Peacekeeping and the delivery of humanitarian aid is a vital component in the repertoire of any modern military and the UK has been at the forefront in contributing to these types of operation at an international level. When preparing for an enduring task such as peacekeeping, it is essential to consider all supporting components that can help deliver a common goal. Whether access to healthcare for the local population has collapsed or maintaining a healthy deployed force, dentistry will inevitably need to be considered and appropriate provision secured.
This paper aims to look at the deployed dental support provided to recent peacekeeping interventions by the British Army.
Describes experiences from three different dental officers on deployments to South Sudan, Sierra Leone and Bosnia.
Explores the difficulties they faced negotiating conflict zones, extreme weather and disease in an effort to provide clinical excellence to their population.
Discusses political, economical and biological factors that initiate humanitarian aid.
South Sudan - Major Andrew Beaven
In 2011, South Sudan gained independence from Sudan.1 As a newly established country, it naturally tried to find its way economically and politically. However, it struggled to unite due to the complex issues surrounding its warring tribes.2 Clashes over land, cattle, natural resources and ethnicity have cost the lives of 400,000 people. Over four million people have been displaced from their homes, with many fleeing to neighbouring countries.3
The United Nations Mission in South Sudan (UNMISS) was formed on 9 July 2011 with an overarching aim to protect civilians.4
The United Kingdom's involvement in this mission began to increase in 2016 and was tasked with:
Protection of civilians
Improving the UN's infrastructure (construction of jetties, roads, helipads and a hospital)
Providing medical support for UN personnel in Bentui.
16 Medical Regiment had the honour of building and manning the first tented medical facility in Bentiu, South Sudan. Timing of this build was essential due to extreme weather conditions throughout the year. The country is prone to tropical thunder storms which impinge on the fragile infrastructure. Roads and airport runways become saturated with soft mud, making the supply chain to and from the capital city of Juba impossible. Even in dry conditions, the best method to reach this remote area of South Sudan is by helicopter (Fig. 1).
A large tented hospital can be fully operational within 12 hours. The basic formation consists of a long corridor with modular tents attached. Each tent is double layered which aids in thermoregulation when combined with air condition or heaters. The dental department could be self-sufficient for 120 days until it would need a resupply of consumables (Figures 2 and 3).
In 2016, the UN camp in Bentiu was responsible for the protection of 120,000 internally displaced persons. This required a sizable UN force which was made up of an array of nations including but not limited to: Rwanda, India, Ethiopia, Nepal, Bangladesh, China, Ghana, Mongolia and Thailand.
The access to dental treatment among all the contributing countries of the UN differs considerably pre-deployment. However, emergency care is a necessity for any force to remain functional. Table 1 shows the presentation of cases that occurred over 60 days.
Pulpitis was the main cause for an individual to present to the dental department. The use of x-ray equipment (NOMAD Pro 2) was essential and analogue images could be generated using self-developing films. The NOMAD Pro 2 was a recent contribution to the dental arsenal and concerns about overexposure to the operator in its handheld position were raised. A customised stand was built so the operator could deliver an exposure at a safe distance to mitigate any fears.
One patient presented with a fever and uncontrollable shaking after recent extraction. With closer scrutiny of his medical history and symptoms, it was proposed that the individual may be suffering from malaria. With a plethora of medical staff and a laboratory on site, diagnosis was quickly confirmed. This demonstrated the unique environment we were in and that knowledge shared among all medical professionals was essential in ensuring patients got directed to the appropriate department for the appropriate treatment. Luckily, this patient made a full recovery and was able to continue his UN tour.
The formation of ulcers and temporomandibular joint dysfunction may have been attributed to increased stress due to extreme living conditions UN personnel were exposed to; temperatures in summer which could exceed 40 degrees. Figure 4 shows a single lined dome-shaped tent which was utilised as sleeping quarters. The tent magnified the sun's strength and temperatures could exceed 46 degrees during the day. Air conditioning units and fans were fitted but they could not combat the extreme heat generated. This arrangement was intended to be temporary until hard-standing accommodation could be built.
Heavy rain prevented all forms of resupply and procurement of food was no exception. The rationing of meals became a normal occurrence and impeded a varied diet. The combination of all these factors played a serious effect on the immune response and the hospital received a steady flow of patients.
Frequent outbreaks of E. coli, Norovirus, Clostridium difficile, Giardia lamblia and Guinea worm affected a high proportion of UN troops including the UK forces. Isolation tents were set up to prevent infectious diseases from spreading quickly throughout the UN force and compromising the main effort of peacekeeping.
This operation provided many unique challenges which were exacerbated by the extreme weather and the array of infectious diseases. However, with diligent planning, areas considered isolated can have a medical facility. It was an honour to serve in a country that was in need of an intervention and I only hope that South Sudan will be able to move forward politically and economically and become a stable country for its people.
Sierra Leone - Major Serena Darke
Unlike most other military operations, the enemy we were battling here was a virus. 'The west African Ebola virus disease (EVD) epidemic was the largest and most devastating outbreak of EVD the world has ever seen'.5
Ebola is a member of the family Filoviridae, which is composed of a single-stranded negative-sense enveloped RNA virus.6 EVD is a recognised zoonosis, with fruit bats as the likely natural reservoir.5 All infections in the West African epidemic could be traced back to an index case of an 18-month-old from a village in Guinea who was infected by contact with insectivorous bats.6 The initial signs and symptoms of the Ebola virus include fever, fatigue, muscle pain and a headache. In the early stages, the symptoms are difficult to distinguish from other diseases such as malaria.7 However, it soon progresses to vomiting, diarrhoea, haemorrhagic diathesis and in severe cases multi-organ dysfunction, leading to shock and death. The incubation period ranges from 2-21 days but symptoms usually appear between days 8-10 and it is at this point the patient is contagious.7 Infectivity increases dramatically as the disease progresses, with the dead having a very high viral load. The disease spreads through contact with bodily fluids of the symptomatic or deceased patients. As a result, a great number of healthcare workers were affected during the outbreak.5
The West African outbreak was publicly announced on 23 March 2014 by the World Health Organisation.5 By 9 July 2014, the United Nations Security Council issued a statement imploring the international community to provide assistance to prevent further spread of the virus.6 On 8 September 2014, the Secretary of State for International Development announced that British military and humanitarian experts would set up a medical treatment centre for victims of the Ebola outbreak in Sierra Leone.8 On 8 October 2014, Philip Hammond confirmed that a total of 750 Ministry of Defence personnel would deploy9 on Operation Gritrock.
Within Sierra Leone, efforts were coordinated by the Department for International Development, with the British military working alongside them. The majority of the force was deployed in the military Ebola Treatment Centre, the first in-country facility dedicated to treating healthcare professionals, both international and local. The remaining personnel were in the command and logistical hub in Freetown5,8 (Fig. 5).
Dental care for Operation Gritrock was initially provided offshore by Surgeon Lieutenant-commander (Surg Lt Cdr) Mair and Dental Nurse (DN) Carter on the Royal Fleet Auxiliary Argus.10 However, upon the ship's departure in March 2015, primary care was taken over by the Role 1 facility in the Headquarters in Freetown with the dental team consisting of myself and Private Bryan.
Our role was not to treat those suffering from Ebola. Instead, we provided care for those helping to defeat the crisis. Historically, dental morbidity accounts for a large proportion of disease and non-battle injury;11 therefore, the presence of a dental team allows for those with problems to be restored to fitness without the need to return home. An additional aim is to improve the dental health level of those deployed in order to reduce future pathology (Fig. 6).
The main challenge encountered during the deployment was the risk of contracting Ebola. With saliva and blood being unavoidable as part of dental care, we needed to be conscious of the risks when planning to treat people (Fig. 7). The EVD risk categories 1-3 were used to aid with this (Table 2). Public Health England issued guidance to dental teams in England advising only category 1 patients should have non-essential treatment with urgent care for categories 2 and 3 requiring referral to local Health Protection Teams.12 However, if this guidance would have been followed in theatre, very few people would have been eligible for treatment and subsequently no reason for the deployment of a dental team. Thus, as the role of the team was to force regenerate, the decision was made to offer emergency care to those in all categories provided they remained apyrexial.
Initial temperature monitoring was conducted at the entrance to the barracks using an infra-red contactless thermometer. Access was only granted if the reading was below 37.5. Should a person have a temperature above this, immediate isolation ensued with investigations from the Medical Officer. Once in the dental surgery, a patient's temperature was again taken, this time with a tympanic thermometer. A verbal check of the patient's EVD risk was taken, determining their category and if any other symptoms of EVD were present. Cross-contamination precautions were taken, with the team using the same personal protective equipment (PPE) used in surgeries in the UK. In order to keep the risk as low as practical for the dental team, the treatment of those in category 2 and 3 of EVD risk was limited to emergency care only with the least amount of intervention possible to relieve pain.
It was an interesting deployment with 114 patients seen over the 14-week period, including 33 emergency care appointments (Table 3). This ranged from acute apical periodontitis to lost bridges. No personnel were returned to the UK for dental morbidity. As for the outbreak, Sierra Leone was officially declared Ebola-free on 7 March 20166 (Fig. 8).
Bosnia - Colonel (Retired) Andrew McDonald
Following on from Operation Desert Storm was a geographically remote conflict with a devastating impact upon the civilian population when compared to the fighting forces. Media reports in early 1992 highlighted a conflict involving Bosnian Serbs, Bosniaks (Bosnian Muslims) and Bosnian Croats in the Balkans.13,14 The result was the participation of the United Nations to stabilise the area. Operation Grapple was the UK's contribution to the UN Protection Force (UNPROFOR) (Figures 9 and 10).
Together with Lance Corporal (LCpl) Steve Kirya (dental nurse and co-driver), I was to be involved briefly in Operation Grapple 3 (December 1993), but predominantly Operation Grapple 4 (March to October 1994). The overarching UN peacekeeping mission was dictated by the Security Council Resolution 743 and comprised of four phases:
Aid to Sarajevo
Escort of humanitarian aid
Protection of safe areas
Monitoring Muslim-Croat Federation and weapons exclusion zones.
My mission, as the sole dental officer to British Forces Command (COMBRITFOR), was to provide emergency dental care to British military personnel (2,450 individuals) and any NATO personnel encountered. As the mission developed, it became necessary to utilise the entitlement matrix as a guide, to ensure we did not become overwhelmed with patients (Fig. 11).
The main British bases were Divulje Barracks, Split, Tomaslavgrad, Gorni Vakuf and Vitez, with Tuzla further north and accessible only by air (covered by a Norwegian dental team). These were the sites (apart from Split, Croatia) of much intense fighting and locations from which the mechanised infantry (Coldstream Guards followed by two Royal Anglian, reinforced by other battalions) operated a warrior armoured escort to all aide convoys from the port of Split.
Initially, the work tempo was modest, with three bases to visit and only British military patients who were dentally fit (pre-deployment preparation). Dental treatment at this point comprised mainly routine replacement of lost restorations and pericoronitis. This was to change as the deployment matured. Movement was slow and cautious, with long and rough mountainous routes, but with spells of excitement. The Warrior crews attempted to navigate a safe path but difficult terrain, ever-moving battles and bombardments meant it was inevitable we would encounter conflict.
Very soon, the success of aide supply and population protection internally within Bosnia was evident. With the arrival of further British Infantry Battalions, their support elements and additional UN contributing nations, the area of operations expanded significantly. Burgoyno in the West, Maglaj in the North and Sarajevo plus Gorazde to the East. Previous armoured convoy routes were now just patrolled.
While the population at risk from the British perspective was not large when providing emergency care, they were highly spread. The British area of responsibility was gaining troop detachments from additional nations, all requiring medical and dental support. The result in certain locations was lengthy sick parades, with some contingents under the mistaken impression that I would sort out all their years of neglect in a few short appointments.
We covered many miles in a short period, in order to visit key locations allowing maximum access to the population at risk. We only had a soft-top Landrover but knew we had to travel carefully via new and often seldom-patrolled districts and rugged mountain roads. We had bulky trial dental kit (Danish Ardcat Mobile Kit); we had to experiment with trailers and various packing plans. The roughness of several routes and consequent damage to the dental kit meant trailers were not practical in this terrain.
Our route from then on, based upon viability of routes and access, consisted of Split, Tomaslavgrad, Vitez, Maglaj, Sarajevo (including attempts on Gorazde), Burgoyno, then back to Split. With maps of varying quality, we experimented with routes, avoided road blocks, steered around conflict areas, or escaped from blockaded Sarajevo. Life was busy and, at times, scary. Many new people were befriended and sights seen (Fig. 12).
The demand for extirpations and extractions escalated, while fractured restorations and pericoronitis were commonplace. Our absence while en route necessitated the need to teach various location medics basic dental triage. We were even called upon to assist notable dignitaries in the interests of fostering good will and trust. In all, we had a very packed and never dull tour. Needless to say, the number of dental teams increased the following tour.
Peacekeeping and humanitarian aid missions that are planned to endure will always need to be reinforced with medical cover. Dentistry forms a big part in ensuring peacekeepers can remain active on the front line and continue with their primary objective. Dental teams must be able to adapt to extreme conditions and be agile to changing circumstances. All the teams depicted in the article performed to the highest standards possible in the most testing conditions and are testament to the training and preparation the British military provides to all its service men and women.
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Beaven, A., Darke, S. & McDonald, A. Keeping the peace with dentistry. Br Dent J 230, 429–434 (2021). https://doi.org/10.1038/s41415-021-2727-3