6. Future Directions
Because many of the issues and problems identified in this study need to be addressed at the strategic, operational, and tactical levels, we discuss three classes of possible Army actions to deal with OOTW: (1) actions the Army and the AMEDD can undertake when their role is clearly defined; (2) actions they can undertake in the absence of clear guidance from higher authority; and (3) actions they may undertake to influence the strategic planning process. We also make recommendations for training and equipping forces to meet OOTW demands.
Defining and Scoping the Medical Mission
Factors Driving Mission ExpansionAs we described in detail in Chapter Five, there are strong pressures toward expanding the medical mission as an operation unfolds. To some extent the Army's activist "can-do" approach toward any mission amplifies this tendency. Unfortunately, neither the Army nor the other military services have the medical structure and resources to tackle all of the medical needs in most areas of the world. Without more clearly defined limits on the medical mission, the demands will quickly outstrip U.S. capabilities and may backfire if other countries' and relief organizations' expectations of medical support are not met.
Up to now, the United States has not articulated a national medical strategy that defines the objectives and medical ROEs for OOTW. To a considerable degree, this is due to the continuing belief that the medical mission is limited to its combat service support role. However, in OOTW medical tends to play a more central role. In operations involving disaster relief, humanitarian assistance, or refugee populations, the medical mission may actually be broader than the basic workload of supporting the deploying force. The U.S. strategy for OOTW needs to recognize that many factors push the services toward accepting a larger mission in these operations. These factors include:
- Needs of civilian populations. The local population often has evident medical needs. In addition, refugees may be present, and existing medical infrastructure may be destroyed or inadequate.
- Needs of coalition partners. A broader set of treatment demands arises among soldiers from other nations and civilian employees of the UN, NATO, or contractors. Some coalition troops may utilize the theater medical system in ways it was not intended. Coalition partners' own medical assets may be inadequate for the mission. And if a key medical asset is not available (e.g., air evacuation), the United States may feel obligated to provide it.
- Demand induced by U.S. actions. The U.S. informal policy described as "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 on their own.
- Ethical and professional considerations. Medical personnel have a professional orientation that implies an obligation to help with urgent medical problems and an understandable desire to respond to medical need, regardless of the official mission.
- Excess capacity. In OOTW, excess medical capacity is unavoidable to a large extent given wide fluctuations in demand and the fluid nature of these operations. As a result, inevitably, the in-theater medical facility will be underutilized at times. This available but unused supply tends to stimulate demand. 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 medical services and to utilize any excess capacity for purposes other than the original mission. Coalition partners also may define a broader medical mission and set of objectives for themselves, creating a disparity between theirs and those of the United States which in turn pushes the United States in a similar direction.
Defining the Medical Mission ClearlyIdeally, what is needed is a clear definition of the scope of the medical mission, particularly about how to treat civilians and coalition forces. Based on our case studies, in this section we outline five important elements that the Army, the DoD, and the U.S. government should consider in scoping the mission and discussing options:
- U.S. objectives in providing health services;
- The desired end state for medical support in a region;
- Delimiting populations eligible for services;
- Civilian patient care, transfer and evacuation;
- Relations with other health care providers in the operation.
End state. The United States should establish what level of care will be provided to civilians (for example, patients injured by U.S. actions or brought in by U.S. soldiers). We would argue that the United States should not be in the position of providing a level of health care to civilians in OOTW that cannot be sustained once the military departs and that may create unrealistic expectations from the host nation and the NGOs. Further, from a health policy standpoint alone, it does not make sense for military hospitals to treat civilians or provide them with state-of-the-art medicine when often the far greater medical need is for public health and preventive medicine services. In addition, a U.S. military hospital is limited in the range of services it can provide in the field and can sustain over the long run. Instead, U.S. policy in providing medical care to foreign nationals ought to be to treat civilians in-country, at a level that the local health care system can support, and to not go beyond that.
Populations eligible for services. The United States needs to articulate an operational definition of entitlement to care that different patient subgroups are to receive. In these operations, in addition to U.S. troops, other eligible groups may include coalition partners and those connected with the force, such as civilian contractors and civilian employees of the UN or NATO. Presumably, not all groups of patients will (or should) have the same access to medical care as the force itself.
For example, the U.S. military may be willing to treat civilian contractors it specifically employs, but not necessarily UN or NATO civilian employees. It may contract out their care, instead. Or it may provide emergency services only to these patient subgroups and require that they be transported out of theater for more definitive care. The military needs to insist on obtaining a clear legal definition of the population to be served.
Patient transfer and evacuation. The medical mission statement should determine the policy and procedures for transferring civilian patients from U.S. military hospitals to local facilities. The medical policy during the Haiti operation was to transfer civilian patients' care to local hospitals as soon as possible. In the Balkans, the U.S. military was fortunate to be in an environment where local community hospitals were available to receive transferred civilian patients. However, even then, if the U.S. hospital had taken casualties in sufficient numbers that required the release of such patients (so beds could be made available) while local community hospitals were also filling up with civilian casualties, the U.S. military might have found itself in the position of having to discharge patients who were not ready for release. In such cases the resulting adverse publicity alone could undo all the goodwill generated in the first place by treating refugees, and this would play at the highest policy levels.
Relationship with other providers. It may be possible to use civilian contractors to provide the medical support for a multinational force in operations where there are no U.S. troops on the ground. This is an expensive option, however, and it was resisted by the UN for Haiti on reasons of cost alone. Recently, the United States considered contracting out the medical support for the UN peace operation in Haiti (UNMIH), but decided against it as being too expensive, since securing civilian physicians and nurses to come into high-risk areas and treat high-risk patient populations would require hefty compensation. Further, contractors may still require U.S. military support in terms of security, logistics, and airlift. And historically, when the U.S. military has utilized civilian contractors for medical support, it has had difficulty controlling them, ensuring quality of care, and getting them to sustain medical support in the way that regular Army units can.
The U.S. military could also contract with NGOs to take over the care of certain groups (such as coalition soldiers or displaced persons). For example, the United States could triage to an NGO those coalition patients who are difficult to repatriate or who can be moved in the event of a mass-casualty situation in order to free up beds. However, the use of NGOs will not work in all situations. Realistically, few will have these kinds of capabilities, many will be unable to sustain their response over the long run, and they may be in-theater for unpredictable lengths of time. The nationality of a coalition soldier also may influence the willingness of an NGO to take on his care. Some relief organizations may wish for the U.S. military to completely assume certain functions, whereas other organizations may only require medical logistics support, transportation, security, or medical teams to assist in the implementation of a program. Further, many relief organizations may be unwilling to have a formal association with the U.S. military out of concerns that they might be viewed as tools of American foreign policy.
For OOTW, the Army should seek to get a national policy that articulates medical objectives and medical rules of engagement covering the areas discussed above. Although formally such mission definition may be the province of other government authorities (e.g., the Joint Staff or the State Department), the Army and the AMEDD need to become more proactively involved in the strategic planning process. Up until now, issues regarding the medical support and the medical mission itself have had little visibility at the Joint Staff or strategic level. Yet by the very nature of these operations, medical often plays a more central role in OOTW. In addition, the Army and the AMEDD will often provide the bulk of medical support. Thus, the Army has a big stake in ensuring that missions are defined in executable ways. The Army can exercise influence, for example, through its representatives on the Joint Staff and through the role of the Army Chief of Staff in the strategic planning process. The Army Chief of Staff, through his position as a member of the JCS and as an adviser to the National Command Authority, will have the authority and the ability to raise the Army's concerns about the medical mission and obtain clarification on objectives and medical rules of engagement at the strategic level. If the Army does not play more actively in this process, it will be limited to providing input only with respect to its Title 10 responsibilities and may continue to be faced with unclear or unsustainable medical objectives in future OOTW.
Launching the Medical Mission as DefinedOnce a mission definition has been agreed upon for an OOTW, it is essential to start off the operation on a strong footing. Our analysis of the case studies suggests two key areas in which the Army and other military forces should take early steps to establish mission limits.
Broadcasting the medical mission. The theater and subordinate commanders need to do a better job of broadcasting the U.S. medical mission to the host nation, local health officials, other troops, relief agencies working in a region, and the press--as one means of averting misunderstandings as to the U.S. mission and medical policies for a given operation. This should include the definition of the patient population to be served and the types of services to be provided to different subgroups. In this way, the United States may clearly articulate medical mission parameters (e.g., treatment of civilians or a multinational force) and avoid unrealistic expectations.
Negotiating the workload with other parties. The burden of working with the local government, local community, and various relief organizations will fall on the services. This suggests that military medical units may need to become more involved in the interagency planning process at the tactical level. Although a civil-military operation center (CMOC) can have a medical cell established within it for this purpose, this rarely occurs. Further, we argue that the officers staffing a CMOC will tend to be too junior to deal with the political aspects of the medical mission. What is needed instead is a senior military medical officer with the experience, authority, and visibility to effectively negotiate the coordination of care of civilians, the transitioning of their care to community hospitals, and the range of activities the U.S. military medical units will undertake in assisting the local community.
To facilitate such negotiations, we recommend that the services or DoD attempt to form a closer working relationship with such organizations as the United Nations High Commission for Refugees, the International Organization of the Red Cross, the World Health Organization, the International Organization of Migration, and other key relief agencies to coordinate the provision and transitioning of care of civilian patients. The JTF Surgeon and his staff are the best candidates to assume this role, as was done in Haiti. This officer would also be responsible for advising the theater commander about the type of assistance required by the host nation and relief community, and for interpreting which activities fall within the scope of the mission.
There are several recent examples that can serve as a template for future operations. During UNPROFOR, the Air Force worked closely with the above organizations to coordinate and establish guidelines for the selection and treatment of refugee adults and children by the U.S. military hospital in Zagreb. This included assigning responsibility for patient evacuation and delimiting the operating parameters by which the military hospital would provide refugee care.
During the operation in Haiti, the JTF Surgeon served as the key medical interface with the Haitian government (e.g., the Ministry of Health), various relief agencies, the Pan American Health Organization, and such U.S. governmental organizations as USAID. In this way, the U.S. military was able to minimize the civilian care undertaken by its hospital and establish a mechanism by which injured or ill Haitians could be readily triaged and transferred to local hospitals.
Building a Solid Base of OOTW Experience and KnowledgeThe Army and the other services now have a substantial amount of information about how to execute medical OOTW missions, given their recent experiences in Somalia, Rwanda, Haiti, and the Balkans. However, this information is not widely disseminated even within the medical commands, and the medical support implications are even less well understood in "line" organizations (which normally command the medical elements). Under these circumstances there is a risk that future operations may be planned and launched without benefit of the valuable experience already accrued. Therefore, we suggest several actions the Army and the other services might take to preserve and build the base of knowledge about conducting OOTW medical support.
First and foremost, the Army and the AMEDD need to understand what these operations are about, their complexities, and how they differ from combat operations. This is critical for planning and tailoring medical support. It is also essential for articulating policy on treatment of civilians and coalition soldiers, and for defining and operationalizing the medical mission's scope. Although policy guidance on these issues should ideally come from the DoD or the State Department, in the absence of such guidance the Army and the AMEDD need to have a plan in mind. For example, the Army may need an evacuation plan for civilians in case an Army hospital is tasked to provide care to foreign nationals.
Pooling the Services' InformationOf the three services, the Army most often serves as the backbone of medical support in OOTW. Given this, the AMEDD may want to take the lead in convening a conference of commanders and medical staff from all three services, as well as from key coalition partners, to discuss UN and NATO medical issues and how to better support coalition or combined operations. Some of the important issues the U.S. military and its coalition partners will need to address include national differences in mission definition, medical policies, troops' levels of medical readiness, and quality of medical assets.
Relations with NGOs and International Organizations
It is clear that the Army and other services do not yet understand how to interact and coordinate with civilian relief agencies and UN entities also involved in OOTW health care delivery. The Army needs to establish more effective methods for communicating with these organizations. Among NGOs, the Army and the AMEDD should identify which organizations it can effectively work with (e.g., those with well-defined and limited missions and adequate resources) and establish an ongoing liaison with these organizations that can carry through on a number of operations. The AMEDD could also establish a list of officers to serve as points of contact for these organizations. At the same time, it is equally legitimate for the Army and the AMEDD to identify those civilian organizations it may not wish to get involved with. Such steps would establish continuity that would facilitate use of NGOs in future OOTW. The example from Haiti, where the JTF Surgeon served as the key medical interface with the Haitian government, various U.S. governmental organizations, and the Pan American Health Organization (PAHO), is a useful template for future operations.
Individual Education and TrainingKey to making the above structure work well for OOTW is the education and training of AMEDD officers and enlisted personnel. As noted in Chapter Five, medical commanders are instrumental in controlling mission creep and in clarifying mission definition. In the training environment, a number of these issues may be addressed.
Clearly, OOTW have a large political element. However, many AMEDD officers and enlisted personnel who are deployed on these missions have had little experience with dealing with these issues at their level of career development. For example, many AMEDD officers are not used to working with other countries' militaries, which may have a different set of political objectives, mission goals, and medical policies. Army and AMEDD officers also are not used to handling direct requests from ambassadors (U.S. or foreign) or from the UN, or dealing with policy issues at the tactical level.
There is a need, therefore, to educate officers at appropriate levels about political issues, UN issues, and coalition and combined operational issues that may arise during the course of these deployments. At the individual level, information on OOTW needs to be incorporated into medical officer professional development courses. For example, in the Officer Basic Course and Officer Advanced Course, a basic introduction to OOTW should occur, including a review of lessons learned from recent operations and after-action reports as well as participation in problem-solving exercises. The Command and General Staff College could provide a forum for holding discussions on the 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 these operations and how policy and political issues may be addressed by commanders.
Training Exercises Integrating Medical and Nonmedical UnitsThe AMEDD needs to become more proactive in educating line officers, in addition to medical officers, about medical issues that may arise during OOTW. During an operation, it will be up to AMEDD officers to advise a line commander on the implications of his decisions in terms of the medical and overall mission. For example, if a theater commander decides to allow his MASH unit to treat civilians, then he needs to be made aware that providing such treatment might tie up beds or medical personnel and use up critical medical or blood supplies. Further, in the event of a mass-casualty situation, civilian patients might have to be released unexpectedly without assurance of an available local hospital or clinic to receive them.
One way to accomplish this would be for Army medical units to become more involved in collective training for OOTW at the Joint Readiness Training Center (JRTC). It is in such a training environment that line officers and Army medical officers could hash out medical decisions associated with OOTW prior to a deployment, rather than rely on ad hoc decisionmaking in the theater. Further, it is here that providers and commanders may receive training on interpreting an operation plan, developing a tactical plan, and making the kind of clinical and command decisions they might face in a Somalia or Bosnia or Haiti scenario. It will be up to the AMEDD to articulate a future training strategy that exposes Army medical units and other types of units to the medical support and public health issues associated with OOTW.
Training Involving Medical-Unique IssuesAt the individual or tactical level, an important question is how to train an Army physician or nurse to respond appropriately in these operations and help avert the tendency toward assuming an additional mission. As described in Chapter Five, the medical staff themselves may inadvertently contribute to mission creep in several ways. First, a physician may "pull" into the theater medical equipment and supplies he is accustomed to using in a peacetime setting (especially, the specialty-trained providers) in order to provide state-of-the-art medical care. This problem is not unique to OOTW, but is part of the fundamental dilemma the AMEDD faces in training medical personnel to adjust to the differences between operational and peacetime medicine. Second, the medical staff may face difficult decisions in the field, such as ethical treatment dilemmas that may arise in dealing with multinational forces. Physicians and nurses need to understand how their actions may inadvertently expand the mission or why certain decisions at the operational or strategic levels were made to contain the treatment burden. Further, the medical staff needs to be given realistic expectations about what they may be called upon to do in these operations.
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. Such training could include, for example, dealing with ethical and treatment dilemmas that may arise in supporting a multinational force. These issues need to be addressed in normal peacetime training; the predeployment preparation phase does not allow enough time to handle them.
The AMEDD also may want to articulate humanitarian ROEs for enlisted and nonmedical officers (although enforcing ROEs is a command responsibility). As we have noted above, mission creep in recent OOTW was exacerbated by nonmedical personnel bringing injured civilians into the U.S. military hospital for treatment.
Flexibility in PlanningAs shown in the two case studies presented above, OOTW tend to be fluid, resource intensive, unpredictable along five or six different dimensions, and characterized by rapidly changing mission requirements. These characteristics make OOTW difficult to plan, requiring that the medical units and the mix of medical personnel be tailored (and sometimes retailored) to meet the demands of the specific mission. This places a premium on flexibility in planning, ongoing mission analysis, and adaptation (such as anticipating changing mission requirements and task organizing in response). To operate in this adaptive way, planners need to understand how to match the right personnel and units with the mission.
Identifying Determinants of Medical DemandFrom a medical standpoint, the critical distinction in OOTW is not whether it is a peacekeeping, peace enforcement, or humanitarian assistance operation. Rather, the key determinants of the medical support requirements include the following:
- Whether the United States is acting unilaterally or whether a multinational force is involved and the level of support the United States has been tasked to provide that force;
- To what extent refugee or displaced populations are a factor;
- Whether there is a humanitarian component to the operation;
- Differences in medical readiness among coalition troops;
- Degree to which the host nation's medical infrastructure may have been compromised;
- Variation in coalition partners' medical assets.
Advance Assessment NeedsA key element in tailoring the force is conducting an advance assessment. Planners at the operational and tactical levels need to understand the type of expertise required for OOTW and assemble the right kind of assessment team (composed of not only physicians, but also preventive medicine officers and community health nurses, for example). A relatively small number of AMEDD officers have had extensive experience in tailoring the medical support for these types of missions. It will be important to spread this experience across the AMEDD and to make sure experienced people are involved in the planning process.
Planning for More than the Combat Support RoleLine planners need to consider not only the medical support requirement for a deploying force, but also what medical force may be needed to achieve specific medical objectives and ensure the mission's overall success. For example, in OOTW involving disaster relief, humanitarian assistance, or refugee populations, the medical mission will be broader than the basic workload of supporting the deploying force. The real thrust of the AMEDD's workload may be in terms of health support to the host nation. However, because the Army and DoD continue to view the medical mission as limited to traditional combat service support, at times they have used the wrong basis for planning, requiring combat medical units to undertake a wide range of activities they were not intended for. This has led to a mismatch in the medical force provided and at times to the inappropriate and inefficient use of medical assets.
There are other unique features of OOTW that make it necessary to consider additional planning factors. For example, planners need to recognize the civilian patient demand units may face. A political reality of OOTW is that the U.S. military will sometimes be tasked to provide care to civilians, whether it is part of the official medical mission or not. As we have noted above, such care will likely include local civilians (especially in emergency situations). Depending on diplomatic or other pressure, it may also include employees and contractors of the UN or NATO, other foreign nationals, and of course soldiers from coalition forces.
Patient and Provider DatabasesOne way of improving the accuracy of planning the medical support is to standardize patient and provider databases on deployments across all three services. Such data are needed to better understand the nature and level of demand associated with OOTW, and to assess the effectiveness of new technologies such as telemedicine in a field setting.
Building a Robust and Flexible StructureThe current challenge to the Army and the AMEDD is to create a medical structure sufficiently flexible and tailorable so that one can readily adjust to one's position along the spectrum of conflict. 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. Further, one needs to be careful not to create extra structure or put into place such a large structure that the system itself may become more unwieldy and inflexible in the process. The key is to build a robust and flexible structure that can respond to a broad range of demands.
Modular and Tailorable StructuresThe modular concept of Medical Force XXI (formerly known as the Medical Reengineering Initiative) has features well suited for providing the kind of flexibility the AMEDD requires. The modular structure should allow the Army to tailor its medical units to meet the varied support requirements of OOTW. As noted in Chapter Five, since OOTW tend to require only parts of a military hospital rather than whole units, it will be important to ensure that a partial deployment of a TOE hospital does not significantly affect the readiness posture of its remaining sections.
Contagious DiseasesAn exception in terms of new structure is the need for a deployable isolation ward capability. The isolation of contagious patients is difficult to achieve in a tent environment, and certain diseases, such as tuberculosis, can pose serious health threats to medical personnel. Creation of a "hard" structure may be necessary, therefore, to allow closed ventilation of these wards and to maintain conditions necessary to protect medical personnel and other patients from highly contagious and serious diseases.
Additional laboratory testing capabilities, however, are not necessarily required for these operations. For example, in the case of AIDS, positive test results would not necessarily affect a patient's treatment nor the precautions the medical staff would undertake. However, given the high rate of HIV in some civilian populations and among some coalition forces, it will be critical to address the concerns of the medical staff as to the risk of exposure in these operations. The AMEDD, therefore, will want to continue to be proactive in terms of education, advance preparation, and counseling of deploying personnel in addressing the risks of exposure to certain serious infectious diseases. In addition, nonmedical personnel will need to be educated on how to minimize their risk of exposure to such diseases.
InjuriesBecause some of the most common types of injuries in OOTW are sports-related, the Army may want to implement an aggressive preventive medicine and physical therapy program for these operations. Such a program could minimize the number of orthopedic injuries, increase the rate of return to duty, and reduce the demand for orthopedic surgery and outpatient physical therapy services in-theater.
As land mines proliferate and pose an increasingly serious medical threat, the AMEDD can expect a continued need to treat complex mine injuries in a field setting. How this may alter the support requirements for OOTW needs to be evaluated. For example, it could be that additional traction capabilities, limited rehabilitative services, and extended physical therapy capabilities in-theater may be required. Particularly in coalition operations where repatriation problems may remain intractable, the AMEDD can expect to continue to face the dilemma of managing the care of these soldiers in-theater longer than what would normally be expected; this needs to be planned for.
Ensuring a Surge CapacityClearly, the size of the military hospital needed for OOTW tends to be small. This means that an Army hospital may easily be overwhelmed in a mass-casualty situation. Not only do planners need to take this fact into consideration, but in addition the Army and the AMEDD may want to consider developing a staging team along the lines of the Air Force's MASF model that would be capable of receiving casualties for initial treatment and then evacuating them out. Such a team could be co-located with the hospital or centrally located and capable of rapid response in the event of mass casualties. Staging teams would formalize the ability of Army medical units to deal with a surge in the event of a near-overwhelming or overwhelming casualty situation and serve as a means of redistributing patients quickly and safely.
Medical LogisticsAs medical units are increasingly tailored to meet varied support requirements, medical logistics will face a difficult set of challenges. Tailoring a military hospital and other deployed medical units for OOTW expands the medical support requirements and complicates the logistician's job, since stock items may no longer meet the needs of a specific operation. As a result, these operations tend to be more resource intensive, personnel intensive, and difficult to predict in terms of requirements for medical supplies and equipment. Given the broad range of operations the Army will be called upon to support in the future, more flexible short- and long-term planning strategies will be needed by the medical logistics community.
Supporting a Broader Patient PopulationThe AMEDD has created support packages, including sets for pediatric and geriatric patient populations, for use in OOTW. For obstetrics and gynecological care, the AMEDD needs to incorporate similar support packages. To date, however, the care the AMEDD has provided these three patient populations has tended to be underestimated. Therefore, it will be critical that planners, medical commanders, and their staff become aware of the need to incorporate such packages as part of the support requirements and better anticipate the nature of the patient population to be served.
If the United States defined its strategic medical objectives more broadly to include some provision of civilian or refugee care, Army hospitals would face additional requirements. At a minimum, an Army hospital would need to be able to set up separate wards for pediatrics and civilian adult patients (i.e., separate wards from those housing coalition forces). It also would require a pediatrician or family practitioner and a limited range of pediatric equipment and medical supplies. Pediatric patients also require housing for adults who accompany a child. In several recent instances, U.S. military hospitals have ended up housing orphan children. The hospitals would need guidelines for determining the type and range of care they should provide such patients in a field setting. Finally, they would probably need a medical officer who could serve as a liaison with UNHCR, the local medical community, and the local government to coordinate the provision and transfer of these patients' care.
TelemedicineTelemedicine has the potential to play an important role in OOTW, where many different specialties may be required to treat a wide range of diseases and medical conditions--all of which cannot be covered by any single medical element. Because OOTW tend to have a ceiling imposed on the total number of U.S. troops, after factoring in the various components of a force, the medical component often is highly constrained in the number of medical personnel that may be deployed. As a result, some have proposed that telemedicine may offer a means to reduce the size of the medical requirement in-theater. However, telemedicine is not necessarily likely to save any "in-country spaces," since even if a few provider spaces are saved, the technical people needed to run the system may cancel out any savings on the provider side. Further, as illustrated by Somalia, a certain minimum level of medical support is required in-theater in order to ensure a surge capability.
There are also technological and operational issues that remain to be addressed in evaluating telemedicine's potential. For example, in the event of a "hot spot" or a combat scenario when the rest of the Army or the JTF is burning up the satellite links with C4I needs, whether medical units will be able to get the bandwidths they need to do quality telemedicine work is an important question to be addressed.
In addition, there are some innovative uses of this technology that remain to be explored. For example, telemedicine may be able to play a significant role in addressing repatriation problems, as well as in providing medical intelligence and linguistic requirements. For instance, a direct link to the embassies of those countries who have contributed troops for a multinational force may help facilitate the evacuation of coalition patients. In terms of medical intelligence requirements, such a capability would allow U.S. military physicians to obtain guidance on ethical issues (e.g., do-not-resuscitate orders on a soldier who has incurred a serious brain injury) or treatment decisions from a soldier's own military medical department. In terms of linguistic requirements, one could envision a military hospital having the capability to talk with language experts within CONUS or to a foreign military physician or nurse stationed in a soldier's source country to facilitate treatment decisions.
However, to date the use of telemedicine capabilities in the theater has been limited primarily to the transmission of images back to fixed facilities within CONUS or Europe and to teleconferencing. Certainly, the full range of this technology's potential has not yet been realized. As the Army and other services move forward with adopting this technology, it will be important to understand better both its potential and its limitations on the battlefield.
Minimizing the Impact of OOTW on AMEDD Readiness and on Peacetime CareContinued support of OOTW has the potential to stress the Army health service support system, affecting both future wartime readiness and peacetime health care delivery to beneficiaries. As discussed in Chapter Five, it is not that any single OOTW is demanding in terms of large numbers of medical personnel or units required. Rather, what makes OOTW challenging is the simultaneity of demands, the fact that these operations tend to be open-ended, and the Army's direction that it support these operations without any degradation in beneficiary care. For example, to meet past OOTW demands, the Army has deployed key elements of some hospitals and has pulled individuals from several other military treatment facilities (MTFs) in order to do so. This in turn affects the entire peacetime health care delivery system.
This might seem to suggest more use of the Reserve Components, where much of the medical structure is located. However, it is difficult to augment deploying units with reservists or to backfill hospitals with individuals in the right specialties when unplanned OOTW missions arise. There are also a number of constraints in the employment of reserve medical assets in these operations, suggesting that the active component likely will continue to be responsible for the bulk of the medical support in future OOTW.
To preserve its 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 the hospital deploys on an OOTW, a complete hospital will still be available for a second deployment. Such units would then know in advance (for a one-year period, for example) that they would be on the "hot" seat for supporting OOTW. This designation could be rotated among existing AC hospitals on a yearly basis.
Such rotating designations would provide an element of predictability, but also open up the possibility for real advance planning for these missions. Under this proposal, the Army could avoid pulling personnel from a number of different MTFs to support a single deployment and, thus, degrading services across the entire peacetime health care delivery system. Also, this proposal would enable individual Army MEDCENs and MEDDACs (from which PROFIS personnel are pulled) to do advance planning to maintain beneficiary care while supporting a deployment. For instance, they may choose to negotiate standing contracts with civilian providers or place deployable PROFIS personnel in noncritical positions to minimize the impact on peacetime health care when they are deployed.
Coalition OperationsAs discussed in Chapter Five, whenever the United States is involved in UN operations or with a multinational force it will encounter some unique problems in terms of providing and structuring the medical support for these operations. Instead of being able to set up an integrated structure of echelons of care with consistent quality, the U.S. military will potentially face a hodgepodge structure with holes and gaps and of variable quality.
Clearly, the U.S. military tends to serve as the backbone of the medical support in multinational operations. Partly this has been because the United States has the best (and the most expensive) medical support available. As a result, historically our allies often have relied on us for medical support, whether it be an explicit or implicit part of the mission. However, in OOTW it is also clear that the United States is the driving force behind much of this in that we impose our own standards on other forces and drag the UN and our coalition partners along with us. Given this, it is up to the United States to put forth a set of solutions that it can live with to define its medical policy in coalition operations. Ideally the United States would secure an agreement with other nations and seek to promulgate the plan through the UN or other multinational organizations.
Echelons of CareThe United States and its other key coalition partners (e.g., Britain and France) may want to take the lead in developing a revised definition of echelons of care, specific to OOTW involving a multinational force. The traditional operational (or "wartime") definition of echelons of care has not worked well in recent OOTW. In wartime medicine, the objectives are rapid intervention, life sustainment support, and evacuation back or airlift out of the theater to a more definitive level of care; in contrast, in peacetime care a physician is able to bring to bear a full range of expertise, medical supplies, equipment, and support personnel to provide comprehensive care to a patient. In UNPROFOR, the British and French utilized the theater medical system appropriately as in wartime, quickly evacuating their injured and sick soldiers out of the theater. If the United States had had troops on the ground or had not been the main provider of health care for UNPROFOR, it would have done the same. The developing countries, however, did not use the theater medical system as it was intended and, instead, utilized U.S. military hospitals more like community hospitals in a peacetime setting. Coupled with repatriation problems, this led the United States at times to provide Echelon IV care for the UNPROFOR force and to treat a disproportionately greater number of troops from developing countries than from other nations.
A draft UN plan or concept for medical support in multinational operations needs to be developed. Such a plan would set standards in terms of medical readiness, unit readiness, training, equipment, and standards of care. It would also need to address such issues as: Should the principle be equal access to the same level and quality of medical care for all forces in these operations? If so, then how can one accomplish this without favoring one set of troops over another and without getting into the provision of peacetime health care in a theater of operations?
One option is that the U.S. military and its coalition partners develop alternative definitions of echelons of care for OOTW. For example, Level I could be defined as providing treatment to military forces only and evacuating them as soon as possible. Level II could treat military forces only for up to three weeks (including minor surgery and emergency care) and then evacuate them. And Level III could include hospitalization for military and civilian patients, including some rehabilitative services, to be provided by civilian contractors. This option would be undertaken primarily for political reasons (e.g., where we elected to treat civilians or decided that we could not accept having two different standards of care for coalition forces in OOTW).
Alternatively, the United States and its coalition partners could set up a policy on echelons of care that says to the UN that Echelon II is as far as we are willing to go and that for other care we expect the UN or the coalition itself to establish contracts with fixed facilities in neighboring countries. Under such an arrangement, soldiers whose own countries lack adequate evacuation resources or are unwilling to repatriate their injured can be transported to these facilities for more definitive care, instead of remaining in-theater. Without such an arrangement, we could face a two-tiered system of care, one for Western forces and another for troops from developing countries, which would probably not be politically sustainable.
The United States has not needed a repatriation policy in the past. However, in the case of OOTW involving a multinational force, it may need to incorporate one as part of the formal mission statement in future operations.
If echelons of care are not redefined, an alternative option may be for the U.S. military to serve as the coordinator of medical care in these operations. In this way, we could ensure that the quality of theater medical assets and the functioning of the health service support system was maintained. This is a limited solution, though, since it does not address the inadequacies in other coalition forces' medical assets, variations in quality of those assets, and the ill-preparedness of some troops. Or the United States may want to continue to impose its standards on other coalition forces in terms of echelons of care, equipment and supplies, training, standards of care, and medical readiness. Doing so could entail training and equipping other forces' medical assets for a specific operation. If we choose either of the above options, then we need to be explicit about it and negotiate compensation up front from our coalition partners or the UN.
Standards of CareDifferences in standards of care and medical practice from country to country pose related questions: Can the United States avoid plugging the holes in the theater medical system? If so, how much variability in the theater medical assets can we afford? What risks do we run by doing so? For example, some militaries have lower standards of care than the United States, particularly in such areas as trauma care, where the United States tends to be far more aggressive. Although we may be able to maintain quality control in a clinic setting by teaming up U.S. military physicians with the medical staff of forces from developing nations (as was done during the MFO Sinai peacekeeping mission), we may not be able to do so in an emergency situation--where the first assets to reach a wounded U.S. soldier may be a medical team from a poor country. In such cases, the standard of care delivered may not match normal U.S. expectations. Does the risk of such incidents mean that the United States cannot afford to allow much variability in theater medical assets in multinational operations whenever U.S. troops are on the ground? If so, then how can coalition medical assets be integrated into a theater medical system such that U.S. troops are protected and the same high quality of medical care is provided to the entire multinational force?
Individual and Unit Readiness of Coalition ForcesWhen the U.S. military has deployed for OOTW as part of a multinational force, it has often failed to realize the shape other countries' forces were in. Some coalition partners proved to have low levels of individual medical readiness and unit readiness. An overall U.S. policy for dealing with the UN and coalition forces must deal with these readiness problems. In the past, we have reacted by plugging the holes in the theater medical system caused by ill-prepared units from other countries--often without the possibility of reimbursement. Further, U.S. military medical units then faced the problem of not necessarily having the right mix of specialists or the right amount or configuration of medical units, equipment, or medical supplies.
In addition, because U.S. military hospitals end up treating disproportionately more troops from developing countries than from other nations, U.S. military medical personnel run a higher risk of exposure to serious infectious diseases (some of which cannot be immunized against) than other troops. This raises several questions: How can the United States ensure the safety and health of U.S. military medical personnel and troops participating in OOTW? For this reason alone, should we only provide medical care to U.S. troops in these types of operations? If this is not politically feasible, does the United States need to insist on standards of medical readiness for all troops comprising a multinational force?
Air Evacuation and LogisticsRegardless of the policy or formal arrangements, the U.S. military can expect to be tasked increasingly to provide MEDEVAC and medical logistics assets in UN-led or informal coalition operations. This stems from the fact that the United States has one of the few militaries with these capabilities. As illustrated by the experience of all three services during missions to the Balkans and Haiti, the military relied on U.S. support over UN systems because of quality problems and differences in standards. Given this, there needs to be a better mesh between logistics and medical units in these operations. Until the inadequacies of the UN medical logistics system can be addressed, U.S. medical units must continue to rely on U.S. supply sources in coalition operations, regardless of the formal tasking. While some coordination may improve this situation, we expect a continued demand and reliance on these U.S. assets, which should be planned for.
Maintaining the Blood SupplyMaintaining the blood supply will continue to be an important concern in OOTW undertaken by a multinational force. Although each coalition partner during UNPROFOR was to be responsible for its own blood supply, in reality only the Western countries were capable of doing so. U.S. policy has been to not use other countries' blood, even when treating coalition soldiers, due to the fact that some countries do not routinely screen for some HIV-related viruses.
In addition, one's ability to tap into the civilian blood supply may be limited in these operations and dependent on whether the local populace itself has a high demand for blood (e.g., because of a larger number of civilian casualties). As seen during UNPROFOR, land mine injuries alone may quickly use up a military hospital's blood supply. This problem, along with concerns about the quality of other countries' screening procedures and cultural sensitivities about who is receiving whose blood, led the CINC to implement a frozen blood program during UNPROFOR. Routine inclusion of such a program in future operations may be necessary.
SecuritySecurity of a military hospital and of its medical staff is an important concern in OOTW, especially those operations involving coalition forces or UN missions. In some instances, a U.S. hospital may be the sole U.S. presence in the theater and thus responsible for all of its force protection needs. In other instances, it may rely on the UN or coalition troops for some force protection. Further, in some OOTW there may not be a "rear" where the hospital can be located.
In addition, because U.S. military personnel are a high-visibility target, it is critical to provide for the security of the hospital and individual medical personnel who may undertake sector visits, MEDEVAC missions, or outreach programs within the local community or to other coalition forces. Security concerns led to tight restrictions on the movement of U.S. military medical personnel within the theater during recent OOTW. Further, as was the case during UNPROFOR, the UN may not always be as responsive to U.S. force protection concerns as one might expect. Other coalition troops also may not provide the level of force protection considered necessary by U.S. standards; for example, non-U.S. forces were responsible for the security of the hospital compound's perimeter in Mogadishu, but there were concerns about the reliability of those troops.
In general, U.S. medical units should be prepared to provide security for a hospital compound's perimeter and take care of their own force protection needs in OOTW. This has implications in terms of the training requirements for OOTW, as well as staffing implications, since a certain percentage of the medical personnel may be tied up with security functions rather than medical functions at any one time.
Providing Training and Support to Local Health Care ProvidersIf the United States defines its strategic medical objectives more broadly to include its military working with the local community in reestablishing or improving the medical system, or assisting relief agencies in becoming self-sustaining, the U.S. Army would need to bring in additional medical equipment and supplies. For example, even though the United States may not be called upon to provide direct medical care to civilian populations, the U.S. Army may be asked to supply a generator or other medical equipment to help a local health clinic become operational again. During UNPROFOR, for example, preventive medicine officers helped Sarajevo to ensure the quality of its water supply and thereby helped to avert an outbreak of cholera in the city.
Other activities may involve training local medical personnel. For example, in Haiti, U.S. military hospital staff did some training of their Haitian civilian counterparts in the local community hospitals. If such activities are to be supported, training materials, engineers, preventive medicine teams, and community health nurses may be required in future operations. If the Army included as part of its medical mission educating other coalition troops on basic preventive medicine and public health measures, in order to minimize these troops' demand for health services in-theater, then community health nurses and public health officers also would be needed.
UN Accounting and Reporting RequirementsFinally, the UN's unwieldy bureaucracy and reporting systems have presented significant problems for the theater commander, JTF surgeon, and their staff in the past. To alleviate such problems, the Army may want to have comptroller support during the initial phase of a UN deployment. Such support would be responsible for figuring out the UN system of reporting and accounting and for establishing a viable system for the combined or joint task force. The comptroller would not necessarily need to be in-theater for the duration of the rotation, but long enough to help get the system up and running efficiently. Class A agents and core staff could then be trained on that system.
Overall ObservationsAs the AMEDD, like the rest of the U.S. military, continues to downsize, no one can clearly envision the strategic environment for the future. We do anticipate, however, that the United States will continue to undertake OOTW, perhaps at an increasing rate.
In this report, we examined how the AMEDD may ensure broad-based flexibility to support the diversity of new missions it faces in OOTW and coalition environments. Most of the issues identified are not unique to UN operations, but also will apply to other multinational operations, such as the current NATO peacekeeping mission in Bosnia.
In general, peacetime OOTW entail a broader set of demands upon the medical component. Planning for future OOTW needs to recognize the breadth of such demands and not assume that they will be limited to the traditional support requirements of combat forces. The medical issues associated with coalition operations, in particular, are complex and have implications for the overall success of the military mission. As seen in our two case studies and in other recent operations, 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 AMEDD headquarters level, but also at the strategic, operational, and tactical levels.
 Another important element is U.S. objectives in supporting a multinational force as part of a coalition operation. Because these operations have a number of features critical to scoping the mission, we discuss those issues in more detail and outline a set of recommendations in a later section.
 Successful examples of collaboration with NGOs can be found. For example, during Provide Comfort the United States worked well with UNICEF in helping it implement an immunization program for Kurdish refugees. Key to the success of this undertaking was the fact that UNICEF had a limited, clear set of objectives for its operation.
 On the other hand, as was the case in Somalia and the Balkans, some NGOs may be concerned that U.S. Army medical units may take over their mission (i.e., compete with them) and so do not want the U.S. military to provide care to refugees at all. Others may be concerned that Army medical units may raise the level of expectations in the theater to one that the NGOs or the host nation cannot sustain upon the departure of the U.S. military.
 This has implications for the organization of the medical support to allow the JTF Surgeon or medical unit commander and his staff to undertake such activities. For example, in Haiti, the JTF Surgeon had a small headquarters staff assigned to him to accomplish this.
 Line commanders often do not appreciate this. Several line commanders who have returned from OOTW told us that what they found they really needed to know more about were medical and public health issues.
 The high rate of AIDS hypothesized among the Haitian civilian population (60 percent) raised a number of serious concerns among U.S. military medical personnel. Despite U.S. medical policy, there was a significant amount of treatment of Haitian civilians that was unavoidable. The fear among the medical personnel was real, and much counseling was needed to explain why treatment of some civilians was necessary, why it was part of their mission, and what precautions could be undertaken. As summarized by the former commander of the 55th Medical Group, the problem was that treating a civilian with AIDS from the medical staff's perspective meant not just risking infection to one's self, but also risking exposure of his or her family to the AIDS virus.
 Although up until now there has been little intent by the AMEDD to split a unit apart and to have the two pieces capable of undertaking independent missions--i.e., operate simultaneously in two different places, the AMEDD may want to reconsider this policy in terms of OOTW. Given the reduction in the number of active-duty hospitals in the overall force structure, the increasing number of OOTW to support, and the problems encountered in utilizing reserve medical units for these missions, Army medical support for OOTW in the future may necessitate greater flexibility as recommended here.
 Providing equipment and supplies, however, runs the risk of these items being sold on the black market. This occurred in several recent operations. The AMEDD instead may want to restrict provision of such materials only to relief agencies and to work with the local hospitals primarily in a training capacity and in the coordination of care of civilians.