Against new enemies whose arsenals include catastrophic medical threats, Navy Medicine is a critical defensive weapon.
If you cannot see, you cannot fight. If you cannot stand, you cannot fight. If you cannot breathe, you cannot fight.
The finest Navy or Marine Corps commander, with thousands of highly trained men and women and millions of dollars of sophisticated technology, will be impotent if threats destroy the health of his war fighters. The weapons we now fear are bugs and gasses. For the Navy to defeat these new and emerging threats, the Navy Medical Department no longer can be viewed solely as mechanics who restore broken bodies to return them to battle. Navy Medicine must serve not only as skilled combat casualty care providers, but also as the critical defensive weapon system—providing surveillance for biological attack, immunizing personnel to reduce bioterrorism threats, performing chemical decontamination of patients, assessing health threats in the environment, and providing expert clinical consultation to operational commanders. Navy Medicine is the force that can keep the war fighters standing, breathing, and fighting.
The Medical Department as Defensive Weapon System
The right defense against a specific threat is critical. Armor cladding protected wooden ships against early torpedoes. More recently, missile defense systems and Kevlar provided protection against offensive weapons. The concept of defensive systems is much more complex today. When a Marine walks into sick call with a rash that is actually an erupting case of smallpox, the weapon needed is nonconventional. What is needed is well-educated and alert health care providers who recognize the problem and rapidly take action to protect the Marine and the unit. Early detection and control of biological or chemical attack—essential in controlling the extent of harm—will depend on the clinical expertise of those who serve in the Medical Department. Quick action will protect hundreds or thousands of war fighters and their families from disease or death.
A system of vigilant monitoring for health hazards during deployment is essential. The Navy has specially trained experts—preventive medicine technicians and physicians, environmental, radiation, and industrial health officers, infection-control practitioners, infectious disease physicians, microbiologists, and biochemists—capable of a wide variety of activities critical to operational success in the new battle space where hazards to health loom large. The Navy Environmental Health Center (NEHC), the core of the service's public health expertise, plays a major role in disease surveillance, monitoring, and prevention. Its teams, including Navy Environmental and Preventive Medicine Units, Forward Deployable Preventive Medicine Units, and Preventive Medicine Mobile Medical Augmentation Readiness Teams, can be deployed to assist the operational commander with a variety of challenges, such as identifying a wide range of biological, radiological, and chemical threats.
We Are Vulnerable to Asymmetric Threats
Our adversaries recognize their inability to meet our forces head on. They instead will choose asymmetric weapons and attacks—aiming for our soft underbelly. To harm us with an unconventional weapon, the enemy must get lucky only once. U.S. intelligence has identified numerous transnational actors with biological and chemical weapons programs capable of producing, stockpiling, weaponizing, and delivering deadly agents such as anthrax, smallpox, and tularemia. According to a 2002 General Accounting Office report, there are many areas of vulnerability in the Department of Defense's capability to defend against chemical and biological weapons and sustain operations in the midst of their use.
Is the threat to U.S. military forces real? Absolutely. Following the Gulf War cease-fire, we learned Iraq had weaponized anthrax and equipped a Mirage jet with spray tank dispensers capable of dispersing the disease agent. If the jet had been deployed against U.S. coalition forces on the first day of the ground war, an estimated 76,300 of the 320,000 massed troops likely would have died. The former Soviet Union's huge bioweapons production program, Biopreparat, employed 60,000 personnel in 1991 with a strategic plan of developing military applications for up to 50 disease-causing agents. These threats pose new questions for the war fighter and medical planner:
- Can we fight and win on a contaminated battlefield?
- Are we organized, trained, and equipped on an individual level to fight and win on a battlefield we have experienced only in the classroom?
- Can we define and achieve the right chemical-biological defense readiness paradigm?
- How ready are we now to conduct warfare operations in a contaminated environment where "maneuver to avoid" is not an option?
- How do we change planning and exercises to incorporate medical expertise and intelligence, disease monitoring, and environmental surveillance?
The 2001 terrorist and anthrax attacks exposed issues that now must be addressed for the U.S. military to continue to achieve its mission in a changed environment. Many of the issues have significant medical implications for war fighters:
- Homeland as battle space. When the U.S. homeland becomes a battleground, there are extensive implications for local, state, federal, and military emergency response systems. The nation has a major medical response capability in the National Disaster Medical System (NDMS), a partnership of the Departments of Defense, Veterans Affairs, and Health and Human Services, and the Federal Emergency Management Agency. A cooperative interagency plan for ensuring adequate hospital beds in the United States to manage mass casualties, NDMS is designed to support the civilian sector when it is overwhelmed by using federal in-patient beds and the military by using civilian hospital beds for military casualty overflow. The system has never been fully tested. A mass casualty event in the U.S. homeland could force civilian and military organizations into competition for beds, scarce equipment such as mechanical ventilators (essential for treatment of diseases such as plague and anthrax), and drugs and vaccines.
- Insidious nature of biological threats. Infectious disease formerly was considered a "disease, non-battle injury" (DNBI). That no longer is an accurate designation. Deadly infectious diseases have been weaponized and could decimate deployed forces or forces in garrison, as well as cripple operational forces emotionally if their families and loved ones are threatened. Bioweapons differ from other threats in that they are stealthy—attack can be silent, odorless, and unrecognized until clinical symptoms appear in the infected individuals. In the case of anthrax, this is often too late to save the victim. Unlike the blast of a bomb, which causes immediate emergency response, a biological weapon could cause major devastation well before the event is recognized.
- Public health actions with legal implications for the military. What role might military forces play in the continental United States if an intentional disease epidemic occurs that requires public quarantine or restriction of public movement? It may be necessary to order mandatory vaccine or drug administration during such an outbreak.
- The lean fighting machine. Today's military deploys fewer, more lethal forces. Losing members to disease or injury has a greater impact on a unit's fighting ability, so prevention of disease figures critically in accomplishing the mission. Thus, Navy Medicine is a vital force enabler to deter, dissuade, and decisively defeat an asymmetric aggressor.
- Communications with the media. The media, as a conduit of information to the public, are a major force when any newsworthy event occurs. In the event of another domestic terror attack, bioweapons attack, disease epidemic, or mass casualty event, the public will demand information from trustworthy, credible experts. Military public affairs experts must be prepared to work closely with medical experts to present information that will not increase fear or induce panic, using a science-based strategy known as risk communications.
- Fear. The terrorist's goal is fear. Without a strengthened role for medical expertise in defense planning, exercises, and operational activities, fear of death or disease could become an insurmountable obstacle for operational commanders. The more confident operational forces are that they are safe, protected, and have competent medical care readily available, the more effective they will remain.
Protecting the War Fighter
Individual protection against incapacitating biological and chemical agents must be a primary consideration in defense planning. Immunization remains the best way to "front load" a protective shield against invisible, disease-causing agents. Combined with full protective equipment and training in its proper use, full-spectrum immunization will ensure the joint war fighter is physically and mentally prepared to fight and win against any threat.
Two concepts illustrate the importance of Medical Department involvement in the battle space when a biological or chemical threat enters the picture:
- Detect to treat is our current capability in the battle space. Medical response to a threat occurs when personnel with clinical symptoms requiring medical care are detected and treated. Sick sailors or Marines, like canaries in the coal mines, may be the first indicator our forces are under attack. Currently, the critical aspect is rapid recognition and correct diagnosis of symptoms. The foundation of rapid recognition is a well-trained and well-prepared medical force.
- Detect to warn is the goal. Technology and systems will give early warning to commanders that the environment has been contaminated—before personnel begin to show symptoms of disease or contamination. This will provide a critical window for operational commanders to analyze, plan, and move. Medical personnel will be critical in defining and interpreting data and intelligence.
The threats that now challenge massed military forces—and the U.S. population—were unthinkable a few years ago. The enemy is faceless, patient, well-financed, and intent on our destruction. His arsenals contain catastrophic medical threats. To defeat them, naval forces must use their Medical Department as a defensive weapon system. It would be unconscionable to not improve operational readiness through enhanced integration and coordination of medical assets, knowledge, and capabilities. Battlespace confidence should be improved now through medical enhancements including biological detection, medical surveillance, bulk decontaminants, and collective protection shelters. By seizing this initiative, Navy Medicine can and will provide a credible medical force to support the joint war fighter in any situation at any time along the full range of operations.
Admiral Arthur is Commander, National Naval Medical Center, Bethesda, Maryland, and Chief of the Navy Medical Corps. His naval service includes assignment as Navy Deputy Surgeon General, duty aboard the USS Kitty Hawk (CV-63), and deployment with the 2d Marine Division during Desert Shield/Desert Storm. He holds degrees in medicine, law, and a Ph.D. in health-care management. He wishes to recognize the research and other contributions of Captain Vincent Musashe, Medical Service Corps, and Lieutenant Commander Richard Guzman, Medical Service Corps, U.S. Navy.