War's Lessons

War's Lessons

It wasn’t until he changed planes on his way to Saudi Arabia that Dean Sienko fully grasped where he was going and what it meant. The first leg of the flight, from the United States to Spain, was pretty much like any other flight. But in Madrid, the U.S. crew got off and an all-volunteer crew in blue jeans got on. They carried gas masks, and Sienko realized afresh what it meant to be heading into combat. It was January 1991, and the first Gulf War was imminent. Hours later, when he got off the plane in Saudi Arabia, Sienko looked around and saw tanks, armored personnel carriers, helicopters, sandbag bunkers, and machine guns.

“This is the real deal,” he remembers thinking. “This is war.” A week later, the fighting began.

It was the first of three overseas deployments that Sienko, 49, has made during his 24-year career as a reserve medical officer in the U.S. Army. And if he’s asked to go again, he’ll go—even though a new deployment will mean saying goodbye a fourth time to his wife and three children without knowing when, or if, he’s coming back.

It will also mean taking another leave from the Ingham County Health Department, where he’s been medical director and chief medical examiner since 1989, and the University of Michigan School of Public Health, where he teaches a course in the epidemiology and public health management of disasters.

Growing up in a working-class Polish neighborhood in Milwaukee, Sienko learned to be proud of his country, and by the time he entered medical school in the late 1970s he was ready to act on that pride. He signed up with the Wisconsin Army National Guard and later joined the U.S. Army Reserves. He’s been a member ever since—throughout med school and a residency in preventive medicine, a two-year stint as an Epidemic Intelligencer Officer with the Centers for Disease Control and Prevention, another stint as a student in clinical research design at the University of Michigan School of Public Health, and his more than two decades as a public health official in the state of Michigan.

Now a brigadier general in the U.S. Army, Sienko says the military has inspired him in unique ways. “To be around people who are so willing to give of themselves for a purpose higher than themselves—that’s noble,” he says.

The military has also opened his eyes. And because of that, colleagues say, Dean Sienko is singularly qualified to help the rest of us open ours.

In some ways, war is like any other disaster. Infrastructures break down. Access to water, electricity, and refrigeration is compromised or vanishes altogether. The health care delivery system stops functioning. Hospitals and medical warehouses may be looted.

But while other disasters—hurricanes, earthquakes, tsunamis, even terrorist attacks—usually end in a matter of days, wars can drag on for months and often years. Sienko understands the toll war takes on both the human body and mind and on a country’s infrastructure.

During his first deployment overseas in 1991, during the first Gulf War, Sienko, a preventive medicine physician, attended to primary medical care for both U.S. soldiers and Iraqi prisoners of war. At their base in Saudi Arabia, he and his hospital team treated hundreds of Iraqi prisoners of war and dozens of U.S. soldiers, and Sienko himself assisted orthopedic specialists with complex fractures and amputations.

Although as an intern he’d spent a month in the trauma unit of Chicago’s Cook County Hospital, Sienko says nothing prepared him for combat trauma. “The weapons are more lethal, more damaging. There are horrific images of faces literally being blown apart after being hit by combat weapons. As a physician you’re more prepared to deal with it professionally—loss of limb, eyesight, life.” But that doesn’t mean it’s easy.

“We’ve all experienced people dying under our watch,” he says.

Mental health is a top concern in combat zones—not only for soldiers but also for providers and “non-combatants who get caught in the middle of these things,” says Sienko.

Combat stress units are trained to deal with potential suicides, but during Sienko’s second deployment to the Middle East in 2003, at the outset of the Iraq War, the suicide rate among U.S. troops suddenly spiked, and Sienko, who was then responsible for medical operations throughout Afghanistan, the Middle East, and eastern Africa, sought help from mental health experts

in the Office of the Army Surgeon General.

A group of psychologists, psychiatrists, and social workers teamed up with the manager of the army’s suicide-prevention program to visit the region and survey hundreds of soldiers.

A variety of factors seemed to be at play, among them long deployments and combat-related stressors like roadside bombs and mortar attacks. Ultimately the team advised that

mental health interventions be increased for American soldiers throughout the Middle East, and according to a recent assessment, the mental health and well-being of troops in the region have improved.

In other ways Sienko’s work in war zones is not all that different from what he does at home. During his 2003 deployment to the Middle East, he had to contend with routine public health issues such as food and water safety (foodborne outbreaks have historically incapacitated armies, he notes). And heat. Temperatures in Iraq can easily soar to 140 degrees, so from his base in Kuwait, Sienko had to devise measures to help prevent heat stroke among American troops, including cooled indoor environments, physical activity at night when feasible, and potable water supplies at all times.

Disease Non-Battle Injuries, or DNBI, posed a further threat, and Sienko had to implement measures to contain both an outbreak of pneumonia among soldiers and the ongoing risk of leishmaniasis, a disease caused by sand flies that leads to unsightly and sometimes painful skin sores. Motor vehicle crashes were another significant issue.

War, Sienko has learned, can be a complicated blend of the everyday and the calamitous.

Peace, often tenuous, imposes its own burdens. In 2001, as part of a NATO peacekeeping mission, Sienko was sent to Kosovo for six months to command a medical task force. His primary job was to provide medical care to American and coalition partners and, under emergency circumstances, critical care to the citizens of Kosovo.

Although there was no longer an acute crisis, and people had access to basic health care needs, matters were far from calm. Tensions between ethnic Albanians and Serbs fueled sporadic outbursts of violence, and Sienko recalls that he and his colleagues had “real questions about the country’s future.” He saw it as very much part of his mission to “try to bridge this ethnic divide.”

That divide extended to health care. By the time Sienko arrived in Kosovo, ethnic Albanians had taken over most of the hospitals that had previously belonged to Serbs, and were often refusing care to Serbs much as those same Serbs had once refused care to Albanians. Sienko worked to get one Albanian-run hospital to provide services to Kosovo’s Serb patients, and with help—and an imposing display of weaponry—from a fellow army officer, he succeeded.

But because of the country’s ongoing political tensions, Kosovo continues to have serious medical infrastructure needs, he says. Professional nursing is still an evolving field, resources are inadequate, and medical education falls short of Western standards. Hospital professionals in Kosovo welcomed Sienko’s advice on issues like infectious-disease control, sterilization of instruments, proper disposal of blood and body fluids, and basic cleanliness.

Sienko says Kosovo illuminates a fundamental distinction between a natural disaster and war. In a natural disaster, people typically put aside political differences and agree to a temporary truce for the common good. After last year’s tsunami, for example, warring factions in Banda Aceh, Indonesia, joined forces to undertake a badly needed immunization campaign.

“But war by itself is different,” Sienko points out. “The disaster is the tension, the conflict. There is no one unifying element to the disaster, as there might be when people need health care because of a tsunami or hurricane.”

After witnessing the dire effects of Kosovo’s ethnic conflict, Sienko found himself reflecting on why such things happen. “It makes you more sensitive to discrimination back at home. Race, religious, sexual orientation—you have to think about that.”

"Back at home” for Sienko is Lansing, Michigan , where he lives with his wife, Mary Jean, and their three children, and where Sienko works as medical director and chief medical examiner of the Ingham County Health Department.

Although he looks every bit an army man—he wears his gray hair close-cropped and sometimes dresses for work in khaki-green slacks and a khaki shirt—Sienko is careful to draw a distinction between his two lives. In Michigan, where he oversees a staff of 350, Sienko is very much a civilian public health official.

Bruce Bragg, director of the Ingham County Health Department and Sienko’s boss, calls him “the best public health physician that I know. If you had to trust something to somebody in the world, Dean would be one of the people that you could call on.”

Some of his integrity is due to Sienko’s SPH training in the 1980s, which stressed “the rigors of good science, asking valid questions, doing exceptional research, all designed to find truth,” Sienko recalls.

And some of his integrity stems from his army training. One of Sienko’s jobs at the health department is to help oversee Ingham County’s disaster-preparedness planning, and in this arena his military background has proved especially useful. During disaster-simulation exercises, Sienko has often found himself thinking “how the military would structure this. Sometimes there are not clear definitions in the civilian world about responsibilities. The military is cleaner that way. There are no ambiguities about who’s in charge. It’s helped me understand incident command, thinking through disasters.”

Janet Olszewski, director of the Michigan Department of Community Health, says Sienko’s presence in the state’s public health administration is “very comforting. There’s nothing like real-world experience to help in your planning efforts, and Dean has a very good understanding of what the pressures are going to be in a situation, and we’re able to establish our plans more realistically.”

Where Sienko feels the civilian world has the most to learn from the military is in the area of crisis management. He notes that during a crisis, military officials conduct highly structured briefings that are synchronized so that information travels quickly and efficiently through the ranks to the highest commander. In Sienko’s case that’s his army boss, a three-star general, who in one hour is briefed “on everything from logistics to transportation to fuel to mail delivery to health care to food to public affairs. He listens, comments, gives direction, and moves on. It’s called ‘battle rhythm.’”

Sienko advocates a similar system for domestic crisis management. Should news of

a pandemic flu outbreak reach Michigan, for instance, he’d like to see public health officials immediately conduct an intelligence briefing that addresses such questions as: “Where’s the flu? What’s the world situation? What has WHO declared?” Next there’d be a briefing on operations: “What’s going on? How many clinics do we have? How many vaccination teams?”

On a visit to the Michigan State Health Department last year, Jim Marks, a senior vice president at the Robert Wood Johnson Found-ation, heard Sienko speak on this topic and says Sienko framed things in ways Marks hadn’t heard before. “Many in public health find the comparison of military approaches with public health approaches somewhat distasteful,” says Marks, but he points out that in a crisis things change. Disasters “require a recognition of how a decision-making structure and process has to be different than the usual one in public health, which is usually a very strong consensus-building process.”

Marks adds that at a time when its infrastructure is “undersupported,” public health

is being asked “to take on issues of a much greater scale than it ever did before—preparedness being one of those, childhood obesity being another.”

What’s more, public health officials increasingly have to collaborate with partners who are accustomed to very hierarchical structures, including the police and the military. Because Sienko is “fluent in both languages,” Marks believes he’s especially adept at bridging those two worlds—and he’s good at training others to do the same.

When he strides into an SPH classroom at eight a.m. sharp on a Friday morning in February—after a 60-minute commute from Lansing—Sienko commands attention. Students who are just nudging themselves awake over lattes perk up, and Sienko starts in. “When you have 189 cases, how many controls do you need?” he asks in reference to an assigned reading on a study of the 1988 Armenian earthquake. A moment later, he reminds the class, “Disasters create certain problems in epidemiology that you’re not going to find elsewhere.”

The course is Epid 651: Epidemiology and Public Health Management of Disasters, and in it Sienko covers everything from pandemic flu to tornadoes and oil spills. Key themes, drawn from his experiences at home and abroad, are the unpredictability of disasters, the challenges of international relief and research efforts, the long-term and widespread impact that disasters can have. And always, the need to prepare.

Several students in his winter 2006 class were heading to the Gulf Coast over spring break to help with the Hurricane Katrina recovery, and they were hungry for real-world advice on what to expect and how to proceed.

Tim Stiles, a preventive medicine resident specializing in epidemiology, had signed up for Sienko’s class to get a better understanding of emergencies. “In today’s situation, it’s something that needs to be considered,” Stiles said. Brantley Carlson, a second-year health management and policy student, took the class in order to learn about emergency preparedness.

Kristen Schweighoefer, MPH ’00, enrolled because nothing like this was available when she was a student at SPH, and as an environmental health supervisor for Washtenaw County, she needs to plan for disasters such as foodborne disease outbreaks and water contamination. She admires Sienko’s “hands-on, practice-based” approach to the course material because, as she puts it, “with disaster preparedness you need to make sure that you have the tools in place to practice it, not just have the information on a shelf in your office.”

Sienko likes teaching in part because he feels it’s his obligation to offer his experience to the next generation of professionals. Experience, after all, has been his own best teacher, and he hopes he’ll inspire his students to think through the nuances and details of disaster work and to grapple with their underlying reasons for undertaking this kind of public health work.

“You’ve got to think through, what am I really going to accomplish here, what can I realistically do,” he says. “Because areas that have been devastated by a disaster need people who are going to make a contribution—more than just warm bodies looking to do good things.”

And at the end of the day, making contributions is what Dean Sienko is all about.

By Leslie Stainton

SPH photos of Dean Sienko by Peter Smith

Send correspondence about this or any Findings article to the editor at sph.findings@umich.edu. You will be contacted if your letter is considered for publication.