The major components of medical readiness are timeless: keeping our military personnel healthy in peace and war. Other aspects, however, are more flexible. If we begin to think outside the box today, we can start to shape the future we desire. The following scenario uses predicted trends in military medicine to create one possible future.
Budget realities and a shift in priorities to domestic concerns created a much smaller U.S. military in the early 21st century. By that time, much of the military hardware purchased in the 1980s was technologically obsolete and worn out, but replacements became so expensive that the services were forced to assign specific mission capabilities to only one or two services (such as tactical aircraft and missile defense) and to buy common equipment (such as helicopters and communication gear) rather than having each service develop its own unique hardware. A new round of base closures since the late 20th century reduced infrastructure another 30%, and the government privatized nearly all support activities on remaining bases. By 2015, computer technology so dramatically reduced the need for manpower that today only 550,000 personnel remain on active duty. Even fighter aircraft are now flown by on-board artificial intelligence with ground supervision.
Military medicine went through its own major downsizing and transition. Medical care now is provided by an integrated system of military, other governmental (especially Veterans Administration), and civilian components tailor-made for regional care delivery. Readiness is the primary focus of medical personnel in uniform, although a majority of them are in the reserves. Because of downsizing, the private sector—with Department of Defense oversight—provides most health care for family members and retirees.
Two major components exist in medical readiness: providing wartime medical services for any operational contingency, and maintaining the peacetime health of our personnel so they are always ready to deploy to a trouble spot. Military medicine has made tremendous strides in preparing for any eventuality. This is important, because the military has expanded its focus to include peace making, peace keeping, nation building, disaster relief, and countering domestic instability, along with responding to traditional military conflicts in an increasingly fragmented world. Better control of wartime environmental factors eliminated most non-battle illnesses, and the use of high-tech stand-off weapons significantly reduced the number of military casualties. Unfortunately, however, the number of civilian casualties remains high, and medical personnel spend a lot of their time managing health problems of the local populace. Support functions—communications, logistics, transportation, civil engineering, and medicine—play a much bigger role in U.S. deployments; high-tech weapons seldom are required. Most military operations combine the forces of several nations, world organizations, and non-governmental agencies—which creates the added challenges of leadership by consensus and the pressures of global public opinion.
Conflicts require speed, mobility, flexibility, and a wide variety of expertise, so we must determine mission requirements and then combine the necessary modular capabilities of whichever service has the required expertise into a joint delivery system. Advances in computer technology have made a tremendous difference. For instance, voice recognition and language translation eliminated the traditional keyboard and monitor, the factors that for so long prohibited us from reducing computers to the size of postage stamps. Today, nearly everything has a computer chip embedded in it to sense, analyze, store data, and provide information. Global broad-bandwidth communications bring TeleVideo to the individual medic in the field or corpsman on the ship. Information, rather than the patient, is moved instantly to experts (human and computer) in the United States for medical management and storage of data into a comprehensive digital medical record. On the battlefield, mobile medical units move rapidly with the conflict and provide comprehensive emergency care. A better understanding of physiology, along with the development of protocols, allows for the minimal number of essential interventions to be performed to stabilize patients, using intelligent medical equipment and fewer supplies; everything necessary is self-contained in the vehicle. Transport to more comprehensive recovery facilities away from the battlefield is an important part of doctrine.
Closure of many military medical facilities and major reductions in personnel brought on by budget realities in the early 21st century forced a total rethinking of medical training and skills maintenance. Perhaps most important, we realized that personnel could be trained and their skills maintained in the civilian sector. Sophisticated mobile medical facilities require technicians with para- medic-level training, so salaried active-duty members work full time in civilian medical transportation systems, with only a couple of weeks a year spent in military exercises. They can be pulled instantly to go into battle. Similarly, many active-duty military physicians, nurses, and medics work in regional trauma systems, where they lead the nation in trauma research to benefit wartime medicine. Virtual-reality educational experiences place personnel in the middle of mock-wartime scenarios, enabling them to perform virtual operations and thereby improving their professional skills.
The majority of medical personnel are in the reserves, but almost all of their training time is spent practicing wartime scenarios by virtual reality or in the field (rather than working in military treatment facilities, doing physicals or administrative duties). The government discovered a ready market in contracting many operational support functions to the private sector, although there is still a core of military medical professionals who maintain the health of active-duty personnel. Their residency training is geared to that mission, and they are board certified in the specialty of military medicine. The high status of this specialty, opportunities for research, and challenging career paths keep them satisfied without expecting to move into the hospital-based specialty care of retirees. In addition, these specialists in military medicine can shift between services for varied worldwide assignments; cultural tradition has maintained three separate medical departments, but their headquarters functions have merged.
The primary focus of military medicine is to maintain the health of active-duty members so that they always are prepared for worldwide deployment. Risk factors are assessed upon enlistment, and a prevention program tailor- made for each individual is tracked throughout one’s career via the global information system. This is accomplished through a sophisticated program of training, self- help, and mentoring, plus periodic assessment. New knowledge of genetics and pathophysiology allows prediction of potential medical problems years in advance, so they can be prevented or controlled. The medical system for active-duty personnel is very responsive to providing early care near the worksite, keeping them on the job. Cultural changes also lead to individuals taking personal responsibility for their own health. To that end, everyone is issued a Personal Medical Assistant (PMA), a pocket-sized expert computer system, to analyze non-invasive assessments of the individual, track the data, and transmit it to the central digitized medical record. The PMA answers questions and provides advice based on that data. Emphasis also is placed on maintaining good mental and spiritual health. Changes in the work environment reduce stress and promote a sense of community, individual worth, and accomplishment.
A fundamental shift occurred in peacetime care, as well. Once the Department of Defense realized that it was accountable for the lifetime care of eight million eligible dependents, it decided that the best way to reduce and manage cost was to improve the overall health of beneficiaries. The government spent research-and-development money to capitalize on technology originally created for wartime monitoring of vital signs to create a medical sensor system imbedded in a wrist watch, which could non-invasively monitor chronic illnesses such as diabetes and hypertension. Data are transmitted to the PMA whenever the patient walks near it, and the PMA’s artificial intelligence helps the patient take responsibility for managing his or her own disease with only occasional intervention by TeleVideo or face-to-face visits to a clinic.
A lot of effort was expended to teach beneficiaries to take responsibility for their own health. Information systems, firms, and Hollywood film companies worked with medical experts to produce CD-ROM education systems that not only contained the latest medical information but also presented it in understandable, attention-capturing ways. The government then distributed this software to the public for use in home computers. Today, there are even more sophisticated virtual-reality educational systems helping family members manage their own health. These preventative programs have more than paid for themselves in savings on medical care.
Information technology that allows beneficiaries to be dispersed throughout the world and the closure of many military medical facilities require that medical care be tailor-made for local areas. Such care is provided using a combination of military resources, contract services, capitated services, and purchased individual services depending upon whatever makes the best business sense for local conditions. Information systems tie the pieces together, so the system is seamless to family members. Reliance upon the best of the private sector allows the military to retain only personnel essential for readiness, while reducing cost. Medical care is provided primarily in an ambulatory setting close to home; most communities have only one or no hospital. A few major military medical centers remain in areas of high active-duty concentration, and these also are used by the private sector, as sharing resources reduces costs.
This futurisitic scenario illustrates one possible outcome wrought from major changes occurring in the world today:
- The military establishment is shrinking because of the loss of a superpower adversary and a growing national debt at home.
- The nature of armed conflict is changing, becoming more diverse and complex, with the breakup of nationstates, rise of anarchy, proliferation of a variety of weapons, and the vulnerability of economic and information systems.
- U.S. medicine is going through major turmoil in an effort to compete while ruthlessly controlling costs. The shift is toward managed care with a primary care focus on ambulatory treatment. Physician extenders and alternative forms of therapy are on the rise.
- The information age is changing society. Data are now available to develop protocols and better manage individual patients. It also is causing responsibility to shift from the medical establishment to individuals.
- A global concept of health is emerging. We soon will have the tools to predict an individual’s risk for future illness and take measures to prevent it. The emphasis will be on a holistic view of health that also focuses on achieving human potential, healthy communities, and protection of the environment for a sustainable society.
- Military medicine will diminish in size and will focus its attention on readiness. Efforts will be directed toward responsive active-duty care.
- The Department of Defense will accept full accountability for care of family members and retirees. It will invest heavily in ways to keep beneficiaries healthy and to enable them to manage their own well-being. At most locations, the responsibility for delivery of that care will be privatized. Even where there is a major military medical presence, integrated delivery systems will rely on contracts and purchased services to fill the gaps in the most cost-effective manner.
- Innovative military medicine will become the benchmark for the United States’ responsive health care delivery system.
Changes in military medicine probably will come faster than we realize. The world of military medicine in 20 years will be dramatically different from anything now imaginable. We can have a significant influence on our future—if we are willing to address the issues seriously and take action. If not, the forces for change in the world will make the future for us. What steps should we be taking today?
- The military must promote a climate that encourages exploring future possibilities. We need to question existing paradigms, create new ideas to meet future challenges, and take risks to try them out. Unfortunately, there are powerful political and economic pressures to preserve the status quo.
- The Assistant Secretary of Defense for Health Affairs and the service medical departments have chartered “MHSS2020,” a comprehensive futures project that is exploring likely health-care trends and scenarios over the next 25 years. This knowledge will be used to design and create the best health-care system for the military.
- Only by analyzing potential future conflicts and determining required capabilities can we spend dwindling resources wisely. New technologies need to be developed while we replace aging infrastructure, improve quality of life, and maintain current readiness.
- Military medicine must work closely with line futurists and planners to redesign deployable medical platforms to meet expected contingencies in a mobile, flexible, joint manner.
- Senior military leadership must stress healthy lifestyles and vigorously stamp out tobacco and excessive alcohol use. Our culture needs to make every service member feel personally responsible for maintaining his or her own health. We should develop systems for assessing and tracking potential risk factors and for providing individually tailored education and coaching to maintain health.
- Investing to create interactive health-education tools would pay for itself through decreased requirements for medical care. To be successful, medical expertise must be marketed in simple and exciting ways by media experts, utilizing multimedia CD-ROM for home computer use—and soon, with virtual-reality devices.
- Our research-and-development capacity should be used to create sensors for monitoring health problems and “Personal Medical Assistants” (compact expert computers) to help our beneficiaries self-manage their health at home. These efforts will pay for themselves in medical delivery savings.
- We must continue to build integrated local health-care systems for family members, using the best of our military and civilian medical resources.
The 21st century will be upon us soon, and every indication suggests that it will bring fundamental changes to the military, the delivery of health care, and our society. We can not halt change and live in the past, because the road to the future permits no U-turns.
Rear Admiral Rowley is Commander, Naval Medical Center Portsmouth, Virginia, and Lead Agent of Tricare Region Two. He is the Chairman of Health Systems 2020, a Department of Defense Health Affairs study looking at the future of military medicine 25 years from now.