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United States of America

Capital: Washington, D.C.Area: 9.826.675 km2Population: 328.000.000Official Language: EnglishArmed Forces Personnel: 561.979Medical Officers: 4.400Military Hospitals / Institutes: 21/n/aMissions: multiple
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Surgeon General


U.S. Defense Health Headquarters
7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

U.S. Military Health System Article

The U.S. Military Global System of Health Services: Unparalleled Capabilities in Support of Country, Allies, and Partners (July 2022) 

 


Contents

1) Leaders in the Military Health System

  • Assistant Secretary of Defense for Health Affairs
  • Joint Staff Surgeon
  • Surgeon General of the Army
  • Surgeon General of the Navy
  • Surgeon General of the Air Force
  • Director Defense Health Agency


2) U.S. Defense Health Headquarters Address

3) MHS Web Site Links

Section 1 – National Context and Summary

  • A.     Geostrategic Situation Overview
  • B.     Organization of Department and Armed Forces


Section 2 – Organizational Structure

  • A.     MHS Organization Overview
  • B.     Health Care in the U.S. & Military Health Care


Section 3 – Firm Base Health System

  • A.     Hospital Services
  • B.     Healthcare beneficiaries
  • C.     Military Medical Research capabilities

                        1. Civilian-Military Research Collaboration bodies
                        2. Trauma and Intensive Care Research
                        3. Military Medicine Academic Journals

Section 4 – Operational Capabilities

  • A.     Overview of Operational Military Medicine Concepts
  • B.     Medical Operational Capabilities
  • C.     Overseas & Operational Deployments

                       1. Overseas Contingency Operations
                       2. Disaster Relief
                       3. Multi-National Military Medical Organizations

Section 5 – Military Medical Personnel

  • A.     Personnel in the U.S. MHS
  • B.     Military Medical Recruitment
  • C.     Military Medical Training

                        1. Initial Training
                        2. Collective Training & Exercises


Section 6 – Civilian-Military Relations

  • A.     Formal Civ-Mil Agreements
  • B.     COVID-19 as an Example of Civ-Mil Coordination



Section 7 – U.S. Military Medical History

  • A.     Abridged Summary of U.S. Military Medical History


References


Leaders in the Military Health System

Leading the U.S. Military Health System (MHS) are the Assistant Secretary of Defense for Health Affairs (ASD[HA]), the Joint Staff Surgeon (JSS) and the Service Surgeons General, and the Director of the Defense Health Agency (DHA). The ASD(HA) is a civilian official who is responsible for overseeing health policy and budgeting across the MHS. The JSS is the chief medical advisor to the Chairman of the Joint Chiefs of Staff and coordinates health services within the Department of Defense. The Service Surgeons General are the senior medical leaders of each military service branch. The DHA is a combat support agency that provides shared health services across the MHS.

Assistant Secretary of Defense for Health Affairs

Ms. Seileen Mullen is currently serving as the Acting Assistant Secretary of Defense for Health Affairs. In this role, she is the principal advisor to the Secretary of Defense and the Undersecretary of Defense for Personnel and Readiness for all Department of Defense health and force health protection policies, programs, and activities.

Link to official biography: Ms. Seileen Mullen | Health.mil

Joint Staff Surgeon

Major General (MD.) Paul Freidrichs serves as the Joint Staff Surgeon. He provides medical advice to the Chairman of the Joint Chiefs of Staff, the Joint Staff and the Combatant Commanders. He coordinates all issues related to health services, to include operational medicine, force health protection and readiness among the combatant commands, the Office of the Secretary of Defense and the services.

Link to official biography: Maj. Gen. Paul Friedrichs > Joint Chiefs of Staff > Article View (jcs.mil)

Link to public affairs: Contact Us (jcs.mil)

Surgeon General of the Army

Lieutenant General R. Scott Dingle is The Surgeon General and Commanding General, U.S. Army Medical Command. Prior to assuming the acting position, he served as the Deputy Surgeon General and Deputy Commanding General (Support), U.S. Army Medical Command, from April 2018 to August 2019. 

Link to official biography: Lt. Gen. R. Scott Dingle | Health.mil

Surgeon General of the Navy

Rear Admiral (upper half) Bruce L. Gillingham serves as the Surgeon General of the Navy, N093/chief, Bureau of Medicine and Surgery. He has served in various positions throughout Navy Medicine to include director of Pediatric Orthopedic and Scoliosis Surgery; Associate Orthopedic Residency Program director; and director of Surgical Services. While assigned to Naval Medical Center San Diego, he was instrumental in establishing the Comprehensive Combat and Complex Casualty Care Center (C5).

Link to official biography: Rear Adm. Bruce L. Gillingham | Health.mil

Surgeon General of the Air Force

Lieutenant General Robert I. Miller is the Surgeon General, Headquarters U.S. Air Force, and also serves as the Surgeon General of the U.S. Space Force. In this role, he advises the Secretary of the Air Force, the Air Force Chief of Staff, the Space Force Chief of Space Operations and the Assistant Secretary of Defense for Health Affairs on matters pertaining to the medical aspects of the air expeditionary force and the health of Airmen and Guardians. 

Link to official biography: Lt. Gen. Robert I. Miller | Health.mil

Director, Defense Health Agency

Lieutenant General Ronald J. Place is the Director, Defense Health Agency (DHA), Defense Health Headquarters, Falls Church, Virginia. He leads a joint, integrated Combat Support Agency enabling the Army, Navy, and Air Force medical services to provide a medically ready force and ready medical force to Combatant Commands in both peacetime and wartime. 

Link to official biography: Lt. General Ronald J. Place | Health.mil



MHS Web Site Links

U.S. Military Health System Official Website: MHS Home | Health.mil

U.S. Army Medical Department Official Website: Home | Army Medicine (health.mil)

U.S. Navy Bureau of Medicine Official Website: Home (navy.mil)

U.S. Air Force Medical Service Official Website: The Official Home Page of the AFMS



Section 1 – National Context and Summary

A. Geostrategic Situation Overview

The United States and its allies operate in a progressively complex, ambiguous, and interconnected global security environment that is marked by the increasing threat of great power competition and the constant risk of radicalized transnational and extremist actors. Preparing to respond to all these factors leads to competition for limited resources and leadership attention. This challenging security environment continues to unfold amid the disruption of a global pandemic, new and emerging technologies, and the diffusion of world power. These new challenges are interacting in unpredictable ways, ways that will continue to test abilities to respond, but also provide new opportunities to partner with allies on innovative global solutions (Office of the Director of National Intelligence, 2022).

B. Organization of Department and Armed Forces

The Department of Defense is America’s defense. The Department’s mission is to provide the military forces needed to deter war and ensure national security. The Department’s traces its history to pre-Revolutionary times and has grown to become America’s largest government agency. See measures in figure 1 below (Department of Defense, 2022).

PhotoFigure 1 - Department of Defense Metrics










PhotoFigure 2 - Library of Congress Photo by Theodor Horydczak (circa 1947)

The Department of Defense is headquartered in Arlington, Virginia in the Pentagon. The Pentagon is the world’s largest low-rise office building. It sits across the Potomac from the U.S. Capitol in Washington, D.C. It holds three times the floor space of the Empire State Building. The iconic five-sided building, pictured in figure 2, finished constructed on 15 January 1943 and hosts the Department to this day.

The Department is organized in a joint structure that is managed by the Secretary of Defense, advised by the Joint Chiefs of Staff (JCS), manned by the Services, employed by the Combatant Commands (CCMD), and supported by Combat Support Agencies (CSA). There are six active components of the Armed Forces: Army, Marine Corps, Navy, Air Force, Space Force, and Coast Guard. There are twenty CSAs and eleven CCMDs. 

Joint operations are led and enabled through the coordination of the JCS. The Chairman of the Joint Chiefs of Staff (CJCS), as the senior ranking member of the Armed Forces, is responsible for achieving a unified strategic direction and command of the combatant forces. The CJCS is responsible for integrating land, sea, and air forces into an efficient team that is directed by the President and Secretary of Defense (Department of Defense, 2022). Also, per 10 U.S. Code 163, the President or Secretary may direct the Chairman to assist in performing their command function and as the direct communicator to and from the combatant commands. See the DoD authority visualization in figure 3.

PhotoFigure 3 - Department of Defense Authority, Direction, & Control Diagram
















Section 2 – Organizational Structure

A. MHS Organization Overview

The U.S. Military Health System (MHS) is organized and structured like the Department of Defense, with the authority, direction and control running from the President to the Office of the Secretary of Defense (OSD), coordinated through the Joint Chiefs of Staff, to the Combatant Commands, with combat forces provided by the Services, and defense enterprise support provided by Combat Support Agencies. First, this means that the Assistant Secretary of Defense for Health affairs (ASD[HA]) within the Office of the Undersecretary of Defense for Personnel and Readiness (USD[P&R]) is the senior most official of the MHS and oversees health policy and defense health program budgeting, excluding warfighting health capabilities budgeted for and managed by the military Services. The Joint Staff Surgeon is responsible for coordinating all issues related to health services, to include operational medicine, force health protection, and readiness. The Combatant Commands are responsible for planning for and executing operational health services in support of Joint operations. The Services are responsible for recruiting, equipping, training, and the readiness of the medical force. Lastly, the Defense Health Agency provides a host of shared health services across the MHS, such as Military Treatment Facilities (MTFs) and pharmacy services, medical logistics, and medical research. It also supports health information technology systems for the joint force (Defense Health Agency, 2022). See the summary organizational diagram in figure 4.


Photo













B. Health Care in the U.S. & Military Health Care

The United States has a mixed public-private health care system. The U.S. Government (USG) provides funding for healthcare through Medicare for people over the age of 65, Medicaid for people with limited income, and Children’s Health Insurance Program (CHIP) for uninsured children in families with modest incomes. U.S. citizens not receiving USG assistance purchase insurance on their own or through an employer. As a mixed system, it is financed in part privately and in part by the USG through taxes.

The U.S. MHS is the most comprehensive military medical enterprise in the world. The MHS has a dual mission, to care for the health and welfare of military personnel so they can accomplish their own missions, known as a “medically ready force”, and to deliver health care during a conflict, also known as delivering a “ready medical force”. The U.S. MHS is how the Military cares for its personnel, retirees, and families, as it is legally required to do (Mendez, 2021).

 

Section 3 – Firm Base Health System

A. Hospital Services

The U.S. MHS operates 49 hospitals or inpatient facilities (32 in the U.S.), 465 military ambulatory care and occupational health facilities (373 in the U.S.), 192 dental clinics (149 in the U.S.), and 250 veterinary facilities (185 in the U.S.). The MHS also offers a civilian network of providers for additional health care services beyond those of the military hospitals and clinics (Defense Health Agency, 2022). See the medical facilities locations below in figure 5 (Department of Defense, 2022).

PhotoFigure 5: Locations-of-333-Department-of-Defense-Military-Treatment-Facilities-providing-data-to.png (600×373) (researchgate.net)
















Across all these facilities, the U.S. MHS has adopted the principles of high reliability organizations with a quadruple aim of improving readiness, providing better care, providing better health, and lowering costs. The facilities offer a wide array of health capabilities which are organized into clinical communities. Clinical communities are interdisciplinary networks of MHS providers who aim to provide the best patient care possible in their field. The communities include Behavioral Health, Neuromusculoskeletal, Primary Care, Women and Infant, Dental, Critical Care/Trauma, Surgical Services, Oncology, Cardiovascular, Complex Pediatrics, and Military-Specific Care (Department of Defense, 2021). Two model MTFs to highlight are Landstuhl Regional Medical Center and Walter Reed National Military Medical Center.

The Walter Reed National Military Medical Center is the world’s largest joint military medical center. It has over 2.4 million square feet of clinical space that provides services to more than 1 million beneficiaries a year (Department of Defense, 2022). The flagship of U.S. military medicine, it is also known as the “President’s Hospital” or the “Nations Medical Center”. Over the years the Nations Medical Center has served every President of the United States, members of Congress and  the Supreme Court, and other U.S. leaders. The facility is pictured in figure 6.

PhotoFigure 6 - Walter Reed Bethesda











The Landstuhl Regional Medical Center is a center of gravity for quality, compassionate, and safe care in Germany. Medical-surgical teams at Landstuhl have saved the lives of wounded warriors from Africa, the Middle East, and Europe. The facility and its teams have helped advance en-route care and surgical care through innovative changes to plasma transfer and extracorporeal life support. Landstuhl has also hosted rotations of civilian surgeons (Pellerin, 2012). The facility is pictured in figure 7.

PhotoFigure 7 - Landstuhl Regional Medical Center











B. Healthcare beneficiaries 

The U.S. MHS, through the TRICARE program, serves approximately 9.6 million beneficiaries. See the table below for details (Defense Health Agency, 2022).

Type of Beneficiary 

Approximate Number of Beneficiaries
 (Total: 9.6 million)

Active-Duty Service Members

1.41 million

Active-Duty Family Members

1.64 million

National Guard and Reserve Members
 (includes active and inactive members)

230,000

Family Members of National Guard and Reserve Members

830,000

Retirees and Family Members <65

3.17 million

Retirees and Family Members ≥65

2.34 million

Table 1 - MHS Beneficiaries


The U.S. MHS saw the following number of admissions, visits, births, and prescriptions filled in 2020 (Defense Health Agency, 2022).


Type of Care

Annual Workload Summary 

Inpatient Admissions

  • ·         Total: 870,8000
  • ·         Military Facilities:166,800
  • ·         TRICARE-authorized Facilities: 335,200
  • ·         TRICARE For Life: 368,7000

Outpatient Visits

  • ·         Total: 92,100,000
  • ·         Military Facilities: 33,500,000
  • ·         TRICARE-authorized Facilities: 31,700,000 
  • ·         TRICARE For Life: 26,900,000

Births

  • ·         Total: 105,500
  • ·         Military Facilities: 32,900
  • ·         TRICARE-authorized Facilities: 72,600

Prescriptions Filled

  • ·         Total: 108,100,000
  • ·         Military Pharmacies: 37,600,000
  • ·         Network Pharmacies: 23,800,000
  • ·         Home Delivery: 5,000,000
  • ·         TRICARE For Life: 41,700,000

Emergency Department Visits

  • ·         Total: 3,398,800
  • ·         Military Facilities: 982,400
  • ·         TRICARE-authorized Facilities: 1,426,100
  • ·         TRICARE For Life: 990,300

Table 2 - MHS Patient Care Numbers


C. Military Medical Research capabilities

In general, the U.S. MHS uses a coordinated, “requirements-driven,” life cycle approach to investment in medical research. Research funds are awarded competitively based on formal requirements to researchers in the biomedical community and civilian academic institutions. Research is guided by MHS staff on multidisciplinary committees and is informed by MHS clinical communities most closely associated with the research program. 

See the abridged list of Military Medical Research and Funding organizations that enable Civilian-Military collaboration broken out below.

1. Civilian-Military Research Collaboration bodies:

For example, the first body in the abridged list, the U.S. Medical Research and Development Command (MRDC) is the arm of the Army responsible for medical research, development, and acquisition. Headquartered in Fort Detrick, MD, it has a global footprint with eight subordinate commands around the world (see figure 8 below). The medical research labs explore chemical and biological defense, combat casualty care, and clinical medicine. The MRDC directs an expansive external research program in cooperation with academia, industry, and other government organizations (U.S. Army, 2022).


PhotoFigure 8 -MRDC Command Locations














Through this collaboration, U.S. MHS research has resulted in portable products and procedures that broadly benefit medical communities. The following table of Knowledge and Materiel Products resulting from Department of Defense funded research and development in Trauma and Intensive Care gives an example of important contributions of U.S. MHS research outcomes to civilian medicine (Rasmussen, Kellermann, & Rauch, 2020).

2. Trauma and Intensive Care Research: 

PhotoTable 3 - US MHS Research Outcomes for Trauma and Intensive Care




















It is important to note that MHS medical research is not exclusively a requirements-driven process. The Department of Defense also sets aside funding for the Uniformed Services University of the Health Sciences (USUHS) to conduct “investigator-initiated” research.  As the U.S.’s leadership academy for military health, USUHS plays a pivotal role in conducting research. Housed in the Walter Reed National Military Medical Center, USUHS partners with military medical centers and civilian universities around the world. 


3. Military Medicine Academic Journals

The U.S. MHS is built on a foundation of data transparency and an integrated and collaborative health care delivery system. A part of that foundation is the Military medicine academic Journals, with novel and relevant biomedical research, that have been developed. One example is the U.S. Army’s The Medical Journal. It is a quarterly, peer-reviewed, professional journal that is distributed worldwide (U.S. Army, 2022). Another example is the Military Medicine journal. It is the official international journal of AMSUS, the Society of Federal Health Professionals. Military Medicine aims to provide a space to discuss problems relevant to government health care. 

Articles and citations from The Medical Journal (link) and Military Medicine are also compiled into PubMed (link), the National Library of Medicine’s journal citation database, which has over 34 million citations and abstracts (National Institute of Health, 2022).

 

Section 4 – Operational Capabilities

A. Overview of Operational Military Medicine Concepts

High-level U.S. MHS Operational Medicine concepts and doctrine are available to the public online. For example, the Joint Concept for Health Services and Joint Publication (JP) 4-02, Joint Health Services, two fundamental guiding documents for Operational Medicine, are found here and here.

Operational Medicine has four main components, (1) generating and conserving the force, (2) posturing the force, (3) protecting the force, and (4) enterprise support. Generating and conserving the force includes activities that ensure individual medical/health readiness for operations, such as education, training, treatment, and preventative care. Posturing the force includes activities that govern the disposition and state of medical capabilities that support Combatant Commands, such as partner engagement, medical logistics, and facility locations. Protecting the force includes activities to defend a healthy individual, unit, and base, such as health surveillance, public health, or protective equipment. Enterprise support activities are those that develop and maintain the force, such as research and development, financial management, and acquisition.


B. Medical Operational Capabilities

From point of injury (POI) to recovery at a hospital providing definitive care, the U.S. MHS delivers a breadth of Medical Operational capabilities across its Services. See figure 9 for a detailed breakdown.


The U.S. and many of its allies use roles of care in doctrine to describe battlefield medical capabilities. The abbreviated U.S. MHS roles are:

  1. Role 1 – First Responder Care:
    this level of care is the first medical care received by the injured party, be it buddy aid, a medic, or self-aid.

  2. Role 2 – Forward Resuscitative Care:
    this level of care provides advanced trauma management and emergency medical treatment, typically considered to be a highly mobile treatment facility.

  3. Role 3 – Theater Hospitalization:
    this level of care is provided in a military treatment facility (MTFs) that is staffed and equipped to provide care to all categories of patients.

  4. Role 4 – Definitive Care:
    this level of care is provided in U.S.-based hospitals and robust overseas MTFs.

PhotoFigure 9 - JP 4-02 Notional U.S. Military Roles of Medical Care




























Across these four levels of care, the U.S. has unique and comprehensive medical capabilities. The United States Air Force (USAF) aeromedical evacuation (AE) system is one of these unique capabilities. The AE system is integral not only to military evacuation, but also to the U.S. National Disaster Medical System (NDMS) and civil-military operations. USAF AE is the only entity in the world capable of safely transporting large numbers of patients over 

PhotoFigure 10 - 379th EAES loading a C-130

long distances at all levels of criticality (Bruce R. Guerdan, 2011). In U.S. military operations overseas, or in the case of a natural disaster at home, the USAF AE has the sole responsibility to move mass numbers of casualties outside of combat zones or affected areas.

A unit that is a part of the AE system is the 379th Expeditionary Aeromedical Evacuation Squadron (EAES). Soldiers in the 379th are qualified to convert the C-17 Globemaster III, C-130 Hercules and KC-135 Stratotanker aircraft into a flying hospital. The 379th EAES often provides short-notice, urgent in-flight care with a survival rate of over 99%, transporting patients from U.S. Central Command to Al Udeid Air Base in Qatar (Perdue, 2020).

C. Overseas & Operational Deployments 

The U.S. sustains the most active-duty troops abroad of any country in the world, with over 175,000 overseas as of 2022 (Central Intelligence Agency, 2022):

5,000 Africa65,000 Europe125 Philippines
1,700 Australia150 Greenland26,500 South Korea
250 Diego Garcia6,200 Guam200 Singapore
150 Canada370 Honduras100 Thailand
650 Cuba56,000 Japan
290 Egypt15,000 Middle East


The U.S. places its troops using a global force management framework in support of strategic guidance to conduct military operations, peace keeping missions, aid in disaster relief, and foster multi-National cooperation.

1. Overseas Contingency Operations

Of the overseas contingency operations conducted from 2021 to 2022, there are two particularly high visibility operations that U.S. Armed Forces have led: Operation Inherent Resolve (OIR) and Operation Allies Refuge (DoD Inspector General, 2021). 

OIR is the name of the U.S. military effort to intervene and defeat the Islamic State of Iraq and the Levant (ISIL). Started in 2014, this ongoing military operation is mainly led by U.S. air power in support of national allies like the Iraqi security forces and Syrian Democratic Forces.

PhotoFigure 11 - USAF C-17 evacuates 823 fleeing Afghans

Operation Allies Refuge is the name of the U.S. military effort that led to the largest airlift in U.S. history of over 120,000 U.S. citizens, Afghans, and other foreign allies (Nicole Gaouette, 2021). As Kabul and the Islamic Republic of Afghanistan fell to the Taliban in August of 2021, Afghan citizens, foreign citizens, and U.S. and NATO forces searched for a swift and safe exit. It became a point of multi-national collaboration with over 30 countries supporting the evacuation.

The U.S. Military Health System (MHS) played a key role in the evacuation by providing care to fleeing Afghans and allies. The Landstuhl Regional Medical Center, highlighted in Section 3, supported more than 35,000 Afghan refugees with primary, preventative, and emergency care. The U.S. MHS overcame the supply, logistical, security, and cultural challenges that come with a rapid influx of patience and provided accommodating, committed, and effective care at Landstuhl and other hospitals during the evacuations (Freeman, 2022).

PhotoFigure 12 - Protective Equipment Demonstration January 2015

Overseas contingency operations can take many forms, including a multinational, interagency global health engagement to provide public health assistance. The Ebola virus disease (EVD) outbreak of late 2013 was a tragic example of this. EVD swiftly overwhelmed the medical capabilities of Sierra Leone, Liberia, Guinea, and much of the international emergency medicine community. This spurred more than 2,000 DoD personnel in support of Operation United Assistance (OUA) to deploy to Liberia’s capital, Monrovia. OUA led the fight against EVD by testing Ebola samples, constructing treatment units, and providing logistical support and training to national medical response, showing the Department of Defense’s (DoD) ability to answer to a unique, international operation (Joint and Coalition Operational Analysis (JCOA), 2016).


2. Disaster Relief 

The U.S. military provides disaster relief around the globe. It is a core capability of the DoD. Typically done in assistance to other U.S. Government agencies, the operation is known as Humanitarian Assistance and Disaster Relief (HADR).  

The Department has shown its positive impact on disaster response both at home and abroad:

  • Philippine typhoon in 2013 – U.S. military partnered with the Philippine military and provided essential medical treatment and supplies.
  • Nepal earthquake in 2015 – U.S. military provided transportation, medical treatment, and training exercises to support host nation capacity to respond to the crisis.
  • U.S. North Carolina hurricane in 2018 – Over 12,000 active and reserve U.S. military forces conducted rescue operations, transportation services, and delivered vital supplies.

The DoD is poised to provide disaster relief support when Nations request assistance. The engagements provide irreplaceable hands-on experience and a unique humanitarian mission. The value of multi-national, partnership-building disaster relief support has been proven as partner Nations display improved disaster response capabilities after joining U.S. Military exercises (Defense Health Agency, 2022).


3. Multi-National Military Medical Organizations

The DoD has a long-standing history of global health engagement to maintain a force ready to deploy anywhere in the world. The Department strengthens its global reach through joint medical exercises and health initiatives with multi-national partners. In these engagements the DoD aims to support and strengthen partner nations, improve interoperability, and improve U.S. capabilities. To that end, the U.S. is a party to a key multi-National military medical organization through NATO (Defense Health Agency, 2022).

Since its founding in 1949, the North Atlantic Treaty Organization (NATO) has developed a robust Military Medical arm. The NATO Centre of Excellence for Military Medicine in Hungary, the Multinational Medical Coordination Centre/European Medical Command in Germany, and the Committee of the Chiefs of Military Medical Services (COMEDS) in NATO play significant roles in facilitating international military medical collaboration, coordination, and expertise (NATO, 2022).

 

Section 5 – Military Medical Personnel


A. Personnel in the U.S. MHS

The U.S. MHS is one of the largest health providers in the nation, delivering care to over 9.6 million beneficiaries. The MHS provides this care through Military Treatment Facilities (MTFs) or through networks of participating civilian facilities. The MHS directly employs over 134,000 personnel across the globe, not including additional medical personnel funded by the Services, see table 4 below.


Personnel

Number MHS Funded for FY21

Civilian

56,920

Military

Total: 77,317

Officer: 27,495

Enlisted: 42,822

Total

134,237

Table 4 - MHS Defense Health Program Funded Personnel


B. Military Medical Recruitment

The U.S. MHS is structured such that the Service medical departments are responsible for recruiting, organizing, and training medical forces for DHA and Combatant Commanders. Therefore, the Services - Army, Air Force, and Navy - have a wide array of means and paths for recruiting the long list of medical roles available including doctors, nurses, pharmacists, and audiologists.  

For physicians, for example, the U.S. Military covers the high cost of medical school in exchange for a commitment to serve and provides the added benefit of unique training and experiences. Three illustrative pipelines for practitioner recruitment are (Department of Defense, 2022):

  • Health Professions Scholarship Program: covers medical school costs and provides training opportunities.
  • Uniformed Services University of the Health Sciences: known as “America’s Medical School” USU provides no-cost medical school with world-class medical training and leadership development programs.
  • Part-Time Service: participants in the Medical Dental Student Stipend Program, provides monthly compensation for civilian medical school in exchange for service in the Reserve or Guard.


C. Military Medical Training 


1. Initial Training

Much like recruitment, the U.S. Armed Forces initial trainings and medical trainings are managed by the Services and therefore vary based on soldier branch, role, and specialty. All U.S. Services have challenging, world-class initial entry training. New recruits go through basic training to learn elementary soldiering skills, such as weapon handling, first aid, fitness, and discipline. See table 5 below for a comparison of duration and locations of Service initial entry training:

Army Basic Combat Training

Marine Corps Recruit Training

Navy Boot Camp

Air Force Basic Military Training

Coast Guard Recruit Training

10 weeks

12 weeks

7-9 weeks

8.5 weeks

8 weeks

Fort Benning

Fort Benning, Ga.

 

Fort Jackson

Columbia, S.C.

 

Fort Knox

Louisville, Ky.

 

Fort Leonard Wood

Waynesville, Mo.

 

Fort Sill

Lawton, Okla.

Marine Corps Recruit Depot, Parris Island

Parris Island, S.C.

 

 

Table 5 - U.S. Service Basic Training Comparison

 

 
 Marine Corps Recruit Depot, San Diego


Great Lakes Recruit Training Depot

Great Lakes, Ill.

Lackland Air Force Base

San Antonio

Cape May Coast Guard Training Center

Cape May, N.J.

 Table 5 - U.S. Service Basic Training Comparison

Doctors in the U.S. MHS do not have to participate in basic training but typically require some initial military training. In the Army, instead of attending basic training physicians participate in Army Medical Basic Officer Leadership Course (BOLC), a 10–14-week course that covers basic soldiering skills and provides an orientation to the MHS.

Specialty military training naturally follows basic training. For example, after completing basic training enlisted Army soldiers contracted as medics go to the Combat Medic Specialist Training Program, a 16-week course in Fort Sam Houston, TX. Likewise for the other services, for which details on advanced training programs and training facilities can be found on Service specific publicly available web sites.


2. Collective Training & Exercises

The U.S. MHS uses military exercises to put training into practice. Military exercises simulate wartime operations as their realistic, complex scenarios train and test units on their readiness and preparedness for mobilizations. The U.S. MHS uses medical exercises to practice operational procedures, integrate units, and refine war plans. 

PhotoFigure 13 - 2016 JEMX at North Fort Hood

For example, on an annual basis the U.S. MHS hosts a culminating Military medical training event for physicians called the Joint Emergency Medicine Exercise (JEMX) at the Carl R. Darnall Army Medical Center in Fort Hood. The exercise trains and tests medical personnel in combat casualty care, aeromedical evacuation, and surgical care. This joint, multi-national exercise has over 2,000 participants with more than 60 medical specialties (LT Patrick R Engelbert, 2020).

The DoD fosters the connection between global health and global security by developing overseas joint international medical training exercises. As of 2021 the U.S. is in the early stages of planning with partner nations for a Medical Readiness Exercise (MEDREX) in Africa. The MEDREX intends to enable U.S. forces to train in unfamiliar environments, share medical procedures and enhance host nation surgery and trauma response. In the exercise the U.S. will partner with Morocco, Senegal, Ghana, Chad, South Africa, Kenya, and Rwanda (Department of State, 2022).

 

Section 6 – Civilian-Military Relations


A. Formal Civ-Mil Agreements

The Department of Defense (DoD) is committed to providing the highest levels of support for public health and domestic crisis. Formal agreements are in place at multiple levels to enable federal, state, local, and territorial interoperability, and collaboration. For example, the Federal Emergency Management Agency (FEMA) has established the National Response Framework (NRF) to guide national responses to all emergencies. The NRF spells out specific Emergency Support Functions (ESF) that define coordinating structures for emergencies for the interagency, built on the scalable concepts of the FEMA National Incident Management System (NIMS) (FEMA, 2022).

Beneath those broad frameworks, there are also interagency partnerships like the National Disaster Medical System (NDMS). The NDMS is a partnership between DoD and the Department of Health and Human Services (HHS), the Department of Homeland Security (DHS), and the Department of Veteran’s Affairs to develop unified responses to natural and man-made disaster needs (Defense Health Agency, 2022). These partnerships rely on military capabilities, like USAF AE, to transport and care for large numbers of complex patients, to fully support citizens in their time of need.

B. COVID-19 as an Example of Civ-Mil Coordination

The DoD is still working closely with HHS, DHS, and the State Department to protect and support the American people in the National and international response to the COVID-19 pandemic. Responding early and effectively, the DoD was the first U.S. Government Agency to 

PhotoFigure 14 - USNS Comfort in NYC amid COVID-19 Pandemic

restrict movement from China. Shortly after the World Health Organization officially identified the virus, the DoD provided 200 beds for State Department officials evacuating Wuhan, China. In early 2020 the DoD was swift to support HHS, providing four evacuee installations and eleven funnel airports to enable thousands of repatriations.

Throughout the pandemic the DoD provided testing capabilities, supplemented civilian education forces, procured respirator masks, deployed strategic medical equipment reserves, enabled rapid vaccine development, built alternate care facilities, deployed combat support hospitals, and deployed the USNS Comfort and USNS Mercy ships (Department of Defense, 2022).

PhotoFigure 15 - First TIS Operation at Ramstein Air Base, Germany, April 10, 2020

The Department also leveraged its history of global health engagement to address this modern crisis. The DoD used a modified evacuation method, developed initially for Ebola patients in 2014, to safely transport COVID-19 patients amid the pandemic. When loaded with the Transportation Isolation System (TIS), patients can receive care and the crew are protected in the Air Force’s C-130 Hercules and C-17 Globemaster III (Correll, 2020).

 




Section 7 – U.S. Military Medical History

A. Abridged Summary of U.S. Military Medical History

There is a long, storied, and celebrated history behind today’s U.S. Military Health System (MHS). There have been Medal of Honor recipients, groundbreaking medical discoveries and research, and major transformations in its history books. Over time the U.S. MHS has grown and changed in concert with advances and innovations in medical treatment, communications technologies, logistics, and travel. Changes in those areas have coincided with the general centralization of medical health services and capabilities. From the civil war, to WWI, WWII and beyond, the U.S. Military Health System has slowly shifted from exclusively providing organic, field medical assets to developing a more comprehensive capability with centralized, “general” medical assets with unified casualty collection and treatment, while still maintaining the ability to rapidly deploy and support in a decentralized manner. 

Since the initial development of formal care programs for service members and their families in the 1950s and 60s, the U.S. MHS has continued to evolve its capabilities and benefits. Even recent history shows the MHS undergoing two major transformations. The first is a once in a generation reform effort of the management of Military Treatment Facilities. Previously administered and managed by the Army, Navy, and Air Force, Military hospitals and clinics now fall under the responsibility of the Defense Health Agency. This transformative effort began in 2018 and the process is enabling standardization, improving dissemination of best practices, and increasing overall access to care across the MHS. The second transformation is the MHS’s new electronic health record system. Dubbed MHS GENESIS, the new system is providing a single health record that is interoperable across the continuum of care using enhanced and secure technology (Defense Health Agency, 2022).

As the U.S. MHS looks at the past to improve care for the future, they rely on Military historians. The National Museum of Health and Medicine is not Service specific and takes a comprehensive look at American Military medicine. The museum offers a unique opportunity for visitors because it is one of the few places that the public can see the effects of disease on the human body. The museum has interactive displays, historic artifacts, and much more. Learn more here: National Museum of Health and Medicine | Health.mil

In addition to the comprehensive perspective of the National Museum of Health and Medicine, the U.S. has branch specific historians and resources as well. Their websites can be found here:

 


 


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