The Role of Medical Development in Support of Security
By: LTC Ramey L. Wilson, USA, MD
The motto of the United States Army Medical Department, "To Conserve the Fighting Strength," often conjures visions of field medics providing care to the injured on the battlefield or surgeons with blood-soaked gowns using skill and ingenuity to save patients from the grip of death. For some, the motto summons images of soldiers lined up for vaccinations or digging field latrines, thus preventing the diseases that are endemic to areas of conflict. There is little doubt that a robust medical support system directly affects security force readiness, by preventing disease and injuries from sapping a force's strength, and by restoring the injured to health. History is full of examples where illness and non-battle injuries caused by poor hygiene or environmental hazards decimated a military's available combat power.
But the motto also alludes to another aspect of safeguarding the fighting force: the psychological benefit for soldiers of knowing that competent care stands ready to serve them if they are injured. When security forces are risking injury or death in the performance of their duties, a competent medical system prepared to care for the injured strengthens their resolve, supports unit morale, and increases the effectiveness of operations by mitigating the risk of injury. As states or international partners work to improve security institutions, they therefore must develop and resource the medical systems that support security forces as part of any security strengthening effort.
Direct Benefits of a Strong Military Medical System
Legitimate governments must maintain a monopoly on the coercive use of force within their borders and abroad.1 How that force is used and who it serves speaks directly to the state's viability and its acceptance by the population and the international community. Without security, both internal and external, progress, growth, and development fail. The proper use of force, usually within the context of a legal system that prevents abuses of power, thus supports the legitimacy of a nation-state. At the most basic level, the members of the security forces must be willing to put their lives at risk to serve the state's interests.
A security officer's willingness to provide effective security, however, varies according to the perceived risks, and the disconcerting risk of injury weighs heavily on the minds of those placed in harm's way. While many factors influence the effectiveness of security forces (e.g., professionalism, leadership, legitimacy of cause, unit cohesion, doctrine, training, organization, and camaraderie), security force members also weigh the risk of injury as they work to improve or maintain security.2 If they deem the risk of injury to be too high, members of the security forces could, while appearing to be conscientious, reduce their risks by conducting operations in a way that ultimately has no substantial impact on security. One can easily predict the results: ineffective operations lead to a lack of real security, and a lack of security stalls stability and development.
My research into this quandary explored the influence of medical support on security operations, and the role of developing medical systems and institutions that support security forces as part of a state's security-strengthening efforts. A comparison of the productivity of security forces in over 150 countries, based on the availability of ambulance services in varying levels of violence, showed that security forces with access to pre-hospital medical care were more effective at doing their jobs. The application of game theory and utility theory to the data revealed that the availability of casualty and evacuation services had a direct influence on the willingness of security personnel to conduct effective operations. Together, these findings clearly suggest the influence of medical support on the behavior and effectiveness of security forces. Without a medical support system to provide care to personnel injured in the performance of security operations, those operations were less effective.3
The benefits of a strong medical system to support security operations may not initially be obvious. In stable areas with good security, the importance of a robust medical support system may not reveal itself until the risk of injury to security forces increases significantly, such as during an uprising or riot. While the risk of injury remains small, security forces place a low value on the presence or absence of medical support, and its lack has no appreciable impact on effectiveness. Once the risk of injury increases, however, the presence of effective medical support directly influences both the behavior of security forces and security.
At its root, security force medical support is a form of insurance. If the state doesn't perceive a need for it, the state is unlikely to invest the necessary resources to provide it. A robust medical support system, which is both technically demanding and potentially expensive, takes time and resources to develop. In the absence of a demand signal urging the development of medical support for security forces, it is understandable why many developing states fail to invest in this aspect of security development. As levels of violence increase and the need for medical support becomes clear, an unprepared medical system will not be able to adapt or develop fast enough to prevent the unnecessary loss of life or a decline in security effectiveness. The risk to the state, therefore, arises from its failure to both appreciate the importance of the medical system and invest the required resources to develop a medical capability before it is needed.
As states proactively evaluate the current and future requirements of their security force medical systems, they must pragmatically consider the capabilities that will be needed during periods of increased violence, and balance potential future needs with current resources. Even in areas of instability and violence, the demand signal for medical support may be artificially low because security forces, in an effort to mitigate their risk in the absence of reliable medical support, have already adjusted their behavior or operations. The true need for medical support may not be known until the security forces aggressively conduct operations; they will, however, be less willing to do this without good medical support. States, therefore, must provide medical support based on the likely requirements if security operations were conducted effectively. This may involve temporarily increasing that support in specific areas until real security is established.
Afghanistan provides an illuminating example of how the presence or absence of adequate medical support directly impacts security development. As U.S. military forces have provided the bulk of medical support to Afghan National Security Forces (ANSF) for the past 10 years, U.S. forces have strengthened and girded the resolve of the Afghan forces. By providing medical support to the ANSF, the coalition secured the risk-mitigating benefits that medical support has on security operations. Providing this service external to the existing Afghan military health system, however, removed the demand signal for the aggressive development of indigenous medical support that could be sustained by the Afghan security forces once coalition forces depart. Instead, coalition forces spent more time assisting the public health departments to meet the medical needs of civilians as part of counterinsurgency strategies, and the ANSF medical system experienced only intermittent and uncoordinated development. With external medical support now decreasing as coalition forces draw down, the nascent ANSF medical support system cannot meet the casualty evacuation requirements generated by independent security operations. The lack of an adequate indigenous security force medical system threatens the effectiveness of Afghan security forces and their ability to operate independently.4
Indirect Benefits of a Strong Military Medical System
The benefits of a strong medical system to support security operations extend beyond the strengthening effects of tactical field care and evacuation. Such a system also provides indirect benefits to the security institutions, the public health sector, the state, and the region.
A strong, dedicated medical system incentivizes service in the security forces and supports recruitment and retention. In countries with a substandard or developing civilian medical capability but a good military system, volunteering for service provides individuals with access to competent and capable medical care for themselves and possibly for members of their family, and maximizes the value of training already invested in current personnel by keeping them healthy.5
By caring for the individuals in the organization, which is a fundamental component of leadership and professionalism, a competent medical system strengthens the professional milieu of the security organization, improves morale, and communicates to the individual and his or her family members that they are valued by the organization.6 For institutions that strive to inculcate their members with a service mentality and professional behavior, providing medical care models the values that the institution expects its members to embrace. If care is extended to family members, the medical system allows security personnel to focus on their duties rather than be distracted by family medical concerns.7
For the public health sector, the benefits of a competent security force medical system extend beyond the security sector. Security forces routinely operate in areas with stunted development and inadequate public services (e.g., poor or scarce public and private hospitals for the civilian populace). A strong security force medical system not only supports security operations under these conditions, but also can be used to assist in providing care to the civilian populace, and to build local capacity to support the public health sector. With expanded resources and the ability to operate in austere conditions, a robust security force medical system can provide medical care in areas where other government entities cannot, thereby ensuring essential care until the civilian sector develops. The security forces, in turn, benefit by demonstrating their service to the population. If done correctly and professionally, medical "civic action" missions connect the security forces to the population and demonstrate that the security forces are there to serve the people, and not the other way around.8 Security force capabilities in the areas of advanced communications, coordination, logistics, and transportation can also augment the delivery of civilian health care through partnerships with the public health sector. The current civilian aeromedical evacuation capability in the United States, for example, began as a joint partnership between U.S. government agencies and the military to improve traffic safety. The solution to a public health problem was facilitated by a robust and capable military medical system.9
For the state, a robust security force medical system can provide medical care to the civilian population when it is not available through the public sector, respond to disasters or emergencies when the civilian medical system is overwhelmed, and partner with other government agencies to develop solutions to complex problems. Investment in the security force medical system also signals the degree to which the state values its citizens, especially those who serve on behalf of their state, and makes the state's commitment clear to the population at large and to the international community. A capable medical system communicates the intent of the state to meet its ethical obligation to its security personnel and reveals the value that it places on service to the state.10
Just as a strong and capable national security force strengthens a state, a robust state has the potential to stabilize a region. When states partner with and strengthen their immediate neighbors, the region benefits from increased security through collaboration, dialogue, and reinforced support. Security cooperation facilitates regional security and enhances the ability of partners to respond in coordination. Regional medical interoperability has the potential to leverage the medical strengths of multiple states to create systems that enable them to solve challenging health problems and to contribute to regional security. During a regional disaster, medical crisis, or disease outbreak, state responses inevitably include security forces. When states have established and maintained prior working relationships with regional partners, they will form an accurate assessment of their partners' capabilities and ability to handle crises. Established medical partnerships will expedite appropriate support integration during the response to a crisis.
Robust and capable medical support for security forces strengthens security operations by mitigating the inherent risk of injury to security personnel. While directly benefiting security operations, an effective and reliable military medical system has the potential to benefit the state beyond direct security support. As states evaluate their security forces and work to improve their effectiveness, they should include a pragmatic assessment of their medical support system in the analysis. If medical capacity is found to be lacking, the state must make the resources available to strengthen and develop the medical support system in coordination with other aspects of security force development (i.e., leadership, professionalism, logistics, the rule of law, tactical training, and proper utilization). Because of the technical nature of medical support and the time needed to build medical capability, efforts to strengthen medical support organizations must be initiated early in the effort to improve military effectiveness. Waiting to develop medical support capabilities until the security force is ready to conduct security operations will likely result in inadequate medical support and will directly impact security force effectiveness.
About the Author(s): LTC Ramey L. Wilson serves as a general internal medicine fellow at the Walter Reed National Military Medical Center in Bethesda, Maryland, and is an assistant professor of medicine at the Uniformed Services University.
1. Max Weber, "Politics as a Vocation," From Max Weber: Essays in Sociology, trans. H.H. Gerth and C. Wright Mills (New York: Oxford University Press, 1946), 78.
2. Ashley J. Tellis, Janice Bially, Christopher Layne, and Melissa McPherson, "Measuring Military Capability," Measuring National Power in the Postindustrial Age (Santa Monica, Calif.: RAND Corporation, 2000), 136: http://www.rand.org/pubs/monograph_reports/MR1110.html
3. Ramey L. Wilson, "Building Partner Capacity and Strengthening Security through Medical Security Force Assistance" (master's thesis, Naval Postgraduate School, Monterey, Calif., June 2013): http://calhoun.nps.edu/public/handle/10945/34763
4. Kevin Sieff, "Without U.S. Helicopters, Afghans Struggle to Save Wounded," Washington Post, 19 May 2013: http://articles.washingtonpost.com/2013-05-19/world/39381408_1_u-s-helicopters-afghan-air-force-soldiers
5. Congressional Budget Office, Recruiting, Retention, and Future Levels of Military Personnel (Washington, D.C.: Congressional Budget Office, October 2006): http://www.cbo.gov/sites/default/files/cbofiles/ftpdocs/76xx/doc7626/10-05-recruiting.pdf
6. Martin C. M. Bricknell and Donald Thompson, "Roles for International Military Medical Services in Stability Operations (Security Sector Reform)," Journal of the Royal Army Medical Corps 153, no. 2 (June 2007): 95–98.
7. Association of the United States Army, Key Issues Relevant to Taking Care of Soldiers and Families (Arlington, Va.: Association of the United States Army, April 2009): http://www.ausa.org/publications/torchbearercampaign/tnsr/Documents/TBNR%20-SoldiersandFamilies.pdf
8. The meaning of civic action in this article reverts to the definition and goal of civic action coined by Edward Lansdale (COL, Ret.) during his time advising in the Philippines. The original goal of the program "set out to make the soldiers behave as the brothers and protectors of the people in their everyday military operations." See Edward Lansdale, In the Midst of Wars: An American's Mission to Southeast Asia (New York: Harper & Row, 1970), 70.
9. Emergency Medical Services Systems Development Act of 1973: Hearings Before the Subcommittee on Health of the Committee on Labor and Public Welfare, 93rd Congress (1973), S. 504 and S. 654 at 269–307.
10. Nancy S. Jeckler, "Just Healthcare for Combatants," The American Journal of Bioethics 8, no. 2 (2008): 13–14.