5. Conclusions

Based on the two case studies presented earlier and additional information on other operations--e.g., the mission in Haiti[1]--we have identified a series of common issues about medical support from which we can draw some generalizations. This chapter discusses these issues in four categories: medical mission expansion and "mission creep"; medical support requirements; problems within coalition operations; and the impact of OOTW support on Army medical readiness and peacetime care.

Medical Mission Expansion

In OOTW, one can expect the medical mission to change as a consequence of the operation itself, thus the need for ongoing mission analysis. In addition, there may be both external and internal pressures for the medical mission to expand--a phenomenon often called "mission creep." In fact, the demand for medical services in OOTW seems open-ended and could consume large amounts of military medical resources, which in turn could undercut readiness for other missions. To manage this demand and to plan for it, the theater commander, subordinate commanders, the JTF Surgeon and his staff, and planners need to recognize forces that exert pressure toward broadening the mission and be able to decide when to resist taking on an additional mission.

Below we identify several ways in which missions are expanded in OOTW: inadequately defined medical missions, mission creep, incomplete mission planning, and changes in the overall operation. We then describe underlying factors that inherently tend to expand such missions.

Inadequately Defined Missions

In some cases, what appears to be mission creep is actually a problem of not knowing the exact mission. An inadequately defined mission results when the scope of the mission, objectives, and specified tasks are unclear and there is wide latitude in how the mission is to be executed. Often, this stems from an absence of guidance from the strategic or interagency levels. For example, during UNPROFOR, the statement of entitlement to care and the population at risk was not well articulated at the outset. The medical objectives that emerged from the interagency planning process were not written at the customary level of detail for a medical mission statement, making it difficult to operationalize.[2] This contributed to mission expansion during UNPROFOR. We suspect this problem applies broadly to all OOTW missions. Without clear guidelines for giving or withholding care, medical providers will tend to react to the immediate need, regardless of the long-term consequences for resources or readiness.

Mission Creep

Under some circumstances the mission may expand not because of vagueness in its definition but because commanders formally depart from their original mission. This is the type of mission expansion most appropriately termed mission creep. For example, the U.S. military may decide to extend the scope of its medical activities to compensate for inadequacies in other coalition troops' medical assets. Or a U.S. commander may decide to allow his medical unit to treat civilian patients and to visit refugee camps to keep the medical staff busy and to boost morale. UNPROFOR was a good example of the United States electing to provide combat stress support, preventive medicine support, and Echelon IV care to compensate for missing assets and poor quality of care among UNPROFOR troops. However, doing so meant going beyond the scope of the original U.S. medical mission.

Some mission creep is initiated by the Army itself. For example, to date U.S. policy in OOTW has been that if actions of its military inadvertently lead to the injury of a foreign national, then it will treat that person. Thus, when a U.S. soldier brings into a military hospital a foreign national who was accidentally hit by an Army truck or caught in an exchange of gunfire, treating that patient does not expand the original mission. But if an infantry soldier out on patrol comes across an injured or seriously ill Haitian and brings that individual into the U.S. hospital for care, treating that person is an instance of mission creep. These two cases are sometimes difficult for soldiers to distinguish. In both Somalia and Haiti, nonmedical U.S. personnel brought a significant number of injured or sick foreign nationals into the U.S. hospital. At various points during these two operations, the medical staff also undertook elective provision of care to foreign nationals. This occurred partly out of a desire to do what medical personnel are trained to do (i.e., provide care to those in need) and partly to keep busy. However, given how the parameters of the medical mission were written for these two OOTW, providing such care represented mission creep.

Some mission creep is derived from external influences. In recent OOTW, there have been numerous requests from the UN, the State Department, OFDA, other contingents, U.S. and foreign ambassadors, and nongovernmental relief organizations (NGOs) for the U.S. military hospital to undertake the care of refugee or civilian patients. During UNPROFOR, the fact that the U.S. military hospital was not burdened by high patient demand during certain phases of the operation convinced others (e.g., State Department and UN officials) that the hospital was capable of extending its mission to treat refugee children and adults.

When requests for refugee or civilian care come from other countries or from the host nation, the theater commander and CINC have some leeway in their decision. However, the political significance of such requests may not be fully understood at the tactical or operational levels. Further, in the case of requests from the UN, the U.S. State Department, the country team, or other foreign diplomats, the theater commander may seek formal guidance but find that it is not forthcoming.

The presence of coalition soldiers can also prompt mission creep. For example, in UNPROFOR there were external pressures for the U.S. military hospital to assume Echelon IV care and long-term management of certain coalition soldiers. However, some of these pressures were also generated within the military. For example, the medical staff knew that, in some instances, a coalition patient might not receive adequate care if transferred to a local community hospital or repatriated to his own country. The decision to manage the care of such coalition soldiers, beyond the level that would normally be expected, is arguably an example of mission creep that was at least partly under U.S. control.

Dental care is another area with a tendency toward mission expansion, though perhaps not as costly as those above. For example, in recent operations the availability of U.S. military dental care in the theater resulted in a high demand for dental services, particularly among troops from developing nations. Some soldiers sought care for acute conditions (i.e., emergency dentistry problems), whereas others sought care for nonemergent problems (i.e., preexisting dental problems not severe enough to affect their performance). For many such troops, this was the first time they had access to dental care. At the same time, U.S. military dentists and providers may also be imposing their own standards of dental readiness on coalition troops; thus, some of this demand may be provider-induced. Providers often have trouble distinguishing between appropriate versus inappropriate care-seeking behavior. To the extent that the demand for services is provider-induced, then it is within the ability of the U.S. military to control the extent of mission creep that occurs at the delivery end.

Incomplete Mission Planning

Mission analysis can be broken down into specified tasks and implied tasks (derivative tasks necessary to support the specified tasks). For example, during Support Hope, the U.S. military was to assist in the distribution of water to refugee camps in order to halt the spread of cholera. To accomplish this specified task, the implied tasks might include bringing in water purification units or tanker trucks to pump and transport water to the camps, or providing airlift to NGOs so they might bring in their own tanker trucks and pumping units. Implied tasks are where one gets on a "slippery slope" toward mission creep, since often there will be wide latitude in how these tasks are defined and interpreted. Further, implied tasks shade off into other activities generated by an understandable humanitarian impulse to help those in need. Mission planning needs to recognize this tendency and determine implied tasks wherever possible.

In addition, planners need to be able to recognize appropriate planning factors for an operation. For example, in coalition operations, troops from some developing countries tend to have lower levels of medical readiness. If their readiness levels are not considered in the planning process, their needs will probably be recognized later, and the mission will expand to cover them. Some might call this "mission creep," but from another perspective it may simply be a result of incomplete planning.

Changes in the Operation

Sometimes, the nature of an operation is altered because of strategic or political conditions, prompting a change in medical support. For example, in Haiti the multinational force was not on the initial planning horizon; the original plan was to support a U.S.-led invasion force only. It was not until after the initial deployment, as the operation evolved into a "nation assistance" mission, that different patient populations were added incrementally (i.e., island nations' troops, U.S. government employees, Brown and Root personnel, and other civilian contractors).

Thus, during Uphold Democracy, the population at risk evolved from an initial invasion force primarily composed of U.S. troops (with the expectation of heavy combat casualties) into a multinational force engaged in humanitarian assistance and nation-building. With the start of UNMIH, the population at risk expanded once again to include troops from other countries in addition to the United States and the island nations. Such changes in the population at risk brought about an unavoidable result of overall mission changes. Although, strictly speaking, this ought not to be termed mission creep, the increasingly diverse patient population certainly did change mission requirements.[3]

Broad political decisions may also undermine the functioning of a theater's medical system, leading the United States to expand its mission. An example can be found in the loss of Echelon II assets due to the departure of the British medical battalion at the start of the third rotation for UNPROFOR. This led the United States to assume responsibility for some aspects of within-theater patient evacuation. We would argue that filling in a critical gap in Echelon II assets, in this instance, was the result of changing mission requirements.

Underlying Factors Affecting Mission Expansion

Excess capacity in-theater. Underlying many of the issues outlined above is excess medical capacity brought into a theater. By the very nature of OOTW, excess medical capacity is unavoidable given that patient demand often varies widely and planning must consider the worst-case scenario. This excess capacity creates two conditions that contribute to mission creep.

First, because patient demand in these operations tends to be relatively low, medical resources may be underutilized in-theater. Then, in order to keep busy, the theater or medical commander and the medical staff tend to use the excess capacity in ways that depart from the original mission. Thus, having excess capacity in the theater creates a tension at the delivery end and at the tactical level, which encourages additional activities.

Second, excess medical capacity leads authorities outside the normal chain of command (e.g., State Department officials, ambassadors, and UN officials) to pressure the U.S. military hospital to expand their activities for humanitarian purposes (e.g., the treatment of refugees) or in other ways that go beyond the original mission of supporting the deploying force.

Multinational forces. In OOTW involving a multinational force, there are several fundamental design flaws in the structure of the theater medical system. These flaws contribute directly to mission creep. First, no single individual has complete command and control over the entire system. For instance, the UN Force Chief Medical Officer functions primarily in a coordination capacity. Although he oversees the entire theater medical system, he has no authority over any of those elements. One outcome is a disjointed theater medical system that may have holes in the support system, due to a failure by some coalition partners to bring in adequate assets or due to the unexpected withdrawal of key assets. This in turn has led the U.S. military to plug critical gaps in the overall system.

Second, a theater medical system composed of assets from different countries will have wide variance in quality across its components. The U.S. military has responded to this problem by imposing its own standards on that system. For example, in Haiti, the United States was tasked to provide Echelon III care for the multinational force and for UNMIH. At the time the UN mission was being planned, the United States insisted that dedicated aircraft for MEDEVAC be provided. The UN refused on the grounds that it was too expensive and told the United States that if it wanted such craft in-theater for its troops, then the U.S. military would have to bring in its own assets and pay for them (which in fact is what happened). Similarly, given a UN medical logistics supply system that does not meet FDA standards and has poor quality control, the U.S. military compensated by using its own supply system. Thus, insisting on adherence to certain standards in coalition operations has an inherent tendency to expand the mission.

Medical Support Requirements of OOTW

One can argue that a number of the medical activities undertaken during OOTW are actually similar to those undertaken during wartime. For example, in a Korean MRC scenario, the U.S. Army may be called upon to deal with a large displaced population. During Operation Desert Storm, the U.S. Army was tasked to provide medical support to a large number of POWs. Treatment of complex mine injuries in OOTW also serves to prepare Army, Air Force, and Navy medical personnel for treating these types of casualties during wartime. Therefore, from a medical point of view, it is not so much that supporting OOTW represents a completely different type of operation from supporting combat, but that medical support requirements for OOTW tend to differ in terms of the nature of the patient population to be served, the demand for medical services, and the mix of personnel and units required.

Nature of Patient Population Served

In OOTW, the patient population tends to be broader than those supporting the deploying force and often may be more loosely defined than in combat operations. For example, in addition to U.S. troops, patient subgroups may include troops from other countries, UN or NATO civilian employees, contract personnel, U.S. government employees, and foreign nationals. In addition, because some militaries have a greater proportion of female soldiers and many UN and NATO employees are women, women will form a much larger subgroup than in typical combat operations.

Of course, the AMEDD has been responsible in the past for treating civilian patient populations during typical combat operations. In OOTW, however, treating civilians is more central to the mission, because OOTW often take place in regions where the host nation's health care infrastructure has been destroyed, where there are large refugee populations present, and where there is a humanitarian component to the operation. Thus, treating children and adult foreign nationals may be unavoidable in OOTW.

The presence of a multinational force also broadens the types of patients and treatment demands. Because a number of foreign militaries rely heavily on reservists in OOTW, these troops will tend to be older. There also may be wide variation in troops' predeployment screening, preventive medicine support, and levels of medical and dental readiness. In general, these troops tend to bring more disease, including infectious diseases, into the theater.

Demand for Medical Services

All the above factors suggest that the population at risk in OOTW will tend to show greater variance than in typical combat operations. In other words, instead of primarily supporting relatively healthy, young adults with few chronic medical conditions, medical personnel will support a population that varies in terms of its health status, age structure, gender, types of infectious diseases brought into a theater, and the range of acute and chronic medical conditions that require treatment. As a result, OOTW frequently entail several added classes of demands and can encompass a broader range of activities than do combat operations.

In addition, a multinational force will tend to "up" the support requirements in OOTW, regardless of whether the United States's medical mission is to support U.S. troops primarily or to support an entire multinational force, as was the case during UNPROFOR and in Haiti. For example, linguistic requirements are problematic for a medical unit if tasked to provide medical support to soldiers from a large number of different countries. To indicate the extent of the problem, during UNPROFOR alone the U.S. military hospital was responsible for supporting troops from up to 31 different countries. Further, caring for certain coalition soldiers can lead to resourcing problems. For example, some patients may draw heavily on supplies and require intensive nursing and physician care due to inadequate care received in the field from their own units, poor preventive medicine support, or delays in transport to the U.S. military hospital. To illustrate, during UNPROFOR one soldier dying of AIDS required massive amounts of antibiotics and other hospital resources.[4]

At the same time, although the range of services required may be broader and the support requirements more intensive, patient demand in OOTW tends to be relatively low and may fluctuate over the course of a deployment (depending on whether the environment is like Somalia, where the potential for combat is high, or like the Balkans, where the main medical threat is in terms of DNBIs and land mines). As illustrated by UNPROFOR, the season of the year can also affect the level and nature of patient demand in these operations.

Type and Mix of Personnel and Units Required

This variance in demand, in turn, has implications for the types of services and the mix of medical personnel and units required for OOTW. For example, in supporting a multinational force, a broad range of clinical services may be called for, including outpatient clinical services, primary care and internal medicine, ob/gyn care, dental services, physical therapy and rehabilitative services, emergency and trauma care, and surgical and intensive care unit capabilities. As a result, in OOTW the demand for clinical services often represents more of what a community hospital would expect to see than a military hospital (e.g., MASH unit), which is normally geared toward trauma and emergency care.

Because patient demand is relatively low, the size of the hospital required for OOTW also tends to be small (e.g., averaged 60 beds and 120-180 medical personnel for Somalia, UNPROFOR, and Haiti). Rarely do OOTW require an entire military hospital unit; rather, the sections of a hospital need to be tailored (in terms of the number and types of wards deployed and the mix of physicians, nurses, and ancillary personnel) to provide a full range of services. Further, problems in repatriating coalition soldiers may lead to a requirement for a holding ward capability or for minimal-care units. In addition, the demand for preventive medicine, public health services, combat stress support, and veterinarian support can be relatively high in OOTW, particularly when a multinational force is present. Thus, it is not just the military hospital itself but these other elements as well that need to be incorporated to meet the full range of demands associated with these operations.

Medical Structure Issues Unique to UN and Coalition Operations

As we saw in the case studies, the UN's current approach of pulling together medical assets from a number of different countries has led to a disjointed system, in which the different echelons of care may not be connected and in which the quality of assets and medical care may vary widely across the different elements. As a result, in these operations the U.S. military's concept of echelons of care falls apart. Such problems, however, are not unique to the operation discussed in the case studies. Such problems arose during the missions to the Balkans, MFO Sinai, Haiti, and Somalia. Whenever an operation involves a multinational force, a big challenge will be finding ways to link the various levels and different national capabilities to construct a viable theater medical system.

Military medical organizations are expensive to maintain. Relatively few countries can afford to have the full range of capabilities or the same high standards as that of the U.S. military. In addition, a number of countries are currently in the process of downsizing their armed forces, and as they do so, many are shifting the bulk of their medical assets into the reserves. At the same time, some nations that rely heavily on reservists for OOTW (e.g., Canada, Britain) have reported recruitment and retention problems because of the increased frequency of deployments. As a result, when it comes time to assemble the medical support for a multinational force, few nations are willing to commit to providing a hospital (Echelon III care), since doing so not only represents an expensive undertaking, but may also require the mobilization of their reserve forces. In addition, many countries are reluctant to contribute medical assets for OOTW, because it may affect their peacetime military and civilian health care delivery capabilities.[5]

As a result, in coalition operations the U.S. military is often tasked to provide Echelon III care and frequently serves as the backbone of the medical support for a multinational force. However, a key lesson from UNPROFOR was that one cannot isolate an Echelon III hospital. Problems in repatriating coalition patients can result in mission changes as the U.S. hospital finds itself managing the care of some soldiers far longer than it would normally expect to or providing Echelon IV care. Although there may be a written evacuation policy, in practice it will become situational depending on various coalition partners' capabilities and willingness to repatriate their own soldiers. Such difficulties in repatriation may also tie up beds and hospital personnel, as well as set up the potential for the hospital to be overloaded in a mass-casualty situation. Further, the U.S. military will not always be able to contract with local hospitals to take on the overflow of coalition patients in a mass-casualty situation or to take on soldiers in need of minimal care only. For example, in Somalia, the local medical infrastructure had been completely destroyed and there were long distances between the Echelon III hospital in Mogadishu and fixed facilities in neighboring countries.

Further, in operations involving a multinational force,[6] there may not be dedicated aircraft available for Echelon II. MEDEVAC and medical logistics are especially problematic, because few countries have dedicated aircraft for MEDEVAC. In addition, some forces may have difficulty in keeping their medical activity going, and some may unexpectedly withdraw their medical assets. Some may promise certain assets but in the final analysis not deliver. Finally, some medical units may come into the theater inadequately equipped, supplied, or trained.

Beyond problems with simply holding the echelons of care together, there is often a mismatch between the U.S. military's expectations and those of the UN and its other coalition partners in terms of how the echelons of care get defined, what standards of care will be adhered to, what level of medical readiness troops will have, what the scope of the medical mission will be and the population at risk to be served, and what medical policies in terms of host nation support and the treatment of civilians are to be followed. For example, in UN operations the medical logistics system can be unreliable or substandard. Finally, as we have noted above, the lack of central authority in the UN system leads to coordination problems, and the UN imposes a cumbersome bureaucracy, complex reporting requirements, and additional layers of command and control.

Impact on Readiness and Peacetime Care

In 1995, the AMEDD had personnel deployed to 76 different countries, not including those who were forward-stationed. Although OOTW tend to require only part of a hospital, this does not mean that their impact on the system as a whole is minor. Partial deployments of hospitals affect unit readiness, and certain medical assets have had a particularly high OPTEMPO in recent years. At the same time, such deployments affect the AMEDD's ability to deliver peacetime health care.

Impact on Personnel and Unit Readiness

In general, OOTW tend to affect personnel readiness positively (at least in the initial phases of a deployment) and unit and equipment readiness negatively. In terms of personnel readiness, the training value of recent operations has been relatively high, though this value is concentrated within the first few months of a deployment. In fact, one could argue that the greatest training value of OOTW occurs during the first rotation and lessens during subsequent rotations, since later hospitals tend to fall in on the first rotation's equipment and just rotate their personnel into the theater. An exception is treating mass-casualty incidents or complex trauma cases (e.g., land mine injuries) and conducting triage, activities that can take place during any rotation. In addition, the training value of OOTW tends to be greatest for commanders and their core staff and for certain medical specialties (e.g., dentistry, preventive medicine, and orthopedic surgery). However, this value will depend on the individual operation and (as seen in the two case studies) may be offset by the underutilization of the medical staff during a deployment.

OOTW tend to require only sections of a hospital tailored to meet the demands of a specific mission (e.g., in support of the UN multinational force (MNF) in Haiti, only half of the 47th Field Hospital's assigned personnel were deployed); as a result, such partial deployments can degrade a TOE medical unit's readiness posture.[7] Although one may assume that the remaining portions of a medical unit are available to support another deployment, this may not be true, since if critical elements are taken (e.g., command and control element, or the only x-ray section of a TOE hospital), then the remaining sections will be unable to undertake an additional mission.

Such partial deployments are potentially devastating, primarily because of the equipment densities of these units. Table 5.1 shows the medical equipment densities for various types of Army hospitals in the current inventory. In the case of a field hospital, for example, if a third of the unit is deployed, the equipment requirement to support it could entail sending the hospital's only complete x-ray, central material service (CMS), pharmacy, operating room, blood bank, laboratory, medical maintenance, or occupational therapy/physical therapy (OT/PT) sections. However, for a general hospital, sending one x-ray section still leaves the hospital with a second section that could be used for a second deployment.

Table 5.1
Medical Equipment Densities for Army TOE Hospitals

Hospital Type X-ray CMS Dental Pharmacy Operating Room Blood Bank Lab Med.Maint. OT/PT
CSH 2 4 3 1 4 1 1 1 1
General 2 4 3 1 4 1 1 1 1
Field 1 1 3 1 1 1 1 1 1
MASH 1 1 0 1 1 1 1 1 0

Partial deployment of hospitals also may affect training, since the remaining part of the unit cannot train if critical equipment is deployed.

The deployment of low-density specialties would probably have little impact on the readiness posture of a TOE hospital, because these medical specialties are PROFISed to a hospital and not permanently assigned to it; thus, another individual within the system could be tapped for the second deployment. Instead, the impact would be more of a systemwide problem if there are insufficient numbers of these individuals in the areas of concentration most needed for OOTW.

However, the AMEDD personnel who may significantly affect a unit's readiness are those permanently assigned to the command and control element of a hospital (i.e., the executive officer, operations officer, company commander, and communications sergeant--the individuals crucial to operating the unit). If this element is being utilized for a partial deployment of the hospital, then the remaining hospital's readiness posture will have been reduced and training compromised.

An additional factor affecting unit readiness is the amount of time it takes to bring a TOE hospital back to its full capabilities following a deployment.[8] Depending on how long and intensive the medical requirements were for a given mission, the recovery period may take up to several months.[9] For example, in the case of the 212th MASH unit (the hospital that undertook the first rotation in UNPROFOR), the recovery process was more extensive because the hospital was required to leave its equipment in place for subsequent rotations to fall in on. In this case, the unit had to receive completely new or refurbished equipment, a process that can easily take two to three months.[10]

In addition, some units have particularly high OPTEMPO (e.g., area support and medical logistics battalions) associated with OOTW. Contributing to this is the fact that beneficiaries must be served in both CONUS and Europe. To illustrate, because two of the four existing medical logistics battalions in the active-duty structure are in Korea and Europe, FORSCOM has only two medical logistics battalions it can access for OOTW.[11] The hospitals have a similar (although lesser) problem. Currently, Europe has three fixed facilities, all of which are TOE units. If one of these TOE hospitals were deployed, it would mean that a substantial number of the hospital's medical staff would have to be backfilled with PROFIS fillers from CONUS to maintain beneficiary care in that installation's facility. In turn, however, the CONUS facilities from which the PROFIS fillers were pulled would themselves need to be backfilled.

Impact of OOTW on Peacetime Health Care Delivery

In previous unpublished RAND research we reported analyses of the impact of recent OOTW on peacetime health care. Here we summarize the important observations and present some recent data from the Haiti deployment. Since the financing of these operations can affect the AMEDD's OPTEMPO and its ability to maintain peacetime health care, we also discuss efforts undertaken by the AMEDD to minimize the financing impact of recent operations.

Although the costs of undertaking OOTW are relatively small compared to the total Army budget, their impact on peacetime health care can be substantial if concentrated in a few programs or installations. Further, these operations tend to whittle away at all levels, including loss of personnel, unreimbursed costs incurred in support of an operation, unfunded programs, or lost training opportunities.

The impact of OOTW on beneficiary care has been a function of the size of the military treatment facility (MTF) and the amount of draw on a facility's medical personnel. The loss of PROFIS personnel[12] for some deployments, for example, has been felt primarily by the smaller installations such as Fort Drum's small medical activity (MEDDAC), which supported the 10th Mountain Division's deployment to Somalia. However, the loss of PROFIS personnel can also be felt by some of the large medical centers (MEDCENs) because of problems the AMEDD has had in relying on reserve volunteers to backfill PROFIS losses sustained by a medical center. To illustrate, for Uphold Democracy the backfill requirement for this deployment was for 81 Individual Mobilization Augmentees, of which 48 were to be physicians.[13] However, only 24 such augmentees were identified (just five of whom were physicians), indicating a significant shortfall in meeting the requirement through volunteerism, particularly in terms of doctors. As a result, Womack Army Medical Center at Fort Bragg, which sustained the largest PROFIS losses because of the deployment of the 28th CSH to Haiti, had its MEDCEN's capabilities degraded (at least temporarily). Specifically, initially three operating rooms had to be closed and the number of elective surgeries reduced, and the North Atlantic Health Services Support Area (HSSA) had to cross-level critical personnel (i.e., bring in active-duty personnel from other MTFs) to help Womack maintain beneficiary care.

The financing impact of these operations on OPTEMPO will also be felt in terms of lost training opportunities and unfunded programs. Further, the impact will be related to the timing of an operation during the course of a fiscal year. Because contingency operations are not programmed for, funds must be diverted from other purposes. So if an operation occurs early in the year, funds can be borrowed from subsequent quarters with the hope of recouping those expenses prior to the end of that fiscal year. However, operations that occur late in a fiscal year have little chance of recouping their expenses in time to utilize those dollars for their intended purpose.

During fiscal years 1993 and 1994, the AMEDD was successful for the most part in minimizing the impact of these operations on beneficiary care. It did so by several means. First, the AMEDD spread the PROFIS requirement across the system in supporting some operations. For example, for the third rotation of Operation Continue Hope (Somalia), the USAMEDCOM pulled a few PROFIS physicians and nurses from a number of different MTFs across CONUS to staff the 46th Combat Support Hospital and to backfill losses, rather than drawing all the hospital's PROFIS requirement from a single MTF.

Second, the USAMEDCOM also tried to minimize the financial impact of these operations by reimbursing MTFs directly to ensure that no program would go unfunded within a fiscal year. That is, the MEDCOM itself, rather than the individual MTFs, took the risk of coming up short at the end of the fiscal year. The 7th MEDCOM in Europe was able to minimize the impact of UNPROFOR on peacetime care by charging all unreimbursed costs to USAREUR's readiness (P2) account.

With the AMEDD downsizing and the number of MEDDACs and MEDCENs decreasing, the potential of these operations to impact peacetime care will likely increase (particularly in Europe), since the number of troops may decline but the beneficiary population does not necessarily drop at the same rate. The Office of the Assistant Secretary of Defense (Health Affairs) has recently become concerned about the impact of these operations, particularly the effect of recent overseas deployments on OCONUS beneficiary care. As a result, all three services were asked to submit a plan on how to minimize the impact of future OOTW on beneficiary care.

We also found that the AMEDD has tended to absorb a number of the direct and indirect costs associated with these operations. As we have discussed, the AMEDD often serves as the backbone of the medical support in terms of providing medical expertise, equipment, personnel, or supplies, often with little hope of recouping many of these expenses. Further, in UN-led operations, U.S. military medical units have tended to rely on their own service's supply system rather than the UN's (again without reimbursement). As seen in Haiti and UNPROFOR, differences in standards between the UN and the U.S. military medical organizations can also lead to the unofficial assumption by the United States of different echelons of care (e.g., MEDEVAC). Because U.S. standards tend to be higher than the UN's and because the United States always ensures a stand-alone capability to take care of its own troops, this has meant that the United States essentially augments the UN's medical assets and the theater medical system itself in these operations; in doing so, it also subsidizes the medical component, since these efforts come out of U.S. funds, not UN funds.

This problem is exacerbated by the fact that reimbursement from the UN tends to be slow and may not fully cover expenses incurred in support of an operation. Reimbursement from other coalition partners also can be uncertain.

[1] The original U.S. mission in Haiti was entitled Uphold Democracy; the follow-on UN peacekeeping mission was identified as UNMIH.

[2] The medical mission called for the provision of 30 medical beds and 30 minimal-care beds and care to UN personnel. However, there was no mention of such requirements as an ICU capability, an evacuation policy, etc. Further, there was no legal guidance on whether "UN personnel" included blue card holders, green card holders, contract personnel, State Department employees, NATO employees, etc.

[3] To some extent it might also be due to an inadequate definition of the population at risk for the multinational force and UNMIH.

[4] The Argentinean AIDS patient, in particular, is a good example of the kind of resourcing and treatment dilemmas that can arise. This soldier's country was reluctant to have him repatriated and was thus deliberately slow in arranging his transport back home. At the same time, the soldier was drawing heavily on hospital resources. The medical staff knew that if they transferred him to the local community hospital, the local standard of treatment for such patients was to set them aside and let them die. Ultimately, the Argentinean patient was transferred to a community hospital where he eventually died, a decision that caused much anguish among the U.S. medical staff as to what was the correct choice. Local civilian hospitals may also have different standards of medical care, depending on a patient's nationality. In one case, the United States transferred a patient to the local hospital because it could not do anything further for him. This patient was eventually returned to the U.S. hospital, and it was clear upon his return that he had not received proper treatment. This caused the U.S. medical staff to become very reluctant to send any more coalition patients to the community hospitals.

[5] In other words, supporting an OOTW may require pulling physicians, nurses, and other critical staff out of the slots they fill in the peacetime structure.

[6] Whether UN-led or NATO-led, a formal combined operation, or an ad hoc coalition operation.

[7] Although we did not examine the impact of specific deployments on unit readiness, the following summary is intended to serve as a basis for considering what the potential effects may have been, given how the AMEDD has supported recent deployments.

[8] This issue often only applies to the first unit that deploys if subsequent rotations fall in on the initial medical unit's equipment.

[9] In a normal overseas deployment, the recovery process typically involves seven steps: (1) pre-redeploy equipment and supply inventories; (2) tear down and pack up; (3) transport equipment and supplies to the port; (4) redeploy medical personnel; (5) receive equipment at the home station; (6) perform maintenance inspections of equipment; and (7) order replacement medical supplies.

[10] It would entail identifying equipment shortages, ordering, scheduling the DEPMEDS field team, receiving new equipment, inventorying equipment, reordering supply shortages, performing maintenance checks on new equipment, and training on the new equipment.

[11] These units are the 18th MEDLOG Battalion in Korea, the 147th MEDLOG Battalion (Rear) at Fort Sam Houston, the 32nd MEDLOG Battalion (Forward) at Fort Bragg, and the 226th MEDLOG Battalion (Rear) at Pirmasens, Germany.

[12] PROFIS is the Army's mechanism for transferring individual professional personnel to deployed or forward-stationed units when needed. For example, during an overseas operation individual physicians may be transferred from a CONUS hospital to a deployed unit. Often the vacant slot in CONUS is then "backfilled" by another physician, perhaps one from the Reserve Components.

[13] That is, the number of reserve medical personnel needed to backfill PROFIS losses for this deployment was 81.

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