The views expressed in this article are those of the author and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense or the United States government.

s documented in this and previous issues of the ASA NEWSLETTER, U.S. military anesthesiologists have been delivering first-rate anesthesiology care in Iraq and Afghanistan in support of Operation Iraqi Freedom and Operation Enduring Freedom for several years. In fact, we have been a key factor in achieving the best battle injury survival rate in the history of warfare. But some military medical missions are not directly related to the treatment of combat trauma. To borrow a phrase from the Vietnam War era, these physicians are working to win hearts and minds in areas of the world where the United States and its allies are viewed with distrust and suspicion. In 2006, I had the rare opportunity and honor to teach anesthesiology in one of these countries.

Marib, August 26, 2006. Dr. Huraibi and Capt. (Dr.) Bonnema relax after the official welcome by Sheikh Ali Al-Fatimy, deputy governor of Marib.

The Republic of Yemen is an Arabic country on the southern corner of the Arabian Peninsula. It is one of the oldest centers of civilization in the world. Particularly in the central mountainous regions, there is tribalism, a strong Islamic tradition, fierce independence and oppressive poverty. Al-Qa’ida is present in Yemen, and we should not forget that on October 12, 2000, the U.S.S. Cole was attacked by suicide bombers during a refueling stop in the port city of Aden. This is a dangerous part of the world where much can be done to improve the image and reputation of the U.S. and its allies in the global war on terrorism.

In 2006, I deployed to Djibouti, Africa, as the Command Surgeon for Combined Joint Task Force-Horn of Africa (CJTF-HOA). The mission of CJTF-HOA is to prevent conflict and promote regional stability and peace through a deliberate policy of direct engagement. The Department of Defense (DoD) labels these activities “Phase Zero” operations.*

Capt. Bonnema standing next to a sign at the entrance to the President’s Hospital, with a picture of President Saleh superimposed on a modern anesthesia machine.

In Djibouti, I met Jean Rinaldo, M.D., the regional medical officer for the U.S. State Department. Her area of responsibility included Yemen, Oman, Eritrea and Djibouti. She informed me that the U.S. Ambassador to Yemen had a difficult problem. American aid is focused on five of the poorest governorates in central Yemen. They are remote, politically sensitive and provide too many places for terrorists to hide. Health care is rudimentary, but the governments of the United States and Yemen had worked together in this area to build the President’s Hospital in the city of Marib, a modest but modern 200-bed facility to serve the medical needs of the province’s most needy citizens. The hospital is well-equipped with anesthesia machines, cardiac monitors and mechanical ventilators, but it lacks the trained and experienced medical personnel to take full advantage of the technology and establish a solid reputation for professionalism and success. Dr. Rinaldo recognized that the hospital needed an infusion of western medical expertise. In our conversation, she discovered that I had been a department head at several U.S. Navy departments of anesthesiology. What happened next was a “eureka” moment, and Dr. Rinaldo invited me to Yemen to teach anesthesiology to the staff at the President’s Hospital. Instantly understanding the unique opportunity and its importance to the overall U.S. mission in the region, I eagerly accepted the offer.

Capt. Bonnema lectures at the monthly academic meeting of the department of anesthesiology, Al-Thawrah Hospital.

After a lot of relatively quick coordination with the Yemeni Ministry of Health, in August 2006, I arrived in the capital city of Sana’a, located on a high-desert plateau. There, I met Yahia Huraibi, M.D., my Yemeni host for the visit. Dr. Huraibi is the first residency-trained anesthesiologist in Yemen, having done his training in the eastern communist German Democratic Republic in the 1970s. Arabic culture has a long history of hospitality for guests, and Dr. Huraibi was a most gracious and charitable host — a perfect representative of his country and its medical establishment.

We traveled to Marib in a convoy of armored SUVs escorted by armed Yemeni military vehicles and officials from the office of President Ali Abdullah Saleh. The trip took us through some mountains and desert terrain that possessed a certain desolate beauty. From the road, it appeared that every man and teenage boy we saw was armed with a rifle or automatic weapon. Yemen is certainly one of the most heavily armed countries on the planet. Almost all the women I saw were covered from head to ankles by a black garment with only their hands and eyes visible to the outside. In the countryside, many of the buildings were constructed out of red mud bricks, and except for the guns, roads and vehicles, the appearance seemed much as it must have been several centuries ago.

Capt. (Dr.) Bonnema at the Opening Ceremony for the Refresher Training in Anesthesiology at the President’s Hospital.

In Marib, I was greeted by Sheikh Ali Al-Fatimy, the deputy governor of the province, and we were generously treated to a traditional Yemeni feast. At the President’s Hospital later that day, we were officially welcomed at a televised ceremony. Soon afterward, I met the 28 medical staff that had gathered from the surrounding countryside to hear my lectures. The group included surgeons, anesthesiologists, and their equivalent of anesthesia assistants, who practiced independently. Most were Yemeni nationals, but a few of the anesthesiologists were from former republics of the Soviet Union. The attendees all spoke Arabic, and Dr. Huraibi courteously served as my interpreter throughout the two days of lecture. He also added his own thoughts and clinical experiences, usually in a humorous and entertaining manner.

I wasn’t sure of the skill level of my audience, so I prepared in advance several multimedia presentations on basic and intermediate peripheral nerve blocks for upper- and lower-extremity anesthesia. I thought these skills would be particularly useful in the more remote and austere practice environments. After answering some excellent questions from my Yemeni colleagues about anesthetic complications and their treatment, I put together lectures for the second day on emergency airway management and advanced cardiac life support. The presentations were all well received, and I was given a very warm farewell when I left Marib.

Returning with my host to Sana’a, Dr. Huraibi took me to Al-Thawrah Hospital, where he serves as chief of anesthesiology. Al-Thawrah is a busy, publicly supported teaching hospital in the center of the capital. I was duly impressed with the main operating rooms — they were remarkably similar to what we have in the United States. The anesthesiology department invited me to address its monthly academic meeting, and I closed out my “visiting professorship” with a lecture on the history of inhalational anesthesia and the essential contributions of American physician Crawford W. Long, M.D.

The U.S. medical presence during my visit to Yemen was not large — just Dr. Rinaldo, Dr. Ahmed Attieg of the U.S. Agency for International Development, a few Embassy staffers and myself. But just about everyone in Marib knew we were there. Although I was there precisely because I was a Navy Medical Corps officer conveniently deployed to the region, I truly felt that I was treated by my Yemeni colleagues only as a fellow anesthesiologist with some knowledge to share with them. And, importantly for me, I also found a good friend in Dr. Huraibi.

Phase Zero medical missions represent a new direction and definite growth area for the U.S. military. These relatively small investments of resources pay disproportionately large dividends in friendship, good will and mutual understanding. Since my mission, the U.S. Embassy and CJTF-HOA have also sent an orthopedic surgeon and a pediatric cardiologist to Yemen, with similar good results. In the long battle against extremism, prevailing in the ideological fight requires that we win the hearts and minds of potential adversaries. Military medicine is doing just that, and my trip to Yemen is but one example.

Craig L. Bonnema, M.D., is Director of Surgical Services, Naval Hospital, Pensacola, Florida, and former Command Surgeon, Combined Joint Task Force — Horn of Africa.