CTAP Interview: LTC Ramey Wilson, U.S. Army
By: Interviewed by: LTC Kashif J. Khan, Pakistani Air Force
This interview is taken from the collection of the Combating Terrorism Archive Project.1 LTC Kashif Jamal Khan, Pakistani Air Force, spoke on 6 May 2013 with LTC Ramey Wilson, U.S. Army, about LTC Wilson's career as a military medical officer.2
LTC KHAN: How did you become involved with military medicine?
LTC WILSON: Before I went to medical school, I was actually a field artillery officer. I spent four years as a field artillery officer and led individuals at the small unit level. I really enjoyed being with soldiers, but also preparing for battle—this is in the mid-'90s so we (the United States) didn't have any big conflicts going on in that time period. I come from a medical family. I went to the Uniformed Services University, which is the Department of Defense medical school in Washington, D.C. It has a mission to train not only physicians but also offers advanced education for nurses and conducts research focused on the practice of medicine in a military environment. So that is how I got into it. The Uniformed Services University is just like any other medical school that is accredited. It also has a special military curriculum to prepare its future physicians to operate in a military environment. So that is how I became a military physician.
Then I went on to do my training in our military treatment facilities at Walter Reed Army Medical Center, and my residency in internal medicine. I finished medical school in 2002, and then I was a resident until 2005. So I was at Walter Reed during the beginning of the Afghanistan war and the Iraq war. Having both the military experience as well as the medical military curriculum really gave me—when I was taking care of patients at Walter Reed, many of whom had just been on the battlefield 18 to 20 hours beforehand—a better understanding of the conditions that my patients were facing.
LTC KHAN: Keeping your experience in mind, how do you think military medicine is different from regular medicine?
LTC WILSON: That is a good question, because I think that difference is a part of military medicine that is often underappreciated. If you think about how we practice medicine in general, we practice in a kind of network made up of different actors and roles, all playing a part in providing good medical care to different types of patients based upon illnesses or disease processes or accidents or whatever. It takes nurses, it takes doctors, it takes surgeons, it takes OB/GYNs to deliver babies, to create that full spectrum—a medical network. You have to be able to draw upon all facets of it.
Now in military medicine, we are going to take a large group of people and displace them from their normal situation, and ask them to go and practice medicine in what is often a very austere environment, usually riddled with insecurity. Those are often the areas where medical development is not as pronounced because of the lack of security, or because it is hard to get people to go practice medicine in those areas. When military personnel get injured, you need to have medical people there who can operate in those austere environments, who understand—from the point of injury all the way back to the United States—that some care is appropriate at some levels and not at others in terms of stabilizing and moving patients. A lot of it has to do with that interface between the traditional medical facility, like a big hospital and doctors' offices, and the warfighter who is out there often in very austere, remote, dangerous places. In general, if a military person is injured, say on the battlefield, they can't just pick up their phone and call the civilian ambulance—who would they call? So the U.S. military develops and resources not only the people but also the technology to move forward and extend the reach of its own healthcare system all the way to the battlefield. We do that at different levels: we have medics who are trained to operate with the soldiers on the ground. We have physicians and assistants who staff forward aid stations, and we have echelons of care where patients are brought through increasing levels of capability and technology as they move back towards the medical treatment facility. So, one of the unique challenges for military medical personnel, I think, is being able to operate in austere environments.
Another unique kind of component is how military medical support has to be integrated into the operational plan. The military physicians and those who are operating at that interface are making the bridge between the place of war and the hospital, and they have to be able to integrate that medical care within the operations that are taking place. A lot of times there is a lack of security in their area as well, so those medical resources, even though they are protected under the Geneva Convention, have to be protected from attackers. There is that aspect of it: being able to work in austere environments, being able to integrate with the military operations, but then also being able to take the technology and the knowledge that we know and apply it in situations that are less than ideal. And you know, it can be challenging.
LTC KHAN: Keeping in view what you have covered, the difference between the military medical system and regular medicine, what do you think is the role of military healthcare? You have touched upon it, so could you elaborate on it?
LTC WILSON: Sure. A good way to think about it is the motto of the Army medical system, which is "To conserve the fighting strength." There are a couple of different facets of the motto that are important. Obviously, when we have patients who are injured in fighting, our role is to take care of them. But another component of that is preventive medicine. Conserving the fighting strength means not only saving the lives and repairing the injuries of those who are hurt, but also trying to keep people from getting injured or sick.
If you look at the history of modern warfare, especially from the past 100 years, more people have had to be removed from the battlefield due to non-battle injuries than from fighting-related injuries. Diseases, mainly infectious diseases, draw away the fighting strength of the force available for the security mission or operations. So a big aspect of military medicine is the prevention of disease: basic hygiene, basic sanitation, reducing the medical health threats that those soldiers are going to face in different areas. Often those areas have climates that are significantly different from the U.S., and harbor diseases we don't see normally in the U.S. We see this commonly, and it is one of the reasons why the U.S. military has been so aggressive in its infectious disease research, such as with malaria. We don't really have a big problem with malaria in the U.S., but in a lot of the places where we operate, malaria is endemic. If you go back to the career of Walter Reed, who our hospital is named for, understanding the etiology and the causes of yellow fever during the building of the Panama Canal was a big part of military medicine. The fighting strength was those workers and military personnel who were helping build the Panama Canal. Yellow fever had been a big impediment to that development in the past.
From the tactical perspective, the United States has an ethical contract with our soldiers that says: Hey, if we are going to put you in harm's way and something bad happens to you, we have a responsibility to take care of you. If the soldiers don't have confidence in that medical care, I think you are going to see the willingness of people to put themselves at risk decrease. They are going to modify their behavior, be less willing to take risks. A lot of times it is that very risk that is needed in order to secure peace or establish peace in the conflict area. So to me, that is one of the key aspects of military medicine. The other aspect, as I mentioned before, is maintaining the force, and taking a preventativemedicine, public-health approach to a very austere environment, to try to keep people from getting sick so that they can focus on fighting rather than worrying about having to relieve themselves every 20 minutes or something like that.
LTC KHAN: What different types of training have you received to learn this military medicine outside of regular medicine?
LTC WILSON: As I mentioned earlier, the medical school that I went to has a specific curriculum that is designed for military medicine. But you know, not all military physicians go to the medical school that I went to. Many go to regular medical schools and then are brought into the Army. The military helps pay for their medical education with the expectation that they will then serve a certain number of years in the Army as a physician. In the Army specifically— the Navy and the Air Force have similar programs—during your medical school training, either in the summers or after your training, you go through professional education courses, like the leadership courses that teach the skills of tactical medical care. Most of that in the U.S. Army is centered at Fort Sam Houston, Texas, which is where the Army Military Medical Department Center and School is located. That is where we train all our medics and so all military physicians will go there.
The Army also offers some specialized training, such as a course on medical management of chemical and biological warfare. We have specific courses for people who don't do a lot of trauma in the hospital but who are going to be deployed to support a forward unit in combat, to improve their trauma and resuscitation skills. A lot of that is built upon the civilian Advanced Trauma Life Support Course.
In the last 10 years, as we have been fighting in Afghanistan and Iraq, there has been a deliberate effort to codify what really makes a difference on the battlefield. That knowledge has been codified into what we call TCCC, or Tactical Combat Casualty Care. The TCCC concept has permeated tactical medical care. For example, the first aid kit that every soldier carries is designed specifically on TCCC principles. The whole idea is that there are certain things that need to be done right. Soldiers need to be prepared to provide that treatment at the point of injury, such as for loss of an airway, or to stop bleeding. This training can really change survivability at the point of injury and allow soldiers to get back to more intensive care. So there are a lot of courses that teach and prepare our soldiers and medical personnel as part of their military education.
A lot of the training has to do with tactical medical care, and I think one of the things that we need to do better is integrating ourselves into military operations: physicians seeing themselves as part of the unit and looking at how they can better use the medical resources in the unit to support the mission's objectives.
LTC KHAN: Keeping in view the 2012 national security strategy, which states that the U.S. is going to go for smaller operations and more partnerships, how, in your opinion, will this change military medical care?
LTC WILSON: I think that is a really good question. Most of our previous doctrine was based on fighting a large, land-based, conventional fight. Because of that, our medical doctrine has been one of care on a linear battlefield: There is a definite front line and a definite rear, and the further you get away from the front line, the more secure it becomes. As you evacuate patients to the rear, they can get better levels of care because each stop along the way back to the hospital has more resources. In Afghanistan, we had more of a noncontiguous battlefield where there wasn't necessarily a front line anywhere.
When you are fighting an insurgency, the regular doctrine of echelon care doesn't necessarily apply. We have had to really adapt. Because our doctrine drives our manning and our resources, we have had to take the resources that we have based upon the previous doctrine and use some creativity in order to provide better care. For example, when I was in Afghanistan in 2007 to 2008, we had to split our aid station into two pieces, with myself at one base and my physician assistant at another. But we also had three satellite fire bases that were manned by only one platoon of infantry. A platoon of infantry usually has one medic. We could reach one of them only by helicopter, and if the weather was bad, they were completely isolated. So that is where you need to have some creativity and look at what are the risks, what are things that we can do to mitigate that situation.
I am a big believer in rehearsals, and I am also a big believer in doing mission analysis before deployment, because when someone is injured, that is not the time to ask, "Hey, what do we need to do?" You need to be running through those problem sets before they actually happen on the ground. You train your medics so that they can do more than just put on a tourniquet and stop bleeding. You teach them to treat muscular-skeletal injuries and basic non-battle injuries. You need to make sure you have good communication plans. Now one of the ways we mitigate that risk is our aerial medevac system. We don't rely on ground medevac in Afghanistan because of the terrain. But there are times where aerial medevac has been denied or is not available because of weather, so you have to think about that before and take actions to mitigate that. The national security strategy is focusing more on having a light footprint, so—especially in the realm of special operations and counterinsurgency— we are going to have small units operating outside the reach of an aerial medevac system. I think the way we are going to have to mitigate the medical risks is through partnership with the host nation. The alternative is that everywhere we go, we have to put a big medical footprint, and that is just not consistent with the strategy moving forward.
You are there in general to develop a partnership with the host nation. Well, part of that is to strengthen the medical systems of our partners. By doing that, I think we can develop interoperability but also provide some protection for our forces that are operating in other countries by making the medical systems of the host country stronger.
LTC KHAN: Can you specify what type of partnership you think is needed? Like providing care, or providing education to the partner countries? Or what specific area do you think is important?
LTC WILSON: Well, I think we are doing this pretty well at the tactical ground level, whether it be special operation medics or even general purpose force medics. When they partner with a host country unit, there is a lot of good teaching and training going on. A lot of it is based on the TCCC principles I mentioned before, on how to provide good unit injury care. I think there can be improvement in providing treatment at levels above that. Like I mentioned before, medical care is done in a network or a system. So that is great if our partners have medics on the ground to take care of injuries right away and prevent death at the point of injury, but the medics then need to have somewhere to send those patients. They need to have surgical capabilities; they need to have physicians who know how to treat those types of injuries; there needs to be a chain of care going back to definitive care at a hospital. I think that is an area where we can really partner a lot better, by developing both the education and the training aspects of our partner systems. We can show that there is value in this. It is not just developing medical capability in general but having it focused specifically on supporting the security forces.
We can say, "Oh yes, that is great. We are going to help build the military health system." But I would encourage people to think even beyond that. Think of it as not just the military but security forces in general, because if you are talking about police forces or local security forces, you can't necessarily build a military medical system that is going to cover partner forces all over the country. And so a lot of times, those host nation security forces are going to need to go to the local civilian clinics where they are already being served. I know some people consider this controversial in terms of the military partnering with civilian healthcare systems to strengthen them, but I think it makes a lot of sense as long as when we do it, we keep our focus on doing things that are actually going to impact security.3
There has been a lot of debate and discussion in the last five to ten years about the use of soft power and the use of medical diplomacy. I think there is a place for that, and we are already doing it in a lot of places, especially looking at pandemic flu outbreaks and weapons of mass destruction. We are working with ministries of health of different countries on their reaction program to pandemic flu, for example. I think that everyone realizes that if we ever have a flu pandemic, the risk will be everywhere. If health ministries are able to take care of their own area, then we can manage the outbreak in general. If everyone is looking to the U.S. or the World Health Organization to manage an outbreak, it will spread too fast and become too big of a problem for us to control. So I think the U.S. has a role in strengthening the other country's civilian healthcare system, but we haven't had a good focus on what exactly we are trying to do. Our work has bled into the priorities of, for example, the Ministry of Health as opposed to making sure those interventions actually support the U.S. Department of the Interior or Defense by directly teaching and developing those capabilities to support security forces.
I think, at the end of the day, we have different pillars of development. Security is the primary role of the military—to help establish and maintain security in the region. No other development can happen in an unsecured area. What the international organizations want, what non-governmental organizations want, is a secure environment into which they can go and do development. So if that is our armed forces' primary role, there is a need and a requirement to have good medical support for all security forces. That gives us a welldefined mandate to go in and work with the civilian medical system. A lot of the criticism we get comes when we try to do things that non-governmental organizations want to be doing with the host country's internal healthcare. I am not saying that is not important, and in some places that may be the biggest medical need in the area. But I think we have to take a larger view and say, okay, the way that need is ultimately going to be met in the long run is to develop security. So we need to make sure that the security forces are effective, and I think, especially in areas of low security or high risk, having good medical care available for those security forces is going to help them establish that security the quickest, which will then allow other organizations to come in and take over the wider medical care role. We have limited resources, too, so if we focus on things outside of security, then security may suffer and then the whole thing suffers. I think by focusing first on security, we can help set the conditions for the improvement of the system overall.
The challenge is that a lot of times, the Ministry of Health officials are focused on what their greatest needs are, so we don't necessarily want to go in and tell them what they should be doing. When your death rate for children is very high, when women are dying in childbirth, that is a real need and can have definite impacts on the future and economic development of that country. But, I think part of our role is to help them also see that medical care is needed for security. I feel very strongly that one of the main roles of military medicine is to develop medical care for internal security forces.4
LTC KHAN: My last question is regarding your recent study, done at NPS, on military medical care. Can you share some of your analyses or some of your thoughts on your study? What were your findings, and what did you propose for military healthcare where U.S. forces are operating?
LTC WILSON: A lot of what I have just been talking about springs from my own training and experience, and what I observed in Afghanistan for two years. It really echoes what I have just mentioned. The U.S. military should focus on developing host country healthcare to support the indigenous security force. I think the first step is to ask what things are we doing already to develop as opposed to provide healthcare, and focus more on the security aspect of it. My thesis specifically tried to answer the question, Does the quality of medical care impact the effectiveness of security forces?5 The answer was very clear. Yes, there is a direct benefit to strengthening security, but there are also secondary benefits that can come from focusing first on developing the medical system for partners' security forces.
Different places have different models for their military. Whether you have a conscription service for your security force or volunteer service, providing good, competent medical care helps with recruitment and retention of the security forces. One of the problems that we have seen among Afghan forces is that there is a lot of turnover. If you are always training new recruits, you are not able to develop that core mid-grade officer, mid-grade noncommissioned officer, the kind of people who stay in the military for a while. Having that military medical care as a benefit can help with retention, which is a secondary benefit. To me, this concept echoes a lot of the spirit of the national security strategy, which states that we are going to strengthen our partners so that they can take care of themselves. Obviously this medical support would have to be tempered and modified for whichever country we are going into.
In some ways, our partners are building an institution that is bridging the gap between medical care and security forces. This can then be leveraged by the state to help itself, to protect and extend healthcare to areas that are maybe too insecure for the civilian medical system to go into. You could look at the region as well. One country's capable, forward-looking military medical system could be used to assist its regional neighbors, or used internationally as part of peacekeeping forces. Such a system also decreases the amount of requirements from other countries, or it increases the total pool of medical folks that could be used as part of international responses, whether it be complex operations or humanitarian assistance. But the only way I think you are going to gain this larger benefit is by working together and developing interoperability. That isn't easy. As one of my mentors once told me, "Anything worth doing is hard because if it was easy it would have already been done."
If we take this perspective that medical care for security forces is an important part of security building, and overlay that with what it takes to provide good tactical medical care as a system, we have all these different touch points for partnership. When you look at the skills and the human capital needed to maintain, operate, and grow a partner's medical system, the U.S. has that capacity in our military medical systems and our medical education program. We also have a large number of military physicians who have a lot of combat experience working in conflict zones—experience that can be shared.
But I think it would be a mistake to say that U.S. military medical staff have something to offer that nobody else has. When you talk about what partnership means, it means that we learn from each other and that we do it together. Not only do militaries have different capabilities and experiences that others can learn from, the same is true in medicine as well. I like to say that good medicine is good medicine no matter who is practicing it. A lot of times, it is just the clinical application of knowledge that is lacking and how you apply that in a military context or security context. But the ability to partner at all these different levels, I think, is an opportunity that has been missed up to this point. The most current U.S. national security strategy, which is directing U.S. military forces to pursue small, light-footprint approaches, should stimulate us to develop those partnerships because we are going to rely on our partners to help provide medical coverage to our forces that are taking part in these light-footprint approaches.
LTC KHAN: Can you say something about training?
LTC WILSON: I think we missed a great opportunity. Every time we do a military exercise, medical response needs to be an integral part of that exercise. One of the challenges I think we have in the U.S. is that the military tactical side of medicine is relatively separate from civilian medical education and training. So finding touch points on institutional levels, whether it be medical school to medical school or hospital to hospital, and developing partnerships, as well as making those medical partnerships an important aspect of training exercises, could help build that partnership and interoperability. I think that is the big stuff.
LTC KHAN: Thank you very much. That was wonderful.
About the Author(s): Wing Commander Kashif J. Khan has served in the Pakistani Air Force for twenty years as a fighter pilot and flight instructor.
1. The Counterterrorism Archive Project aims to collect and archive knowledge on strategy, operations, and tactics used by military and other security personnel from around the world in the 21st century fight against global terrorism. Collectively, the individual interviews that CTAP conducts will create an oral history archive of knowledge and experience in counterterrorism for the benefit of the CT community now and in the future.
2. This interview has been edited for length and clarity. Every effort was made to ensure that the meaning and intention of the participants were not altered in any way. The ideas and opinions of all participants are theirs alone, and do not represent the official positions of the Naval Postgraduate School, the U.S. Department of Defense, the U.S. government, or any other official entity. The original interview is available on video to CTFP members at www.globalecco.org/archives
3. LTC Wilson later clarified this thought: Where we get into problems is when we focus on areas that don't specifically support or impact security. By focusing on those parts of the civilian medical system in the host country that strengthen security forces, such as trauma care and evacuation, U.S. medical resources can support security development. In this way, the necessary conditions can be created for other agencies to help develop a lasting healthcare system.
4. LTC Wilson later noted: The civilian health community is the sector that needs to focus on providing care to civilians. Having said that, in areas where the civilian health community won't operate due to lack of security, we can provide needed care to those civilians as a bridge to civilian development while security is being established.
5. LTC Ramey Wilson, "Building Partner Capacity and Strengthening Security through Medical Security Force Assistance," Master's thesis, Naval Postgraduate School, Monterey, California, June 2013.