398 December 18, 1984 WILL AMERICA BE'ABLE TO TREAT ITS BATTLEFIELD WOUNDED INTRODUCTION The U.S. long has taken pride in its ability to care for its battlefield wounded. Rapid medical attention in South Vietnam for instance, enormously increased the chances for survival of wounded GIs. How well American casualties will be treated medical- ly in future and possibly larger conflicts, however is a matter of growing concern. The.medica1 care on han d , available, or currently programmed is insufficient to treat the numbers of casualties likely to result from heavy armed conflict The Military Departments! medical force structures do not provide sufficient personnel authorizations and units to assure an adequate level of support either overseas or in the United States in the event of war was the assessment of onesenior Defense officia1.l While a war in Europe would create a crisis in medical care for the Armed Forces, "the situation is no less grave in t h e Far East," said Assistant Secretary of Defense John H. Moxley, 111, at the 1982 Association of Military Surgeons Conference. added: He Letter, Office of the Assistant Secretary of Defense to Major General Henry Mohr (U.S. Army, Retired), October 12, 198 4.

Keynote Address by John H. Moxley, 111, M.D at the 38th Annual Meeting of the Association of Military Surgeons of the U.S San Antonio, Texas November 2, 1982.

This is the 8th in a series of papers prepared for The Heritage Foundation's Defense Assessme nt Project, directed by Heritage Senior Fellow Lt. Col. Theodore J. Crackel (U.S. Army, Ret 2 It is the medical support for the Rapid Deployment Joint Task Force (RDJTF however, which poses our greatest problem stages of RDF (Rapid Deployment Joint Task F o rce operations when casualties can be expected to be the heaviest Shore-based hospitals cannot support the initial Although this has been apparent for some time, efforts to correct it have been painfully slow and inadequate. Some law makers seem to believ e that a draft of doctors, nurses, and medical technicians when war begins will produce instant medical support. Regrettably, it will not. Action is needed now to prevent what could be an insurmountable problem in a sudden crisis involving large numbers of casualties THE PROBLEM The United States generally has had long lead times to mobilize for war. World War I1 mobilizations, for example commenced two years before the U.S. actually entered the war.

Today major hostilities could erupt without warning scena rios require suitable medical support to be at hand before or whenever hostilities erupt Short-warning The Itwartime Medical Posture Studylit completed in 1980 by the Armed Services and the Office of the Secretary of Defense is the benchmark analysis of w artime requirements and capabilities.

This two-year study evaluates comprehensively the requirements for supporting a large-scale conflict critical needs within a theater of war for operating rooms and acute care facilities It calls attention to the Defici encies in medical capabilities and evacuation methods which media reports claimed could have resulted in 10,000 to 30,000 additional losses, were discovered during a major Pentagon exercise in 19

78. The report in The Washington Star on November 2 1979, w hich noted this, was called by a senior Defense official Itone of the best unclassified reviews I have seen It 3 Studies following Armed Forces readiness exercises in 1978 1979, and 1980 each disclosed massive shortages of deployable medical units. Of tho s e available, many units reportedly were so deficient in medical professionals that they were incapable of mission performance Office of the Secretary of Defense Letter, November 1979, to Chairman and members of the Reserve Forces Policy Board, Subject Nif t y Nugget I 3 A 1981 General Accounting Office (GAO) report to the Congress asks llWill There Be Enough Trained Medical Personnel in Case of War?Il4 At the end of 1980, states the GAO, only 18 percent of the Army's wartime requirements for operating rooms were available for use in Europe and Marine Corps were reported to have nothing, except the Marine Corps' organic Navy field units and Navy facilities afloat.

Battlefield operating rooms are very important because wounded often cannot be evacuated safely u ntil they are treated conclusion of the GAO report was that the numbers and the types of medical personnel in active and reserve forces fall short of projected requirements for any wartime scenarios.

The report also concluded that medical personnel on act ive duty had insufficient training in combat casualty care. Its recommendations to correct this included pre-registering civilian medical personnel with the Selective Service System, improving medical mobilization planning by the Defense Department, convi n c ing civilian hospitals to plan to accept military casualties, and increasing active duty personnel training in combat casualty medicine. The Department of Health and Human Services, meanwhile stated that revised standby legislation was needed to permit registration and induction of medical personnel after the Pentagon more precisely identified its requirements for an emergency.

Overall the GAO determined that the Services had only 53 percent of the trained personnel necessary The Air Force had only 10 pe rcent. The Navy The The Department of Defense has not yet confessed to this shortage, insisting that most of the needed medical personnel are on hand. The difficulty is that they are not addressing wartime needs realistically GAO, the Defense Department s eems content with manning levels that reflect a peacetime situation hostilities break out-=may be even more bleak than it appears.

In such a case, many of those skilled in combat casualty care would have to train new personnel zones even more shorthanded t han the numbers indicate Despite their own studies and that of the The immediate picture-should This could leave the combat In 1981, Dr. John F. Beary, 111, then Acting Assistant Secretary of Defense for Health Affairs, using conservative computer-generat ed casualty estimates for a NATO conventional war scenario, determined that only one in ten wounded servicemen would receive necessary lifesaving care, using both the active and reserve resources then available.

During November 1982, Assistant Secretary of Defense John H.

Moxley told the Association of Military Surgeons of the United States The harsh reality is that if the United States committed its forces to major combat today, whether in the Far East, Southwes t Asia, or Europe, we could not care for a significant portion of our casualties. We do not have enough deployable hospitals of any kind to 4 provide even the emergency surgical to pre are the predicted numbers of ation P treatment required patients for e v acu On May 1, 1984, Assistant Secretary of Defense for Health Affairs William Mayer, M.D., told the House Appropriations'Defense Subcommittee that while the Ilmilitary departments have made great strides toward improving our ability to meet this responsib ility we still have some significant medical readiness deficits."

Explained Mayer Our wartime scenarios have predicted that, if a full scale conventional conflict broke out in Europe tomor row, we would have sufficient medical capability to provide initial surgery for only 20 percent of the estimated casualties We are woefully short of deploy able medical systems for wartime, and much of the deployable equipment and materikl that we do have is old and obsolete. We are still faced with critical shortages of key medical personnel who would be needed in wartime, most notably surgeons and nurses 6 The following month, Mayer warned the Senate Appropriations Defense Subcommittee that about three-quarters of American service men wounded in a major conflict would n ot get the Illifesaving stabilizing, hemorrhage-stopping surgical care" needed to survive.7 These statements .differ little from appraisals made of military health care capabilities for the Armed Forces in 1978, 1980, and 19

82. The situation has not improved significantly, despite the continuing recognition of the problems.

POSSIBLE CHANGE THROUGH THE SELECTIVE SERVICE ACT Medical care shortages could even create a major obstacle to mobilization in case of an emergency of 1948, as amended in 1973 and 1980 , states The Selective Service Act No person shall be inducted until adequate provision shall have been made for such medical care, and hospital accommodations as may be determined by the Secretary of Defense or the Secretary of Transportation to be essen tial Comptroller General (GAO) Report to the Congress, "Will There Be Enough Trained Medical Personnel in Case of War HRD-81-67, June 24, 1981 Moxley, op cit.

Statement, Honorable William Mayer M.D Assistant Secretary of Defense for Health Affairs before t he Subcommittee on Defense, Committee on Appro priations U.S. House of Representatives, May 1, 1984 Statement, Honorable William Mayer, M.D Assistant Secretary of Defense for Health Affairs before the Subcommittee on Defense, Committee on Appro priations U .S. Senate, June 12, 1984 5 This Drovision could restrain Selective Service from draftins anyone for- military service until medical support, including doctors, nurses, technicians, and facilities is procured and in place emergency involving heavy combat c ould result in devastating military consequences to the nation Failure to correct existing problems in advance of an Preventing this almost surely requires at least a peacetime registration, classification, physical examinations, and full readiness .for i n duction of doctors, nurses, and certain medical technicians. Needed, too, are at least 60,000 additional male and female llcorpsmenll (uniformed medical specialists who are as essential to the casualty treatment process as doctors and nurses.8 Though the P entagon claims that it is taking steps to enhance medical preparedness, its letter of October 12, 1984, admits If we entered a major conventional war today, the Department of Defense could not provide an adequate level of medical support to our force HOW TO ATTRACT MEDICAL SUPPORT TO THE SERVICES Several factors are responsible for the present shortage of military medical personnel.

Law, between 1950 and 1973, thousands of physicians entered military service to satisfy service requirements. This law however, was repealed along with the demise of the draft in 1973.

The measure had permitted physicians to complete their medical education rather than be drafted while in training, but it ex tended their liability for induction to age

35. These physicians rem ained on active military service for two years and had an additional obligation to remain in the Reserve for four years after discharge Under the so-called Doctor Draft Under the Doctor Draft, approximately 30,000 health pro fessionals were called for ind u ction. Most were physicians although osteopaths, dentists, veterinarians, nurses, and other health professionals also were conscripted. The majority of these accepted Reserve Force commissions on a voluntary basis in lieu of induction. Only about 70 of th e professionals called refused to enter the military and had to be drafted A precedent exists for drafting women in health care profes sions. President Franklin D. Roosevelt in 1945 proposed to draft nurses, and the House of Representatives passed such a m easure but by the time the Senate came to act on the bill, the number of nurses responding to the President's appeal for volunteers had Mohr, op. cit Ibid. 6 increased to meet wartime needs dropped.

The matter consequently was Since 1973, the military serv ices have had to compete with the civilian market for physicians military at a disadvantage, as physicians in the private sector This predictably places the can earn considerably more money than military doctors can, and further, need not be separated fro m their families. Because of this, recruiting medical health professionals is difficult, even for the Reserves.

The military Services attacked the problem, beginning in It has begun to train doctors, and the first class 1972, by creating the Uniformed Services University of the Health Sciences graduated in 19

80. This institution, however, will produce only about 25 percent of the Services' needs-and the peacetime needs at that. The balance is to be provided under the Health Profes sions Scholarship Progra m, which trains doctors at civilian schools. This, however, is only a partial solution. It still does not address the problem of potential wartime requirements.

And it does nothing toward solving the problem of health care professionals, other than supplying more doctors.

Issues and Current Initiatives The 1981 GAO Report recommended that the Secretary of Defense and the Director of the Selective Service System jointly develop provisions to be included in a standby legislative proposal for a postmobilization draft of medic a l personnel Itas soon as possible It further recommended that possible registration and induction of health care personnel be coordinated with the Federal Emergency Management Agency (m because of its responsibilities for mobilization of civilian personne l and other resources.

Though the Pentagon agreed with these recommendations, and though the Senate Appropriations Committee was severely critical of reports that up to 75 percent of casualties at the onset of hostilities would not receive necessary care, neither the Adminis tration nor Congress has submitted the needed legislation.

The Defense Department and military services have a wide range of initiatives underway. These include heavy reliance on the Reserve Forces to fill the gap between wartime requi rements for medical care and facilities and those on hand. But in expect ing the shortages of health care personnel to be provided by the Reserve Forces, the Pentagon fails to recognize that the Reserve Forces, too, are short of doctors, nurses, and medic al specialists and equipment. The Pentagon is playing a shell game: pretending that authorizing such a structure in the Reserves is the same as having it in place.

On the other hand, the Pentagon has recognized the shortage of deployable medical systems fo r overseas medical treatment hospitalization, and evacuation systems. It plans to increase 7 those capabilities by spending $3 billion between 1986 and 1990 to obtain lladequatelt theater hospitalization and evacuation capabilities by 1993, augmented by p r e-positioning medical supplies and equipment at or near possible operational sites, and by use of host nation support If Contracts have been awarded to convert two tankers into hospital ships. Each ship will have the capability to support 1,000 beds and 1 2 operating rooms for delivery in October 1986 and will be stationed in Norfolk.

The second, to be stationed in San Diego, says the Defense Depart ment, will be ready in July 1987 greatest extent possible in meeting wartime requirements. The Defense Depart ment states it has Itapproved medical support agree ments with friendly nations and has other agreements currently under negotiation.Il However, there is no assurance that the next major war will be where the U.S. has prepositioned medical supplies or whe r e host nation support is available. It is reasonable to expect, moreover, that host nations will place highest priority on their own needs in the event of military conflict and that their obligations to care for U.S. wounded may be of relatively low prior i ty The first ship is, scheduled Pentagon policy is to use "host nation supportll to the Senior U.S. field commanders are concerned about this but are more or less resigned to it with an uncomfortable sense that it is the best we can get at the present tim e Reliability in a crisis is questionable and, at best, a calculated--perhaps dangerous--risk.

The Services and the Defense Department have other initia tives in progress, such as more realistic field exercises, more combat-oriented medical training, enhan ced medical manpower mobilization data, and increased Reserve component medical person nel and unit readiness. These actions would appear to be in recognition of and reaction to the persistent problems inhibiting adequate military medical support. They fa l l short of being sufficient to cope with the inevitable crisis as to the medical treatment capability if a major war were to develop without warning current initiatives dealing with these widely recognized shortages An appropriate sense of urgency is not reflected in In addition, there is growing concern about sustaining the necessary level of medical care should major hostilities continue over a prolonged period of time.

MILITARY MEDICAL SUPPORT IN THE U.S The Defense Department also is considering the ne ed to increase medical care facilities in the U.S. in order to care for returning combat casualties. Among these measures are: 8 Use of Veterans Administration hospitals, where an estimated 31,577 beds could be available.

Use of civilian hospitals through the Civilian-Military Contingency Hospital System, a voluntary arrangement with civilian hospitals and supporting staff in case of war. So far, 770 hospitals have pledged 61,000 beds. In 1985, this system will be incorporated into a new National Disaster Medical System designed to respond medically to natural or man-made disasters. Its goal is 100,000 beds in 71 metro politan areas across the country.

These initiatives, however, will not meet the wartime medical needs of the Armed Forces if they are sudde nly plunged into heavy combat, producing large numbers of casualties. And as more deployable and U S. hospitals are activated, more and more doctors nurses and medical specialists will be needed.

CONCLUSION The current state of military medical facilities and manpower i.s such that the armed forces would be severely short of combat medical care if major hostilities erupted today or in the near future tion. Initiatives in progress within the military Services and the Defense Department are steps in the rig h t direction, but they cannot hope to cope with a major war. As such, the existing shortages of doctors, nurses, medical specialists, and facilities cannot be alleviated under current and planned programs to a level adequate to treat the casualties of heav y combat the Reserve Forces recruit enough personnel in these skills And this care crisis is not receiving sufficient atten Nor can Knowing that adequate medical care for casualties is not on hand to back them up, combat commanders might be extremely reluc tant to take their troops into combat. justifiable public resentment and protest calling into military service the health care personnel required at the outbreak of major hostilities. Until medical care facil ities and personnel are in place, the Selectiv e Service Act prohibits inductions. The Administration, therefore, should ask Congress to modify the Selective Service Act and to grant the federal government authority to draft medical specialists, includ ing women. Registration, physical examinations, an d qualification by skills are the minimum peacetime requirements to assure imme- diate accountability To do so would trigger No legislative authority exists to provide the means for More attention needs to be criven to the Procurement of equipment and fiel d medical care-facilities In addition, field and combat zone training must be improved for medical units and health care personnel if they are to function in remote areas and under the relatively primitive conditions often found in combat 9 RECOMIWNDATIONS The 'Department of Defense should 1. Be prepared to provide more llmedicsll in case of war or mobilization.

The Defense Department should accelerate its program of initiatives for improving health care for military personnel especially under combat condit ions. This calls for immediate action to introduce and pass an amendment to the Military Selective Service Act that requires the registration of all persons between the ages of 18 and 46 years who are trained in a health care occupation. This age range is necessary because of the length of time required for education, training, and credentialing of qualified health care personnel, and for the provision of a pool of qualified registrants large enough to spread the liability for induction over a wider segmen t of the population should include all those with technical medical skills, females as well ae males, not previously registered. This would apply to health care personnel only, and should not extend to regular registrants. not be deferred until a military e mergency'occurs 2 Programs for reliance on host nation support for medical care should be reexamined realistically in light of potential crisis conditions and conflicting needs of those nations The new measure The identification of health care specialists must Review promises of host nation medical support 3. Add medical units to the force structure.

Funds should be authorized for establishment in the Reserve Forces of additional surgical field and 1,000-bed general hospitals plus other required medical un its. Sustaining medical care in severe and continuing combat should be carefully considered, and appropriate measures adopted to assure the capability of providing proper medical attention and health care in combat zones over prolonged time periods, if ne cessary 4. Be better prepared to receive casualties back home.

Agreements must be finalized with Veterans Administration and civilian hospitals to assist in care of casualties in an emergency personnel in combat 5. Reevaluate the stated requirements for tr ained medical Numerous studies have shown real shortages of qualified essential medical capabilities these shortages. The Pentagon must create medical units in the Current planning does not addresslo active and reserve forces on the basis of up front, war time-not peacetime-needs.

Prepared for The Heritage Foundation by Maj. Gen. Henry Mohr (U.S. Army, Ret Defense Assessment Project Papers No.

1. Theodore J. Crackel, "Reforming 'Military Reform Heritage Back- grounder No. 313, December 12, 1983 No 2. Robert K. Griffith, "Keeping the All-Volunteer Force Healthy," Heritage Backgrounder, No. 353, May 18, 1984.

No 3. J.A. Stockfisch, "Removing the Pentagon's Perverse Budget Incentives,"

Heritage Backgrounder No 360, June 19, 1984 No 4. Mackubin Thomas Owen, "The Utility of Force," Heritage Backgrounder No 370, August 1, 1984.

No 5. Richard L. West, "Military Compensation: A Key Factor in America's Defense Readiness," Heritage Backgrounder No. 387, October 18, 1984 No 6. Anonymous, "The Advantages of Two-Year Budgeting for the Pentagon,"

Heritage Backgrounder No. 391, November 5, 1984 No 7. C. Lincoln Hoewing, "Improving the Way the Pentagon Acquires Its Weapons," Heritage Backgrounder No. 396, November 28, 1984.