Lessons Learned from the War in Ukraine for the Bundeswehr Medical Service

“Zeitenwende”
24 February 2022, the start of Russia’s war of aggression against Ukraine, marks a profound turning point. This war has changed the world. Every day, the media illustrate this with horrific pictures of the maltreated country at the Black Sea and by presenting the various reactions from all over the world.

In February 2022 already, NATO responded by reinforcing the enhanced Forward Presence (eFP) Battle Group in the Baltic States to more than 1,600 troops. In response to the Russian attack on Ukraine, an enhanced Vigilance Activities (eVA) Brigade was planned in addition to reinforce NATO’s eastern flank in Lithuania. Meanwhile, the German Federal Minister of Defence has ordered the formation and deployment of a combat brigade that will be permanently stationed in Lithuania.

Until today, Ukraine has received continuous and large-scale deliveries of equipment and armaments from stocks of the Bundeswehr (i.e. the German Armed Forces) and supplies from industry, which are financed from funds of the German Federal Government’s enhancing and enabling assistance, including LEOPARD main battle tanks, MARDER armoured infantry fighting vehicles, PzH 2000 armoured self-propelled howitzers, MARS II rocket launcher systems, DINGO all-protected carrier vehicles, patient transfer ambulances and field medical treatment facilities (MTF), as well as thermal clothing, power generating aggregates, tents, and food rations.

In view of the Russian war of aggression against Ukraine, the High Representative of the European Union for Foreign Affairs and Security Policy, Josep Borrell, in August 2022 brought up to discussion a new program for the training of the Ukrainian Armed Forces. Several EU states, the US, Canada and the UK train Ukrainian soldiers on the basis of national arrangements. The European Union Military Assistance Mission in support of Ukraine (EUMAM Ukraine) is initially planned for two years. It is intended, among other things, to train special capabilities of combat and combat (service) support forces and to provide capabilities in areas such as command post organization, mine clearance and medical support. In order to reduce the risk of Russia attacking the training mission, training is organised and conducted in countries such as Poland and Germany. Most recently, Germany and the Bundeswehr have been involved in the training of armoured troops, infantry, air defence, artillery and medical support. In addition, a proposal was prepared in cooper- ation with The Netherlands on how to strengthen countermine training.

Support by the Bundeswehr Joint Medical Service
The Bundeswehr Joint Medical Service (BwJMedS) has provided further support and assistance to Ukraine. Providing training support for combat trauma surgeons, combat lifesavers and paramedics is a force-intensive and time-consuming task in this context. The coronavirus pandemic resulted in a significant backlog in training in the BwJMedS and the Bundeswehr in general, especially in the field of individual training. The grow- ing importance of medical training, in particular for non-medical personnel, is becoming increasingly evident in the German Armed Forces as well. They are the ones who, so to speak, hold the lives of their wounded comrades in their hands before qualified medical care is available and must be empowered to provide competent first aid on the battlefield. They are working “at the sharp edge”. Investments must be made in their capabilities – in the Bundeswehr, but also in the support of the Ukrainian Armed Forces.

In addition, the BwJMedS also takes over Ukrainian patients, including movement and treatment, in cooperation with the German Federal Office of Civil Protection and Disaster Assistance (Bundesamt für Bevölkerungsschutz und Katastrophenhilfe; BBK) and the German Joint Information and Situation Centre (Gemeinsames Melde- und Lagezentrum; GMLZ) established there. Basically, however, materiel support as well as the assignment of additional training personnel is possible only from resources the BwJMedS can make available, subject to capacities permitting, and that are operational ad hoc. Multinational cooperation (here with Estonia) has been of immense importance, especially with regard to support with a Role 2 MTF.

The BwJMedS is more challenged and more in demand than ever. Following the comprehensive corona pandemic assistance provided since 2020, supporting Ukraine is now one of the main tasks. The coordination and takeover of Ukrainian war patients concerns a continuation of the treatment of Ukrainian casualties in Bundeswehr hospitals (BwHosp) – more than 240 patients by the end of 2021 – which has been ongoing since 2014 after Russia’s annexation of Crimea. The BBK has already evacuated almost 1.000 patients to Germany by air, with the participation of the Bundeswehr, and some of them have been treated in the BwHosp.

Lessons learned from the War in Ukraine
During a COMEDS (Committee of the Chiefs of Military Medical Services in NATO) plenary in 2023, the Ukrainian Surgeon General presented an initial evaluation of the current conflict in Ukraine from a medical service point of view. His presentation was the first available medical report from a war on the European soil since World War II and provided the ideal opportunity to review the assumptions and rationales used to date in the Bundeswehr medical support planning process. In this context, six lessons can be identified:

1. The necessary protection level of medical forces during operations. Like in Syria, Afghanistan and Iraq, the distinctive emblem is barely observed or completely ignored by the Russian Armed Forces in the Ukraine.

2. Comparative analysis of the casualty rates of the personnel involved and their injury categories. That tells us something about the quantity and the quality of the required medical resources.

3. Evaluation of medical evacuation (MEDEVAC) with regard to the transport assets employed and the number of patients to be moved.

4. High mobility and flexibility of the elements of the MEDEVAC chain with regard to the availability of forces, space and time.

5. Need for interministerial health care in the sense that health care is a whole-of-government responsibility.

6. Relevance of medical support for the morale and operational effectiveness of armed forces.

At present, for example, the patient evacuation organisation is led by the Ukrainian Ministry of Health. The following problem areas are more than clear: long MEDEVAC times; overload of the hospitals; exhaustion of evacuation capacities; and, lack of expertise.

According to the assessment of the World Health Organisation, this leads to a qualitative and quantitative overstretch of the Ukrainian Ministry of Health and generally results in an insufficient patient evacuation organisation. Against this background, and considering a national/collective defence scenario, it may be appropriate for the German Federal Ministry of Defence to relocate the patient evacuation organisation in Germany with its capabilities and skills available so far. In order to exploit the existing potential, it is also indispensable to further expand the areas of digitalisation and resources.

Protection level of the Red Cross
From information and statements by independent observers and pictures of the Ukrainian Medical Service, it becomes clear that in this conflict too, the Red Cross as a distinctive emblem, regrettably has hardly any protective effect. Even worse, medical facilities and vehicles have obviously been attacked deliberately to cause lasting damage in terms of materiel, personnel and morale. Public media coverage also confirms this perception of perfidious warfare. In addition, no distinction is made between military forces and civilian personnel. In the course of the conflict, a growing casualty rate among the supporting medical personnel will increase the already existing deficits in medical care. Therefore – contrary to the popular belief that the distinctive emblem alone is sufficient – a level of protection and mobility for the medical forces must be implemented that corresponds to that of the supported units. Both entities move in the same area and are exposed to the same threat. The armoured vehicles and protected and highly mobile MTFs required in this context serve to protect and provide reliable and safe care to the patients and own personnel. In addition, the resilience of the medical service must be increased by providing sufficient personnel and materiel to compensate for any casualties without significant losses in medical care.

Casualty rates, injury categories, flexibility of the MEDEVAC chain
In direct comparison, the calculations on the number of casualties show a similar average number as previous planning, although not enough data are available to calculate the casualty rates in an evident manner. The number of killed-in-action casualties in the Ukrainian conflict is presumably significantly higher than that calculated by NATO, on which the German planning ratio- nales are based. As a consequence, it becomes apparent that a medical service that is not sufficiently dimensioned leads to dis- proportionately higher losses after combat. The types of injuries, in particular explosion, splinter and burn injuries, require a high level of qualification and good training of first aiders and medical personnel as well as extensive medical materiel (e.g. tourniquets, bandages and haemostatic agents for extremity and soft-tissue haemorrhage control). The available reports clearly show pro- longed treatment times and, consequently, a significantly worse outcome for the severely wounded patients. An appropriate MEDEVAC chain that observes the required timelines for medical treatment will ultimately guarantee the rescue of human lives or the quality of survival. This, however, requires sufficiently trained and operational personnel, MEDEVAC assets and MTFs to be used flexibly as elements of the MEDEVAC chain.

Patient evacuation
Medical evacuation was also analysed in terms of quality and quantity. Results from a Ukrainian analysis show that the distribution among the modes of transport (66% ground-based, 33% airborne) calculated so far by the BwJMedS in the war in Ukraine has significantly shifted from aeromedical evacuation (AE) to ground MEDEVAC. Of particular importance in this context are improvised rail transport assets. The reasons for this are, among other things, the lack of air superiority and the associated threat to AE assets. Nevertheless, particularly strategic AE will remain highly significant, especially for international crisis management and national crisis and risk management for German nationals abroad. In our final analysis, we can state already today that the Bundeswehr lacks large-capacity MEDEVAC assets for large num- bers of patients and that significantly higher capacities are needed to cope with the expected numbers of patients. Additional large- capacity vehicles – for example buses – are required especially in tactical MEDEVAC. As a consequence, rail-based MEDEVAC with hospital trains is of particular importance over larger distances. In addition, in the case of medical evacuation of large numbers of patients over long distances, close cooperation with multinational and civilian relief organisations is indispensable and must be sought, which could then provide accompanying personnel and personnel providing medical care. Many thought-provoking impulses were already given in the past. Because of other priorities, however, they have often not been addressed.

In summary, under the current conditions, there is an undeniable need and urgency to make the BwJMedS more sustainable and thus to protect the life and health of the soldiers and wards entrusted to us in a sustainable manner. The bitter experiences from the war in Ukraine should serve as a warning!

Lessons learned for the German national and collective defence
Interministerial health care
From a medical perspective, Germany will largely be on its own in the event of crisis and war, just as every other nation in Europe is presumed to be. This in contrary to the current situation in Ukraine, where many third nations offer help and receive patients and refugees. Because of its role as a hub and a kind of turn- table on the one hand and its clinical-medical standards on the other, however, Germany is attributed substantial significance in the multinational context of transnational health care. The presumed number of victims of war operations moved to Germany will increase and the presumed partly hybrid war acts are likely to have increasing consequences for Germany over time. In addition to the normal needs of civilian health care, this will lead to a considerable increase in the number of patients, which will put a huge strain not only on the national medical evacuation chain but also on the treatment capacities in the hospitals. In order to be able to effectively face this situation, national precautionary measures must be taken early. This concerns the establishment and strengthening of trauma networks, coordinated patient flow management, stockpiling of blood products and medical materiel, planning and stockpiling of materiel for central accommodations and medical zones, as well as organisation and provision of patient movement and admission capacities. Reliable access to pharmaceutical companies and wholesalers based in Germany must also be ensured. Only a situation picture established at an early stage and constantly augmented across all competent Federal ministries, government and non-government organisations can achieve this whole-of-government and coordinated action. The framework for this would be a Health Security and Preparedness Act for Germany which is so far missing from the set of already adopted national safety laws.

Germany’s assumed role as a hub
Germany as a hub is already a standard task for the BwJMedS in daily routine duty. Already during the deployment phase, BwJMedS forces will be included in the respective deployment packages in considerable numbers and will thus no longer be available for the provision of military medical care in Germany. This affects routine operations to the extent that the military-medical specialists from the BwHosp are seconded to the field MTFs and are therefore no longer available in the hospitals which, as Role 4 MTFs, are still part of the MEDEVAC chain to provide definitive treatment. The result of this single set of forces in a national/collective defence scenario is a reduced admission and treatment capacity in the BwHosp. This can only be counter- acted by distributing civilian patients to civilian hospitals at an early stage upon activation, thus creating free Role 4 capacities for the wounded. At the same time, also reservists and relief organisations must be called on for support. It goes without saying that the clinical capacities of the BwHosp will no longer be sufficient by far with increasing combat intensity and thus number of patients, and that it will be indispensable to generally rely on external – that means civilian – treatment capacities. Likewise, the provision of medical support to the Bundeswehr in Germany in the event of a situation development towards an Article 5 scenario is becoming increasingly limited, since also the BwJMedS will suffer casualties in the course of war operations and medical forces will have to follow up. Here, too, the unavoidable reliance on the national health care system and, in particular, the price for the single set of forces approach becomes evident. As the situation develops, the tasks to be performed by Germany as a hub can less and less be performed by the Bundeswehr Joint Medical Service alone, but are a whole-of-government task with the Bundeswehr Joint Medical Service having a coordinating function headed by the Surgeon General of the Bundeswehr. In addition, the medical support of the civilian population affected and of potential refugee flows must be mentioned and taken account of. These needs are established common sense in the German government.

Health care in Germany in the event of crisis, conflict and war
In order to be able to cope with the whole-of-government task of “coordinating health care in the event of crisis, conflict and war”, established structures and processes are required that must be coordinated and technically implemented in a comprehensive approach. In this context, the position of the Surgeon General of the Bundeswehr as the senior advisor to the Commander in Chief of the Armed Forces who has overall responsibility for the performance process of “ensuring health care” can be the connecting link between civilian and military forces, assets and requirements. A military-influenced judgment to assess the medical situation and to control the processes in a crisis or war scenario, embedded in the regular command and control structure of the Bundeswehr, allows for targeted, whole-of-government strategic action. In all phases of Article 4 and 5 scenarios, there is considerable information interest regarding a holistic health picture of Germany that must continuously develop on the basis of the Bundeswehr medical situation picture. It is the close cooperation between a BwJMedS situation centre and the situation centres of the German Federal Ministries of the Interior and Health as a sub-process of situation management performed by the Federal Ministry of Defence. It enables exactly this interministerial whole-of-government situation picture and already in peacetime and leads to the confidence of the servicemen and women as well as of the German population. The increasing demand for civilian support in health care is confronted with rapidly decreasing medical support capabilities of the Bundeswehr within Germany. This is to be coordinated, designed with resilient structures and, as a whole, to be understood as a whole-of-government task to protect the health of the German population. This requires a legal framework that is developed and coordinated in a comprehensive approach and, ideally, results in a Health Security and Preparedness Act for Germany.

Influence on the morale and operational effectiveness of armed forces
The relevance of medical support for the morale and operational effectiveness of armed forces is described in many ways, and indeed emphasized, by the Ukrainian Armed Forces and in the international perception. In 2022, the renowned magazine Foreign Policy headlined: “Ukraine’s Military Medicine is a Critical Advantage”. This is also illustrated by the fact that the Ukrainian soldiers emphasize the special importance of training in medical matters – be it for non-medical personnel or for medical personnel – during their training in Germany. Good and intensive medical training saves lives at the front; far forward by initial measures to stop bleeding – in particular by the correct use of tourniquets as well as with qualified care at all Roles of medical support.

Conclusion
The need for a Health Security and Preparedness Act has already been discussed. Only a holistic and consolidated situation picture of the health care situation on a legal basis can ensure the medical support of the armed forces within the scope of host nation support and of the civilian population in Germany. Current cooperation, for instance with the Federal BBK, shows that there is an absolute need for action in the area of health care, although initial approaches are promising. The BwJMedS will become the real effector in the continuous creation of reliable and resilient rescue and medical care structures, through its contribution to military medical research and the fight against biological and chemical threats, thereby contributing substantially to the strengthening of resilience. At the German Ministry of Defence level, therefore, the strategic and interministerial coordination of health care issues and the coordination of civilian and military approaches is of particular importance. To this end, it is indispensable to anchor the overall responsibility for Bundeswehr health care at the strategic level in the German Federal Ministry of Defence. This is the only way to ensure direct advice to the Commander in Chief of the Armed Forces and close contact between the BwJMedS and the civilian health care system. This holistic approach enables national health care to be ensured in keeping with the medical care of the armed forces in such a way that coordinated and resilient medical care can also be provided under Article 4 or 5 conditions in a uniform command and control structure.

The current single set of forces of the Bundeswehr Joint Medical Service is clearly limited in terms of quantity and sustainability. To ensure the sustainability of the medical specialist personnel without interruptions, earmarked and/or reserve forces for the BwJMedS must be planned for and assigned, and their assured call-up made possible by legal regulations. The current concept of the Reserve of the BwJMedS only insufficiently generates reservists for medical specialist and licensed physician posts. All suitable reservists hold full-time medical or non-academic health professions, honorary positions or secondary employments in the civilian sector. Both sides use the same resources, so to speak. Given the general national shortage in the required specialist personnel, the buildup of reservists therefore is difficult.

Consequently, the staffing of posts mainly with additional active personnel must be considered. The planning framework for the BwJMedS must therefore be adapted. The same challenge exists in the “fight” for cross-sectional specialists (for instance for camp operation, IT, supply and food). Without relying on available spe- cialist personnel from the civilian health care system, detailed planning of non-active units for the BwJMedS in line with the Bundeswehr Reserve Concept can likewise be applied to a limited extent only. It is therefore of great importance to further consolidate cooperation with hospital networks and groups and also to place the integration of the German Red Cross on a broader and more resilient foundation than before. Therefore, the BwJMedS must intensify its efforts for reinforcements not only through individual personnel but especially through close cooperation with institutions and organisations for the purpose of establishing a robust integrated health care network in Germany that is capable of augmentation.

In terms of plans and concept, the BwJMedS is already geared to supporting the Bundeswehr in a national/collective defence scenario. This is consistently confirmed by the observations in and lessons learned from the war in Ukraine with regard to the provision of materiel and vehicles as well as facilities and the training of medical and non-medical personnel. Now, the requirements must urgently be met without further delay in order to enable responsible medical support.

The observations made in the war in Ukraine underline the necessity to make available as quickly as possible the required and urgently needed resources for the BwJMedS for the purpose of a balanced development of forces and responsible for the life and health of the soldiers entrusted to us.

We must now continue to operationalise and implement the lessons learned presented in order to further improve the medical support of the Bundeswehr in a national/collective defence scenario.

Literature with the author.

Author:
Colonel (MC) Dr. Kai F. Schmidt, MSc
Head of Division Operations/Missions, Medical Service
Bundeswehr Joint Medical Service Headquarters,
Command and Control
Von-Kuhl-Straße 50, 56070 Koblenz, Germany
Email: kai9schmidt@bundeswehr.org

Date: 07/16/2024

Source: European Military Medical Services 2024