U.S. Navy Hospital Ship Missions

To assist partner nations in their efforts to build health sector capacity , counter the ideological influence of nefarious groups, and support public diplomacy, the U.S. government deploys Navy hospital ships to perform humanitarian assistance missions.   The U.S. Department of Defense (DoD) currently maintains the U.S. Naval Ship (USNS) Mercy based out of San Diego, California, and the USNS Comfort based out of Norfolk, Virginia.  Although the primary mission of these hospital ships is to provide rapid medical capability for deployed military personnel, it is their secondary mission of providing humanitarian assistance that has dominated their use.  Since 1990, the USNS Comfort has deployed twice in support of deployed military personnel (First Gulf War and Operation Iraqi Freedom), and the USNS Mercy has deployed once (First Gulf War).  However, the Comfort and Mercy have collectively deployed on seven humanitarian assistance missions (Pacific Partnership, five times; and Continuing Promise, two times) and five disaster responses (Haitian migrant processing, two times; and Asian Tsunami, Hurricane Katrina, and the Haiti Earthquake).  This is a one to four ratio between the primary and secondary missions of these hospital ships – a clear role reversal.
With 12 operating rooms and 1,000 hospital beds (80 intensive care unit beds, 20 postanesthesia care unit beds, 400 intermediate care beds, and 500 minimal care beds), the floating tertiary care facility provides services and capabilities during humanitarian assistance missions and disaster responses otherwise limited or unavailable to the populations of developing nation.  Surgical procedures range from orthopedic surgery to cleft palate repair.  Additional humanitarian and civic aid programs conducted during the hospital ship missions include veterinary, dental, and engineering civic action programs.  These programs are typically conducted in more remote locations with support from host nation Ministry of Defense and Ministry of Health personnel.  Working through, by, and with the host nation is an effort by the U.S. military to increase the host nation’s credibility among the population while attempting to support existing national programs.  Reaching out to remote populations also increases the visibility of U.S. participants on these missions, which may influence the perceptions of the United States writ large. 
The USNS Mercy originally served as an oil tanker and was converted to a hospital ship before commissioning by the Navy in 1986.  In 1987, the USNS Mercy conducted a humanitarian mission at seven ports in The Republic of the Philippines and South Pacific.  More than 62,000 outpatient and almost 1,000 inpatients were treated.  In 1990, the USNS Mercy was activated to support forward deployed military personnel during Operation Desert Shield.   A total of 690 multinational allied force patients were seen, and almost 300 surgeries were conducted during the six-month mission to the Middle East region.   The Mercy would not deploy again for another 15 years, when it would provide humanitarian assistance in the South Pacific following the devastating 2004 Asian tsunami.  
The DoD developed a novel public-private partnership to leverage nongovernmental organization (NGO) support during the tsunami response.  More than 200 civilian medical professionals from the NGO Project HOPE supported the USNS Mercy in meeting the humanitarian needs of the region (1, 2).   More than 107,000 patients were treated, 466 surgeries were performed, 11,555 pairs of glasses were distributed, and more than 6,900 dental procedures were performed in Indonesia, Papua New Guinea, and Timor-Leste during the disaster response (3). National polls in Indonesia following the mission showed a significant improvement in the overall opinion of the United States among host nation citizens (4).
Today, the hospital ship Mercy supports the U.S. Navy Pacific Fleet based out of Honolulu, Hawaii and is building upon the tsunami experience by participating in Pacific Partnership humanitarian missions.  The Mercy is deployed biennially in support of Pacific Partnership in which the U.S. DoD collaborates with interagency partners such as U.S. Agency for International Development, regional partner nations, host nations, and NGOs.  Many of the partner organizations deploy on the Mercy to multiple countries of strategic interest over a period of approximately four months.  The USNS Comfort deployed in 2007 and 2010 to Central and South America as well as the Caribbean region, replicating these humanitarian assistance missions.
 
Historical Context of Hospital Ships
Hospital ship missions are not new to the U.S. government or the international community.  The hospital ship USS Hope was commissioned by the Navy in 1944 to render forward deployed medical care to wounded service members in the Pacific during World War II.  Acquired by the Navy just 15 days after the USS Hope, the hospital ship USS Consolation also supported operations in the Pacific before being decommissioned in 1955 and later chartered to the People-to-People Health Foundation and renamed SS Hope in 1960. 
The SS Hope departed for her inaugural mission to Indonesia in September 1960 to provide medical support and training to the Indonesian population.  For the next 14 years, the SS Hope would conduct 11 voyages serving underdeveloped areas of the world.   Missions included port calls in East Asia (South Vietnam), South Asia (Sri Lanka), North Africa (Tunisia), Central America (Ecuador, Nicaragua, and Colombia), South America (Brazil and Peru), and the Caribbean (Jamaica).  It took only four years after the SS Hope was decommissioned in 1974 before another civilian organization, the NGO Mercy Ships, would assume a similar humanitarian mission.
Mercy Ships was established in 1978 with a mission to reach populations in developing countriesy in desperate need of medical services.  This NGO recognized that 21 of the 24 world’s largest cities were port cities, and within just 100 miles of these 21 cities lived two-thirds of the world’s population (5).  To reach this population, Mercy Ships purchased their first vessel in 1978 and began recruiting health care professionals from around the world to provide services on the ship.  The Anastasis was an 11-ton passenger ship that was converted into the world’s largest NGO hospital ship.  After 29 years of service, the Anastasis was retired in 2007 and replaced by the Africa Mercy.  The new vessel remains the largest NGO hospital ship in the world and is staffed by professionals representing 30 different countries.  Since 1978, Mercy Ships has performed services valued in excess of $834 million and has impacted more than 2.9 million individuals with over 563 port visits to 53 developing nations and 17 developed nations (6).   In addition to the U.S. Navy and NGO Mercy Ships, China recently built and deployed their Navy hospital ship the Peace Ark to conduct humanitarian assistance missions around Africa and the Central America and Caribbean regions in an effort to achieve their foreign policy goals.
 
A Soft Power Casualty?
Although patient output numbers achieved during U.S. Navy hospital ship humanitarian assistance supported missions are large (Table 1) and other projects completed during the missions perceived effective by the mission participants (e.g., distributing eyeglass), the actual health outcomes for the host nations are largely unknown.   How health services are prioritized and provided whether based on cost-benefit analysis, return-on-investment strategies, or disease burden of the host nation country is also not clear.  Recent analysis found that these missions have some impact on strengthening partnerships among the various participants; however, their ability to achieve the National Military Strategy objective of strengthening international and regional security is just now being considered (7).  But is it too late?
Recent budget cuts to the DoD have directly impacted what had become one of the U.S. government's most visible soft power tools.  The planned USNS Comfort’s 2013 Continuing Promise humanitarian assistance mission and the Mercy’s 2014 Pacific Partnership mission were both cancelled.  Perceptions of why these hospital ship humanitarian missions were cancelled include their high associated costs, which are not publically available but assumed to be more than $100 million each, as well as the inability to quantify what has been achieved as a result of these significant investments.   Additionally, the high maintenance costs of these large vessels in an era when rapidly deployable medical assets with the support of rotary and fixed-wing air evacuation resources has become the norm for medical support to deployed forces engenders questions regarding the hospital ships' relevance in today's operational environment. 
As the DoD ponders the future of these hospital ships, consideration should be given to an increased role of other U.S. government actors and international partners in these humanitarian assistance missions.  It could be argued the Department of State (DoS) garners the largest return on investment because the greatest dividends achieved through these missions are in the public diplomacy space.  Maybe the DoS could increase its financial investment for these missions, allowing the DoD to sustain their ongoing efforts.  Other partner nation participants such as Australia and Japan have played greater roles in recent Pacific Partnership missions by contributing a larger contingent of personnel as well as deploying ships to support the humanitarian mission requirements.  A true partnership would lend itself to a greater balance in terms of contributions by all the hospital ship participants and possibly allow DoD to stay engaged in these soft power missions.  There are no easy answers.  However, with sage leadership and real partnership, the future of hospital ship missions can be shaped to support what pundits anticipate as an increase in humanitarian requirements in a globalized world.

References
 
1. Peake JB. 2006. The project HOPE and USNS Mercy tsunami "experiment". Military Med 171(10 Suppl 1):27–29.
 
2. Timboe HL, Holt GR. 2006. Project HOPE volunteers and the Navy hospital ship Mercy. Military Med 171(10 Suppl 1):34–36.
 
3. Provencher MT, Douglas TD. 2011. Humanitarian assistance and disaster relief aboard the USNS Mercy (TAH-19). J Surg Orthoped Adv 20:38–43.
 
4. Terror Free Tomorrow. 2006. Unprecedented terror free tomorrow polls:world's
largest Muslim countries welcome US Navy. http://www.terrorfreetomorrow.org/upimagestft/Final%20Mercy%20Poll%20Report.pdf.
 
5. Hancocks S. 1995. Mercy ships. FDI World 4:17–18, 20.
 
6. Mercy Ships. 2011. Annual review, 2010. Garden Valley, TX: Mercy Ships.http://www.mercyships.org.nz/assets/files/2011%20Annual%20Report.pdf.
 
7. Licina DJ, Mookherji S, Migliaccio G, Ringer C. 2013. Hospital ships adrift?  Part 2:  The role of US Navy hospital ship humanitarian assistance missions in building partnerships.  Prehosp Disaster Med 28:592–604.
 
Table 1. USNS Mercy Mission Statistics
Year and Mission Countries Supported Participants (Identified in the Literature) Outputs
2010 Pacific Partnership
  • Cambodia
  • Indonesia
  • Palau
  • Papua New Guinea
  • Timor-Leste
  • Vietnam
  • 8 Partner nations
  • 17 NGOs
  • 100,000+ medical patients
  • 1,500+ dental patients
  • 58,000 pairs of glasses distributed
  • 124 pieces of medical equipment repaired
2008 Pacific Partnership
  • Federated States of Micronesia
  • Papua New Guinea
  • Republic of the Philippines
  • Timor-Leste
  • Vietnam
  • 10 Partner nations
  • 6 NGOs
  • 90,000+ medical patients
  • 1,300 surgeries conducted
  • 14,000 dental patients
 
2006 Humanitarian Assistance Mission
  • Bangladesh
  • Indonesia
  • Republic of the Philippines
  • Timor-Leste
 
  • 60,000+ medical patients
  • 1,083 surgeries conducted
  • 19,375 immunizations administered
  • 1,141 pairs of glasses distributed
2004 Operation Unified Assistance
  • Indonesia
  • Papua New Guinea
  • Timor-Leste
  • Project Hope – 200 members
  • 107,000+ medical patients
  • 466 surgeries conducted
  • 6,900 dental procedures
  • 11,555 pairs of glasses distributed