1. Introduction

Background

As the United States contends with the strategic uncertainty of the post-Cold War era, it must consider the role of its military forces in operations other than war (OOTW). Despite concerns about the conduct of recent UN operations and ongoing debate in Congress about limits on the U.S. role, the U.S. military can expect to be called upon to undertake such OOTW missions as peacekeeping, peace enforcement, and humanitarian assistance.

Participation in OOTW missions implies the need to provide medical support to U.S. forces or to multinational forces. In fact, one might argue that given the very nature of these operations, medical support tends to play a more central role than in combat operations. Whether the mission is to assist civilians in disaster relief, to support U.S. or multinational forces in a peacekeeping operation, to distribute medical and other supplies in a humanitarian effort, or to provide medical support in a nation-assistance program, medical support is a key component. Further, medical units often find themselves in areas where the medical infrastructure has been destroyed or there are large refugee populations. Presenting a further challenge, experience shows a strong tendency for OOTW medical missions to expand as the operation continues, with the potential to consume large amounts of scarce medical resources.

Meeting these needs will have a direct impact on the Army Medical Department (AMEDD). First, these missions come at a time when the AMEDD itself is downsizing. Several of the Army hospitals that deployed to Somalia, the United Nations Protection Force (UNPROFOR), and Haiti were scheduled to deactivate upon their return. In Europe, the 7th Medical Command has recently deactivated, with U.S. European Command going from eleven to two fixed medical facilities within the past several years. Yet this theater is also the location of a number of recent OOTW and a location where several new ones may be on the horizon. The drawdown also has imposed its own set of constraints on the AMEDD, and the effects have been exacerbated by the fact that OOTW are often open-ended in nature, making it challenging to plan their medical support.

At the same time, the AMEDD has to be concerned with how to support OOTW without degrading beneficiary care. Ensuring quality medical care for the services' beneficiary population--particularly for dependents overseas--is an important concern of both the Army leadership and OASD (Health Affairs). As the current situation in Europe illustrates, the size of the U.S. force may draw down and the number of fixed facilities decline, but demand for beneficiary care does not decrease proportionally with reductions in the size of the force. How the wartime structure and peacetime structure achieve a balance in meeting these two sets of demands will continue to be an important challenge for the AMEDD.

Therefore, to minimize the impact of OOTW missions on the AMEDD's primary mission and on peacetime health care, the AMEDD needs to explicitly consider the requirements of these missions and what adjustments may be needed to accommodate them in the future.

Objectives

This report has two main purposes. First, it describes and synthesizes the lessons of recent military experience in medical support for OOTW missions. Second, it distills that experience into suggestions for improving OOTW support while minimizing the impact on the AMEDD's readiness mission and its delivery of peacetime health care.[1] We deal primarily with five key 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 a 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 deliver peacetime heath care?
  • What kind of planning, education, and training may be required to better prepare the Army to support OOTW in the future?

Approach

To examine these issues, we use a case study approach combining both qualitative and quantitative data for selected deployments where the primary medical mission was to support U.S. forces or a multinational force. Two main operations were examined as case studies:
  • The Balkans: The UN operation known as UNPROFOR and the U.S. operation known as Operation Provide Promise (OPP).
  • Somalia: Operations Restore and Continue Hope (ORH and OCH).
To a lesser degree, we also examined the AMEDD's role during the operations in Haiti. This included the initial U.S.-led effort (known as Uphold/Maintain Democracy) and the follow-on UN peacekeeping mission (known as UNMIH). Because Haiti was the more recent deployment, we were unable to do as detailed an analysis of this mission as we did for the others.

Interviews were conducted with AMEDD and other military personnel who had participated in or planned these operations.[2] We further examined documents on selected deployments, as well as Army manuals and other DoD reports on such topics as OOTW and health service support in a theater of operations. These included after-action reports, field manuals, information papers, briefing charts, and numerous government and military documents (e.g., GAO reports, military pamphlets). Specific sources are cited in the text footnotes. Also, several of the medical activities (MEDDACs) and medical centers (MEDCENs) that supported these deployments by sending Professional Filler System (PROFIS) personnel provided us with both information papers and summaries on the impact of recent operations on their own activities and on patient care. Interviews with resource management officers, medical personnel, and logistics officers at these installations rounded out our information.

Specific data and methods for the operations in the Balkans and Somalia are described in the case studies presented below.

Organization of the Report

This report is organized into several chapters. In Chapter Two, we examine how the AMEDD's wartime structure is set up for supporting traditional combat missions as a way of providing a baseline to evaluate the OOTW requirements seen in the case studies. In Chapter Three, we present the case study of the AMEDD's involvement in the Balkans, and in Chapter Four, we present the case study of Somalia. Chapter Five draws some generalizable conclusions from both case studies, and Chapter Six suggests future directions for improving AMEDD support in OOTW.


[1] Although we focus on the AMEDD's role in OOTW, many of the recommendations and issues discussed herein are also applicable to the other services' military medical departments, as well as to those of U.S. coalition partners.

[2] Because these personnel are typically scattered across different military treatment facilities when not deployed, this involved tracking down individuals who had participated in recent operations of interest. Further, due to the drawdown in Europe, many of the medical personnel who had participated in UNPROFOR had already scattered to a number of different locations, complicating the interview process.


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