Germany, Federal Republic (Joint Medical Service)

Basic Task of the Military Medical Service

The core task of the Bundeswehr Joint Medical Service (BwJMS) is to protect, sustain and restore the health of service personnel.

The spectrum of health care services in the Bundeswehr is tailored to the requirements of operations abroad and is the product of all capabilities and capacities needed for protecting, maintaining, promoting and restoring the physical and mental health, social well-being and operational readiness of the soldiers in accordance with current scientific and technological standards. These services include tasks of preventive medical care, free health services, military medicine, dental medicine, veterinary medicine, military pharmacy (including food chemistry), CBRN medical defence and other tasks under public law. 

From this spectrum, specific services will be provided for soldiers in the fields of health care, medical training and medical support. The guiding principle for the quality of medical care during deployments abroad is to guarantee a treatment outcome that, in terms of quality, corresponds to medical standards in Germany. For that purpose, the medical service engages in specific projects of cooperation with national military and civilian partners also under the aspect of burden-sharing.

Structure

Consistent orientation towards mission-related tasks, the streamlining of command and control structures and the continued focus on tasks that require a medical licence are essential determinants of the Bundeswehr Joint Medical Service.

In order to achieve these goals and maintain personnel sustainability, the Bundeswehr Joint Medical Service comprises a total of approximately 18.000 military and 3.000 civilian posts.

          

                                 

                   The Surgeon General is the commanding general of the German Joint Medical Service and, in medical matters, exercises control over the medical services of all other services and branches of the Bundeswehr.

He also commands the Bundeswehr Medical Service Headquarters (BwMS HQ) located in Koblenz, which at field army level is the highest military medical command in Germany. It is under the direct control of the Federal Ministry of Defence (FMoD).

All command and control structures of the Bundeswehr Medical Service are organized at the Bundeswehr Medical Service Headquarters, focusing on a process-oriented organisation rather than on customary staff branches. In the training branch, for example, staff from personnel management works alongside with staff from operations and readiness.

The Bundeswehr Medical Service Headquarters (BwMedSHQ) is directly subordinated to the Federal Ministry of Defence and supports the Surgeon General of the Bundeswehr in carrying out his duties. Therefore all processes for the Bundeswehr Joint Medical Service, such as planning, leadership, control and steering, are coordinated on one tier. That also applies to the professional leadership of the medical services in the branches of military services and military organization sector. The planning conceptually anticipates potential future military operations and evaluates the capabilities and resources required to fulfill the mission. Thereby all activities will be considered, which are aligned to the future composition of the medical service as an enabler in combination with all armed forces. Primarily the fulfillment of the commitments made to the NATO and EU as well as the national functional guidelines and timelines for the medical care pursuant to NATO standards are directive for the planning. The national implementation of these framework specifications takes place via the system networks of the capability profile of the Bundeswehr. The scope, capabilities and the material equipment are determined by the planning variables of the essential users (especially the army, air force and navy) with regard to the strength of the personnel approach and the requirements for protections and mobility.

At the same time BwMedSHQ assumes the function of a monitoring authority for the Bundeswehr in the field of public law supervision, insofar as this has been transferred to the BwMedSHQ by statutory regulations.

The large number of challenging tasks and the presence of high-ranking representatives of the Bundeswehr Joint Medical Service clearly shows the complexity of the task as well as the importance of the BwMedSHQ.

Good health care is based, among other things, on high-quality equipment and facilities. The rapid development cycles in medical technology must also be met in the Bundeswehr Joint Medical Service. This is the only way to achieve appropriate treatment results based on state-of-the-art science and technology. Current procedures in the procurement of commercially available medical equipment cannot keep pace with this at present. In order to accelerate the procurement of medical material by the Federal Office for Infrastructure, Environmental Protection and Services of Bundeswehr, a functional element was set up in the Bundeswehr Medical Service Headquarters. Another goal is to relieve the Federal Office of Bundeswehr Equipment, Information Technology and In-Service Support.   By transferring the procurement of non-weapon system-related products (including commercially available medical material) to the Federal Office for Infrastructure, Environmental Protection and Services of Bundeswehr, the aim is to focus the Federal Office of Bundeswehr Equipment, Information Technology and In-Service Support on its core task. It was possible to achieve an initial capability with own forces and resources. Full establishment will only be possible in the medium term.

The task spectrum covered ranges from cross-border crisis management to collective and national defence. A particular focus is on CBRN (chemical, biological, radiological, nuclear) medical defence and on the coordination of strategic, supra-national medical evacuation.

The Medical Service Command maintains an Operations Center dealing with special challenges. The COVID 19 pandemic required the bundling of information, preparations and central support decisions in the course of administrative assistance. The medical support for the reinforcement of NATO's eastern flank in connection with the war in Ukraine and the management of war casualties are currently being coordinated in the Operations Center.

A feature unique to the Medical Service is its responsibility for the organisation and management of Strategic Aeromedical Evacuation (StratAirMedEvac) operations. The responsibility includes stationing, military security, alerts and mobilisation.

Its responsibility for the organisation and management of Strategic Aeromedical Evacuation (StratAirMedEvac) operations is a unique feature of the Medical Service. The responsibility includes stationing, military security, alerts and mobilisation.

As regards equipment, medical materiel logistics and protective tasks, Bundeswehr Medical Service Headquarters in particular takes charge on a centralised basis, of the following tasks for Bundeswehr routine duty at home and on deployment:

• conducting of duties to be carried out by the person in charge of operational and supply responsibility in order to maintain deployment capability and readiness for operations; 
• development of basic requirements and principles for the equipment of the Bundeswehr Joint Medical Service;
• conceptualization of technical requirements in relation to medical materiel logistics to support the provision of medical care;
• estimation of the situation, planning and issuance of orders in relation to logistics;
• management of logistics personnel in the Bundeswehr Joint Medical Service; and
• execution of protection duties for CRBN defence and self-protection in the Bundeswehr Joint Medical Service.

In 2019 the Multinational Medical Coordination Centre / European Medical Command (MMCC/EMC) was established in Koblenz. Task of the MMCC/EMC is to provide coordinating support to the medical services of NATO and EU. The experience made in the management of large-scale medical emergencies or the Ebola crisis has shown that the interdependencies between public health protection and external and internal security are increasing. A future core task of MMCC/EMC will be civil-military cooperation, in particular with the organisations and institutions of the EU nations and establishments. MMCC/EMC supports in the provision and assessment of the medical situation picture for NATO and EU, which is jointly developed with the nations and NATO/EU organisations.

The five Bundeswehr Hospitals are commanded directly by the BwMSHQ. Therefore, a division of hospital management is integrated into the command structure of the BwMSHQ under the direct control of the Deputy Commanding General of the BwMSHQ. 

Five Bundeswehr Hospitals located in Koblenz, Ulm, Berlin, Hamburg and Westerstede are directly subordinated to the Bundeswehr Medical Service Headquarters as well as the Central Institutes of the Bundeswehr Medical Service at Kiel and Munich and Supervisory Centers for Public Law Tasks of the Bundeswehr Medical Service North (Kiel), West (Koblenz), East (Potsdam) and South (Munich). 

The military hospitals take care of a multitude of tasks, which are all necessary to maintain the basic operation of the hospitals. As part of the findings from our participation in missions, since 2007 the military hospitals consistently have been aligned to the requirements for the provision of medical care in use. Without the execution of all these tasks, an adequate treatment of the personnel on missions would be impossible.

Therefore, military hospitals treat military personnel as well as civilian patients. To acquire the requested spectrum of patients, the military hospitals are involved in the civilian land-based and airborne emergency service in the respective region. The military hospitals include a capacity of 1811 beds to serve as training centres for our medical personnel, to have a suitable range of diseases and injuries and to have special skills to treat patients with (poly)trauma, patients with mission-related mental and psycho-traumatic disorders and patients with infectious diseases. Of their total of 1811 beds, 787 are approved for civilian inpatient care and thus serve as a contribution to the overall German healthcare system. Without this integration in the civilian health care system, the military hospitals would not be able to fulfil their task to qualify the physicians for missions. Thus a relevant spectrum of patients and a relevant mix of medical cases or injuries is needed, in order  to prepare the physicians for their duties.

The military hospitals thus form the central part of the commitment to ensure the effectivity of the medical service. In addition to the provision of their own staff for missions abroad, they are primarily responsible for the medical education of members of the Medical Corps, pre-deployment training, continuing education and training of our medical specialists.

At the division level, two commands and the Bundeswehr Medical Service Academy are subordinate to the Bundeswehr Medical Service Headquarters.

The leadership mission "medical support on operations" is executed at Operational Medical Support Command (OMSCOM) in WEISSENFELS. Subordinate to this capability coordination command are four medical regiments, Medical Training Regiment, and Medical Service Rapid Reaction Regiment, as well as three Medical Logistics Centres. Operational Medical Support Command in WEISSENFELS – as kind of "permanent lead command" – is thus responsible for providing medical operational forces and for coordinating and steering their pre-deployment training. 

The Bundeswehr Joint Medical Service has four Medical Regiments, elements of which will be stationed at or close to Bundeswehr hospitals in order to strengthen the training and exercise system and to increase options for the mutual support between field units and Bundeswehr hospitals. Three Medical Regiments are located in Weißenfels/Berlin, Rennerod/Koblenz and Dornstadt/Ulm. The main task of the medical regiments is to provide personnel and material to maintain a hospital on deployment, augmented by medical specialists from the military hospitals and the regional medical facilities.

Related to collective defence and as a consequence of the latest NATO Summits, future medical units will be also stationed in the vicinity of the potential beneficiaries. That was one of the reasons the fourth Medical Regiment was recently stationed in Rheine.

In addition, the Medical Service Rapid Reaction Regiment in Leer combines all airmobile and airborne medical capabilities of the Bundeswehr Joint Medical Service to ensure that medical care and support are made available to troops on deployments abroad within a very short period of time. During longer deployments, rapid response forces are relieved by stabilization forces.

Basic training of medical trainee soldiers and pre-deployment training of medical personnel is provided by the Medical Training Regiment in Feldkirchen.

Regional Medical Support Command (RMSCOM) in Diez exercises command and control over all regional medical facilities in Germany. In numbers, there are 13 Medical Support Centres, 128 Medical Clinics, 15 Medical Clinics with Speciality Services and the Bundeswehr Centre of Sports Medicine. The aim is to ensure that military personnel  never is more than 30 kilometres or 30 minutes away from the nearest regional medical treatment facility.  

The spectrum of the Medical Support Centres includes Medical care by General Practitioners, dental care, medical care by specialists (out-patient clinics) and occupational health care. The Bundeswehr Centre of Sports Medicine provides advice to military sports teams, works in research on the topic of sports and preventive medicine, develops concepts (individual personal fitness training et alia) and has a significant part in the rehabilitation of personnel injured during missions abroad.

In addition, the Medical Support Centres are also in command of the 13 Medical Squadrons whose task it is to provide medical support to the troops.                                 

The Bundeswehr Medical Service Academy in MUNICH constitutes the fourth capability pillar. It is the central research, capability development and teaching facility of the Bundeswehr Medical Service. In addition, there are three available departmental research facilities within the FMoD area of responsibility for the field of CBRN medical defence.

Military Hospitals

Bundeswehr Central Hospital Koblenz: 509 beds, 23 medical departments

Bundeswehr Hospital Ulm: 496 beds, 20 medical departments

Bundeswehr Hospital Berlin: 367 beds, 16 medical departments

Bundeswehr Hospital Hamburg: 307 beds, 17 medical departments

Bundeswehr Hospital Westerstede: 135 beds, 10 medical departments (a cooperation of civilian and military facilities in one hospital)

Institutes, Research and Public Health

Veterinary and pharmaceutical laboratory diagnostics including potable water and food examination are provided by Central Institutes of the Bundeswehr Medical Service at Kiel and Munich.

Medical research in the field of detecting and preventing CBRN-Threats is conducted in the laboratories of the institutes affiliated with the Medical Service Academy in Munich. The Bundeswehr Institutes of Microbiology, of Pharmacology and Toxicology, and of Radiobiology are also stationed in Munich. The Bundeswehr Institute of Preventive Medicine in Andernach and provides research and operational assets for injury protection, health protection and surveillance capabilities.

                                                     

Medical Logistics

Medical logistics is provided by three Medical Logistics Centres located in Quakenbrück, Blankenburg and Pfungstadt.

The main task of a Medical Logistics Centre is to supply military missions and regional medical facilities with pharmaceuticals and medical devices. Pharmacists and pharmacy staff assure storing and shipment in accordance with national and international regulations.

Training and provision of personnel for military missions is another important aspect. The regional medical facilities are provided with advice on drug selection and proper usage of medicines. In addition, the centres provide repair and maintenance of medical equipment.

Thus, the Medical Logistics Centres cover a variety of logistical and pharmaceutical capabilities to ensure sufficient health care to the soldiers of the Deutsche Bundeswehr.

Field Deployments

Medical care for personnel who become ill, injured or wounded during deployment is provided through the medical evacuation chain. This chain of closely interlocking phases ranges from self and buddy aid through medical care in field medical treatment facilities to final clinical treatment and rehabilitation in Germany. The medical evacuation chain consists of four medical service treatment levels. Depending on the severity of the illness or injury, the patient will pass through some or all of these levels. Well-trained specialist personnel and efficient, mobile equipment are available for the benefit of personnel at all times.

First aid through self and buddy aid forms the start of the medical evacuation chain. Initial emergency medical care is rendered at Mobile Aid Stations (Role 1). Trained medical specialists perform on-site triage, shock and pain management as well as haemostatic measures. They also ensure the clearance of the respiratory tract and artificial ventilation.

Mobile Aid Station Role 1

Complimentary emergency diagnostic services and treatment are provided at Mobile Surgical Hospitals (Role 2). These are able to deal with acute injuries and disorders and the relevant surgeons and anaesthetists. A Mobile Surgical Hospital consists of mobile containers. Tents are used in some cases. The size and facilities of a centre are adapted to the requirements of each deployment.

                                                       

Mobile Surgical Hospital (enhanced)

Field Hospitals (Role 3) provide in-patient and out-patient specialist medical care. They have extended surgical, intensive care and specialist diagnostic and treatment facilities and, if necessary, can stabilise casualties for direct evacuation back to Germany.

Field Hospital Role 3

In relation to the type and severity of their injuries, casualties are generally transported back to Germany in specially equipped Bundeswehr aircraft within the framework of StratAirMedEvac. Special equipment includes Patient Transport Units (PTU) for the movement of intensive care patients. Six PTU can be installed in Airbus A-310 aircraft operated by the Deutsche Luftwaffe (German Air Force, see Luftwaffe).

Airbus A-310 with Patient Transport Units

      

 

The main elements at Role 4 level are the Bundeswehr Hospitals in Germany. If necessary, civilian hospitals and rehabilitation centres are also used. These facilities provide the further treatment of patients who have been evacuated from the area of deployment. As a rule, strategic air medical evacuation aircraft land in the reserved military zone of Cologne-Bonn airport. From there, patients are transferred to the Bundeswehr hospitals.


 Protected Casualty Transport Vehicles used (examples)

Yak

Hägglund (Photo: Medical Service/Laymann)

Boxer (Photo: Medical Service/Thiel)

Fuchs (Photo: Medical Service/Dittrich)

Eagle IV

Dingo 2

Wiesel 2

Current missions:

1999 – KFOR / Kosovo

2015 – CD / CBI Jordan / Iraq

2006 – UNIFIL / Lebanon

2008 – ATALANTA / Horn of Africa

2013 – MINUSMA / Mali

2013 – EUTM / Mali

2013 – MINURSO / West Sahara

2017 – eFP BG LTU / Lithuania

2019 – UNMHA / Yemen

Civil-Military Cooperation

The Bundeswehr cooperates with its civilian counterparts in terms of measures, personnel and resources. The purpose of the cooperation is to promote a closer relationship between Bundeswehr units on the one hand and civilian authorities and the civilian population on the other. 

The Bundeswehr Joint Medical Service has established seven centres for civil-military cooperation across Germany for subsidiary medical support.

These centres have the following capabilities:

-     Conducting triage and providing medical treatment within the scope of available capacities, operating facilities in the following medical support roles:

-     Role 1 – mobile aid station. (All-terrain) patient evacuation capacity and casualty decontamination capability required planning and allocation of the necessary medical personnel as determined by the Bundeswehr Medical Service Headquarters.

-     Role 2 – mobile surgical hospital. Requires at least one week of planning (including reconnaissance, transportation and setup) and allocation of the necessary medical personnel as determined by the Bundeswehr Medical Service Headquarters.

The above capabilities can only be provided with the involvement of medical personnel from the Bundeswehr hospitals and the Central Institute of the Bundeswehr Medical Service and, where applicable, only with the (involvement, kein guter Ausdruck) of materiel resources from the command area, since it may not be possible for one centre alone to provide these capabilities.

Medical Services of the Army, Navy, Airforce and Joint Support and Enabling Service

In the year 2000, the personnel of all medical corps of the branches of the armed forces were combined into the Bundeswehr Joint Medical Service. Only smaller subunits in every branch of the armed forces were left, led by their own surgeon generals. The surgeon generals are responsible for health and medical related aspects in view of their branches’ specialties.

The Army Medical Corps

The Surgeon General of the Army commands the Army Medical Corps on behalf of the Army Chief of Staff and the Surgeon General of the Bundeswehr as a specialized service. At the same time, he represents the interests of the Army with respect to the Surgeon General of the Bundeswehr and vice versa.

The Surgeon General of the Army is located in the German Army Headquarters and advises the Army Commanders directly on medical service matters and those relating to the Medical Services of the Army. All Corps and Division Surgeons, the Flight Surgeon of the Army, and the Senior Medical Officer in the Army Training Command work under his command.

Medical Service of the Rapid Response Forces Division 

The Medical Service of the RRFD works under the command of the Division Surgeon. The Special Operations and Air Maneuver Forces of the Army are located in this division. The potential deployments of the RRFD are characterized in particular by a high degree of mobility, air mobility, a high level of threat, the bridging of large distances with an appropriate distance to their own troops, surprise, speed and secrecy.

The specific characteristics of Army Special Operations and Air Maneuver Forces training, exercise and deployment are considered in medical services support, so that in the two paratrooper regiments of the Airborne Brigade and in the SOF their own medical personnel are organically deployed to support the troops.

Airborne mobile aid station and rescue vehicle BV 206 - optimized for the deployment of the airborne troops

The two independent Airborne Medical Companies of the Paratrooper Regiments are commanded by Medical Staff Officers. They each have an airborne patient treatment platoon, two airborne rescue platoons and their own Patient Evacuation Coordination Cell (PECC). The ability to parachute jump is an essential precondition in order to be able to follow without restriction the parachute regiments, which are to be supported in all deployment types/options. For this reason, both Airborne Medical Companies are fully capable of parachute jumping.

Deployments of the Special Operations Forces (SOF) of the Army receive medical support from air-mobile emergency physician teams and air-mobile medical teams, as well as air-transportable Role 1 facilities. An Air-Mobile Emergency Physician Team of the SOF consists of two Special Forces Senior NCO paramedics, a SOF emergency physician, and a driver. The Special Forces Senior NCO paramedics are fully trained as both commandos and paramedics. The SOF emergency physician is a Medical (Staff) Officer who is specialized in emergency medicine and SOF-specific infantry and other medical service training.

Wiesel 2 San – patient care optimized in terms of size and weight reduction

The option of being ready for deployment in special operations can only be guaranteedby the broad and in-depth training of everyone involved. The forces providing medical care must be aware of the effects of excessive heat in the desert, tropical conditions or extremely low temperatures in Arctic latitudes in the same way as they are acquainted with the clinical pictures? and specific features of the respective climate zones.

The Medical Service of the German Navy

The Medical Service of the German Navy ensures medical care for all seagoing and flying units of the fleet, deployed or in port, including the Navy´s special and specialized forces, using the very latest in medical technology and procedures. The Navy Medical Service provides health support for Navy operations and training ashore and afloat. It works closely together with the Bundeswehr Joint Medical Service to provide primary surgery and dental care during Navy operations and training afloat.

The Naval Medical Institute

The Naval Medical Institute covers the field of maritime medicine and the entire range of scientific, research, care-providing, preventive and teaching facilities. Due to the increasing importance of departmental research, it was divided into the three sections Maritime Medicine, Diving and Hyperbaric Medicine and Research and Education.

Deployments Afloat

The medical capabilities of deployed Navy units vary strongly and depend on the platform and the embarked personnel. All levels of medical care can be provided, ranging from two Role 2 naval rescue centres (NRC) in which several medical teams perform primary surgery within clinical timelines on a combat support ship, to surgeons and anaesthesiologists embarked on frigates, to shipboard physicians or highly trained ship´s paramedics performing pre-hospital emergency care.

German Air Force Centre for Aerospace Medicine (AFCAM)

By fusion of the former office of the Surgeon General German Air Force and the Air Force Institute of Aviation Medicine, a new institution was established in October 2013: the German Air Force Centre for Aerospace Medicine (Zentrum für Luft- und Raumfahrtmedizin der Luftwaffe (ZentrLuRMedLw). This centre covers all responsibilities for the “Aerospace Medicine” sector on behalf of the Bundeswehr including the Flight Medical Service of all flying units. While the Surgeon General of the Air Force is the highest-ranking Flight Surgeon of the Bundeswehr, the Chief Flight Surgeons of the Army and the Navy are assigned to AFCAM, and the head of one of the three divisions of AFCAM is the Chief Flight Surgeon of the Air Force. 

The Flight Medical Service of the German Air Force

The Flight Medical Service of the German Air Force is responsible for providing flight medicine in all operational air wings, global mission support, health support administration, aeromedical training and medical equipment for our flight surgeon clinics as well as AE (aeromedical evacuation) onboard our various aircraft. The air wing’s flight surgeon clinics comprise of flight surgeons, flight surgeon assistants, physiotherapists and sports trainers. They provide medical support as family practitioners of our aviators and air traffic controllers as family practitioners and function as aeromedical examiners (AME), as well. Additionally, they support the German AE system as medical directors (MD) onboard our AE-aircraft. Command, support and guidance are provided by Division III, the Competence Centre for Flight Medical Service and the Chief Flight Surgeon of the Air Force.

Flight surgeons in the field / Aeromedical Evacuation

Appropriate and continuous aeromedical support is also an essential factor in successfully maintaining military flight operations at a deployed operating base. Special requirements thus apply with regard to the training, motivation and proficiency of flight surgeons stationed in the field. A deployed flight surgeon must also be capable of acting as an Aeromedical Evacuation Coordinating Officer (AECO), providing the aeromedical expertise required by the casualty evacuation chain.

A flight surgeon must have the abilities required to perform the duties of the Medical Director (MD) in all Tactical Aeromedical Evacuation (TacAE) and Strategic Aeromedical Evacuation (StratAE) missions and, like the civilian senior emergency physician, to coordinate the civilian emergency medical services during airborne evacuation. A Medical Crew Chief (MCC) is at hand to assist the flight surgeon. The Aeromedical Evacuation (AE) flight crew also includes the Medical Device Technician, whose job it is to ensure that onboard medical equipment and material are both functional and safe. The direct medical treatment and monitoring of wounded, injured and sick personnel being transported by aircraft are provided by the specialists of the Bundeswehr Joint Medical Service.

The Medical Service in the Joint Support and Enabling Service 

The Medical Service in the JSES provides specialist advice for force commanders, performs military pharmaceutical tasks for the Bundeswehr, and fulfils specific specialist tasks. The JSES further ensures the provision of medical care at Bundeswehr agencies abroad (outside of military operations).

Senior Medical Officers (SMOs) in capability coordination commands serve as medical advisors to force commanders. In addition, they analyse physical and ergonomic requirement profiles for various specialist tasks and contribute medical expertise to the further development of technology and procedures. These tasks are especially important with respect to future personnel development. 

The Surgeon General of the Joint Support and Enabling Service, the Bundeswehr Logistics Centre, and medical materiel depots perform military pharmaceutical tasks. Military pharmacy elements have in-service, maintenance and supply responsibility for medical materiel in the JSES. They furthermore represent the interests and technical issues of medical materiel management in the further development of logistic systems at the interface to the main logistics process.

A broad range of specific specialist tasks are performed in national and international HQs, authorities, commands and agencies and are carried out by medical advisors, special instructors at schools, veterinarians for working dogs, and toxicologists in the CBRN corps.

The Subdivision of the Surgeon General of the Joint Support and Enabling Service controls and coordinates health support and medical materiel logistics in the JSES.

The responsibilities of the Surgeon General include:

• assessing medical operational readiness in his area of responsibility,
• providing expert advice to the Chief of Staff of the Joint Support and Enabling Service and the Surgeon General of the Bundeswehr in all medical matters of the JSES,
• assuming in-service and supply responsibility for medical materiel in his area of responsibility,
• exercising functional control over subordinate medical elements and providing intermediary or final reports for decision-making processes.

Civil-Military Cooperation