Overview: From the Editorial Board
Future Issues in Military Medicine and the military-medicine.com Journal
If you are reading this, you will know that we have refreshed the military-medicine.com website and re-energised the ‘Journal’ component. We hope to recreate the contribution made by the physical journal ‘Military Medical Corps International Forum’ to the professional debate in military medicine by focussing on the role and contribution of ‘military medical services in supporting national security objectives’. We have chosen this phrase to emphasise the role of military medical services as a component of the armed forces, which, in themselves, contribute to the security of our nations. However, we believe that our military medical services make a much greater contribution than solely as a support function alongside communications, logistics, engineering and personnel support. As the COVID crisis has shown, as well as medical support to military operations, military medical services are a national strategic asset within our whole national health economies. They have a critical role supporting the health of our country’s armed forces. They can contribute to military-to-military diplomatic collaboration and the shared commitment of nations within coalition operations. Finally, they can reinforce civilian medical capabilities, both at home and as part of an international response to humanitarian crises. We hope that the military-medicine.com Journal will provide a platform for such debate. This short editorial suggests some future issues that our contributors might wish to examine.
Relationships between national security and health
Many national security risk registers listed a pandemic as a high likelihood and high impact risk, but our mitigation measures have proved inadequate to control the threat from the COVID virus. Our government policies are still evolving to balance the risk from the virus to individual and population health versus the impact of the control measures on every other aspect of societal activity. Many members of our military medical community have the privilege of attending professional military educational programmes (primarily Staff Colleges) that study the nature of conflict and war, the role of security in international relations, and the role of armed forces in society. This knowledge might make us uniquely placed to debate the relationship between national security and health as a counterpoise to the humanitarian debate based upon the relationships between individual human security and health. Both might inform political choices about investing in access to healthcare as a security capability in its own right, alongside other national security institutions. This is particularly important in the strategic balance of investment between state security and societal welfare.
Relationships between civilian and military healthcare.
Building upon the notion that access to healthcare might be a security capability in its own right, the entirety of a country’s health economy could be considered to be a key component of a country’s critical national infrastructure that provides resilience against strategic shocks. The balance of providers of health services between federal government ministries, local government institutions, insurers, not-for-profit organisations, commercial companies, and charities varies by country (1). However, the COVID crisis has demonstrated that military health services are a highly adaptable national strategic reserve under direct federal control that can be mobilised more quickly and flexibly than any other component of our health systems (2). As our countries consider how to invest in recovering our health services from the COVID crisis, there might be an argument that considers military medical services as a national security capability alongside the arguments that are justifying security investments into other non-conventional domains such as cyber and space (3). Our military medical services will need to identify the best packages of ‘dual use’ medical capabilities that should be maintained for the future, including the civil-military co-ordination mechanisms that have evolved to use them to best effect to support the civilian health and social care system during the COVID crisis.
Relationships between armed forces and their health services.
The armed forces (especially military medical services) have been a highly visible demonstration of the mobilisation of all components of national power to the COVID response. Less visible, but equally demanding, has been the contribution of military medical services to the protection and maintenance of the health of the armed forces and their direct beneficiaries, including treating COVID patients from this population. Whilst many military activities have been reduced to mitigate the risks from COVID, military medical services have had to maintain their clinical capabilities, surge their public health capabilities, and rapidly adopt new ways of working including introducing digital and remote health technologies. The COVID experience has probably demonstrated that military medical services are a Defence level capability encompassing medical personnel who have been recruited as soldiers, sailors, airmen and civilians but work together, able to care for patients irrespective of the type of clothing that both they and their patients wear. We probably need to develop new concepts for the design of military health systems that places our patients at the centre of the clinical service across their ‘life course’ (4). This may have important implications for the cultural and structural design of military heath systems for the future. These themes have been covered in the series of interviews from senior leaders in the NATO military health system that have been recently published in the military-medicine.com Journal.
The military medical system workforce.
The COVID crisis has reinforced the centrality of the health workforce as the key determinant of the capability and capacity of the whole health system. People are also the most expensive component, needing to be recruited, trained, educated, rewarded, and retained. The COVID crisis has also shown the importance of workforce flexibility, including the need to re-deploy, new-skill, and task-shift across clinical teams. Military medical training institutions have rapidly adapted their modes of training delivery and introduced new training packages to meet the new learning needs of military health professionals in response to the COVID crisis. It is likely that military medical services will need to invest considerable intellectual analysis to ensure that there remains a credible career proposition for health professionals to join and stay working within the military medical services. This proposition will need to be successful within an increasingly competitive market for talent.
There have been many false promises about the potential for new medical technologies to improve the clinical care of military patients on the battlefield. Whilst the last two decades has seen an increased likelihood of survival for military casualties and an improvement in the quality of life for injured Veterans, it could be argued that this has been the result of old lessons relearned (good quality basic first aid, value of whole blood etc) and the opportunity provided by a stable field medical system supported by exceptional levels of medical evacuation. This was reinforced by a medical system that focussed on treating a single clinical condition (military trauma) over a sustained period. It would be interesting to compare the rate of military medical innovation over the first decade of the 21th Century with the much shorter periods of World War 1 and World War 2. There is less evidence of successful adoption of universal electronic health records across the battlefield, the exploitation of health data for all clinical conditions affecting all patients in the military health system (as an example, there are very few analyses of clinical care of non-military patients in military field hospitals), and the introduction of health surveillance across a deployed force. However, the imperatives from the COVID crisis have seen the widespread adoption of telemedicine to enable remote and asynchronous clinical care. In addition to highlighting the clinical opportunities from new medical technologies, it would be interesting to discuss how to adopt these at the organisational level so that medical technology is considered as an enhancement in military medical capability rather than just new equipment.
Tactical developments and deployed experience.
There were many articles in the ‘Military Medical Corps International Forum’ that provided a narrative description of individual experiences of leading and managing military medical services at the tactical level. The military-medicine.com Journal maintains access to electronic copies of these papers. It remains important for future leaders of military medical services to be able to read about the challenges faced by their predecessors so that they can learn from this experience rather than having to use their own experience to learn old lessons. We hope that authors will continue to submit the same style of papers on these topics to this journal so that this repository continues to collect contemporary records of personal experiences. We would wish these accounts to be as honest as possible (within the bounds of security and military law) so that readers can learn about the reality of manging medical support in the military environment.
The Editorial Board hopes that our military-medicine.com Journal will prove to be a value source of analysis on the role and contributions of ‘military medical services in supporting national security objectives’. We aim to fill and expand the space filled by our predecessor ‘Military Medical Corps International Forum’ and to exploit the opportunities from publishing via a digital platform. We aspire to publish content that is relevant to an international audience and complements the more clinically orientated papers published by other academic journals of military medicine. This editorial has provided some topics that authors may wish to consider when writing articles for this Journal.
Martin Bricknell CB OStJ PhD DM
Lieutenant General (ret.) Professor
Former Surgeon General of the UK Armed Forces
Rob van der Meer, MD
Brigadier General (ret)
Former Surgeon General of the Netherlands Armed Forces
Gerald M. Kerr, MD
Former Surgeon General & Director Medical Corps Irish Defence Forces
1. Bricknell M, Hinrichs-Krapels S, Ismail S, Sullivan R. Understanding the structure of a country's health service providers for defence health engagement. BMJ Mil Health. 2021 Dec;167(6):454-456. doi: 10.1136/bmjmilitary-2020-001502. Epub 2020 Jun 4. PMID: 32503861; PMCID: PMC8639950. Available at: https://militaryhealth.bmj.com/content/167/6/454
2. Bricknell M. Analysing civil-military command and control in the response to the covid-19 pandemic. Military-medicine.com. 22 Dec 21 Available at: https://military-medicine.com/article/4176-analysing-civil-military-command-control-in-the-response-to-the-covid-19-pandemic.html
3. Bricknell M, Horne S. Personal view: security sector health systems and global health. BMJ Mil Health. 2020 Sep 30:bmjmilitary-2020-001607. doi: 10.1136/bmjmilitary-2020-001607. Epub ahead of print. PMID: 32999086. Available at: https://militaryhealth.bmj.com/content/early/2020/09/29/bmjmilitary-2020-001607.long
4. Bricknell M, Cain P. Understanding the whole of military health systems: the defence healthcare cycle. The RUSI Journal 2020 ; 65 : 40 – 9. Available at: https://www.tandfonline.com/doi/full/10.1080/03071847.2020.1784039
Source: Lt Gen (ret) Martin Bricknell & Photo: Bundeswehr / Anne Weinrich