season.

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Check all permissions paperwork well in advance of arrival. This is especially important if the renewal period of permissions falls into the deployment window.

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Even then, be prepared to innovate and adapt in the face of solid commitments falling through at the last minute.

MEDICAL SUMMARY Medical impact can be divided into four categories: 1. Delivery of medical supplies. A container of medical supplies was delivered as scheduled and promised during the team's time in Werkok. In addition, we made contact with a local pharmacy supplier in Nairobi. The team obtained crucial medicines from this pharmacy. These medicines included IV/IM antibiotics, IV/IM morphine, ketamine, and IV/IM valium, and malarone tablets. These medicines were used during the operative cases in Werkok and Pibor, and the unused medicines were handed off securely to Dr. Ajak Abraham in Werkok. Team Rubicon also delivered an ultrasound probe which when hooked up to a laptop computer (which Dr. Ajak Abraham had) functions as a fully operational ultrasound device.

2. Medical Patients: The team saw approximately 10 patients per day in Werkok, and over 150 per day in Pibor. The team collaborated with local physician Dr. Ajak Abraham and clinical officers Jean Jaque, Jean Dr. Geelhoed teaches course on portable ultrasound Michele, and Juma in Werkok; working side technology by side with these medical providers. In Pibor, the team worked in conjunction with two medical officers there, although not as closely. There were few local medical providers in Pibor, and therefore the team worked pretty much alone.

3. Surgical Patients: Dr. Glenn Geelhoed along with Dr. Ajak Abraham and medical student Kanaan Samy provided the surgical care of patients in Werkok and Pibor. Dr. John Sutter provided the anesthesia. Team members of varying skill provided supportive pre-operative, operative, and postoperative assistance.

South Sudan, 2011

4. Teaching: Teaching rounds were held every evening in Werkok, as well as during the care of patients.

In addition, the clinical officers in Werkok were instructed on how to properly use the ultrasound device.

RECOMMENDATION 1. Delivery of Medical Supplies: While there were many useful items in the shipping container, some of the items were not as useful. For example, there were many laproscopic instruments. There is currently no laproscopic capability in Werkok and thus the utility of these instruments comes into question.

Additionly, the organization and packing of the medical supplies was inadequate. The team spent a great deal of time reorganizing the supplies from the container. Recommendations include a more thorough needs assessment from the local providers, and a more organized packing system before shipping. Finally, the team lacked adequate testing devices. These could have been packed in the US or picked up in Nairobi (glucometer, UPTs, rapid malaria tests, etc‌) 2. Medical Patients: The model for patient care in Werkok was adequate as Team Rubicon medical providers worked side by side with South Sudanese medical providers, learning from each other and treating patients according to local standards. However, there weren't enough patients. The team’s time in Werkok coincided with Cattle Camp, a period when most people leave the towns and villages for the countryside to learn skills and customs associated with the care of cattle. Recommendations include sending a team at a time when patients are there and in need.

In Pibor, the medical clinic sessions were inundated with hundreds of patients, they were slightly unorganized, and not focused on the task at hand‌treating PID/infertility and teaching locals how to recognize and treat as well. The clinics were outside, which made examining patients difficult. In addition, many medicines and detection systems (i.e. pregnancy tests, glucometers, urinalysis) were not available.

Finally, the sheer numbers of patients made it difficult to treat just one type of illness (PID), as there was diversity in illnesses.

Recommendations include: performing a more thorough needs assessment from local providers, Paramedic Josh Webster at the MCH in Werkok leaders, and NGOs already in the area; better intel; a better organized clinic delivery system to include triage and focus on the issue of PID/infertility.

3. Surgical Patients: Again, in Werkok there just were not enough patients. We had the equipment, medicines, and local staff, but there were not enough cases.

In Pibor, the surgical cases went very well. In Pibor, the team would have benefitted from prior conversations with local NGOs in the area who had adequate facilities, instead of showing up last minute with such a request.

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Follow up in 2 and 4 weeks in both Werkok and Pibor reported no complications.

4. Teaching: In Werkok, the teaching was organized and there were 4 local providers who benefitted. However, as stated earlier, there weren't enough patients.

In Pibor, there were no local medical providers engaged in teaching. Dr. Ajak Abraham benefitted from the teaching and apprenticeship during the surgical cases, but there were no local Murle health providers. Recommendations include talking with Murle leaders and medical providers prior to arrival so that their staff is ready, engaged, and present.

ACTION 

Complete a “Needs Assessment” prior to any proactive mission.



Procure testing materials/devices.

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Implement WHO surgical checklist for operative cases.

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Create a list local providers, community leaders, and NGOs. Contact them prior to the mission in order to ensure cooperation and coordination of services.

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Ensure any Team Rubicon return to Werkok or South Sudan is done at a time when patients are there. This can be accomplished via (4) above.



Develop a packing list for any shipping container and stick to this list.

MEDIA SUMMARY Media was essential to the mission due to the general lack of reporting on the cities of Werkok and Pibor prior to TR’s arrival. It also served to keep TR’s supporters informed of the team’s activities. The media component of the team was the designated journalist, Team Rubicon member Brittany Smith.

Her duties were to document via photography, video, and journaling for daily TR blog updates. Her background in photojournalism lent itself to telling the story of TR’s mission. Her time and equipment were donated for the month of deployment.

The equipment employed to carry out the media aspect of the mission included the following:     

Inmarsat BGAN satellite terminal two Brunton solar panels laptop computer Cannon 5d camera Cannon G12 camera

South Sudan, 2011

     

Cannon 24mm-70mm L series lens Cannon 200mm-400mm L series lens Cannon flash Gary Fong flash diffusion Hand-held camcorder Flip Cam video recorder.

RECOMMENDATION All photo equipment was suitable for the mission. As mentioned above, a Mac laptop would streamline the Brittany Smith en route to Kenya media process. A MacBook Air would be lightweight yet have a have a larger screen for image viewing. A portable black computer shade cloth would help with viewing images on the computer in direct sunlight conditions.

Unless a partnership with a media company can be established prior to the next mission, media updates should be curtailed to every other day. This would cut the expense involved with purchasing international BGAN time.

ACTION 

Inspect equipment prior to deployment in order to determine the status of prepaid communication services such as the “overseas card” for the BGAN.



Establish a partnership with an organization that streamlines information processing for remote devices in order to reduce expenses of uploading and downloading large amounts of information.



Research solar charging batteries designed for use in extreme weather conditions.

SECURITY SUMMARY Before deploying into Sudan, Team Rubicon was aware of the current reports of civil unrest among the southern Sudanese. The recent referendum to divide the country caused a political power vacuum and led to sporadic violent episodes throughout the border region. The violence that was being reported was coming from a former general in the SPLA named George Athor Deng who had lobbied unsuccessfully to become a state politician following the referendum. After his loss, he took his remaining loyalists and escaped to Jonglei state where he harassed other SPLA units and fought with the southern Sudanese people.

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TEAM RUBICON, After Action Report

This threat was seen as the most critical hindrance to developing an adequate security presence on the ground. Since their actual location was unknown, the accepted view of these forces was that they were a mobile paramilitary group, but that they did not necessarily harbor aggression towards aid workers.

These forces had never engaged in direct violence against personnel from other medical NGO’s in the area.

In order to mitigate the threat of paramilitary aggression, Team Rubicon implemented multiple layers of security. These included: 

An initial hot-spot brief by the security leader detailing the multiple courses-ofaction to take should violence erupt within the city of Werkok.



Emplacement of an immediate-action-drill for the team should violence come within reach of the compound and imminent exfiltration was necessary.

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Staging of two uniformed local police with AK-47’s within the medical compound on 24 hour alert.

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Collaboration through our liaison Jacob Gai with a 15-man armed police force within the city of Werkok for outer perimeter security.

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Daily intelligence updates from our liaison and resident medical staff regarding the bandit situation that exists in that part of South Sudan.

TR liaises with local security forces

Once outside of Werkok, the team was exposed to different security risks. The police units in Pibor were in charge of our security, but the team did not have dedicated security at the surgery/bunk area.

The threat was partially mitigated because this area was a well-known church compound surrounded by a concrete wall with a barbed wire fence. To dampen any local threats the team was honored at a local church celebration and introduced to the community as medical personnel.

As the trip continued, the team spent multiple days in a Ugandan People’s Defense Force (UPDF) compound on the border of Central African Republic (CAR) waiting for entry into CAR. While there, the UPDF provided security for the team.

Certain safety protocols were taken throughout the trip in order not to present “targets of opportunity” for any potential aggressors. These included: 

Keeping in teams of at least two when departing the compounds.



Not going outside the compound at night for any reason.

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Maintaining a high state of alert during activities where large crowds were involved or when introducing tribal leaders to each other.

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Carrying, but never brandishing, some item that could be used as a defensive tool.

South Sudan, 2011

These measures, as well as friendly site coordination by our team leader Dr. Glenn Geelhoed, gave Team Rubicon an adequate level of security while in South Sudan. The arrangements for our arrival served as the most useful portion of the security plan overall. Dr. Geelhoed had alerted the local players of our arrival so by the time the team landed everything was in place for us to work in a hospital/field clinic setting with necessary haste.

Further, dedicated air support gave us the ability to evacuate an area should the need arise. The air support was pre-arranged by Dr. Geelhoed and was available to us in the areas that we were most in need of it. Communication with the pilot was crucial to determining our evacuation possibility and estimated time of departure (ETOD).

RECOMMENDATION Team Rubicon learned much about the difference between media reports and local reports concerning transient threats in South Sudan. The “bandit situation” turned out to be the biggest threat, but was largely glossed over in the media or blended into violence stemming from military action. What was reported as “extreme unrest” amounted to little more than urban crime that the local population knew well how to handle. In a country where everybody has an AK-47, it was not necessary to purchase our own weapons for security. Further, in a developing nation where occasional frontier violence is the norm, it became unrealistic to assume we would be involved in the fighting ourselves. As the locals would have it, their fight was their fight. We were medics and were needed elsewhere.

The mission to South Sudan was in part nation-building through medicine; and through medicine TR did the most good. Team Rubicon was briefed by the security leader that an international incident involving weapons could be disastrous to the mission. That said, there is always an inherent right to self-defense.

ACTION     

Develop an accurate understanding of the security situation on the ground by communicating with local nationals instead of relying on news sources that may over-report or distort violence.

Maintain constant communication with mode of transport (car, bus, plane) in case an immediate exfiltration becomes necessary.

Use commercial location devices (beacons) in desolate countries to relay location should the need for escape and evasion (E&E) occur.

Develop robust but practical E&E plan for all members.

Implement usage of a 5-point contingency plan “GOTWA” o G – Going (where are you going) o O – Others (others going with you) o T – Time (time you’ll be gone) o W – What (what to do if you don’t come back, both parties) o A – Actions (action to take if there is trouble, both parties)

Example: “I’m going to the town for a meeting with the police chief. Dan is coming with me. We’ll be gone an hour. If we don’t come back in an hour give us a buffer of another 30 minutes before coming to

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TEAM RUBICON, After Action Report

look for us, because formalities at the meeting can be time-consuming. After that buffer we are going to be moving back towards the camp on foot. If there is trouble we will move back to the camp by foot unless it is too dangerous, in that case we will stay in place and seek protection from the local police. In case of trouble come find us in the Land Rover, if that appears too dangerous, stay in place and wait for us to return.�

MISSION STATISTICS The following is the total list of medical interventions either performed by the team directly, or assisted with by team members during the mission.

Number of operative cases: Ventral hernia repair R hip mass removal Hymenotomy/surgical repair of Imperforate Hymen Inguinal hernia repair Ganglion Cyst removal

8 2 1 1 3 1

Number of clinic patients treated Type: Malaria Typhoid Brucellosis Pneumonia Otitis Media Tuberculosis Malnutrition African Trypanosomiasis (sleeping sickness) Schistosomiasis Onchocerciasis (river blindness) Leprosy (consisted of wound care, 70 patients) Tapeworms/Intestinal cestodes/Helminths (i.e. de-worming) Pelvic inflammatory disease Diarrhea

500+

Teaching Clinics Performed 5 Ultrasound techniques (ultrasound machine delivered on mission) Surgical cases per above Spinal anesthesia Conscience sedation Tropical medicine didactics addressing disease processes mentioned above Medical supplies delivered 1 One entire shipping container including antibiotics, sutures/surgical supplies, hospital beds, IV sets, airway devices, chest tubes, bag valve masks, pulse ox meters

South Sudan, 2011

KEY LESSONS LEARNED 

Logistics in Africa are tenuous at best. When shipping goods to Africa, remember that logistical systems may not be based on legal procedures. It may be best to utilize bribery or local political pressure.



Do not rely on a resupply. Once in austere locations, if something breaks, don’t count on it ever getting replaced. One in none. Two is one.



Good electronics are worth their weight in gold. A trustworthy piece of electronic gear that costs a fortune is always better than a cost-effective item that becomes a paper-weight.



Take care of yourselves, because no one else will. When offered food or water that might be contaminated with local bacteria do not accept out of courtesy. If you get sick, then you can’t treat the sick.



Air transport is priority number one. If you can get dedicated aircraft, then all the other problems of international travel become very, very manageable.



Medical needs assessments are necessary. Get a quality, recent, situation report from a local before you decide what supplies to bring. All the suture in the world isn’t useful during a cholera epidemic.



Proactive missions do not generate the same revenue as reactive missions. It’s difficult to pay for proactive missions using TR’s social media engagement model.

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TEAM RUBICON, After Action Report

KEY ACTIONS 

Continue to develop local assets in the most impoverished areas of South Sudan in order to garner reliable situation reports about medical needs and security threats.



Maintain a gear cache for deployments to locations with unreliable supplies of water and food.



Develop a partnership with other aid organizations who operate their own aircraft and are willing to “rent” them out to other NGO’s.



Develop a rapport with aid organizations operating in your area of operations before deployment. This may make them more willing to cooperate on projects.



Develop an alternative revenue model for proactive missions.