Confidence in leadership directly affects operational success in war, and one facet of command responsibility that has a forceful impact on this confidence is the establishment of an effective medical support system. The significance of medical support was articulated clearly in the wake of the terrorist bombing of the Marine compound in Beirut, Lebanon, in 1983. The senior medical inspector, a U.S. Navy medical officer, then-Rear Admiral James A. Zimble, cautioned:
A well-prepared and able military medical system conveys four powerful messages. It tells the American people that its leaders have prepared means to care for their sons and daughters who may be sent in harm's way; it tells our adversaries that we have a credible, sustainable fighting force; it tells our military commanders that we will sustain their forces; it tells our troops that we care. The last is most vital: in the absence of medical readiness we can have no assurance that our troops, the flesh-and-blood elements of our weapon systems, will retain the will to fight, which is the crucial factor in the equation for victory.
The sustainability of the fighting force should be a paramount concern of every combat commander. His judgment in formulating this dimension of combat operations often determines whether his warfighting concepts and plans will be supportable. In any combat maneuver, therefore, the decision for medical support ultimately is the commander's responsibility.
The Grizzly Realities
Historically, 20% of all injured combatants die in battle. Of every ten combatants who die from battle injuries, nine die on the battlefield, and 65% percent of combat deaths occur within five minutes of injury and are not salvageable. Another 15% die up to 30 minutes after injury, and 20% die after 30 minutes. Half of those who die are victims of uncontrolled bleeding.
Estimates indicate that nearly 20% of those who die during combat suffer from surgically correctable injuries and might have been saved except for delays in the application of definitive treatment. Among these, the single major cause of death is hemorrhage. Some die as a result of bleeding from wounds of the upper and lower extremities; others of torso injuries. An additional group dies of potentially reversible blockages of breathing, and still other casualties die of potentially reversible tension pneumothorax (a buildup of air sucked into the chest, secondarily compressing the heart and lungs).
Medical support must be integrated with tactical operations, and some battlefield conditions may preclude speedy access to some casualties or threaten the safety of care givers. Nevertheless, the structure and operation of combat medical services are influenced heavily by command direction, and the immediate salvageability of the bleeding wounded and those with critical chest injuries are affected by this determination. The commander exercises significant discretional judgment in analyzing the various benefits and tradeoffs of medical support options, and lives may be contingent on these deliberations.
At the operational level, military medical capability—sound preventive medicine as well as casualty support doctrine, facilitated by sufficient human and material assets—is an integral component of an effective combat force. The twin disciplines of health maintenance and casualty management are crucial underpinnings of any operational undertaking and may be pivotal in determining its success. It is within a commander's discretional authority either to take heed of this reality and absorb the costs of these services, or to disregard it and direct all of his assets to combat arms operations. The latter option, however, is undertaken at some risk to the operational plan.
The Importance of Health Maintenance
The neglect of health maintenance by Field Marshall Erwin Rommel in the western desert of North Africa during 1941-42 contributed to his decisive loss at the second battle of Alamein. In contrast, the efforts of British Field Marshall Sir William Slim turned around the deteriorating condition of personnel under his command during the World War II campaign in the jungles of Burma.
Rommel—Within Rommel's Afrika Korps, for every German absent from duty because of battle injury, three were lost to disease, most notably dysentery, hepatitis, and malaria. Even during the climactic battle at Alamein, sickness was second only to being taken prisoner as a source of German attrition. Through sickness, Rommel temporarily or permanently lost a force equal to twice his average combat strength, and such elite units as the 15th Panzer division were understrength by as much as 60%.
The complete lack of sanitation among both the Germans and Italians in the Alamein position did much to undermine not only their morale but also their combat effectiveness. As the British Medical Journal described, "Enemy defensive locations are obvious from the amount of faeces lying on the surface of the ground.... This contempt for hygiene became such a menace to the enemy as to affect from 40 to 50 percent of his front line troops. The enemy appears to have no conception of the most elementary sanitation measures, and has a dysentery rate so very much higher than ours that it is believed that the poor physical condition of these troops played a great part in the recent victory at El Alamein."
Despite being twice evacuated to Germany because of hepatitis, Rommel either never learned to employ his medical staff effectively, or more likely was uninterested in the medical aspects of manpower maintenance and conservation. There is no evidence he recognized the commander's ultimate responsibility for the health and welfare of his troops.
Slim—In Burma, Lieutenant General Sir William Slim, on taking command of South East Asia Command's 14th Army, faced significant manpower attrition as a result of disease and injury abetted by a most inhospitable environment. Exercising his leadership responsibilities, Slim drastically reduced losses by vigorously enforcing a malaria control program and implementing an in-theater fixedwing air evacuation program for casualties.
Slim directed multiple remedial steps: employ the latest medical practices in treating sick and wounded; obtain adequate supplies of recently developed therapeutic drugs; move treatment facilities close to the troops; provide accessible air evacuation for seriously ill or injured men; and work to improve morale, thereby reducing the malingering and unsanitary practices that augmented the already high sick rates. As he noted, "My second greatest problem was health (the first was supply and the third, morale). In 1943, for every man evacuated with wounds we had 120 evacuated sick. The annual malaria rate alone was 84 percent per annum of the total strength of the army, and was still higher among the forward troops.... A simple calculation showed me that in a matter of months at this rate my army would have melted away."
General Slim continued, "More than half the battle against disease is fought not by doctors, but by regimental officers. It is they who see that the daily dose of mepacrine (an antimalarial drug) is taken." The general initiated surprise checks of units, and every man was examined. "If mepacrine was not taken; if the overall result of the blood tests confirming mepacrine intake was less than 95% positive, I sacked the commander. I only had to sack three; by then the rest had got my meaning." Because of this emphasis from the top, "slowly, but with increasing rapidity, as all of us, commanders, doctors, regimental officers, staff officers and NCOs, united in the drive against sickness, results began to appear.... admissions to hospitals and malaria in forward treatment units sank lower and lower until in 1945 the sickness rate for the whole 14th Army was one per thousand per day."
Implications of Casualty Management
In any over-the-water assault, Navy and Marine Corps operational commanders must make choices regarding combat service support, including health care. These decisions will be modulated by the reality that some overall offensive assets must be used for this support system. In essence, every aspect of combat service support bears a price tag. As commanders consider the development of a medical support system, they might:
- Decide on first aid only, through buddy and corpsman/medic care. This would result in a far greater complication and death rate among the wounded and would curtail returns to duty drastically.
- Decide on local first aid and then evacuation to ships. This would require a well-developed command, control, communications, and medical regulatory network, as casualties must be directed to the proper ships for sorting of wounds and proper treatment. This course would have a negative effect on assault and resupply turnaround times.
- Decide on local first aid, a command, control, and communications medical regulation network, and in addition, forward advanced capability medical teams to stabilize and sort casualties, facilitating a more selective evacuation of only the seriously wounded. This would minimize impact on resupply and assault vehicles by evacuating only those who require advanced rear echelon care.
If appropriate priority is not given to forward medical care, evacuation, and a sophisticated casualty regulation network, a commander runs the risk of a huge logistical burden and an adverse impact on morale as the dead and injured accumulate. There also will be an adverse impact on the transport of assault echelons if medical evacuation back to casualty receiving ships is not planned, practiced, and controlled effectively. Inattention to these issues will mean the loss of trained troops who could have been treated, stabilized, and even returned to duty.
On a larger scale, new U.S. Navy and Marine Corps littoral strategies could become medically unsupportable. To meet the modern mandate for compactness and simplicity in maneuver units, unrealistic medical support expectations have been attached to a warfighting strategy that allows for only minimal medical support function ashore. Marine Corps landing force medical assets have been reduced in size. Medical battalions have been lightened and downsized. The patient holding capacities of operational medical units have been reduced, and multispecialty consultation has been virtually eliminated. These changes have been made with the expectation of rapid transfer of casualties back to ships of an afloat sustainment base lying over the horizon—vessels with combined and potentially conflicting combat and combat service support responsibilities. This may be especially pronounced if the combat roles of these vessels result in dispersed geographic locations, rendering them inaccessible to casualty evacuation vehicles. In addition, the medical facilities within the casualty receiving and treatment ships of the LHA and LHD classes are not fully capable of large-scale sustainment of the uniquely complex injuries and illnesses typically accrued during combat.
Without effective integration of medical doctrine with warfighting plans and expectations, the requirements for medical readiness cannot be identified, codified, or quantified—and neither the Navy's "Forward... from the Sea" nor the Marine Corps' "Operational Maneuver from the Sea" strategies will be properly supported in medical terms. The absence of command oversight and input has resulted in differing interpretations of medical readiness, and produced uneven priorities for medical support.
Confidence in Leadership
Recent reports by Italian health officials cited the occurrence of leukemia, allegedly contracted after service in the Balkans amidst the residue of detonated weapons made from depleted uranium, in six soldiers. This has reignited fears similar to those surrounding the Gulf War Syndrome and the anthrax vaccine, and has prompted some veterans and active-duty personnel to wonder whether anyone in authority cares about their welfare.
After the bombing of the U.S. Marine compound in Beirut, a Medical Review Group was empaneled to evaluate the ability of the U.S. military medical system to react to such incidents or, by extension, to a larger conflict. The report detailed serious deficiencies, attributing them in large part to a lack of medical evacuation resources, shortages of equipment and personnel, and inadequate joint planning for wartime or contingency requirements. The shortfalls also were the result of the low priority habitually assigned to medical readiness in the planning, programming, and budgeting process. As the report noted, "Had the ratio of killed-outright-to-wounded been reversed, so that over 200 casualties had required treatment, rather than 100, the medical system might have failed."
Less than a decade after the tragedy at Beirut, Operation Desert Storm provided an opportunity to gauge progress in achieving medical readiness goals, but significant shortfalls remained.
In today's Navy, fleet medical support doctrine unfortunately remains insufficiently defined, inadequately validated, and not specifically integrated into the "line's" warfighting concept of operations. These limitations render it difficult to define requirements for medical readiness in the fleet, as evidenced by the inconclusive and meandering discussions within the Navy medical community over what form of supporting activity should replace the two current hospital ships, both of which are vestiges of a Cold War contingency strategy. Rather than a senseless debate by staff corps personnel over the value of rejuvenating one used ship-frame (LSTs vs. LPHs) over another, these decisions must ultimately be made by operational commanders, to be determined above all else by the requirements of warfighting strategy.
Ultimately, the requirements for future amphibious expeditionary medical capabilities are within the discretional province of operational commanders. While weighing the benefits and tradeoffs of a combat casualty support program, they must assess the cost of such support in terms of demand for their offensive assets and impact on their tactical mobility. To facilitate these decisions, they are beholden to their medical staffs for advice, but they themselves must have an appreciation for the wounding agents in war and the unique logistical requirements for management of both environmental health hazards and combat-unique casualties within a setting of austerity and restricted support.
Captain Smith is a professor of urology at the Medical College of Georgia in Augusta. He also is adjunct professor of surgery and military and emergency medicine at the Uniformed Services University School of Medicine in Bethesda, Maryland.