As the United States contends with the strategic uncertainty in the post-Cold War era, it must consider the role of its military forces in operations other than war (OOTW), such as peacekeeping, peace enforcement, or humanitarian assistance. In these operations, medical issues tend to play a more central role than in combat operations and the medical support requirements tend to be broader, particularly if a multinational force is involved. Hence, OOTW may place greater and new demands on the Army Medical Department (AMEDD).

This report synthesizes recent military experience in medical support for OOTW, and it recommends ways for the Army to improve OOTW support while minimizing the impact of OOTW on the AMEDD's wartime readiness mission and on peacetime health care delivery to its beneficiaries. It deals primarily with five issues:

  • How do the medical support requirements of OOTW differ from those of combat missions? What special demands are imposed by OOTW, especially when multinational forces are involved?
  • How can the Army manage the inherent pressures toward open-ended expansion of the medical mission in OOTW?
  • How can the AMEDD build a robust and flexible system to meet the broad range of demands associated with these operations?
  • How can the Army minimize the impact of OOTW on the Army's readiness mission and its ability to provide beneficiary care?
  • What kind of planning, education, and training may be required to better prepare the Army to support OOTW in the future?
To address these issues, we examined two main deployments: the UN operation in the Balkans in 1992-1994 and the U.S.-led mission to Somalia in 1993-1994. We also conducted a less extensive analysis of the U.S.-led mission to Haiti in 1994-1995. For each deployment, our main sources were documents and interviews with key participants and officials, supplemented by quantitative data on unit configurations and patient- and provider-level data on deploying medical units.

Nature of OOTW Medical Demand

The demand for medical services in OOTW differs in some important ways from that in combat operations. First, the patient population tends to be much broader, with more diverse treatment needs. In addition to U.S. troops, Army medical units may be called upon to treat (a) local civilians, (b) refugees, (c) troops of coalition partners, and (d) employees of the U.S. government, UN, NATO, or civilian contractors. These patient groups vary more than U.S. troops in their health status, age structure, proportion of females, and type of acute or chronic medical conditions requiring treatment in-theater. In addition, troops in a multinational coalition force tend to have lower levels of predeployment medical screening, preventive medicine support, and medical and dental readiness--increasing medical support requirements. These differences also mean that the AMEDD may be called upon to provide a broader range of services (including pediatric and ob/gyn care) in these operations and must be prepared to treat certain infectious diseases and chronic medical conditions not common among U.S. forces. Thus, in OOTW the demand for medical services is often closer to what a community hospital would face, compared to a military hospital in support of combat operations, which is geared primarily toward trauma and emergency care.

Second, other available medical assets may be deficient. For instance, the existing medical infrastructure of the host nation may have been destroyed. Coalition partners' own medical assets may be inadequate for the mission; troops in a multinational force will differ in the level and type of equipment, supplies, and training of their medical personnel and units, as well as in the quality of care these assets provide. As a result, the United States may feel compelled to compensate for these differences by plugging holes in the theater medical system, supplementing other troops' medical assets, and imposing U.S. standards of care.

Third, some coalition patients may require intensive or prolonged hospital care that goes beyond what military health service support is designed to provide in a theater of operations. To begin with, some patients may be in poor condition owing to lack of preventive medicine in the field, inadequate Echelons I or II care by their organic medical assets, or delays in transport to the U.S. military hospital. For example, in the Balkans the forward surgical teams within the UN force provided widely varying quality of care and uneven coverage across different sectors. The U.S. hospital may also find it difficult to repatriate some coalition patients if adequate treatment is not available in their home countries. Indeed, some countries' deficiencies in quality of care may serve as an incentive for them to leave their soldiers at a U.S. military hospital.

Fourth, many OOTW missions have a humanitarian component, including public health actions or prevention (e.g., ensuring the quality of the local water supply to prevent the spread of cholera, or establishing basic sanitation conditions within a refugee camp or community hospital). In such situations, the Army may find itself providing medical supplies, community health services, public health education, training, and even basic equipment to shore up the local medical infrastructure.

Fifth, although OOTW require a broader range of services, patient demand tends to be relatively low. The size of the hospital required is often small (averaging 60 beds and 120-140 medical staff in recent OOTW). This suggests that the military hospital may easily be overwhelmed in a mass-casualty situation and that medical evacuation will become a top priority. For instance, Somalia was an example of the AMEDD doing its combat mission in an OOTW environment; patient demand was relatively low, characterized by peaks and valleys yet always with the potential for combat. That theater illustrated not only the low-end requirements in OOTW, but also the difficulty of planning medical support for these types of missions. A key lesson from Somalia may have been to staff for a little more than the average and then ensure the capability to extend for the surge.

Overall, we found the critical determinants of the medical support requirements in OOTW to include (a) the presence of refugee or displaced populations, (b) whether there is a humanitarian component to the operation, (c) the degree to which the host nation's medical infrastructure has been compromised, (d) whether the United States is acting unilaterally or with a multinational force, (e) the level of support the United States has been tasked to provide to a multinational force, (f) differences in medical readiness among coalition troops, and (g) the degree of variability in coalition partners' medical assets. Because of these features, OOTW can present a broad range of resource demands with rapidly changing mission requirements, suggesting the need for flexibility in planning and ability to tailor support to the mission.

Mission Expansion

Such conditions generate both internal and external pressures for the medical mission to expand--a phenomenon often called "mission creep." In OOTW the demand for services is often open-ended and has the potential to consume large amounts of medical resources, undermining Army readiness for other missions. Some key factors that push toward a larger mission include the following:

Needs of coalition partners. A broader set of treatment demands arise among soldiers from other nations. Some coalition troops may utilize the theater medical system in ways it was not intended, and coalition partners' own medical assets may be substandard.

Demand induced by U.S. actions. The U.S. informal policy of "if we hurt them, we fix them" leads to involvement with civilian populations in any event. In addition, U.S. soldiers may bring in sick or injured civilians to the military hospital for care.

Excess capacity. In OOTW, excess medical capacity is unavoidable to a large extent, given the wide fluctuations in patient demand and the fluid nature of these operations. As a result, the in-theater medical facility may be underutilized at times. This available, but unused, supply tends to stimulate demand. In addition, military medical units often find themselves in areas with overwhelming medical need among the local civilian population. Providers also want to continue practicing their specialties to maintain their clinical skills.

Outside requests and influences. The UN, coalition partners, foreign ambassadors, other U.S. agencies, and the State Department often urge the Army to expand the medical mission. Coalition partners also may define a broader medical mission and set of objectives for themselves, creating a disparity that pushes the United States in a similar direction or sets up unrealistic expectations of the U.S. military's medical role.

Ethical and professional considerations. Medical personnel have a professional orientation that implies an obligation to help with urgent medical problems (among civilian and coalition populations) and an understandable desire to respond to medical need, regardless of the formal mission parameters.

Inadequately defined missions. Guidance from the strategic or interagency levels may not adequately specify who is entitled to what type of care in OOTW. The lack of articulation of a national medical strategy for OOTW that defines the objectives and medical rules of engagement has led to ambiguity, which in turn encourages mission creep.

Given the above factors, this report describes several actions the Army and other U.S. agencies might take to bound the medical mission appropriately. These include:

  • Clarifying up front the medical mission, its objectives, desired end state, and classes of patients eligible for services;
  • Limiting treatment of civilians to the level of care customary in the region and not imposing U.S. standards of care that the host nation or nongovernmental organizations (NGOs) are unable to sustain once the U.S. military departs;
  • Addressing repatriation problems by establishing procedures for evacuating coalition patients to their home countries, facilities in neighboring countries, or local hospitals;
  • Relying on civilian contractors or negotiating workload with local medical facilities and NGOs in areas where they can help or have a comparative advantage over the U.S. military.

A Robust and Flexible Structure

Because OOTW tend to encompass a broad range of medical tasks but require less total capacity than combat missions, it does not make sense for the AMEDD to construct new structure for these operations. Rather, the key is to build a robust and flexible structure that will allow the AMEDD to respond to the breadth of demands it now faces. The report details several recommendations for structural improvements, including the following:

Modular units, consistent with the concept of Medical Force XXI, and tailorable for the demands of OOTW.

A deployable isolation ward capability for treating patients with serious contagious diseases such as tuberculosis.

Extended preventive medicine and physical therapy services, as well as limited rehabilitative capabilities to treat land mine injuries and sports-related injuries (both common in OOTW).

Development of staging teams or other means of ensuring a surge capability to handle and quickly evacuate casualties in a mass-casualty situation that might overwhelm a small hospital.

Special-purpose support packages for geriatric, gynecological, and pediatric care. Also, minimal-care wards for housing soldiers or translators who accompany injured or sick coalition soldiers, adults who accompany a child, orphans, and coalition patients who may no longer require care but for whom there are delays in repatriating them back to their unit or home country.

Extended use of telemedicine capabilities has the potential to play an important role in OOTW, where in-theater personnel ceilings may prevent deploying the many different specialties required to treat the full range of diseases and medical conditions encountered. Innovative uses of this technology also need to be explored. For example, telemedicine may be able to play a role in addressing repatriation problems and meeting the expanded medical intelligence and linguistic requirements associated with OOTW.

Minimizing Impact on Readiness and Peacetime Care

Several factors give OOTW the potential to affect future wartime readiness and peacetime health care delivery: the simultaneity of demands, their open-ended character, and the Army's direction that it support them without any degradation in beneficiary care. To preserve its medical support capabilities in the face of OOTW demands, the Army may want to consider designating certain medical units as OOTW hospitals and staffing those hospitals with two of each of the most critical functional elements. For example, of the 13 CONUS TOE hospitals currently in the active-duty structure, the AMEDD could build one or several into a "1.5" hospital. Then, if half of a hospital deploys on an OOTW, a complete hospital would still be available for a second deployment.

Such units would then know in advance that they will be on the "hot seat" for supporting OOTW, and this designation could be rotated among active-duty hospitals on a yearly basis. This would allow the Army to avoid pulling personnel from a number of different military treatment facilities to support a single deployment, and it would open up the possibility for advance planning to maintain beneficiary care while supporting an OOTW. For example, military treatment facilities might rely on standing contracts with civilian providers or place deployable PROFIS personnel in noncritical positions to minimize the impact of these deployments on peacetime health care.

Planning, Education, and Training

Flexible planning. First and most critically, Army planners need to consider not only the medical requirements for supporting a deploying force, but also the broader missions the Army may be assigned in OOTW. For example, in operations involving humanitarian assistance or refugee populations, the medical mission is likely to be broader than the basic workload of supporting the deploying force. In fact, the real thrust of the AMEDD's workload may be to provide health support to the host nation. Yet planners continue to view the medical mission as limited to its traditional combat service support role. This in turn has led to a mismatch between the requirement and the force provided, and at times to the inefficient use of medical assets. To avoid such problems, we offer three recommendations.

First, planning should recognize the special medical requirements related to civilian populations and multinational forces. For example, lack of preventive medicine and poor quality of care by some coalition troops' medical teams may mean that a U.S. Echelon III hospital receives more patients whose treatment is complicated or resource-intensive. And a political reality of OOTW is that the U.S. military may be tasked to provide care to civilians--not only local people, but refugees, UN and NATO employees, and coalition soldiers--whether or not it is part of the official medical mission.

Second, planning should explicitly consider the varied types of at-risk populations, categories of patients, and medical conditions enumerated above. Although it is not possible to plan for all eventualities, in general we can do better at predicting the population at risk and the key determinants of the support requirements in OOTW.

Third, planning should include advance assessment teams with OOTW expertise. Such teams should include not only physicians with prior OOTW deployment experience, but also preventive medicine officers, community health nurses, and others with special expertise for OOTW.

Individual education and training. Clearly there is a large political element associated with OOTW. Yet many of the AMEDD officers and enlisted personnel who have deployed on these missions have had little experience in political matters. This encourages mission creep at the individual and tactical level. Such tendencies could be combated by better education and training.

For AMEDD officers, the Officer Basic and Advanced Courses could include an introduction to OOTW with a focus on problem-solving exercises, and the Command and General Staff College could provide a forum for discussions on medical support requirements, public health issues, and other problems medical units face in OOTW. The Army War College curriculum could include coursework on planning and leading OOTW, as well as on policy and political issues. In addition, the AMEDD may want to articulate humanitarian rules of engagement for enlisted and nonmedical officers in OOTW.

Integrated medical and line training exercises. To educate both line and medical officers, Army medical units could become more involved in collective training for OOTW at the JRTC. It is in such a training environment that line and Army medical officers could hash out many of the medical decisions and practices associated with OOTW prior to a deployment, rather than relying on ad hoc decisionmaking in the theater. Further, medical commanders and their core staff could receive training on interpreting an operation plan, developing a tactical plan, and making the kind of clinical and command decisions they may face in a Somalia, Bosnia, or Haiti scenario. Since medical units in the past have had limited participation in JRTC training exercises (e.g., providing site support), it will be up to the AMEDD to articulate a future training strategy that will incorporate this type of experience.

Medical-unique training. Physicians, nurses, and other providers also need training in the types of treatment dilemmas they may encounter in OOTW, on how to respond appropriately to help avert the tendency toward assuming an additional mission, and on how actions undertaken at the delivery end may inadvertently lead to an expansion of the medical mission. In addition to JRTC training, one way to accomplish this would be for the AMEDD to undertake medical-unique training for OOTW at Camp Bullis to help medical personnel anticipate the demands and treatment decisions they will confront.

Requirements of Coalition Operations

Coalition operations pose unique problems in providing and structuring medical support. In general, the U.S. military tends to serve as the backbone of the medical support in OOTW, regardless of whether the mission is to support U.S. troops or a multinational force.

Instead of being able to set up an integrated theater medical system with consistent quality across echelons of care, the U.S. military often faces a structure of highly variable quality, with holes and gaps among the different elements. Given this, the United States and its other key coalition partners may want to take the lead in developing a revised definition of echelons of care, specific to OOTW involving a multinational force. Such a plan would set standards for medical readiness, unit readiness, training, equipment, and standards of care, as well as a realistic evacuation policy.

International differences in standards of care and medical practice raise serious questions for U.S. medical support. For example, how much quality variation can the United States afford in the theater medical system--and what are the attendant risks? Few militaries are as aggressive as that of the United States in such areas as trauma care, and some have substantially lower standards of care. Although one may be able to ensure quality in a clinic setting, U.S. military medical personnel may not be the first assets to reach a wounded U.S. soldier in an emergency situation during a coalition operation. This suggests that the United States may not be able to afford much variability in the theater medical assets. Instead, it may want to serve as the coordinator of medical care. Or the United States may want to continue to impose its standards on other coalition forces. If either option is selected, the United States needs to be explicit about it and negotiate compensation up front for these additional activities.

In general, the United States can expect to be tasked increasingly to provide air evacuation and medical logistics in multinational operations, since it has one of the few militaries with such capabilities. And, as illustrated by the experience of all three services in the Balkans and Haiti, the U.S. military must rely on its own logistics support rather than UN systems, because of quality problems and differences in standards.

Overall Conclusions

As the Army and the AMEDD, like the rest of the U.S. military, continue to downsize, no one can clearly envision the strategic environment they will be operating within in the future. We do anticipate, however, that the United States will continue to undertake OOTW, perhaps at an increasing rate.

In general, we found OOTW to entail a broader set of demands upon the medical component. Planning for future OOTW needs to recognize the breadth of such demands, especially in multinational operations. The AMEDD will need to ensure a broad-based flexibility to support the diversity of new missions it will be called upon to undertake in an OOTW environment. At the same time, though, given the overwhelming medical need and the fact that the U.S. military often serves as the backbone of the medical support in OOTW, the United States needs to focus and contain its medical involvement in these missions where possible. Finally, many of the medical issues identified here are systemic--to be confronted successfully, they need to be addressed not only at the Army headquarters level, but also at the strategic, operational, and tactical levels.